Chronic pain and disability in diabetes

There are several potential sources of acute and chronic pain in older diabetic patients, many of whom have two or more painful conditions. Major contributors to chronic lower extremity pain in older diabetic patients include peripheral neuropathy and peripheral arterial disease. Although chronic pain is always present in neuropathies, painful peripheral neuropathies are especially disabling in older patients because of detrimental effects on balance, sensorimotor function, gait, and functional autonomy. Older diabetic patients have worse PAD below the knee than their non-diabetic peers and higher risk of amputation. Research has demonstrated that diabetics have more severe PAD but complain more of atypical leg pain with exertion and rest, rather than the classic intermittent claudication. Musculoskeletal pain is very common in older persons and it is often difficult to diagnose the underlying pathology. In the absence of a definitive diagnosis, symptom management to prevent functional decline becomes paramount in the care of older patients. Among patients who score positive on a simple pain screen, a more detailed follow-up assessment should include pain history and a detailed description of pain frequency, duration, location, and impact on mood and functioning. Correct classification of the pain syndrome according to pathophysiologic mechanisms will establish whether pain is neuropathic (e.g. diabetic neuropathy) or nociceptive (e.g. arthritis pain or other somatic or visceral pain), or of mixed pathogenesis. Regardless of the underlying conditions that cause pain, the presence of persistent pain, particularly back pain and lower-extremity pain, has a marked disabling effect, adding to the risk for functional limitation or worsening disability and further reducing the quality of life of older patients with diabetes. From this point of view accurate assessment and appropriate management of pain will help older diabetic patients to maintain their activities and independence. Individually tailored therapeutic trials are the hallmark of effective pharmacotherapy for persistent pain in older diabetic patients. Providers face particular challenges in assessment and treatment of persons who have cognitive impairments. These patients are particularly vulnerable to medication side effects and also to undertreatment. The AGS guidelines for pain management emphasize use of an interdisciplinary approach. Referrals to pain specialists, pain clinics, and rehabilitation specialists are important and often underutilized components of chronic pain management for older patients. Efforts within primary care practices to promote better patient self-management of chronic conditions may be beneficial for older adults with diabetes.