What are the recommended muscle relaxers for a 90-year-old patient with neck pain?

From the Guidelines

For a 90-year-old patient with neck pain, muscle relaxers should be used with extreme caution due to increased risk of side effects in elderly patients. The safest approach would be to start with non-pharmacological treatments such as gentle physical therapy, heat application, and massage, as recommended by the 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV 1. If medication is necessary, cyclobenzaprine (Flexeril) at a reduced dose of 5mg at bedtime (half the usual adult dose) for a short duration of 1-2 weeks may be considered, as it has been found to be moderately superior to placebo for short-term pain relief in patients with acute low back pain 1. Other options with potentially fewer cognitive side effects include baclofen starting at 5mg twice daily or methocarbamol 500mg twice daily. All muscle relaxants carry significant risks in elderly patients including sedation, confusion, falls, and urinary retention, as noted in the diagnosis and treatment of low back pain guideline from the American College of Physicians and the American Pain Society 1. These medications should be used at the lowest effective dose for the shortest possible time, with close monitoring for adverse effects. The patient should be advised to take the medication when they can rest safely afterward and to avoid driving or activities requiring alertness. Key considerations for treatment include:

• Starting with non-pharmacological treatments
• Using muscle relaxants with caution and at low doses
• Monitoring for adverse effects
• Avoiding driving or activities requiring alertness while taking medication
• Considering alternative treatments such as cognitive behavioral therapy, yoga, or physical and occupational therapy, as recommended by the 2017 HIVMA of IDSA clinical practice guideline 1.

From the FDA Drug Label

Cyclobenzaprine hydrochloride tablets are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions Improvement is manifested by relief of muscle spasm and its associated signs and symptoms, namely, pain, tenderness, limitation of motion, and restriction in activities of daily living Cyclobenzaprine hydrochloride tablets should be used only for short periods (up to two or three weeks) because adequate evidence of effectiveness for more prolonged use is not available and because muscle spasm associated with acute, painful musculoskeletal conditions is generally of short duration and specific therapy for longer periods is seldom warranted

The recommended muscle relaxer for a 90-year-old patient with neck pain is cyclobenzaprine. However, it should be used with caution and under the guidance of a healthcare professional, as the patient's age and potential comorbidities may affect the drug's efficacy and safety.

• The dosage should be started at a low dose (5 mg) and titrated slowly upward as needed and tolerated.
• The patient should be monitored closely for adverse effects, such as drowsiness, dry mouth, and dizziness.
• Cyclobenzaprine should only be used for short periods (up to two or three weeks) due to the lack of evidence for its effectiveness for more prolonged use 2.
• Tizanidine may also be considered, but its use in the elderly should be cautious due to the potential for reduced clearance and increased risk of adverse effects, such as hypotension 3.

From the Research

Recommended Muscle Relaxers for Neck Pain in 90-Year-Old Patients

There are no specific studies that recommend muscle relaxers for 90-year-old patients with neck pain. However, some studies provide information on the treatment of neck pain in general.

• The study 4 suggests that muscle relaxants may be beneficial in acute neck pain associated with muscle spasm.
• The study 5 reviews conservative treatment strategies for patients with musculoskeletal causes of neck pain, including the use of medications such as opioids, nonsteroidal anti-inflammatory drugs, adjuvants, and topical analgesics.
• The study 6 found that multimodal non-pharmacological interventions, such as exercise and manual therapy, may reduce pain and disability in patients with chronic non-specific neck pain.

Alternative Treatment Options

Some studies recommend alternative treatment options for neck pain, including:

• Exercise therapy, which has been shown to be effective in reducing pain and disability in patients with neck pain 7, 8.
• Manual therapy, which may be beneficial in reducing pain and improving function in patients with neck pain 6, 8.
• Acupuncture, which has been shown to be effective in reducing pain in patients with chronic non-specific neck pain 8.

Important Considerations

When treating neck pain in 90-year-old patients, it is essential to consider the potential risks and benefits of different treatment options. Muscle relaxants may be associated with adverse effects, such as drowsiness, dizziness, and interactions with other medications. Alternative treatment options, such as exercise therapy and manual therapy, may be safer and more effective in the long term.