SÍNDROMES DOLOROSOS DE LA TERCERA EDAD

376

Los médicos familiares y los especialistas que tratan a pacientes de la tercera edad, deberán distinguir entre los diferentes síndromes dolorosos que se presentan en este grupo de edad.

Sabemos que un síndrome es la combinación de signos y síntomas, que presenta un paciente ante una patología clínica.

El dolor es probablemente con mucho la queja más frecuente en el paciente geriátrico. Ambos el diagnóstico y tratamiento del dolor requieren una atención especial. Desde un punto de vista general la clasificación más aceptada de un síndrome doloroso sigue siendo: agudo, persistente o crónico (más de seis semanas) y esto permite la intervención terapéutica más apropiada. El manejo de dolor crónico requiere un enfoque diferente y todo un equipo médico con diferentes especialidades para obtener resultados satisfactorios.Cuando se trata a pacientes jóvenes, es relativamente más fácil establecer si los síntomas tienen una base orgánica establecida (con y sin trauma) y se puede distinguir más claramente la patología, además, el interrogatorio suele ser más preciso, sin embargo, en los pacientes ancianos se presentan síntomas de dolor debidos a múltiples patologías y varios déficits funcionales que en muchas ocasiones son confundidos como dolor.

Los síntomas de dolor en el viejo, pueden afectar a cualquiera y tienen múltiples etiologías. Los padecimientos crónicos tales como artrosis, (a nivel de cadera, rodilla, hombro, columna), la osteoporosis, artritis reumatoide, enfermedades cardíacas y otros padecimientos relacionados con procesos degenerativos pueden hacer imposible determinar la causa exacta del dolor y también pueden hacer difícil establecer una terapéutica efectiva. El término “dolor crónico” es mucho más significativo en el viejo porque la mayoría de los pacientes de esta población tienen dolor persistente y es perfectamente justificado, debido a múltiples padecimientos. Sin embargo, ¿qué es lo que define a un síndrome de dolor crónico? Claramente, los pacientes con este problema intratable tienen síntomas y alteraciones que van más allá de lo esperado.

Muchos médicos pueden identificar rápidamente a sus pacientes con dolor crónico, aunque esto no es una descripción clínica básica, sino más bien una descripción de pacientes que frecuentemente atienden y parecen no responder a los muchos tratamientos iniciados. Esta es una situación nada satisfactoria sobre todo para la mayoría de los médicos familiares, y el grupo de especialistas a quienes los pacientes son referidos. Y es por esto que los pacientes se encuentran de pronto dentro de un ciclo de envío-tratamiento-envío. Como decimos nosotros, todos se “echan la bolita”. Esto es visto todos los días en los servicios médicos institucionales y de seguridad social.

Los pacientes de la tercera edad que presentan síntomas de dolor crónico se encuentran entre los retos más importantes, y sobre todo porque varios médicos los encuadramos muchas veces dentro de un cuadro psiquiátrico. Desafortunadamente, ante la persistencia del dolor tales pacientes son referidos al especialista, considerando que están exagerando sus molestias; pero esto es tan importante, que debemos investigar cuales son las posibles causas de origen del dolor. Antes de mirar a una valoración mental, es importante establecer como revisar los distintos síndromes dolorosos.
Los síndromes dolorosos pueden ser fácilmente distinguidos en pacientes jóvenes ya que la mayoría son debidos a traumas directos (contusiones, fracturas, esguinces), pero en adultos mayores, puede haber una mezcla de dos o tres de ellos, además de un proceso degenerativo agregado. Determinar cada uno de ellos será de gran importancia, ya que esto determinará el tratamiento apropiado. La omisión de esto lleva a que frecuentemente la causa del dolor sea refractaria, se agoten las estrategias terapéuticas y los pacientes se sientan defraudados y frustrados.
El dolor agudo puede definirse claramente, si a la manifestación del mismo se agrega: una causa precipitante, la evidencia clínica de inflamación severa, enrojecimiento, calor, malestar y en muchos casos la incapacidad para el apoyo o movimiento.
Como ejemplos tenemos dolor por cáncer, por neuropatía diabética, neuropatía inducida por agentes quimioterapéuticos, herpes zoster, fibromialgia, osteoporosis. Todos estos cuadros se pueden manifestar como síndromes dolorosos, pero si dos o más enfermedades o procesos se suman, entonces las manifestaciones clínicas se exacerban.

A diario se presentan múltiples patologías que cursan con dolor neuropático periférico: lesiones nerviosas que acompañan a las fracturas y que pueden afectar a plexos, raíces o nervios periféricos, como las que se producen en la extremidad superior (plexo braquial por grandes traumatismos, lesión del nervio mediano en la muñeca, el cubital en el codo, el radial en el húmero) y menos habituales en la extremidad inferior (ciático poplíteo externo, o el tibial posterior).

El dolor neuropático al que se suma un dolor nociceptivo, derivado de problemas compresivos a distintos niveles se ve con mayor prevalencia en patología discal, problemas de espacio a nivel de los canales osterotendinosos del codo, carpo o tarso, en los que por diversos motivos la cirugía no se descarta.
Los adultos mayores, en su gran mayoría tienen enfermedades agregadas, es frecuente encontrar, por ejemplo: Diabetes mellitus + hipertensión sistémica + osteoporosis + enfermedad articular degenerativa; todas ellas por separado son generadoras de dolor local o periférico, y, obviamente juntas son una bomba de tiempo.

El dolor en el adulto mayor, debe tratarse de la mejor forma posible, en ciertos casos, estudios especializados como una resonancia magnética o una electromiografía, pudieran ser necesarios para llegar a un diagnóstico preciso. Tenemos que hacer caso a ese dolor que se va convirtiendo en una molestia crónica, siempre hay una pista a seguir, una maniobra o movimiento que lo produce o lo aumenta, una incapacidad, una sensación de compresión, en fin las manifestaciones menos imaginadas pueden presentarse. Como familiares de un adulto mayor con dolor, tenemos que darle la oportunidad de que se diagnostique adecuadamente, de que se pueda tratar y después de todo que no sufra; los médicos generales, especialistas, algólogos, todos podemos ayudarles. No debemos hacer un lado las manifestaciones dolorosas de nuestros pacientes o familiares de la tercera edad, podrían ser aviso de padecimientos mayores.

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