Suggest Treatment For Chronic Back Pain In An Elderly Person With Osteoporosis

Question : Patient is a 96 year-old female who had a fall in mid-2015 and suffered compression fractures to her lower back. She has since suffered chronic back pain. The pain appears to be more present when she attempts to mobilise rather than when she is seated and it has become worse in recent weeks for a some reason. She has osteoporosis and her GP thinks that arthritis may be contributing to her chronic pain. The patient is on a pain patch, Norspan (Buprenorphine 5 mcg per hour), and paracetamol which do not appear to be of much use in alleviating the pain. The patient had been on Norspan 10 mcg per hour, but became more somnolent and generally less alert which put her at greater risk of experiencing another fall. In addition, there did not appear to be any improvement in pain relief on the higher dosage. As a result, she was put back on to 5 mcg per hour plus paracetamol. The patient also has advanced dementia. The problem is obviously a complex one and I appreciate that there may be no easy solution. Moreover, you do not know the full details of the patient's medical history. However, could you make any suggestions for improved pain relief which I could discuss with her GP? Her GP does his best but is not an expert in pain relief. I am particularly concerned that heavy-duty opioids could make her totally non compos mentis. Her dementia is bad enough as it is. Her liver and kidneys are apparently all right for her age. She has tachycardia which is being treated with 25 mg of Metroprolol per day.