Geriatrik Hastalarda Ağrı Yönetimine Birinci Basamak Yaklaşımı
Özet
Geriatrik bireylerde ağrı; işlevsellik, uyku, ruh hali, sosyal katılım ve yaşam kalitesini etkileyen çok boyutlu bir sorundur. Multimorbidite, kırılganlık, bilişsel bozukluk, polifarmasi ve yaşa bağlı farmakokinetik ve farmakodinamik değişiklikler, değerlendirme ve tedaviyi güçleştirir. Bu bölüm, geriatrik ağrı yönetimine birinci basamak yaklaşımını güncel kanıtlar doğrultusunda ele almaktadır. Değerlendirmede ağrının mekanizması, süresi, şiddeti ve işlevsel etkisi belirlenmeli; kırmızı bayraklar, komorbiditeler, organ fonksiyonları ve ilaç etkileşimleri araştırılmalıdır. Bilişsel olarak korunmuş hastalarda öz-bildirim ölçekleri, iletişim güçlüğü veya ileri demansı olanlarda ise gözlemsel araçlar kullanılmalıdır. Tedavi biyopsikososyal, kişi merkezli ve bireyselleştirilmiş olmalı; eğitim, egzersiz, fizik tedavi, öz-yönetim ve psikolojik destek gibi non-farmakolojik yöntemler temel yaklaşımı oluşturmalıdır. Farmakolojik tedavide en düşük etkili dozla başlanmalı, yavaş titrasyon yapılmalı ve advers etkiler yakından izlenmelidir. Düzenli yeniden değerlendirme, bakım veren katılımı ve depreskripsiyon; bağımsızlığın, hareketliliğin ve yaşam kalitesinin korunmasına katkı sağlar.
Pain in older adults is a multidimensional problem affecting function, sleep, mood, social participation, and quality of life. Multimorbidity, frailty, cognitive impairment, polypharmacy, and age-related pharmacokinetic and pharmacodynamic changes complicate its assessment and treatment. This chapter reviews a primary care approach to geriatric pain management based on current evidence. Assessment should identify pain mechanism, duration, intensity, and functional impact while screening for red flags, comorbidities, organ dysfunction, and drug interactions. Self-report scales should be preferred in cognitively intact patients, whereas observational tools are required for individuals with advanced dementia or communication difficulties. Management should be biopsychosocial, person-centered, and individualized. Non-pharmacological strategies, including education, exercise, physical therapy, self-management, and psychological support, should form the foundation of care. When medication is needed, treatment should start at the lowest effective dose, be titrated slowly, and include close monitoring for adverse effects, particularly with nonsteroidal anti-inflammatory drugs, gabapentinoids, antidepressants, and opioids. Regular reassessment, caregiver involvement, and deprescribing are essential to minimize medication-related harm and to support not only pain relief but also preservation of independence, mobility, and quality of life.
Referanslar
Borsheski R, Johnson QL. Pain management in the geriatric population. Missouri Medicine. 2014;111(6): 508–511
Schofield P, Dunham M, Martin D, et al. Evidence-based clinical practice guidelines on the management of pain in older people: A summary report. British Journal of Pain. 2022;16(1): 6–13. doi:10.1177/2049463720976155
Günvar T. Birinci Basamakta Kronik Ağrı Yönetiminin Temel İlkeleri. Turkish Journal of Family Medicine and Primary Care. 2009;3(3): 14–17
Kolcu G. Birinci Basamak Sağlık Kuruluşlarında Ağrı Yönetimi. Klinik Tıp Aile Hekimliği. 2017;9(1): 20–22
Herr KA, Garand L. Assessment and measurement of pain in older adults. Clinics in Geriatric Medicine. 2001;17(3): 457–471. doi:10.1016/s0749-0690(05)70080-x
Pickering G, Kotlińska-Lemieszek A, Krcevski Skvarc N, et al. Pharmacological pain treatment in older persons. Drugs & Aging. 2024;41(12): 959–976. doi:10.1007/s40266-024-01151-8
American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7): 2052–2081. doi:10.1111/jgs.18372
Collins JT, Walsh DA, Gladman JRF, et al. The Difficulties of Managing Pain in People Living with Frailty: The Potential for Digital Phenotyping. Drugs & Aging. 2024;41(3): 199–208. doi:10.1007/s40266-024-01101-4
Lohman MC, Mezuk B, Fairchild AJ, et al. The role of frailty in the association between depression and fall risk among older adults. Aging & Mental Health. 2022;26(9): 1805–1812. doi:10.1080/13607863.2021.1950616
Nijs J, Kosek E, Chiarotto A, et al. Nociceptive, neuropathic, or nociplastic low back pain? The low back pain phenotyping (BACPAP) consortium's international and multidisciplinary consensus recommendations. The Lancet Rheumatology. 2024;6(3): e178–e188.
Verhagen A, Downie A, Popal N, et al. Red flags presented in current low back pain guidelines: a review. European Spine Journal. 2016;25: 2788–2802. doi:10.1007/s00586-016-4684-0
Patel ND, Broderick DF, Burns J, et al. ACR Appropriateness Criteria® Low Back Pain. Journal of the American College of Radiology. 2016;13(9): 1069–1078. doi:10.1016/j.jacr.2016.06.008
Singh A, Akkala S, Nayak M, et al. Impact of Pain on Activities of Daily Living in Older Adults: A Cross-Sectional Analysis of Korean Longitudinal Study of Aging (KLoSA). Geriatrics. 2024;9(3): 65. doi:10.3390/geriatrics9030065
McLennan AIG, Winters EM, Gagnon MM, et al. The psychometric assessment of the older adult in pain: A systematic review of assessment instruments. Clinical Psychology Review. 2024;102513. doi:10.1016/j.cpr.2024.102513
Department of Health (Victoria). Pain in older people 2026. (30/03/2026 tarihinde https://www.health.vic.gov.au/older-people-in-hospital/pain-in-older-people adresinden ulaşılmıştır )
Schofield P, Abdulla A. Pain assessment in the older population: what the literature says. Age and Ageing. 2018;47(3): 324–327. doi:10.1093/ageing/afy018
McLennan AIG, Winters EM, Gagnon MM, et al. The psychometric assessment of the older adult in pain: A systematic review of assessment instruments. Clinical Psychology Review. 2024;114: 102513. doi:10.1016/j.cpr.2024.102513
Felton N, Lewis JS, Cockburn SJ, et al. Pain assessment for individuals with advanced dementia in care homes: A systematic review. Geriatrics. 2021;6(4): 101. doi:10.3390/geriatrics6040101
Tagliafico L, Maizza G, Ottaviani S, et al. Pain in non-communicative older adults beyond dementia: a narrative review. Frontiers in Medicine. 2024;11: 1393367. doi:10.3389/fmed.2024.1393367
Dowell D, Ragan KR, Jones CM, et al. CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. Morbidity and Mortality Weekly Report Recommendations and Reports. 2022;71(RR-3): 1–95. doi:10.15585/mmwr.rr7103a1
World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings 2026. (30/03/2026 tarihinde https://www.who.int/publications/i/item/9789240081789 adresinden ulaşılmıştır)
Antunes TPC, Jardim FG, de Oliveira Abreu CIP, et al. Chronic pain self-management strategies for older adults: An integrative review. Life. 2024;14(6): 707. doi:10.3390/life14060707
Shtroblia V, Petakh P, Kamyshna I, et al. Recent advances in the management of knee osteoarthritis: a narrative review. Frontiers in Medicine. 2025;12: 1523027. doi:10.3389/fmed.2025.1523027
Engels L, van den Akker M, Denig P, et al. Medication management in patients with polypharmacy in primary care: A scoping review of clinical practice guidelines. Journal of Evidence-Based Medicine. 2025;18(1): e70015. doi:10.1111/jebm.70015
Mian P, Allegaert K, Spriet I, et al. Paracetamol in older people: towards evidence-based dosing? Drugs & Aging. 2018;35(7): 603–624. doi:10.1007/s40266-018-0559-x
Freo U, Ruocco C, Valerio A, et al. Paracetamol: A review of guideline recommendations. Journal of Clinical Medicine. 2021;10(15): 3420. doi:10.3390/jcm10153420
Narayan SW, Naganathan V, Vizza L, et al. Efficacy and safety of antidepressants for pain in older adults: A systematic review and meta-analysis. British Journal of Clinical Pharmacology. 2024;90(12): 3097–3118. doi:10.1111/bcp.16234
Ferreira GE, McLachlan H, McLachlan AJ. Antidepressants for pain in adults. Pain Management. 2024;14(10–11): 531–533. doi:10.1080/17581869.2024.2432281
Attrill L, Schofield P. Perspectives on approaching pain management in patients with dementia. Pain Management. 2024;14(3): 153–161. doi:10.2217/pmt-2023-0095
Sharma R, Sharma T, McCready-Branch B, et al. Medication use by older adults with frailty: A scoping review. Pharmacy. 2025;13(6): 170. doi:10.3390/pharmacy13060170
Santos KC, Durkee-Neuman E, Ong A, et al. Pain management in cognitively impaired older adults. International Journal of Nursing and Health Care Research. 2024;7(3): 1528. doi:10.29011/2688-9501.101528
Turner SG, Pillemer K, Demetres M, et al. Physical pain among family caregivers to older adults: A scoping review of the literature. Journal of the American Geriatrics Society. 2024;72(9): 2853–2865. doi:10.1111/jgs.19037
Boon JT, Herr K, Schirle L, et al. Caregiving self-efficacy and pain assessment by family caregivers of people living with dementia. Geriatric Nursing. 2023;53: 146–152. doi:10.1016/j.gerinurse.2023.06.025
Noh H, Jeong H, Kan D, et al. Older adults' perspectives on deprescribing and non-pharmacological pain management in the Deep South. Journal of Applied Gerontology. 2025: 7334648251411577. doi:10.1177/07334648251411577
