Drugs Aging (2014) 31:711–719 DOI 10.1007/s40266-014-0210-4

THERAPY IN PRACTICE

Management of Fibromyalgia in Older Adults Mary-Ann Fitzcharles • Peter A. Ste-Marie Yoram Shir • David Lussier

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Published online: 17 September 2014 Ó Springer International Publishing Switzerland 2014

Abstract Fibromyalgia (FM) is a pain syndrome characterized by dysregulation of pain-processing mechanisms. FM may arise de novo or evolve following nervous system sensitization after an identifiable triggering event or related to a peripheral pain generator such as osteoarthritis. Although the focus symptom of FM is generalized body pain, patients may also experience sleep and mood disturbance, fatigue, and other somatic symptoms leading to the concept of a polysymptomatic condition. In view of prevalent other comorbidities in older patients, FM may be overlooked and management may be neglected, thereby contributing to poor well-being. Pertinent to the older patient is to ensure that the diagnosis of FM is correct and that other conditions are not misdiagnosed as FM. Whereever possible, treatment strategies should emphasize non-pharmacologic interventions that encompass healthy lifestyle habits, with attention to adequate physical activity in particular. Drug treatments should be tailored to the individual needs of the patient, with knowledge that they may offer only a modest effect, but with caution to ensure that adverse effects do not overshadow therapeutic effects.

M.-A. Fitzcharles (&) Division of Rheumatology, Montreal General Hospital, McGill University Health Centre, 1650 Cedar ave, Montreal, QC H3G 1A4, Canada e-mail: [email protected] M.-A. Fitzcharles
P. A. Ste-Marie
Y. Shir
D. Lussier Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, QC, Canada

Key Points Fibromyalgia, diagnosed clinically and without specific abnormal findings or a biomarker, may be a neglected condition in the older patient Treatments should be centered on nonpharmacologic strategies, with the expectation that drug therapy mostly offers a modest effect Pharmacologic treatments should be offered in minimum effective doses and be constantly reevaluated.

1 Introduction In contrast to the copious literature pertaining to fibromyalgia (FM) in general, little attention has been given to FM as a condition that occurs in the older patient. FM is a syndrome with symptoms that overlap physical and psychological domains. With an interesting history originating as a neurological/psychiatric syndrome recognized as neurasthenia in the early 1900s, thereafter thought to be a musculoskeletal disorder by the late 20th century, FM is again center stage in the neurologic arena in the 21st century. The current most plausible explanation for the pathogenesis of FM is a symptom complex primarily driven by dysregulation of pain-processing mechanisms with resulting central pain sensitization. Particularly pertinent to the older population is the concept of peripheral pain generators such as what occurs with joint pain due to osteoarthritis (OA), leading to pain sensitization and

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subsequent diffuse pain. Although most commonly recognized in middle-aged women, FM also occurs in younger persons, men, and the older population. FM is a composite of complaints leading to the concept of a polysymptomatic condition, but with widespread body pain recognized as the cardinal symptom, and with other symptoms present with variable prevalence and intensity. This range of symptoms contributes to the heterogeneity in the presentation with associated challenges in diagnosis and management. The first premise in treating older persons with a presumed diagnosis of FM is to ensure that the diagnosis is correct, as other conditions may present similarly with widespread pain. The aim of this paper is to specifically address the management of FM in older persons, with particular attention to pharmacologic interventions. A comprehensive literature search using MEDLINE, CINAHL, Cochrane, PUBMED, EMBASE, Cochrane Library, and PsycINFO was undertaken to identify treatment recommendations for FM with particular focus on treatments for the older FM patient. In addition to the formal search, a manual search from the references cited by original studies, reviews, and evidence-based guidelines was also used where indicated.

2 Diagnosis of Fibromyalgia FM is defined as a chronic pain syndrome, present for at least 3 months and accompanied by other somatic symptoms that can include fatigue, sleep disturbance, cognitive changes, mood disorder, and other somatic symptoms. As defined by the 2010 American College of Rheumatology revised criteria for a diagnosis of FM, two thirds of the symptom burden is due to pain, whereas one third is due to other symptoms [1]. FM can present as a spectrum of severity, with some persons only mildly affected, whereas others report considerable suffering [2, 3]. Symptoms of FM are not static, with most persons experiencing a waxing and waning course. In a recent study of persons aged over 55 years with FM, pain, stiffness, sleep, and mood disturbance were the most prominent symptoms reported by over 80 % of participants, with a tendency for pain symptoms to affect more body locations over time [4]. The pain associated with FM may be difficult for patients to describe owing to an absence of a consistent location, a tendency for fluctuation, and a quality that may have neuropathic characteristics. There is usually a background of diffuse pain, but with a tendency for various locations to have a more intensive focus of pain that can move from site to site without plausible explanation. Pain quality may be described as aching or burning, with the latter suggesting a neuropathic origin.

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FM is therefore a clinical diagnosis highly dependent on information obtained by the history, with no confirmatory physical finding, abnormal laboratory test, or biomarker. Apart from the presence of generalized soft-tissue sensitivity, a reflection of global reduction in the pain threshold, the physical examination is within normal limits for the patient’s age. Abnormal physical findings in older persons may be the result of concomitant conditions such as OA of the spine and peripheral joints, or cardiovascular or neurologic disease. Although the tender point count has been embedded in the diagnosis of FM since the original American College of Rheumatology criteria were published in 1990, tender points have now been eliminated from the clinical assessment in view of the inconsistent subjective nature of this finding [1, 5]. The diagnosis of FM is therefore based on a clinical construct, without the need to fulfill specific criteria in an individual patient.

3 Causes of Fibromyalgia Onset, Prevalence, and Factors Pertinent to the Older Patient As the pathway to central pain sensitization may have many avenues, with some particularly pertinent to the older patient, causation of FM remains mostly speculative, with a number of factors possibly operative in an individual patient. Familial studies point to some genetic predisposition, with up to a quarter of relatives of FM patients reporting diffuse pain, and a similar number for FM diagnosed in the offspring of women with FM [6, 7]. Genetic factors may also interact with a dysfunctional stress response system to predispose some individuals to the onset of FM following a triggering event [8]. Up to one third of persons with FM report previous good health prior to a specific event, such as a physical or psychological stressor, which resulted in the onset of FM [9]. Notwithstanding these associations, the majority of persons are diagnosed with FM with no identifiable reason for onset. FM as such was not fully recognized till 1990; therefore, the older person who was born in the mid-20th century and who might have experienced body pain in former years may not have been assigned any specific diagnosis, but in later years may be recognized as having had symptoms compatible with FM. Musculoskeletal pain increases with age, with up to 80 % of persons aged over 65 years reporting some daily pain [10, 11]. With a focus purely on the symptom of widespread pain, defined as pain affecting multiple sites including non-joint sites, as distinct from FM, 15 % of women and 10 % of men report widespread pain [12]. It therefore follows that the prevalence of FM may be greater in older compared with younger individuals. This notion is supported by the findings of two recent studies, one from

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Germany reporting a 2.5 % prevalence rate of FM in middle-aged persons vs. 3 % in those aged over 60 years, and a 1.42 vs. 1.91 % prevalence in an American study [13, 14]. New-onset widespread pain occurred in almost 20 % of persons aged over 50 years in a 3-year population study with a diagnosis of diffuse OA identified as an associated factor [15]. Additional contributing factors in this study were baseline pain status, physical health-related quality of life, anxiety, sleep complaints, and cognitive complaints. It is still unclear whether symptom severity of FM in the older person differs from those in younger persons, although the burden of comorbidities in the older population may influence the report of the global health status [10, 16]. Symptoms of FM may therefore be ignored by patients and physicians alike, with other comorbid illnesses perceived as having greater importance in the older population.

4 Differential Diagnoses and Factors to Consider When an Older Person Presents with Widespread Pain There are three factors to consider when an older person presents with possible FM. First, FM may have been present for many years, even without a definitive diagnosis, and symptoms may simply be persisting into later life. Second, it is possible that FM may be presenting de novo in an older person, or there may be a background of low-grade ill-defined pain that is augmented by new pain as occurs in OA. The concept of peripheral pain generators from OA joints provides a plausible explanation for a diffuse pain syndrome in some patients. This concept is supported by the newer understanding of FM, highlighted by the 2010 criteria for a diagnosis of FM, whereby as few as three locations of pain in combination with other symptoms of fatigue could identify a person as having a polysymptomatic syndrome. Finally, and probably most importantly, symptoms of diffuse pain masquerading as FM may be the result of some other cause. As for any assessment of an older person, especially those aged over 70 years, attention must be paid to frailty, a health status of diminished strength and physiologic function that may contribute to a person’s vulnerability and poorer health outcome [17]. Even on a background of FM, any new symptom should not immediately be attributed to FM, but should be critically evaluated as new medical conditions will emerge over time. For example, a change in fatigue may occur because of anemia, a malignancy, a connective tissue disease, or even depression. Ensuring that the diagnosis of FM is correct in the older patient is therefore vital. A number of conditions other than FM should be considered in the differential diagnosis. Diagnoses that can be confused with FM can usually be eliminated by a careful

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clinical evaluation and may be grouped into the following categories: musculoskeletal, neurologic, endocrinologic, psychiatric/psychological, and drug related [18, 19]. Patients with an early stage of an inflammatory rheumatic condition such as rheumatoid arthritis, polymyalgia rheumatica, or myositis may have generalized body pain, but identifiable physical or laboratory abnormalities develop over time and clarify the diagnosis [20, 21]. OA at multiple sites may overlap with diffuse pain, but alternately may initiate a sensitization that evolves into FM. Similarly, spinal disease and especially spinal stenosis may present with more generalized pain rather than the commonly recognized symptoms of claudication. Hypothyroidism, hyperparathyroidism, and severe vitamin D deficiency may present with body pain, but generally have other associated symptoms and abnormal laboratory findings. Neuropathic pain owing to peripheral neuropathy from any cause may appear similar to the pain of FM, although neuropathic pain is expected to be more localized. Psychological and psychiatric disease may present with body pain, and include depression, somatization disorder, and even drug seeking, which is a condition not to be discounted in the older patient. Although depression is a common co-associate with FM, depression alone may be associated with body pain [22]. Particularly in the older population, iatrogenic causes of pain owing to medications include the statins, bisphosphonates, aromatase inhibitors, and more recently the use of proton pump inhibitors [23–25]. Finally, pain due to a neoplasm must be remembered. FM may also accompany other medical, neurologic, or rheumatologic illnesses as a comorbid condition [18]. To direct treatment appropriately, it is important to appreciate that FM can coexist with these conditions. For example, a persistent complaint of pain due to FM in a patient with rheumatoid arthritis would be incorrectly treated by increasing treatments with disease-modifying agents, rather than addressing the symptoms associated with FM.

5 General Treatment Principles for Fibromyalgia In the last decade, guidelines for the management of FM have been published by groups in Europe and North America, including the European League against Rheumatism, the Canadian Pain Society, and the Association of the Scientific Medical Societies in Germany [19, 26, 27]. The essence of all current guidelines, supported by a recent network meta-analysis, is to emphasize the importance of multimodal treatments that encompass both non-pharmacologic and selected drug treatments in a symptom-based approach that is tailored to the individual [28]. In line with the heterogeneity of symptoms in persons with FM, there is currently no single treatment that is effective for all

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patients. With only three drugs, pregabalin, duloxetine, and milnacipran, having received US Food and Drug Administration approval, and with even more limited approval worldwide, any other drug treatment constitutes off-label use. If a drug has not received regulatory approval, use should not be precluded, but due attention should be given to the current evidence for use as well as the risk-benefit ratio. Studies in FM patients, some of which have included older persons, indicate that the effect of pharmacologic strategies is modest at best, often with adverse effects of medications outweighing the therapeutic effect. Although caution should be exercised when prescribing medications for the older population, a recent study of pharmacologic claims from commercial managed healthcare plans reported a high burden of medication use in older FM patients with over 80 % prescribed two or more medication classes, and 30 % prescribed five or more medication classes [29]. Continuation of any drug therapy must be repeatedly assessed. Additionally, adverse effects may develop because of an interaction with other drugs, pharmacokinetic changes related to aging, and the development of comorbid disease. 5.1 Non-Pharmacologic Management Non-pharmacologic treatments should be an integral component of any treatment strategy for the older population with FM. Even though non-pharmacologic treatments have been extensively studied, no single strategy outperforms others, with education, exercise activity, cognitive behavioral therapy, and multidisciplinary therapy, incorporating at least one educational/psychological therapy with one exercise therapy offering an advantage [30, 31]. Education and active participation with reassurance regarding ‘‘no harm’’ caused by physical activity should be the focal point of treatment, especially if a patient is passive regarding health and lifestyle practices [32]. The distinction between ‘‘hurt’’ and ‘‘harm’’ will reassure patients that while physical activity may be associated with some increase in pain (i.e., hurt), treatments can be tailored to cause no harm. Physical fitness in older persons with FM can be negatively affected by FM symptoms, but also by age-related decline. While the 2012 Canadian Fibromyalgia Guidelines recommend that any physical activity program is desirable, less vigorous activities may be more appropriate for older patients, with exercise limited for a number of reasons. The current trend to have a routine of leisure exercise for health benefits may be foreign to the older population, cultural issues may not have emphasized the need for additional activity beyond normal daily functioning, and the onset of pain conditions may lead to fear of harm. Therefore,

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recommendations for physical activity, adjusted to the specific needs of the older persons, may include gentle activities such as Tai Chi, chair yoga, Qi gong, or even rocking chair activity. 5.2 Pharmacologic Management In general, with only scarce data available for medication use in older FM patients, the overriding principle for drug treatment must emphasize medication dosage adjustments owing to varying pharmacokinetics, associated comorbidities, concomitant medications, and greater sensitivity to adverse effects. Especially important is the effect on cognition that may occur for many medications used to treat FM and may appear trivial, but present a risk for safety in the older population. Therefore, any pharmacologic agent should be rigorously re-evaluated to ensure the need for continuation, and should be prescribed in the lowest effective dose possible, and ideally for a limited time. 5.2.1 Simple Analgesics Acetaminophen is the first-line drug treatment for most persons with any pain and is traditionally recommended as a step one agent in the analgesic ladder by the World Health Organization. Although the primary analgesic action of acetaminophen is not known, modulation of COX-1, COX-2, or COX-3 enzymes in the brain, the impact on neurogenic inflammation or serotonergic mechanisms, and the effects on the endocannabinoid system are postulated [33–35]. The long-standing perceived safety of acetaminophen has recently been challenged because of concerns of liver toxicity from excessive dosing related to freely available over-the-counter preparations and combinations with other agents. Mainly metabolized in the liver to inactive compounds, with a terminal half-life elimination of sulfate and glucuronide metabolites prolonged in renal failure, the recommended daily dose has progressively been reduced over the years to a current maximum of 2,600 mg per day [36–38]. Nevertheless, the American Geriatrics Society still recommends a maximum of 4,000 mg/day, arguing that the safety profile is better than other pain-relieving medications, but with the need to monitor liver function tests, with dosage adjustment if needed. Unless it is shown that a higher dose has better analgesic efficacy in an individual patient, it seems reasonable to suggest a maximum daily dose of 2,600 mg/day. 5.2.2 Nonsteroidal Anti-Inflammatory Drugs Notwithstanding the lack of evidence for effect, nonsteroidal anti-inflammatory drugs (NSAIDs) were amongst the medications most commonly used by persons with FM,

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with over half of older FM patients reporting use, and were also more favored than acetaminophen [4, 39, 40]. Even with a recommendation by the American Geriatrics Society to avoid the use of all NSAIDs in view of the risk profile, up to one third of older FM patients were receiving an NSAID prescription according to a claims database [29, 41]. NSAIDs should therefore not be prescribed, unless specifically used to treat the pain of an associated condition such as a flare of OA. Use should therefore be limited to the lowest dose and for the shortest period of time because of adverse effects involving the gastrointestinal, renal, and cardiovascular systems [42]. 5.2.3 Opioid Analgesics Opioids are effective drugs for the relief of acute pain, but with less convincing evidence for chronic pain management, and especially for FM. The effect of opioids, other than tramadol, has never been formally studied in FM, with the use of strong opioids not supported by any guidelines. Nevertheless, these drugs are commonly prescribed [29]. Studies report that from a quarter to a half of older FM patients receive an opioid, with tramadol prescribed for over a quarter [4, 29]. Opioids present important risks for the older population because of age-related decreases in hepatic, renal, and gastrointestinal function, the association of polypharmacy and the acute effects on cognition and motor control that can lead to injury. In addition, the progressive increase in opioid prescription has seen a parallel increase in their use as drugs of abuse [43, 44]. Although issues of personal abuse may be less important in older persons, it is known that most opioids accessed illegally had been obtained by valid prescriptions, raising concern for the safety of older persons who may be filling a prescription legally, but are being targeted by criminals. Some opioids such as tramadol, tapentadol, and buprenorphine have more than one analgesic mechanism of action, presenting an attractive treatment option. The parent compound tramadol has added serotonin and norepinephrine effects, whereas tapentadol has effects on noradrenergic receptors. Similar to codeine, tramadol is predominantly metabolized in the liver via the cytochromeP450 isoenzyme 2D6, whereas tapentadol is metabolized to a non-active component via hepatic glucuronidation resulting in fewer drug-drug interactions. Only tramadol has been studied in FM, although both agents have demonstrated efficacy in the management of musculoskeletal pain, with generally improved tolerability compared with the traditional opioids. Tramadol has shown a positive effect on pain in FM, with associated benefits to quality of life [45, 46]. Buprenorphine has not been studied in FM, and none of the aforementioned drugs has been studied in older FM patients. Although lacking convincing evidence,

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clinical experience suggests that opioids may be useful in selected patients, but with caution regarding adverse effects, and with a recommendation to begin with the weaker opioid agonists such as codeine or tramadol, before moving to the stronger opioids. 5.2.4 Cannabinoids Cannabinoid use for pain modulation remains controversial. Cannabinoids are available as synthetic oral agents such as dronabinol and nabilone, an oromucosal extract of cannabis-based medicine, or the herbal product derived from the plant cannabis sativa, increasingly accepted as a medicinal product. The acute effects on cognition and psychomotor control pose important concerns for the older population. Nabilone has been studied in two small randomized controlled trials in FM patients, with improved pain and function reported in one, and equivalency with amitriptyline for sleep in the other but without effect on other symptoms [47, 48]. Both studies reported more adverse effects in those using nabilone. In an uncontrolled study, pain scores were reduced 2 h after herbal cannabis use in 28 FM patients, but without impact on function [49]. In the absence of any study examining the effect of cannabinoid agents in older persons with FM, use is not recommended. 5.2.5 Anticonvulsants The analgesic effect of anticonvulsants has been recognized since the 1970s with initial reports focusing on neuropathic pain, and more recently effect in FM. Acting as neuromodulators to dampen neuronal excitability, the gabapentinoids, classified as second-generation anticonvulsants, have shown efficacy in the treatment of FM, although the clinical meaningful effect may be small [50– 54]. In a meta-analysis of treatment effects of gabapentin and pregabalin in FM, there was strong evidence for a reduction of pain, improved sleep, and improved healthrelated quality of life, and some impact on fatigue and anxiety [54]. Adverse effects of drowsiness, weight gain, and edema have led to reduced doses in clinical practice, in contrast to the higher doses used in clinical trials [55, 56]. Only a minority of patients report substantial benefit, whereas more will have moderate benefit, with one third of patients achieving at least 50 % pain relief with monotherapy [57]. In an analysis of 127 randomized trials, with five studies included for meta-analysis, Hauser and colleagues reported strong evidence for pain reduction, improved sleep, and improved quality of life for gabapentin and pregabalin [54]. Both gabapentin and pregabalin are well absorbed after oral administration, have good bioavailability, and are

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excreted unchanged by the kidneys, requiring dosage adjustment in renal impairment, a common finding in the older population [58]. Studies as well as postmarking data indicate that there are few serious adverse effects or drug interactions, but significant adverse effects lead to discontinuation, or failure to achieve optimal doses. In older patients, adverse effects (dizziness, sedation) are significantly reduced by administration at bedtime, allowing better quality sleep. In a real-life analysis of pregabalin use in older FM patients, the average dose of medication was about 150 mg/day, a quarter of the maximum daily recommended dose, but without an appreciable reduction in other medications [29]. 5.2.6 Antidepressant Medications Antidepressant medications have an effect on pain independent of the effect on mood via augmentation of serotonin and norepinephrine. This mechanism of action has prompted studies in patients with FM, examining tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and more recently, serotonin norepinephrine reuptake inhibitors (SNRIs) [59–67]. Unfortunately, none of these studies specifically addressed use in older FM patients. 5.2.6.1 Tricyclic Antidepressants TCAs in doses lower than used to treat depression have been the traditional drug treatment for FM, but with caution in older persons because of anticholinergic effects and associated drowsiness as a result of anti-histamine effects. The best studied in this group are the older TCAs. Amitriptyline and its metabolite nortriptyline have shown efficacy in the treatment of FM, but with modest effect that tends to wear off over time [68]. TCAs have demonstrated short-term efficacy for improved sleep, with a modest effect on other symptoms [59, 64]. Nortriptyline is reported as less effective than amitriptyline [69]. Cyclobenzaprine, commonly used as a muscle relaxant and structurally similar to the TCAs, improved sleep with very low doses of 1–4 mg at night [70, 71]. All these medications have serious adverse effects in older patients, including cognitive deficits, balance impairment, falls, and cardiac toxicity, and should therefore be avoided in line with the 2009 American Geriatrics Society recommendations. If used in patients who have not responded to other safer drugs, extreme caution and monitoring must be applied. 5.2.6.2 Selective Serotonin Reuptake Inhibitors Because of the side effect profile of TCAs, other antidepressant medications have been evaluated. SSRIs have however not shown consistent analgesic effect [72]. In a systematic review of 26 studies, 13 for amitriptyline, 12 for SSRIs

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(five paroxetine, four fluoxetine, two citalopram, one sertraline), and three for SNRIs (two duloxetine, one milnacipran), all agents with the exception of citalopram, showed a positive effect on pain and on other symptoms of FM, including fatigue, depression, sleep, and improved quality of life [67]. In a subsequent meta-analysis of 18 randomized controlled trials with a median duration of 8 weeks (range 4–28 weeks), the effect size for pain reduction was most evident for TCAs, with SSRIs and SNRIs showing a smaller effect on pain [62]. 5.2.6.3 Serotonin Norepinephrine Reuptake Inhibitors The SNRIs, duloxetine and milnacipran, agents with a balanced effect on serotonin and norepinephrine, have shown consistent improvement in pain and function in FM, with sustained response up to a year [73–79]. In a Cochrane systematic review which included three studies of duloxetine in FM, this agent at a dose of 60 or 120 mg daily was effective for pain relief over a period of both 12 and 28 weeks [63]. Severe adverse events were few, but 29 % of patients experienced troublesome adverse effects including nausea, headache, dry mouth, and insomnia, with discontinuation of treatment in 16–20 % [63, 80]. If there is no response within 8 weeks, prolongation of treatment is unlikely to add any additional benefit [73]. These agents have a potential for interactions with other serotonin-elevating agents such as tramadol; however, serotonin syndrome is rare and with appropriate monitoring should not be an obstacle when selecting an effective pain-relieving strategy. 5.2.7 Other Treatments Other drug categories with potential for use in FM include dopaminergic agents, tranquillizers, and 5-hydroxytryptamine 3 receptor antagonists. Anti-parkinsonian drugs that augment dopamine are an effective treatment for restless legs, a frequent accompaniment to FM, with a small study reporting improvement in pain with pramipexole but with use tempered by gastrointestinal adverse effects and recent reports of compulsive behaviors [81]. The risks of tranquillizer use in older persons are considerable, especially the cognitive and motor effects. Even with these known risks, benzodiazepines were prescribed for almost one third of older FM patients in a claims database survey [29]. Sleep disturbance is a prevalent symptom in FM patients as well as older persons. Subjective sleep improved with zopiclone in two studies of 41 and 33 FM patients, but without change in polysomnography [82, 83]. Quetiapine, an atypical or second-generation antipsychotic agent, commonly used off-label for sleep has shown some effect on sleep and fatigue, but not global function or pain in three small studies in FM, two of which were open-label

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[84–86]. However, when studied in persons with FM associated with major depression, quetiapine was associated with improved depression as well as measures of pain and quality of life, suggesting that this agent may be a treatment choice for persons with FM and concomitant clinical depression [87]. Melatonin, another agent with the potential to improve sleep has only been studied in a small uncontrolled pilot study in 21 patients over 4 weeks with some suggestion of improvement [88]. Agents that have been primarily used as anti-emetic drugs are the 5-hydroxytryptamine 3 receptor antagonists, with some preliminary evidence for effect [89].

6 Summary FM is likely under-recognized in the older patient, as physicians pay more attention to other comorbidities. Similarly, there may be a perception that symptoms associated with FM represent normal aging without the need for further attention. Pain in an older person greatly impacts on well-being, meriting recognition and evaluation. When assessing an older person with diffuse body pain, care should be taken to ensure that the diagnosis of FM is correct. In the presence of other comorbidities requiring pharmacologic treatments, non-pharmacologic strategies are a first-line treatment for FM symptoms. When prescribing medications, attention must be paid to the nuances of prescriptions in the older population and with expectations for modest effects only. As most classes of medications commonly used to treat FM symptoms carry considerable risk in older persons, careful monitoring for adverse effects and continued therapeutic benefit are warranted. Conflicts of interest M-.A. Fitzcharles has served on advisory boards and speaker’s bureaus, and received speaker honoraria from Amgen, Janssen, Johnson & Johnson, Eli Lilly, Pfizer, Purdue, and Valeant. P.A. Ste-Marie acknowledges salary support from the Louise and Alan Edwards Foundation. D. Luissier has received speaker honoraria from Eli Lilly, Merck, and Pfizer. Y. Shir declares no relevant conflicts of interest. No sources of funding were used to support the writing of the manuscript.

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