Holistic Senior Care , pain and arthritis mgt every Wednesday in San Jose CA

Holistic Senior Care , pain and arthritis mgt presented by Motherhealth caregivers

What: Learn how to use holistic senior home care in giving comfort to those with chronic health issues, terminally ill and home alone from Connie Dello Buono.  Learn pain and arthritis management from Quli Zhou, L.Ac. MS

When: Every Wednesdays, starting next week at 11/14/2018 , 6-7:00pm at 1066 Saratoga Ave #100 San Jose CA 95129 ; 1-hour Q&A

RSVP or just join us: 408-854-1883 or email at motherhealth@gmail.com


pic 5.JPG Connie has been helping home bound seniors live with
comfort and in the company of loving caregivers.
She uses massage , nutrition and herbs complimenting
the current standard of care of those with stroke, cancer,
Alzheimer and other chronic health care issues.
She has been training caregivers and families
about holistic care. Many of her clients live longer
and are happy with their caregivers matched my Connie.
She owns Motherhealth LLC providing holistic and
caring caregivers to homebound bay area seniors. 408-854-1883
motherhealth@gmail.com www.clubalthea.com
quli Dr. Quli Zhou has over 25 years of experience and
has treated over 10,000 patients. Trained in China
she is a Master Graduate of Chengdu University of
Chinese Medicine, and received the Acupuncturist
of the year award in 2001. She was also rewarded
as a distinguished professor of Chinese medicine
in 1995 and listed in the “Who’s Who” in 2002.
She specializes in treating pain, digestion problems,
depression, infertility and woman’s hormone imbalance.
408-241-6638 doctor@myeternalhealth.com
Other speakers We welcome other speakers and collaborators to serve bay area
in areas of wellness and holistic senior care.


Healing tips, arthritis, skin, digestive and stress issues

My first video this 2018 is taken from page 1 of my upcoming ebook, Healing from within with the last 3 slides containing tips on arthritis, stress, skin and digestive issues.

Papaya Leaf Extract renews muscle tissue

As alternative medicine grows in popularity, people are beginning to search everywhere for natural, health-promoting foods and supplements. It seems apparent that organic food rises far above conventional in helping to maintain a healthy body, but even organic food is highly depleted in nutrients compared to decades ago. There is little way around natural supplementation today, as soil is depleted and mainstream vitamins provide little or no benefit. People can utilize the health benefits of turmeric, vitamin D, and cacao, but there are other very powerful supplements out there that will contribute to incredible health.

Papaya Leaf Extract a Powerful Health Booster

One supplement you should not overlook is Papaya Leaf Extract. Papayas are excellent sources of dietary fiber, vitamin C, vitamin A, vitamin E, and folate, while at the same time being rich in antioxidants, flavonoids, and carotenes. Papayas also contain high amounts of enzymes called papain and chymopapain, which are critical ingredients for a healthy body. Enzymes are responsible for almost every aspect of life and health, and are needed to help control all mental and physical functions.

So what are the real uses for papaya leaf extract ? The beneficial properties surrounding papaya have been known for generations, but they are now just gaining back some attention. Some of the healing properties papayas provide are:

  • Increased quality of proteins in whole organism.
  • Revitalization of the human body and a maintaining of energy and vitality.
  • Encouraged renewal of muscle tissue.
  • Supported cardiovascular system.
  • Strengthened immune system
  • Help with the digestive system by breaking down proteins and supporting production of digestive enzymes.
  • Treatment for skin wounds that don’t heal quickly.
  • Prevention of cataract formation.
  • Lowered risk of emphysema in smokers and passive smokers thanks to high vitamin D content.
  • Alleviated inflammation.
  • Help with nausea and constipation.
  • Fighting various cancers and aiding the cardiovascular and gastrointestinal systems.
Although papaya leaf extract is often viewed as an excellent treatment for digestive disorders as well as disturbances of the gastrointestinal tract, it provides many more health benefits than just that (as outlined above). The papain enzyme found in papaya has also been utilized around the world to eliminate parasites within the body.


Gut health – green bananas, mangoes and papayas

When I was growing up, we eat green mangoes with salt or salted small shrimp. We cooked the green bananas and green papayas in a soup base meal.  Now, I have used green papaya smoothie when my father had lung cancer, green mangoes for salads and cooked green bananas for my mom’s arthritis.  Mangoes are rich nutrient-filled fruits among all the fruits.




By Dr. Mercola

  • Green (unripened) banana, papaya and mango contain higher amounts of digestive-resistant starch than ripe ones, which is important for optimal gut health. Sample recipes are included
  • Unripe banana is composed of as much as 80 percent starch, most of which is digestive-resistant starch. As the banana ripens, the starch gets converted into sugars
  • Unripe Langra mango has as much vitamin C as 35 apples or nine lemons, and while ripe and unripe papaya are both rich in antioxidants and fiber, green papaya contains higher amounts of potassium


Are you getting enough fiber in your diet? If not, your health may suffer in more ways than one. A common sign your diet is lacking in fiber is constipation and irregular bowel movements, but that’s really just the tip of the iceberg.

Fiber-rich foods like vegetables promote optimal gut health by nourishing beneficial gut bacteria. Certain fruits are also high in fiber, including underripe bananas, papayas and mangoes.

These fruits have yet another feature that makes them interesting. Their nutritional content changes depending on their ripeness, and in their unripened state, they contain higher amounts of digestive-resistant starch, which is important for optimal gut health.1

The idea that an unripe fruit might be healthier than a ripe one may seem seriously counterintuitive.

The sugar content of a fruit is typically used as an indicator of quality — not because the sugars are in and of themselves necessarily an indicator of quality, but they’re typically associated with the plant’s mineral content. Hence, it can be used as a marker of quality.

To measure sugar content, a refractometer or so-called Brix meter is used. The most common Brix meters measure on a scale of 0 to 32 degrees Brix, and the sweeter the fruit, the higher the nutritional content is thought to be.

However, in the case of mango, its vitamin C content is actually much higher in the unripe fruit than in the ripened one. Vitamins and minerals are also not the sole reason for eating fruits though. Fiber is also important, and in some cases unripe fruit is a better option.

What’s so Great About Digestive-Resistant Starch?

Fiber is typically classified as either soluble or insoluble. However, from a health standpoint, the fermentability of the fiber is what’s really important. Digestive-resistant starches are low-viscous fibers that resist digestion in the small intestine and slowly ferment in your large intestine.2

Here, resistant starches act as prebiotics, feeding healthy bacteria. Due to their slow fermentation, they won’t make you gassy. They also add significant bulk to your stools, and help you maintain regular bowel movements.

Best of all, since they’re indigestible, resistant starches do not result in blood sugar spikes. In fact, research suggests resistant starches help improve insulin regulation, reducing your risk of insulin resistance.3,4,5,6

Besides underripe banana, papaya and mango, other foods high in resistant starch include white beans, lentils, seeds and products like potato starch, tapioca starch and brown rice flour.

(Interestingly, cooking a normally digestible starch such as potato or pasta and then cooling it in the refrigerator will alter the chemistry of the food, transforming more of it into resistant-type starch.7)

Green Bananas

As noted by Authority Nutrition, “before it ripens, a banana is almost entirely starch, which composes up to 70 to 80 percent of its dry weight. A large part of this starch is digestive-resistant starch. As the banana ripens, the amount of starch and resistant starch decreases and is converted into sugars.”8

Because of their high-resistant starch content, green bananas can be used to safely treat diarrhea in children and adults.

Green Mangoes

There are over 500 varieties of mango, some of the most popular of which include Malda, Alphonso, Langra, Sipia, Sukul and Bumbaiya. Interestingly, unripe mango is an exceptionally rich source of vitamin C. Green (unripe) Langra mango contains as much vitamin C as 35 apples, nine lemons or three oranges.12

I have seven mango trees in my yard that are just about ready to ripen and look forward to trying them underripe. In India, green mango is used as a natural remedy for:

Gastrointestinal (GI) disorders: Green mango, eaten with salt and honey is used to treat a range of GI problems, including diarrhea, dysentery, piles, morning sickness, indigestion and constipation.

Liver problems: The acids in unripe mango increase bile secretion and act as an intestinal antiseptic. It also helps purify your blood and acts as a liver tonic. Green mango with honey and pepper is used for stomach ache due to poor digestion, hives and jaundice.

Blood disorders: The high vitamin C content of unripe mango helps improve blood vessel elasticity and increases formation of new blood cells. It also aids absorption of iron and decreases bleeding. According to the Indian magazine Deccan Herald:13

“Eating an unripe mango daily during the summer season prevents … infections, increases body resistance against tuberculosis, cholera, dysentery, anemia etc.

It tones the heart, nerves and cures palpitation of the heart, nervous tension, insomnia and weakness of the memory … Eating raw mango with salt quenches thirst and prevents loss of sodium chloride and iron during summer due to excessive sweating. It tones up the body and helps one to tolerate the excessive heat.”

As with green papaya, there’s a caveat. Avoid eating more than one unripe mango per day, as it may cause throat irritation and/or indigestion when eaten in excess. Also avoid drinking cold water immediately afterward, as it coagulates the sap, thereby increasing the risk of irritation.

Smart Home accommodations for seniors and special needs

smart home thermostat on wall of seniors home

Implementing smart home solutions

Imagine this scenario: You come home from work and your front door, sensing your presence, automatically unlocks for you. You walk in, carrying bags of groceries, and as you enter the kitchen, the lights turn themselves on. You put your groceries away and realizing that you forgot an item, you send a request to your grocery store for a delivery using a touchscreen built right into the refrigerator. You settle down in the living room to watch television. Sensing that you’re slightly chilly from information gathered from your smart watch, the thermostat automatically increases the temperature of your home to keep you comfortable. You go to bed at 10:30, like always, and as you pull the covers up over your head, your bedroom lights automatically dim. If you listen carefully, you can hear the click of your doors automatically locking for the night.

Does this scenario sound like a scene from a futuristic sci-fi movie? Believe it or not, the technology described above already exists, and can be retrofitted into almost any home in America with the expertise of the right contractor or solution provider. Across the country, individuals are implementing such smart home solutions to lead more comfortable and convenient lives. Not only accessible to the mega-rich, a self-adjusting thermostat, or a security system that can be controlled from your mobile phone, are now budget-friendly additions that nearly anyone can have.

Perhaps some of the greatest opportunities that smart home technology offers are for the elderly and the disabled, for whom living at home can pose daily struggles. Thanks to smart home technology, seniors and disabled adults are able to live in their own homes with less fear or restriction, giving them a sense of freedom and confidence they have been missing for years.

Struggles with home living

This guide was designed to provide a thorough understanding of the latest smart home technology, and suggestions for specific software and devices that can be incorporated into a home to accommodate each of seven of the most common types of disabilities: hearing difficulty, vision difficulty, speech/language difficulty, cognitive difficulty or memory loss, ambulatory difficult, arthritis, and self-care/independent living difficulty.

If you or a loved one struggle with daily home living due to a disability, this guide will offer inspiration and actionable advice for opportunities to make your home life more comfortable and convenient through use of the latest smart home technology. To help you plan, no matter your financial situation, we’ve indicated for each product if the solution will accommodate a low ($), moderate ($$), or high smart home budget ($$$).

What is a Smart Home, and How Does It Work?

The term smart home covers a wide range of home-based technology that is integrated between devices using an Internet connection. From the home dweller’s perspective, a smart home provides comfort, security, safety, accessibility, energy efficiency, and convenience through the use of appliances, lighting, electronic equipment, heating and cooling systems, entertainment systems, and home security solutions. In a smart home, all such devices can be controlled remotely by any desktop computer or mobile device with Internet access, or preset using a pre-defined preferential schedule. They can even be customized on a room-by-room basis. Many smart home solutions can also accept voice commands for the ultimate in-home convenience.

The Internet of Things (IoT)

Smart homes are becoming a large component of a digital phenomenon known as the Internet of Things (IoT). The IoT refers to all those devices that are interconnected and identifiable to one another through digital networks. Think of your smart watch talking to your home security system via the Internet. As technology continues to advance, it’s predicted that such interconnectivity will become the norm, and will continue to be a necessity for individuals who struggle with daily home-related activities due to age or disability.

The Genesis of Home Device Interconnectivity

Believe it or not, the catalyst for smart home technology preceded the twenty first century. It all began in 1975 when a Scottish company developed a product known as X10. X10 allowed compatible products to “talk” to one another using a home’s electrical system. The X10 allowed for such conveniences as turning off a lamp in the bedroom while seated in the living room. Though using what we would today consider a primitive technology system, fundamentally the X10 aimed to deliver many of the conveniences smart home technology companies aim for today.

Why are Smart Home Features Gaining in Popularity?

At one time, smart homes and smart home devices were thought to be only obtainable by the wealthy, and only desirable by the tech-savvy, such as Bill Gates who spent over $100 million building his smart home outside Seattle, Washington. Aside from interest in smart home features purely for the cool-factor that they offer digital-trend setters, smart home technology is gaining in popularity among those who want to optimize their home to ensure safety, energy efficiency or leverage technology to overcome the hurdles of home-living in the face of a disability.

Another reason smart home device use is on the rise, is due to the proliferation of new, interconnected technology. Some of the most advanced technology companies are finding ways to connect such everyday devices as thermostats and stereo systems to the IoTs. Such availability of products is making it affordable and convenient for the average home owner, or the special needs home owner, to bring smart technology into their home.

Smart Home Advancements

For many years, the pinnacle of smart home innovation was Bill Gates’ $100 million creation. At Gates’ smart home, everyone is pinned with an electronic tracking chip. As one travels through the home, lights turn on ahead of you, and fade as you leave a room behind. Your favorite music, or the television show you’re watching, will follow you from room to room. Perhaps most impressively, if two individuals enter the same room, the smart system will attempt to compromise on settings it believes both occupants will enjoy.

While Gates’ home may have paved the way for smart home innovation, advancements in smart home technology are being made annually. According to Kigo, a vacation rental software company, 10 percent of U.S. broadband households intend to purchase a smart thermostat in the next year. Even more impressive? Kigo advises that global smart home connected appliances are expected to reach 223 million units by 2020. While smart home technology used to be the focus of only techy start-ups, it is now being adopted by more established entities, such as Amazon, that launched “Alexa,” its intelligent personal assistant smart home device in 2014 that integrates with its Echo smart speaker. What follows are some of the key milestones in modern smart home innovation. Click here to view a full interactive smart home timeline from Mashable:

  • 1975 – ¬X10 is created in Scotland to connect devices with one another.
  • 2010 – Nest, the Wi-Fi connected thermostat is introduced to the market.
  • 2012 – The app SmartThings is launched on Kickstarter. By 2013, it had shipped more than 10,000 hubs.
  • 2013 – Smart home devices dominate at the Consumer Electronics Show (CES), the biggest international tradeshow focused on consumer electronics.
  • 2015 – Such smart home innovations enter the market as the self-watering (and talking) flower pot, and a Wi-Fi connected coffee pot.

Establishing Protocols

To date, there have been no standard regulations for the automation of home devices, leading some to hesitate before smart-retrofitting their homes. There is also no overarching governing body, making some fear the consequences of a smart home hacked by cyber extortionists.

There are some entities attempting to offer guidance to developers and tech companies, however. The IEEE Standards Association (IEEE-SA) is a leading consensus building organization that nurtures, develops and advances global technologies, through IEEE, the world’s largest technical professional organization dedicated to advancing technology for the benefit of humanity. In addition, Zigbee is a non-profit organization that serves as the only open, global wireless standard to provide the foundation for the IoT by enabling simple and smart objects to work together to improve comfort and efficiency in everyday life. The ZigBee Alliance is an open, non-profit association of approximately 400 members working to drive development of innovative, reliable, and easy-to-use ZigBee standards.

Digitalization. Cheerful and positive senior woman in wheelchair using laptop

Smart Home Advantages for Seniors and The Disabled

In a world where lights can turn themselves on and off as you pass through rooms, and pantries can maintain their own inventories, the impact that such conveniences can have is maybe felt greatest of all for those that suffer from age-related or developmental disabilities. According to the Centers for Disease Control and Prevention (CDC), it’s estimated that one out of every five adults in the United States is living with a disability. The most common disabilities include:

For each of the disabilities listed above, what was once an incapacitating disorder that made living independently in one’s home nearly impossible, life-simplifying smart-home technology advancements are allowing individuals to remain comfortably, and safely, in their own homes—where they most want to be. What follows are smart home solutions that can make independent living possible for each of the previously listed disabilities. No matter the budget.

Hearing Difficulty

According to the Hearing Loss Association of America, it’s estimated that 20 percent of Americans are living with some degree of hearing loss. The most impacted population segment includes seniors, as one out of three individuals at age 65 suffers from hearing loss. Imagine the challenges of an individual living alone who suffers from a hearing disability. How many audio cues do you rely upon in your home? If you could not hear, how would you know if your doorbell rang? When your oven timer was done? When your washing machine or dishwasher finished its cycle? Or if a home intruder was attempting to break in? Consider these smart home innovations for the hearing impaired:

Colored Notification Lights

A smart home convenience that can add comfort and reassurance to the home of a hearing-impaired resident is the installation of a colored light notification system. To help alert the hearing impaired of a variety of scenarios, the latest smart home innovations blink, and even use a series of colors to signify different types of alerts. For example, you may be able to customize your home so that your lights blink orange when a stranger arrives at your door, or purple when a specific family member comes home, or blink blue to indicate laundry is done. Such alerts help the hearing impaired to maintain a self-sufficient home environment.
Such lighting systems are available with a variety of features, from voice-controlled dimming (working in conjunction with Amazon Echo’s Alexa), while others allow for more customized color notification programming. They range from around $30 for a voice controlled dimming light to $200 for a complete set with greater capabilities.

Pros Colored lights can notify you of a variety of pre-defined home needs.
Cons The bulbs are more expensive than traditional light bulb, and also require the purchase and installation of a hub device.
Customizations Some systems allow you to customize what each flashing color indicates, allowing you to lead a more informed and confident home life.
Product Considerations Some brands, such as the Philips Hue, can integrate with smart home hubs, such as the Amazon Echo. If you plan to integrate your lights with existing systems, make sure the brands you choose are compatible with your existing equipment.
Installation Some customization and personalization may be required to set color preferences, or to tie into a smart home hub, however professional installation should not be required.
Budget $$

Smart Doorbells

A variety of smart doorbells have been designed to assist the hearing impaired. Some integrate with smartphone apps and can alert a hearing-impaired individual when someone is at the door by causing the phone to vibrate or blink an alert light.

Taking the concept one step further, a camera doorbell allows an individual to see who is on the other side of the door by sending a camera feed to a smart phone. Through an interconnected speaker system, the homeowner can also speak to the guest. In the case of seniors with hearing loss or mobility issues, this allows them to ask their guest to wait while they make their way to the door.

An alternative smart doorbell option functions through the use of audio frequency waves. These products emit a sound on a unique frequency that can be detected by the deaf.

Perhaps the most fully functioning products add an additional security component by adding a motion sensor to detect activity outside the home. Such features help protect the hearing impaired from the threat of a home break-in by alerting the home owner with a smart phone alert when it’s detected that someone is outside the home.

Pros Smart doorbells can offer the hearing impaired the comfort and security of knowing they are protected from intruders, and that they won’t miss an important visitor. As an added security feature, a homeowner can turn on the doorbell camera to check on the house at any time.
Cons Most, with the exception of the audio frequency options, require integration with an existing smart phone.
Customizations Some smart doorbells can be integrated with home security systems, allowing you to give a voice command to unlock the door if you’ve been notified of a visitor, and have confirmed visually that it’s someone you want to let into your home.
Product Considerations Budget may be the most significant factor when deciding which smart doorbell to select. Most smart doorbells are available for a few hundred dollars, depending on their features, although stand-alone audio frequency doorbells are typically the least expensive. If you have a smart home hub that connects multiple smart home products, you may want to choose a doorbell that can integrate with your hub.
Installation If you choose a more complex system that requires integration with a home security system, you may want to consider professional installation.
Budget $ – $$
Also Benefits Those with mobility issues.

Two-Way Communication Device

To enable the deaf or hearing impaired to more easily participate in dialogue with those who do not speak sign language, UNI is a smart assistive technology gaining popularity and support on the crowdfunding platform Indiegogo. The product, which is designed in the shape and size of a tablet, detects hand and finger gestures with a special camera algorithm that converts the sign language into text for the non-hearing impaired. It is also equipped with a microphone that converts speech into text to assist the hearing impaired. When both participants in the conversation are using an UNI device, they can carry on a meaningful conversation. The device sells for about $200.

Pros UNI does not require Wi-Fi to use the sign-to-voice and voice recognition features, which means it can be used even when Wi-Fi is not available.
Cons UNI is not yet available via mainstream retailers. To reserve an UNI device, visit the company’s page on Indiegogo. Also, in addition to the purchase price, UNI requires an annual subscription, which means you will be subject to ongoing costs.
Customizations UNI allows a user to save custom language to its dictionaries to personalize the experience for the user. UNI also remembers your movements to constantly improve its translations.
Product Considerations UNI is only compatible with English and American Sign Language. If English or ASL are not the primary languages of the intended users, UNI will not be a viable communication option.
Installation There is no installation required for UNI, just the need to learn its interface and capabilities.
Budget $$

Vision Difficulty

It’s estimated by the CDC that 4.6 percent of Americans have a vision disability. In addition, it’s estimated that 6.5 million Americans over age 65 have a severe vision impairment. No matter the age at which vision loss occurs, the possibility of not being able to live an independent lifestyle can be terrifying. Vision difficulties may mean an inability to navigate one’s home, identify safety risks in the home, or detect intruders. Consider these smart home innovations for the vision impaired:

Voice-Controlled Home Entertainment Systems

The visually impaired still enjoy listening to their favorite television shows, however managing television equipment and interacting with standard visually based interfaces can be impossible. New innovations in entertainment systems offer the visually impaired the ability to change channels with voice commands and listen to a talking guide.

Pros Independent management of home electronics.
Cons Functionality is typically limited to searching for content, and does not assist with other needs, such as volume or power control.
Product Considerations Solutions are available from Apple TV, Samsung, and Comcast. The decision for which system to choose may depend on your other home electronics and their compatibility with one another.
Installation Assistance will be needed to set-up the hardware and, if applicable, integrate the device with the home internet system.
Budget $$
Also Benefits Those with mobility issues or arthritis.

smart home hub with speaker

Smart Home Hubs

Devices such as Amazon’s Echo with Alexa, the Apple Home KitGoogle Home, or SmartThings offer home owners the ability to give voice commands in order to access information or control a variety of integrated home devices. For a modest fee, a smart home device can be set up to command a variety of smart home devices, such as home security systems, home entertainment systems, and thermostats, using voice commands—an ideal capability and ultra-convenience for the visually impaired.

With a smart hub, a vision impaired home owner could request to hear a summary of the latest news, or ask for a timer or alarm clock to be set. By integrating your smart hub with other smart phone devices, oral commands can be given to lock the doors, turn the television on to a specific channel, or turn the lights off in the room. The Amazon Echo retails for about $180, and the Google Home retails for about $120. Additional smart home devices are sold separately.

Pros Can act as a stand-alone device or as a smart home hub when paired with other compatible smart technology.
Cons Each hub product is compatible with a different set of smart home devices, so if integration is desired, research will be needed to determine which devices can integrate with one another.
Customizations For the tech savvy, some smart home hubs can be customized further, as the Amazon Echo provides a channel on IFTTT, a free online automation service that lets individuals craft their own automated command preferences using an “if this, then that” logic.
Product Considerations Depending on your home and interconnectivity needs, plan to research the capabilities of each type of device to choose the brand that suits your needs. Currently, the Echo integrates with more smart home device brands. While Google integrates with August, Belkin Wemo, Frigidaire, Honeywell, Insignia, Lifx, Logitech Harmony, Next, Philips, Rachio, Samsung, TP-Link, Wink, and anything with a Chromecast attached to it, the Echo supports all of those except Chromecast, as well as Blink, Carrier, DigitalStrom, Haiku, Leviton, Lowe’s Iris, Lutron, Netatmo, and many others.
Installation Setting up a stand-alone smart home device does not require hard wiring or complex integration; however technical assistance may be needed if you intend to customize your smart home hub to help you command other smart home devices.
Budget $$
Also Benefits Those with mobility issues, or arthritis.

Smart Braille Watch

The Dot Watch provides the visually impaired with the freedom to communicate and live more independently. It is the first Braille smartwatch and it can connect via Bluetooth to any smartphone, then retrieve and translate text into Braille on the face of the watch, one letter at a time. It can notify the wearer of emails, tweets, or even allow him to read a book, in addition to, of course, telling time. While much less expensive than most braille readers, the Dot Watch will retail, once available, for about $290.

Pros Allows the wearer to read incoming messages, emails, tweets, and books.
Cons The Dot Watch is still in production and is only accepting pre-orders. The initial release will only be available in English and Korean.
Customizations The initial launch will not offer customization.
Product Considerations The primary consideration for a visually impaired individual considering at Dot Watch is if they would prefer to read messages in braille, or use a device that can speak incoming messages, such as a smart phone or smart home hub.
Installation Not required.
Budget $$

Speech or Language Difficulty

According to the National Institute on Deafness and Other Communication Disorders (NIDCD), approximately 7.5 million Americans have trouble using their voices. The causes are far ranging. Spasmodic dysphonia, for example, is a voice disorder caused by involuntary movements of one or more of the muscles in the larynx that can affect anyone. Women between the ages of 30 and 50 are particularly susceptible to the condition. In addition, Laryngeal papillomatosis, a condition in which tumor grow inside the larynx, though rare, can severely impact speech as well. Another cause of speech disability includes cleft palate, the fourth most common birth defect and one that impacts one out of every 700 live births.

Speech disabilities sometimes accompany hearing loss, particularly in cases where an individual is born with a hearing disability, or develops one at a young age, and the development of speech capabilities is impeded. Whether an individual experiences speech disability alone, or it is accompanied by hearing loss, they face unique challenges in managing their day-to-day lives. What follows is a smart home solution for the speech impaired.

Speech Interpretation

Talkitt is an application that helps individuals with speech impediments to better communicate with those around them by translating unintelligible pronunciations into understandable speech. The device works in any language. Currently, the initial device, plus a three-year subscription, can be purchased for $250.

Pros Allows the hearing impaired to better communicate with others who may not be able to understand them due to a speech impediment.
Cons Talkitt is not yet available for purchase through traditional retail. It is still in the process of generating funding through Indiegogo. Talkitt will require an annual subscription, so after initial purchase, additional fees will apply.
Customizations Talkitt recognizes patterns in an individual’s speech and creates a personal speech dictionary for the user to produce more accurate translations over time.
Product Considerations Only one version of Talkitt will be part of the initial launch. In the future, the brand intends to make its application available on desktop computers and wearable devices.
Installation No installation is required. Talkitt can be downloaded onto any smart phone or tablet.
Budget $$

Cognitive Difficulty

According to the CDC, 10.6 percent of Americans have a cognition disability. Adults 45 to 64 years of age are more likely than any other age group of adults to report a cognitive disability. In addition, memory loss, dementia and Alzheimer’s are serious condition that impact seniors, making it extremely difficult for them to safely live independent lives as their cognitive abilities deteriorate. Alzheimer’s disease is a degenerative brain disease and is the most common cause of dementia, a condition characterized by a decline in memory, language, problem-solving and other cognitive skills that impacts an individual’s ability to perform everyday activities. Fortunately, thanks to advances in smart home technology, more seniors and individuals with cognitive disabilities are able to live in their own homes, and more independently, longer. Below are some innovations helping keep those with cognitive difficulty safe and comfortable at home.

Health Monitoring

One of the greatest concerns for patients with cognitive disabilities is the fear that if not properly cared for, they will fail to take proper care of themselves. There are plenty of low-tech Telehealth and other software systems that can help organize medication schedules, but thanks to a new device called Lively, family members and caregivers are able to better monitor those with cognitive disabilities—remotely. With Lively, sensors are placed around the home that learn an individual’s normal routine for such activities as taking medications, sleeping, eating, as well as their typical activity habits. The information is captured by the sensors and interpreted by the Lively Hub where it is sent to a website.

Caregivers and family members can refer to the patient’s Lively web portal to view activity. Most importantly, Lively will ping notifications if it determines abnormal or unsafe activity. Lively sensors can be attached to a refrigerator to ensure the patient is eating properly, to pill bottles to ensure medication is being taken at the right times, or to a set of keys to monitor time out of the house. Currently, the Lively system retails for about $50.

Pros Thanks to the integration with the Lively Hub, a Wi-Fi connection or home network are not needed.
Cons Some users have reported inconsistent effectiveness of the device sensors.
Customizations Lively learns patterns in an individual’s behavior so that if abnormal behavior is identified, caregivers can be alerted.
Product Considerations Only one version of Lively is available at this time.
Installation Installation is easy and simply requires set up of the sensors, plug in of the hub, and learning how to interface with the website.
Budget $
Also Benefits Those with a self-care disability, or mobility issues.

Key Finders

As memory begins to decline, one of the most common daily frustrations is remembering were important home items have been left, such as house keys. A key finder typically works with a Bluetooth device and can be connected to a smart phone to help identify the location of lost keys. A wide range of products are available that start at $8, and increase to $60.

Pros Most key finders can be attached to more than just a set of keys to help keep track of a variety of important home items.
Cons In most cases, if you are caring for someone remotely, you’ll need to be in close proximity to help them locate lost keys using the smart phone paired to the tracking device.
Customizations Some products offer geofencing, which means you’ll receive an alert if your keys travel outside a pre-set range.
Product Considerations Some options, such as the Track Bravo can be integrated with a smart home hub. Also, various products have different ranges, so depending on the size of your home or property, be sure to choose the product that best suits your anticipated needs.
Installation No installation is required, just pairing with your mobile device.
Budget $
Also Benefits Those with mobility issues.

Ambulatory Difficulty

The CDC estimates that 13 percent of Americans have a mobility disability. Mobility challenges can stem from a variety of causes, including birth defects, amputations, general age-related impairments, or injuries. For someone who has developed an injury, one of their greatest fears is the loss of their freedom, and the worry that they will no longer be able to live independently in their home. A variety of smart home solutions are helping those with mobility issues remain in their homes and live capable, independent lives.

Internet-Connected Electronics

For homes not previously built to accommodate someone in a wheelchair, day-to-day activities as simple as turning light switches on and off can become daunting tasks. Now, there are smart home solutions that will connect home electronic systems to the Internet, allowing lights to be controlled from a smartphone. This includes lighting, window blinds, pet feeders, air conditioners, washers and dryers, sprinkler systems, ovens, and thermostats.

Pros Those with limited mobility can interact with essential home devices from the safety of a wheelchair, or without the fear of a fall.
Cons For some, the availability of a variety of interconnected devices becomes difficult to manage when each requires the use of a separate mobile phone app. For many, this is the benefit of choosing devices that can integrate with a single smart home hub device.
Customizations Depending on the device, some can be programmed to perform specific activities at certain times (like turn your bedroom lights on every day at 6 a.m.), or can learn your preferences over time.
Product Considerations A growing number of manufacturers are entering each category of interconnected home electronics. Choosing the product that is right for you will depend on your budget, your needs, and whether or not the device needs to integrate with a smart home hub.
Installation Installation varies by product. A pet feeder, for example simply needs to be plugged in and tethered to your Wi-Fi, while a sprinkler system will require professional installation.
Budget $ – $$
Also Benefits Those with a self-care disability, or arthritis.

smart house, home automation, device with app icons. Man uses his smartphone with smarthome security app to unlock the door of his house.

Door Locks and Security Systems

Smart home locks security systems give individuals with mobility issues the comfort of knowing that they are safe in their own home. A range of products is available. Basic models allow an individual to lock and unlock doors using a smart phone, a convenience for individuals for whom walking across the home to lock and unlock the doors throughout the day can be a challenge.

More sophisticated systems offer more complex home monitoring and capabilities that allow you to turn lights on and off, lock doors, and view video cameras no matter where you are in the world, as long as you are connected to the Internet.

Pros The convenience and comfort of knowing you can maintain a safe home. Most products integrate seamlessly with most deadbolts. As an additional security feature, you can choose to be notified if your door opens, even if you’re not at home.
Cons Some smart home security systems require a contract in order to utilize their full surveillance capabilities, so make sure ongoing costs factor into your budget.
Customizations Some products can be customized with a preferred schedule, so that doors lock and unlock at the same time every day, depending on your needs. You can also set some products to automatically lock your door if it has been unlocked for a predetermined amount of time.
Product Considerations Depending on your needs and your budget, choosing the right product will mean deciding if you simply need to lock and unlock doors using a smart phone in order to accommodate mobility difficulties, or if you need more robust security and surveillance services. In addition, some smart home locks and security features can integrate with other smart products, such as a smart home hub. If integration is essential to you needs, be sure to choose a product that is compatible with other products in your home.
Installation Depending on the system you choose, you may need both technical set-up assistance, and professional installation.
Budget $ – $$
Also Benefits Those with a self-care disability, or arthritis.

Motion Controlled Smart Phone

Many smart home devices function with smart phone integration, yet for those who suffer from mobility issues, the ability to use a touch screen may not be possible. To assist those without the control of their hands, the Sesame Phone accepts commands using small head movements tracked with a front-facing camera. Head movements mirror typical touch movement. For example, gesturing to the right tells the device to swipe right. A nod may tell the device to play. The Sesame Phone retails for $1200.

Sesame Phone is only compatible with Android apps.

Pros Sesame Phone can also function with voice commands.
Customizations By integrating the Sesame Phone with other smart devices, or with a smart hub, the phone can be used for more than just phone calls. It can be used to control other smart home devices, such as home electronics, or the thermostat.
Product Considerations Sesame currently only utilizes the Google Nexus phone for its hardware. If you currently utilize an iPhone that is integrated with other devices, switching to an Android phone may result in other integration issues.
Installation No set-up is required.
Budget $$$
Also Benefits Those with a speech disability


What may seem like an inconvenience, is truly a disability for the millions of people living with the pain and limited mobility that accompanies Arthritis. According to the CDC, from 2013 to 2015, an estimated 54.4 million U.S. adults annually had been diagnosed with a form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia—all conditions that cause severe pain and limited movement, and can make basic household chores a challenge.
While many of the solutions available for individuals with mobility issues can benefit those with Arthritis, such as Internet controlled electronics, in addition, the product below can benefit those living with this chronic pain condition.

Smart Toothbrush

Oral health is important to overall health, yet for individuals living with arthritis, the simple act of vigorously brushing their teeth can be a challenge. Now smart toothbrushes are making oral care easier for those with grip and coordination issues. Smart toothbrushes provides much of the brushing action necessary with less manual movement, helping to ease discomfort for those with joint pain.

Pros Smart toothbrushes have built-in pressure sensors and timers for optimal oral health.
Cons Even though most smart toothbrushes are affordable and can fit most budgets, they are more costly than traditional products, take up more space, and require regular charging.
Customizations Speed settings allow you to accommodate your personal sensitivity needs. In addition, those with an integrated app allow you to optimize your brushing habits.
Product Considerations A wide range of products are available, at a variety of price points, sizes and weights. Choose the product that fits your budget and is most comfortable in your grip.
Installation None
Budget $
Also Benefits Those with a self-care disability, those with mobility issues.

Self-Care/Independent Living Difficulty

It’s estimated that 6.5 percent of Americans have an independent living disability, and 3.6 percent of Americans have a self-care disability. For those struggling with such disabilities challenges may range from an inability to dress oneself, to an inability to grocery shop, run errands, or take oneself the doctor. Of particular concern for seniors, self-care disabilities may be accompanied by cognitive, ambulatory, hearing, or vision disabilities, further necessitating the support for accommodations and devices that can enable one to live a more independent life, at home, for as long as possible.

Assistance Applications

assist-Mi is an assistance application that helps disabled individuals to get assistance in real-time by connecting service providers and caregivers with disabled individuals who may need transportation help at a moment’s notice. For individuals with a self-care disability, assist-Mi enables them to find a nearby caregiver who can assist with the types of activities they are unable to do on their own, such as traveling to work, going shopping, or running errands.

Pros Improves the daily lives of people with a self-care disability by connecting them with nearby caregivers. The app also provides a directory of accessible nearby service providers, such as retailers and facilities for convenient reference.
Cons The app works by connecting the disabled with nearby caregivers. If you live in a more rural area, your options for nearby caregivers may be limited. Similarly, depending on the exact time you need assistance, there may not be someone nearby available to assist.
Customizations Smart location-based technologies personalize the experience so that those in need are paired with nearby caregivers. In addition, a user can create a custom profile and save personal preferences.
Product Considerations assist-Mi primarily enables disabled individuals to obtain transportation assistance. If in-home care is the primary concern, such needs may be beyond the scope of the assist-Mi application.
Installation None
Budget $ The app is free from the iTunes® App Store and Google PlayTM Marketplace.
Also Benefits Those with mobility issues, the vision impaired.

smart fridge that creates a shopping list

Wi-Fi Enabled Refrigerators

While the most advanced refrigerators offer the average, able-bodied individual convenience, for those with self-care needs, they offer a much-needed health benefit. The most advanced models of Wi-Fi enabled refrigerators have built-in cameras that allow you to see what’s inside the refrigerator without opening the door. You can also leave notes and appointment reminders on the refrigerator’s front digital display—a convenience for those who may also suffer from memory loss.

Perhaps most impressive of all, smart refrigerators will keep track of your re-stock needs and allow you to send a grocery list directly to a participating grocery store (such as Whole Foods, Fresh Direct, or Shop Rite), for delivery right to your door. Such conveniences enable home-bound individuals to be able to remain well cared for in their own home.

Pros Thanks to the re-order and delivery functionality, home bound individuals don’t need to be reliant upon caregivers to help restock their food.
Cons Not every grocery store offers online ordering and delivery. Depending on where you live, the ability to re-order products may not be feasible.
Customizations For products with built-in on-screen apps, you can keep track of notes, calendar items, appointments, and grocery needs, helping you to personalize the product and it use.
Product Considerations Budget may be the biggest consideration when choosing a smart refrigerator, since product features and installation costs range greatly, even more so than installing standard appliances. In addition, some brands integrate with smart home hubs. If you need to integrate your refrigerator with your smart home hub, be sure to choose a compatible system.
Installation Assistance will be needed to bring the large refrigerator into the home. Depending on your technical aptitude, you may need assistance pairing it to your Wi-Fi and setting your preferences.
Budget $$$ While a variety of products are available with features that range in complexity, most costs range from $1300 to $6,000.
Also Benefits Those with mobility or cognitive disabilities, those with arthritis.

Additional Resources

For some, the addition of a few smart devices into the home could make all the difference needed to live independently. For others, the greater need is for a more integrated and robust use of the IoT to make a wider variety of home activities feasible. For still others, depending on their needs and the complexities of their disability, what is needed to keep them in the home where they belong may be a fully customized home environment.

Organizations do exist that are helping to build custom smart homes for the disabled, including veterans, seniors, and families with a special needs child. While a custom home requires the most significant funding considerations, there are organizations helping to make such projects affordable. If a fully customized smart home is what you need, explore the resources below:

TechHomes.com – Offers a state-by-state directory of smart home communities, builders, and resources.

RISE – Founded by actor Gary Sinese, RISE (Restoring Independence Supporting Empowerment), builds adaptive homes for disabled veterans.

Hive – Offers a series of interconnected smart devices that can be integrated with one another to create an end-to-end smart home living environment. Hive products can be retrofitted into existing homes, or installed into custom builds.

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Low back pain in older adults

A 102 yr old female in a care home facility complains of back pain every morning but she is un-medicated, still walks, dances, sits often during the day and loves to eat. She has good teeth, does not worry like others of her peers and loves to dance. She has early Alzheimer’s disease.


Low back pain in older adults: risk factors, management options and future directions


Low back pain (LBP) is one of the major disabling health conditions among older adults aged 60 years or older. While most causes of LBP among older adults are non-specific and self-limiting, seniors are prone to develop certain LBP pathologies and/or chronic LBP given their age-related physical and psychosocial changes. Unfortunately, no review has previously summarized/discussed various factors that may affect the effective LBP management among older adults. Accordingly, the objectives of the current narrative review were to comprehensively summarize common causes and risk factors (modifiable and non-modifiable) of developing severe/chronic LBP in older adults, to highlight specific issues in assessing and treating seniors with LBP, and to discuss future research directions. Existing evidence suggests that prevalence rates of severe and chronic LBP increase with older age. As compared to working-age adults, older adults are more likely to develop certain LBP pathologies (e.g., osteoporotic vertebral fractures, tumors, spinal infection, and lumbar spinal stenosis). Importantly, various age-related physical, psychological, and mental changes (e.g., spinal degeneration, comorbidities, physical inactivity, age-related changes in central pain processing, and dementia), as well as multiple risk factors (e.g., genetic, gender, and ethnicity), may affect the prognosis and management of LBP in older adults. Collectively, by understanding the impacts of various factors on the assessment and treatment of older adults with LBP, both clinicians and researchers can work toward the direction of more cost-effective and personalized LBP management for older people.

Keywords: Risk factors, Spine, Disc degeneration, Management, Low back pain, Elderly, Genetics, Falls, Brain, Pain assessment


The average lifespan of humans has dramatically increased in the last decade due to the advance in medicine [1]. According to the United Nations, the world population of individuals aged 60 years or above will triple by 2050 [2]. In the UK alone, approximately 22% of the population will be 65 years or older by 2031, exceeding the number of those aged less than 25 years [3]. However, the fast-growing aging population also increases the likelihood of non-communicable diseases (e.g., musculoskeletal complaints). Studies have suggested that the prevalence of musculoskeletal pain in older adults ranges from 65 to 85% [4, 5], with 36 to 70% of them suffering from back pain [5, 6].

Low back pain (LBP) is the most common health problem among older adults that results in pain and disability [4, 710]. Older adults, aged 65 years or above, are the second most common age group to visit physicians for LBP [11]. Earlier research suggests that LBP prevalence progressively increases from teenage [12] to 60 years of age and then declines [1316], which may be ascribed to occupational exposure among working-age adults [17, 18], or age-related changes in pain perception or stoicism [19]. However, recent studies have revealed that LBP remains ubiquitous among older adults at their retirement ages [20, 21]. In population-based studies, the 1-year prevalence of LBP in community-dwelling seniors ranged from 13 to 50% across the world [4, 13, 2224]. Similarly, while up to 80% of older residents in long-term care facility experience substantial musculoskeletal pain [2527] and one-third of these cases are LBP [28], often older residents’ pain is underreported and inadequately treated [2527].

It is noteworthy that both the incidence and prevalence of severe and chronic LBP increase with older age [13, 29, 30]. Docking et al. [17] reported that the 1-month prevalence of disabling back pain (pain that affected daily activities within the past month) increased from 3.8% among people aged between 77 and 79 years to 9.7% among those aged between 90 and 100 years. Williams and coworkers [31] also found that individuals aged 80 years or above were three times more likely to experience severe LBP than those aged between 50 and 59 years. Because severe LBP usually results in poor treatment outcomes and functional disability [17, 32], timely LBP management of older adults is crucial. Importantly, compared to working-age adults, older adults aged 65 years or above are more likely to develop chronic LBP that lasts for more than 3 months [13, 33]. A Spanish study found that the prevalence rates of chronic LBP among females and males aged 65 years or older were 24.2 and 12.3%, respectively [34], while an Israeli study documented that the prevalence of chronic LBP in people aged 77 years was as high as 58% [35].

Notwithstanding the high prevalence of LBP among older adults, their pain is usually undertreated. A recent study showed approximately 25% of senior nursing home residents with chronic pain did not receive analgesics, and only 50% of all analgesics were prescribed as standing orders at suboptimal doses, which did not follow geriatric clinical guidelines [36, 37]. According to those guidelines, older patients with chronic pain should receive analgesics as a standing dose rather than on an as-needed basis in order to ensure adequate concentration of analgesic in serum for continuous pain relief [36, 38]. Standing-dose analgesics are particularly important for people with cognitive impairment because they cannot appropriately request medication.

While undertreatment of LBP in older adults may be ascribed to the avoidance of high-dose analgesics (e.g., opioid) prescription, it may also be attributed to the difficulty in identifying the presence or causes of LBP. Research has shown that less than 50% of primary care physicians have strong confidence in diagnosing the causes of chronic LBP in older adults [32]. Consequently, this may result in over-reliance on medical imaging or improper LBP management (e.g., undertreatment). Imperatively, untreating or undertreating older adults with LBP may result in sleep disturbances, withdrawal from social and recreational activities, psychological distress, impeded cognition, malnutrition, rapid deterioration of functional ability, and falls [39]. These LBP-related consequences may compromise their quality of life and increase their long-term health care expenses [40].

Although various medical associations have published clinical guidelines on conservative management of chronic pain in older adults [37, 41, 42], there is paucity of literature summarizing various causes or risk factors of developing severe/chronic LBP among older adults. Since a better understanding of these factors can improve LBP management, the objectives of the current narrative review were to summarize potential causes of LBP, risk factors for chronic LBP, special consideration for LBP management (e.g., pain evaluations among patients with dementia) in older people aged 60 years or older, and future research directions.

Search strategies and selection criteria

Potential articles were identified for review through PubMed from January 1, 1990, to November 30, 2016. Search terms included keywords and medical subject headings related to “low back pain,” “LBP,” “older adult*,” “senior*,” “elderly,” “cognitive impairment,” “dementia,” “nonverbal,” “community-dwelling,” “nursing home,” “long-term care facilities,” “risk factor*,” “brain,” “genetics,” “assessment*,” and “intervention*.” Various Boolean terms were used in conjunction with various search terms. Articles were selected based on the relevance of topic and restricted to the English language. The reference lists of relevant articles were also included for review. A total of 2182 citations were identified from the search. Of them, information from 320 articles was used in the current review.

Potential causes of low back pain

Non-specific or mechanical low back pain

Like among young adults, the majority of LBP among older adults has no definite pathology (e.g., fracture or inflammation) and is diagnosed as non-specific LBP. These patients experience LBP that is altered by posture, activity, or time of the day. Non-specific LBP may originate from different pain sources [43]. Disc degeneration on magnetic resonance imaging (MRI) is more prevalent with age progression and as such in older adults; however, it is less likely to be the pain source as compared to young adults [44]. Conversely, facet joint pain in seniors may present as localized LBP with or without posterior thigh pain during walking. The pain may be aggravated during trunk extension, ipsilateral lateral flexion, and/or rotation [45]. Lumbar degenerative spondylolisthesis (defined as forward or backward slippage of a cephalic vertebra over a caudal one secondary to a degenerated disc and altered facet joint alignment) is common among women aged 60 years or older and is usually associated with facet hypertrophy [46]. The presence of degenerative spondylolisthesis alongside facet hypertrophy and thickening of ligamentum flavum may results in pain, spinal stenosis, and neurological deficits in older adults [46, 47]. Although spinal degenerative changes may induce LBP, not all anomalies on lumbar medical imaging are related to LBP because abnormal imaging phenotypes are ubiquitous among asymptomatic older adults [44, 4850].

Additionally, non-specific LBP may originate from structures other than the lumbar spine. Many older patients with chronic LBP display physical findings comparable to sacroiliac joint pain (83.6%) and myofascial pain (95.5%) [51]. Symptoms of sacroiliac joint disorders are similar to facet joint pain, which includes localized LBP with or without posterior thigh pain that can be alleviated by lying [52]. Myofascial pain is a localized palpable tenderness and tightness within a muscle that resists passive stretching and reproduces predictable referred pain pattern on palpation [53]. Myofascial pain in lumbar muscles or piriformis are common among seniors. Collectively, it is difficult to identify the sources of non-specific LBP because its causes are usually multifactorial. Various factors (e.g., anxiety, depression, coping strategies, and pain genes) can modify the severity and chronicity of LBP [31, 35, 50].


While non-specific LBP is usually localized at the lumbar region and/or thigh, the compression of nerve roots or spinal meninges by degenerated spinal structures (e.g., herniated discs, facet joints, and/or epidural fat) [54] may lead to radiculopathy that radiates distal to the knee. The clinical presentation of radiculopathy depends on the location of neural tissue compression. Lumbar spinal stenosis (LSS) secondary to degenerative changes (e.g., osteophytes and hypertrophic ligamentum flavum) at a single or multiple level(s) may lead to unilateral or bilateral radiculopathy and neurogenic claudication with or without LBP [5557]. Neurogenic claudication is characterized by numbness and heaviness of legs after prolonged walking, which can be eased by a flexed position (e.g., forward leaning or sitting) [5860]. On the contrary, the presence of osteophyte/narrowing in the lateral recess or in the vertebral foramen may result in radicular leg pain without LBP [61]. Research on asymptomatic or some clinical populations have suggested that the prevalence of degenerative LSS ranged from 6 to 13.1% [62, 63] and the rate increases with age [64]. A population-based imaging study found that the prevalence of degenerative LSS (i.e., ≤10-mm anteroposterior diameter of spinal canal) in young (<40 years) and older adults (>60 years) were 4.0 and 14.3%, respectively [64].

Osteoporotic vertebral fractures

Given the hormonal changes following menopause, women are more susceptible to osteoporotic fracture and related LBP [65, 66]. Approximately 25% of all postmenopausal women suffer from vertebral compression fracture and the prevalence of this condition increases with age [65]. It is estimated that the prevalence of vertebral compression fracture in women aged 80 years or above can be as high as 40% [65]. As compared to patients with non-specific LBP, patients with vertebral fractures experience more disability [67]. Unfortunately, only one third of the cases are correctly diagnosed because many seniors assume bone and joint pain as part of the aging process [68]. As such, physicians should pay more attention to examine seniors with acute onset of localized LBP that may or may not present with paraspinal muscle spasm. A recent systematic review suggests that older age, corticosteroid use, and significant trauma are the risk factors for vertebral fractures [69]. The common site of compression fractures occur at the thoracolumbar region [7072]. Depending on the mechanism of fractures, some vertebral compression fracture may result in radiculopathy. The most common fracture mechanism is due to a flexion movement or trauma that causes an anterior wedge fracture [73]. Since the posterior vertebral body remains intact and the collapsed anterior vertebra heals without regaining height, it will result in a kyphotic deformity without compromising the spinal cord [73]. Another type of vertebral compression fracture involves the center part of the vertebral body without affecting the anterior or posterior wall. This type of fracture does not affect the spinal cord. A less common osteoporotic vertebral fracture involves the axial compression of the entire vertebral body or the posterior portions of the vertebra that may compress the spinal canal and results in neurological deficit [7173].

De novo degenerative lumbar scoliosis

De novo degenerative lumbar scoliosis (DNDLS) is a spinal deformity in older adults that results in disabling LBP/leg pain and suboptimal quality of life. [7476]. DNDLS is defined as a lumbar scoliotic curve with a Cobb angle ≥10° in the coronal plane that develops after 50 years of age in people without a history of adolescent idiopathic scoliosis. [77]. The reported prevalence of DNDLS in the adult population has ranged from 8.3 to 13.3% [7880], while that in adults older than 60 years was as high as 68% [81]. Multifactorial causes have been suggested for DNDLS, including intervertebral disc degeneration and genetic predisposition [8284]. It is believed that the asymmetrical biomechanical load on the vertebral endplate on the concave side of the curve may cause inflammatory responses in the endplate and adjacent bone marrow of the vertebral body, which may result in LBP. [8587]. This premise has been substantiated by a recent study that found (1) bone marrow edema in DNDLS was more prevalent in older adults with LBP than those without LBP, (2) bone marrow edema was more frequent on the concave side of the DNDLS curve, and (3) the location of bone marrow edema on MRI was closely associated with local lumbar tenderness [87]. However, no significant relation between Cobb angle and LBP symptoms in older adults has been reported [81]. Interestingly, the curve progression rate of DNDLS is higher than that of adolescent idiopathic scoliosis [77]. Three radiological variables (i.e., increased intervertebral disc degeneration, an intercrest line passing through the L5 level (not L4 or higher), and apical lateral vertebral translation for at least 6 mm)) have been identified as predictors of DNDLS curve progression [77].


The incidence rates for all neoplasms exponentially increase with age [88] although only less than 1% of the causes of LBP presented to primary care physicians are attributed to spinal tumors [89]. A majority of these tumors are related to metastasis and only a handful of them are primary tumors [9095]. The common metastatic sources of LBP are prostate and kidney although primary malignant tumors (e.g., chordoma, plasmacytoma, or lymphoma) are also be found in older adults [90]. Unlike young adults, seniors are unlikely to have primary benign tumors (e.g., osteoblastoma, osteochondroma, osteoma, eosinophilic granuloma, and aneurysmal bone cysts). Clinically, typical symptom of spinal tumors is progressive, unremitting, localized, or radiating pain that are aggravated by movement, worse at night, and cannot be eased by rest. In addition, patients may experience weakness and feel the presence of a lump [96].

Spinal infection

Vertebral osteomyelitis (VO) is a life-threatening infectious musculoskeletal disease in older people caused by an infection of vertebral bones [97]. Given the growing aging population, the incidence of VO is increasing [98100]. Although the reported incidence rate of VO in the general population only ranges from 2.5 cases to 7 cases per 100,000 people-years [99, 101], the mortality of these patients can be as high as 12% [99, 102]. Four causes of VO have been suggested. First, pathogenic bacteria may be disseminated hematogenously from a distant infected source and multiply at the metaphyseal arterioles of vertebral bone that causes microabscess formation, bone necrosis, and fistula within bone [103]. Staphylococcus aureus is the most common pathogen. Second, tubercular VO may occur in seniors who have contracted tuberculous infection at young age. Mycobacterium tuberculosis may be transmitted to and remains in the vertebral bone. Age-related deterioration of the host’s immunity or certain incidences (e.g., osteoporosis, trauma, or non-myobacterial infections) may reactivate M. tuberculosis in the bone that causes osteomyelitis. Third, aerobic gram-negative bacilli in older men with urinary tract infection may rarely reach the lumbar spine through Batson’s plexus and cause VO [97]. Fourth, iatrogenic infection following spinal surgeries or injections may cause vertebral osteomyelitis. Clinically, patients with VO may present with fever, elevated C-reactive protein, paraspinal muscle spasm, LBP, neurological deficits, and epidural abscess. Additionally, patients with tuberculous osteomyelitis may have a groin mass because of the presence of abscess in psoas muscle [97]. Taken together, greater age and certain comorbidities (e.g., diabetes, hemodialysis usage, liver cirrhosis, malignancy, and infectious endocarditis) are known to increase inpatient mortality of VO [99]. Clinicians should be suspicious of VO if older patients with the abovementioned comorbidities demonstrate unidentified fever and/or LBP [99]. Clinical findings, laboratory results, bone scintigraphy, and/or spinal biopsy are usually used to make differential diagnosis of VO.

Similarly, older people are more prone to develop pyogenic spondylodiscitis, which involves the infection of disc and adjacent vertebral bones. It has been estimated that the incidence rate of non-tuberculous or non-postoperative spondylodiscitis in the general population is approximately 0.2 to 2.4 cases per 100,000 people-years [101, 104106], while that for people over 65 years old is as high as 9.8 cases per 100,000 person-years [107]. A recent population-based study reported that males aged 70 years or older displayed six times higher incidence rate of pyogenic non-tuberculosis spondylodiscitis than males under 70 years old. Likewise, females aged 70 years or above were three times more likely to exhibit pyogenic non-tuberculosis spondylodiscitis than younger counterparts [98]. Clinical presentations of spondylodiscitis are comparable VO. S. aureus is the major cause of pyogenic spondylodiscitis [108], while other bacteria (e.g., Streptococcus and Pneumococcus) may also cause the disease [98]. Magnetic resonance imaging is the gold standard for imaging pyogenic spondylodiscitis, which is visualized as reduced signal intensity of the affected disc and adjacent vertebral bodies with unclear endplates definition on T1-weighted images and enhanced signal intensity on T2-weighted images [109].

Visceral diseases

Since it is not uncommon for seniors to have co-morbidities, it is important to consider other non-spinal pathologies that usually present as chronic LBP. Several visceral diseases (e.g., dissecting abdominal aortic aneurysm, cholecystolithiasis, nephrolithiasis, prostatitis, urinary tract infection, and pelvic inflammatory disease) have known to generate symptoms comparable to chronic LBP [110].

Cauda equina syndrome

This syndrome is ascribed to the compression of multiple lumbar and sacral nerve roots in the spinal canal that lead to bowel, bladder, and/or sexual dysfunction, as well as perianal region numbness [111]. Depending on the location of nerve roots compression, patients with cauda equina syndrome may or may not experience sciatica. Potential causes of this syndrome include central disc herniation or spondylolisthesis at the lower lumber levels, spinal tumors, dislocated fracture, and abscess within the spinal canals [111]. Additionally, this syndrome may be secondary to some rare iatrogenic causes (e.g., spinal anesthesia or postoperative hematoma).

Risk factors of developing severe/chronic low back pain in older adults

Although most LBP is self-limiting and begins to improve after a few days and resolves within a month [110], some patients are susceptible to chronic LBP that lead to significant disability. While age is a well-known risk factor for chronic LBP [112], other factors may perpetuate LBP in older adults (Fig. 1). The understanding of these factors can help identify high-risk patients and improve their LBP management. Since older adults usually face both age-related physical and psychosocial issues, comprehensive assessments and treatments are needed to effectively manage LBP in seniors.

Fig. 1

Factors affecting the development of severe or chronic low back pain among older adults

Non-modifiable risk factors

Altered supraspinal pain processing

Recent evidence suggests that normal aging may be associated with alterations in pain perception [113, 114] central pain processing [114] and/or neuroplastic changes to pain responses [115]. Both experimental pain and functional neuroimaging studies have found that older people display age-related increase in the heat pain threshold [116] and reduced responses in middle insular and primary somatosensory cortices toward a 44 °C heat stimulus [117]. These age-related neuropsychological changes in pain processing may reduce older peoples’ awareness and reporting of pain that may lead to undiagnosed health problems/injuries.

Conversely, some psychophysical studies reported that older adults displayed lower tolerance to various types of pain stimuli (e.g., ischaemic, mechanical, electrical, heat, or cold) [113, 114, 118] decreased pain thresholds for mechanical pressure [114, 116] or ischemic pain stimuli [119] and higher pain rating for noxious stimuli as compared to young adults [120]. Although speculative, the increased pain sensitivity in older adults may be attributed to diminished descending pain inhibition in older adults. Neuroimaging studies have shown that the volumes of brain regions responsible for pain processing (i.e., the cingulate, insula, striatum, hippocampus, cerebellum, and prefrontal cortex) significantly reduce as people age [121126]. These findings may indicate age-related reduction in perceptual motor processing, diminished coordination of inhibitory motor response to noxious stimuli, and/or impaired descending endogenous pain inhibitory modulation [127130]. Since patients with fibromyalgia are known to have significantly less striatal release of dopamine in response to experimental muscle pain [131] and people with chronic LBP are characterized by regional decreases in gray matter density in bilateral striatum (especially nucleus accumbens, putamen, and caudate) [132], the reduced pain-related striatal activity in seniors may indicate age-related impairment in endogenous pain modulation [127129].

Additionally, age-related changes in neuroplasticity may decrease the pain tolerance in older adults. Compared to younger individuals, older people tend to show more rapid temporal summation of noxious heat stimuli in their central nervous system [116, 133135]. Similarly, older adults display a prolonged period of capsaicin-induced hyperalgesia that may lead to relentless pain sensitization and sluggish resolution of neuroplastic change [115]. Importantly, the central pain processing can be further complicated by dementia-related neurodegeneration [113, 136]. Depending on the severity, locations or types of neurodegenerative changes, seniors with dementia or Alzheimer’s disease have demonstrated increased pain threshold and tolerance [137] or decreased pain threshold [138, 139]/pain tolerance [140]. Taken together, age-related changes in central pain processing of older adults may contribute to severe or chronic LBP in seniors.

Importantly, people with chronic back pain suffer from global and regional changes in functional connectivity and/or gray matter density in the brain that may perpetuate persistent pain [132, 141]. Human resting-state functional MRI research has revealed that, as compared to asymptomatic individuals, patients with chronic pain (i.e., back pain, osteoarthritis, and complex pain regional syndrome) demonstrate significantly decreased functional connectivity of the whole-brain and diminished regional connectivity in specific brain regions (e.g., supplementary motor cortex, mid-anterior cingulate cortex, superior parietal lobe, and part of the somatosensory network) but enhanced connectivity in thalamus and hippocampus [141]. These patients also display changes in allegiance of insula nodes or some lateral parietal nodes to certain brain modules (e.g., the sensorimotor brain module, default–mode network module, and attention module) [141]. These findings indicate that chronic pain is associated with decreased motor planning (supplementary motor cortex) and attention (superior parietal lobe) but increased somatosensory inputs to the cortex (thalamus) and chronification (hippocampus) [142, 143]. Similarly, a 1-year longitudinal study showed that people who experienced persistent back pain during the study period demonstrated significant decreases in global gray matter density as compared to healthy controls and patients who recovered during the period [132]. The same study found that patients with persistent back pain had significant regional decreases in gray matter density at bilateral nucleus accumbens (a key mesolimbic region), insula (pain perception cortex) [144146], and left primary sensorimotor cortex, yet reduced negative functional connectivity between insula and precuneus/dorsolateral prefrontal cortex, and diminished functional connectivity of primary sensorimotor cortex [132]. The consistent findings of various studies suggest that chronic pain may lead to global and/or regional disruption of functional connectivity and structures of the brain that may hinder the treatment effectiveness for people with a history of recurrent or chronic pain [141].


Females are more susceptible to chronic LBP than males regardless of age [20, 31, 34, 112]. Jimenez-Sanchez and coworkers [34] estimated that women were two times more likely to develop chronic LBP than men. The higher prevalence of chronic pain in females may be attributed to complex biopsychosocial mechanisms (e.g., less efficient pain, habituation or diffuse noxious inhibitory control [147], genetic sensitivity, pain coping [148], and a higher vulnerability to develop temporal summation of chemically [149] or mechanically evoked pain) [150]. Further, women commonly have a higher number of concomitant chronic diseases (e.g., osteoporosis, osteopenia, and osteoarthritis), which are known to be risk factors for developing chronic LBP and psychological distress in older adults [34, 112].

Genetic influences

Recent research has highlighted that genetic factors play an imperative role in modulating pain sensitivity, responses to analgesics, and vulnerability to chronic pain development [50]. Some genetic factors not only predispose people to spinal disorders (e.g., scoliosis [151] and intervertebral disc degeneration [152, 153]) but also alter brain structures [154, 155] that may modify central pain processing and perception [156]. For instance, polymorphisms of the catechol-O-methyltransferase gene are known to affect the cognitive and emotion processing of pain in the brain [156]. While variations in some gene expression (e.g., val158met single-nucleotide polymorphism (SNP)) may modulate temporal summation of pain [157], other SNPs (e.g., catechol-O-methyltransferase gene, interleukin-6 GGGA haplotype or SCN9A gene, or hereditary sensory neuropathy type II gene) may alter pain sensitivity through different mechanisms (e.g., affecting voltage-gated sodium channels, altering myelination of nerve fibers, or modulating anabolism/catabolism of catecholamine neurotransmitters) [158163]. Collectively, some people (including seniors) may be more susceptible to develop chronic LBP because of their genetic makeup. Future studies are warranted to examine if age may modify the expression of pain genes in older adults.

Additionally, genetic variations may influence the analgesic requirement or treatment responses to opioid analgesics [164]. A recent meta-analysis underscores that SNP A118G (a genetic variant of μ-opioid receptors, OPRM1) can modify postoperative opioid requirement and analgesic responses [165]. Notably, while Asians with minor G allele require more postoperative opioid analgesics, Caucasian counterparts do not display increased opioid analgesic requirements. This discrepancy highlights the genetic differences between the two ethnic groups and/or distinct interactions between A118G SNP and environmental influences [165]. Interestingly, the OPRM1 A118G SNP has significant influence only on the treatment responses of patients receiving morphine but not fentanyl [165]. The divergent pharmacogenetic responses indicate that different opioids may have different ligand-receptor dynamics [166]. Importantly, the expression of other pain genes (e.g., COMT or beta-2 adrenergic receptor alleles) [158, 167, 168] and other polymorphisms in the OPRM1 gene locus [169] can interact with A118G SNP and environment to cause differential pain sensitivity and opioid treatment responses in different races and gender [164, 170]. As such, it highlights that individual treatment responses of patients with LBP may be related to different pharmacogenetic variations.

Prior work exposures

While occupational exposures to whole-body vibrations, lifting, bending, twisting, stooping, have been identified as potential risk factors for LBP in the working-age group [171], increasing evidence suggests that previous occupational exposure to physically strenuous work increases the risks of LBP in retired seniors [172, 173]. A prospective study involving more than 1500 individuals showed that previous occupational biomechanical exposure to bending/twisting or driving for at least 10 years increased the odds of having persistent LBP in retired adults aged 58 to 67 years after adjusting for body mass index and psychological disorders [172]. Likewise, retired post office workers aged 70 to 75 years with LBP were characterized by more than 20 years of work-related regular lifting of heavy weights [173].

Demographic factors

Lower education levels, lower income, and smoking are related to higher propensity of LBP in older people [20, 21, 31, 112]. It is suggested that more educated individuals experience less LBP symptoms because they have a better understanding of pain, a better compliance to treatment, and a strong willingness to adopt a healthy lifestyle [174]. Conversely, people with poor economic status may have difficulty in accessing healthcare in certain places [175]. Patients with limited resources may delay seeking healthcare until their symptoms are intolerable, which in turn increases the chronicity/severity of LBP across the life course [176]. A multinational study has shown that people in the poorest socioeconomic quintile were 1.4 times more likely to have LBP with reference to the highest quintile [31]. Interestingly, compared to those older adults who have never married, those divorced, married, separated, and widowed have at least 1.5 times odds to experience LBP [31].

Modifiable risk factors

Yellow flags

Psychological distress (e.g., anxiety or depression) is a risk factor for persistent or debilitating LBP in older adults [34]. A longitudinal study showed that older persons with a high depressive symptom score at baseline were two times more likely to have LBP at the 4-year follow-up [17]. Similarly, Reid et al. [177] found that depression was significantly correlated to disabling LBP in seniors aged 70 years or above. Importantly, since persistent LBP can also be a predictor of depression and anxiety [178], psychological assessments should be incorporated in the examination of older patients with chronic LBP.

Multiple studies have found that fear-avoidance beliefs (FAB) are closely related to chronic LBP in older people [179181]. A cross-sectional study consisting of 103 older patients with chronic LBP (65 years or older) and 59-age-matched asymptomatic controls showed that higher FAB as measured by a questionnaire, older age, and higher LBP intensity predicted poorer self-reported functional capacity [179]. Another study on 200 older adults with chronic LBP revealed that higher physical activity subscale scores of the FAB questionnaire were related to higher Roland Morris Disability Questionnaire scores and slower gait speed [180]. Similarly, a population-based survey study found that increased FAB were related to higher self-reported LBP-related disability, poorer physical health, and higher risk of falls in older people (62 years or older) with LBP [181]. Vincent et al. also found that kinesiophobia was related to chronic LBP-related disability in obese older adults [182]. These consistent findings suggest that FAB are important therapeutic target to address among older people with chronic LBP.

Conversely, some studies reported inconsistent findings regarding the relation between other yellow flags (e.g., kinesiophobia and pain catastrophizing) and functional capacity or LBP-related disability [182184]. A recent randomized controlled trial among 49 obese, older adults with chronic LBP demonstrated that reduction in pain catastrophizing following 4-month resistance exercise was related to decreased self-reported LBP-related disability [184]. However, Ledoux and coworkers found that kinesiophobia, pain catastrophizing, and depression were unrelated to the functional capacity among older adults with chronic LBP [185]. Kovac and colleagues also found that FAB and pain catastrophizing had only a minimal clinically significant effect on self-reported LBP-related disability of community-dwelling older (above 60 years) adults with LBP [183]. This discrepancy may be attributed to differences in study designs, cultures, living environment, or age-related changes in the relative influence of FAB on LBP-related disability level [183]. Given that multiple psychological factors (e.g., anxiety, depression, FAB, and coping strategy) may have different interactions among themselves and other age-related physical and social factors in influencing the genesis and persistence of chronic LBP, future studies should clarify the effect of individual yellow flags on LBP progression among older adults. The findings may help develop optimal multimodal treatment approaches for older adults with LBP [186].

Physical activity

Different types and amounts of physical activity are related to persistent LBP in older adults [112]. Generally, moderate or vigorous physical activity heightens the risk of LBP regardless of age [112, 171]. A population-based study found that moderate (at least 30 min of moderate intensity activity on five or more days per week) and vigorous (at least 20 min of vigorous activity on three or more days per week) physical activity were significantly associated with increased risk of persistent LBP among women aged greater than or equal to 65 years, while walking for 30 min on five or more days a week and strength exercises on two or more days per week lowered the risk of persistent LBP after adjusting for age and body mass index (BMI) [112]. Similarly, the study identified that strength exercises lowered the risk of LBP among men aged greater than or equal to 65 years after accounting for age and BMI [112]. As such, clinicians should evaluate the activity level of patients and provide recommendations accordingly.


Like in other age groups, smokers are more likely to experience LBP. It is thought that smokers may have different pain perception as compared to non-smoker although the effect of smoking on pain perception remains unclear [187]. However, animal and human studies have shown that smoking may induce degenerative changes in spinal structures, such as intervertebral discs [188191]. As such, these degenerative changes may compress the neural structures and cause neuropathic LBP.

Social factors

Social factors may affect the genesis and persistence of LBP [192]. It is well known that social factors (e.g., the social environment or groups that individuals live, grow up, or belong) can influence the onset and progression of diseases or disability (including widespread pain) [193, 194], especially among older adults [195, 196]. Because social conditions can induce social stressors (e.g., poor housing, crime, and poor living environment), affect risk exposure (e.g., poor eating habit leading to obesity), influence psychology and emotion (e.g., social pressure and sense of inequalities), and compromise access to health services (e.g., health-care education or use of healthcare) [192]. Health-care stakeholders should recognize and address various social factors that can impact older adults with LBP. For example, since older adults with less social ties are more likely to experience disabling pain because of depression [192], proper public health programs and resource allocation (e.g., social work counseling services and health education) may target these vulnerable seniors (e.g., oldest old or seniors with depression). Importantly, residents with LBP living in long-term care facilities may rely on nursing home staff (e.g., nursing assistants) to provide medications or personal care. The attentiveness and responsiveness of nursing home staff will affect the recovery and persistency of LBP in these residents.

Self-perceived health

Seniors with poor self-perceived health status are more likely to experience severe LBP. A cross-sectional study on adults aged between 70 to 102 years found that poor self-rated health was strongly associated with LBP [197]. Similarly, a longitudinal study revealed that people with poor self-reported health were four times more likely to report LBP at the 4-year follow-up than those reporting very good health [17]. The same study also found that those who required health or social services (e.g., meals on wheels or home help) at baseline had a significantly higher risk of reporting LBP at follow-up [17].


Research has shown that comorbidities are related to chronic LBP in seniors. Jacobs et al. [35] found that females, hypertension, joint pain, pre-existing LBP, and loneliness, were predictors for developing persistent LBP in individuals aged 70 years. Another study revealed that comorbid chronic conditions were positively related to at least one LBP episode in the last month in low- and middle-income countries [31]. Specifically, the odds of LBP were 2.7 times higher among seniors with one chronic comorbid condition, compared to seniors without comorbidities, while the odds ratio was 4.8 for people with two or more comorbidities [31]. As mentioned above, patients with Parkinson’s disease may experience hypersensitivity of pain due to the decrease in striatal dopaminergic function [198, 199]. However, such pain can be alleviated by the administration of L-dopa [200].

Special considerations for low back pain management of seniors

While comprehensive history taking, self-reports of pain characteristics and pain-related disability, as well as proper physical examination all are necessary for differential diagnosis among older adults with LBP [201], attention should be also given to assessment and treatment of seniors with LBP so as to optimize pain management (Fig. 1).

Self-reported pain assessments

While patients with mild-to-moderate dementia can reliably report pain intensity using traditional visual analog scale or Numeric Rating Scale (NRS) [202, 203], other self-reported pain assessment tools have been developed and validated in the older population to improve pain evaluation (Table 1). The 11-point NRS is commonly used in clinical settings, where 0 means no pain and 10 means the worst pain imaginable [204]. Faces Pain Scale and Revised Faces Pain Scale (FPS) comprise different facial expressions indicating different severity of pain experienced by patients [205]. They have been validated among different older populations [168, 204, 206208] and were rated as preferred tools over the NRS by Chinese [209] and African-Americans [210]. The Iowa Pain Thermometer (IPT) is a descriptor scale presented alongside a thermometer to help patients conceptualize pain intensity as temperature levels [204]. Compared to the FPS, Verbal Descriptor Scale, and visual analog scale, the IPT is deemed to be the most preferred scale among older adults [204].

Table 1

Self-reported pain assessment tools for older adults with cognitive impairment

Observational pain assessments

Although self-reported pain assessment is the gold standard, clinicians need to validate the self-reported pain with observed pain behavior during physical examination. While some seniors with cognitive impairment may report exaggerated pain without coherent pain behavior due to perseveration [211214], others (e.g., with severe dementia or poststroke aphasia) may have difficulty in communicating pain intensity or pain-related disability [215] that may lead to insufficient/inappropriate treatment [216]. Currently, there is no consented guideline regarding the relation between the trustworthiness of self-reported pain and cognitive functioning [217]. Therefore, health-care providers (e.g., physicians or nursing home nurses) should identify people with potential cognitive impairment and modify their pain assessment and treatment in order to effectively manage cognitively impaired patients with LBP. It has been suggested that clinicians should consider assessing the cognitive function of older adults with LBP if patients have a known history of dementia, self or family report of memory loss, difficulty in providing details of LBP history that requires supplementary input from caregivers, age above 85 years, or inconsistency between observed pain behaviors and self-reported pain [212, 213, 218]. Some dementia screening tools (e.g., Montreal Cognitive Assessment [219], Mini-Cog [220, 221], and Saint Louis University mental status examination [222]) have been recommended based on their psychometric properties, ease of use, and accuracy in identifying people with dementia [223]. Patients with positive screening results should be referred to subspecialty dementia experts (e.g., neurologists, geriatricians, or geriatric psychiatrists) for formal dementia evaluation in addition to LBP treatment. Collectively, early identification of cognitive impairment and psychiatric comorbidity (e.g., depression) in older adults with LBP can optimize the pain management plan (e.g., assistance from caregivers and prescription of psychiatric medications).

Since people with moderate to severe dementia may display agitation, anxiety, or nonverbal pain behaviors (e.g., grimacing, yelling, hitting, or bracing), failure to detect pain as a potential cause of agitation may result in unnecessary prescription of anxiolytics or antipsychotics [224]. As such, proper procedures for evaluating nonverbal dementia patients should include: using a validated observational assessment tool to evaluate pain behaviors during rest and painful conditions/procedures, seeking surrogate report of pain behaviors, and monitoring responses following an analgesic trial [223]. Since the prevalence of dementia in people aged 85 or older can be as high as 50% [218], family members or informants are recommended to accompany these patients to meet health-care providers so as to provide detailed pain information [223]. Several recent reviews have identified at least 24 observational pain assessment instruments for estimating pain in nonverbal patients [225227]. Table 2 describes six commonly used assessment instruments. Unfortunately, since many of them only detect the presence/absence of pain, rather than quantify the pain severity [217, 228], these tools may be better used to monitor longitudinal changes in pain (e.g., increases/decreases in pain behavior) or treatment responses. Regardless, if the observational pain behavior assessment indicates the presence of significant pain in patients, the sources of pain should be identified through physical examination and proper treatment should be given. If inconsistency occurs between the observational assessment and self-report of pain, other causes (e.g., fear of pain and depression) should be identified and managed. If comprehensive evaluations and an analgesic trial cannot identify any sources of pain experienced by patients with dementia, the persistent pain complaint may be attributed to pain perseveration, which is the repetitive reporting of pain without actual distress. Collectively, future studies should refine existing observational tools by identifying the most important behaviors for evaluating the presence and severity of pain (including LBP) in cognitively impaired patients.

Table 2

Six commonly used nonverbal pain tools for older adults with cognitive impairment

It is noteworthy that although certain physiological parameters (e.g., increased heart rate, blood pressure, and perspiration) may indicate the presence of pain, these physiological indicators may be inaccurate among older adults with chronic pain [217]. Additionally, older adults with dementia may have diminished autonomic reactions to pain [229, 230]. Therefore, effective evaluation of pain behavior may be more relevant for older adults with severe dementia and pain.

Fall assessment and prevention

Given that older people usually display reduced physical capacity [231], cardiac output [232], muscle mass and strength [233], and older adults with LBP are more likely to suffer from decreased mobility and functional deterioration than younger sufferers. In addition, older adults with musculoskeletal pain are more likely to experience fear of falling [234] and fall incidents [23]. Specifically, LBP is known to be an independent risk factor for repeated falls in older women [235]. A prospective study revealed that community-dwelling seniors with chronic LBP (more than 3 months) had a significantly higher risk of falls (adjusted OR for injurious falls ranged from 2.11 to 2.46) as compared to asymptomatic counterparts [236]. Likewise, seniors with LBP in the past 12 months are more likely to be recurrent fallers [23]. Since falls is the leading cause of persistent pain, disability, and mortality among seniors [36, 237], physicians and nursing home workers should assess fall risks of older adults with LBP [238] and refer them for fall prevention intervention, if necessary.

Pain medications

The American Geriatrics Society has published recommendations on pain management of geriatric patients with nonmalignant pain. In particular, a standing order of analgesic (e.g., acetaminophen) is recommended for older adults with chronic pain so that they can have a steady concentration of analgesic in the blood stream [239]. Tramadol is recommended to be prescribed with caution for patients with a known risk of seizure (e.g., stroke, epilepsy, and head injury) or for those taking medications that may lower seizure threshold (e.g., neuroleptics and tricyclics) [239]. In addition, the guideline also suggests that if acetaminophen cannot control pain, non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., COX-2 therapy or non-acetylated salicylates) may be used as adjunct therapy [239]. However, since some traditional NSAIDs may cause gastrointestinal upset, clinicians are recommended to prescribe non-acetylated salicylates for older patients with peptic ulcer and gastrointestinal bleeding. Although there is no ideal dose for opioid prescription among older adults with LBP, the effective dose should be carefully titrated to fit individual needs. To attain better pain relief with minimal side effects secondary to a high dose of a single medication, it is recommended to concurrently use two or more pain medications with different mechanisms of action or different drug classes (e.g., opioid and non-opioid analgesics). It is noteworthy that opioid (e.g., codeine) may increase the risk of falls and other drug-related adverse effects (e.g., depression, nausea, tachycardia, seizure, or falls [240, 241]) in opioid-naïve older patients during the opioid initiation period (i.e., within the first 3 months) or during the use of long-acting opioids [242, 243]. Therefore, specific education and caution should be given to these patient groups.

In addition, because older patients with chronic LBP are commonly associated with depression or anxiety, it is not uncommon for them to take antidepressants (e.g., serotonin reuptake inhibitors) or benzodiazepines. Since some of these psychoactive drugs may compromise their memory, cognition, alertness and motor coordination [244, 245], special care should be given to these patients to minimize their risks of falls, hip fractures, or road traffic accidents [246]. For instance, concurrent prescription of tramadol and the selective serotonin reuptake inhibitor (an antidepressant) may increase the risk of serotonin syndrome (e.g., hyperthermia, agitation, diarrhea, tachycardia, and coma) that may lead to sudden death [247, 248]. If patients have an elevated risk of opioid overdose (e.g., alcoholism [249], a history of opioid overdose/drug abuse [250], concurrent consumption of benzodiazepine or sedative hypnotics [251], or poor compliance to opiate medications [252]), they should undergo an overdose risk assessment, a urine drug abuse screening prior to opioid prescription, an education on drug overdose, and frequent clinical follow-up so as to mitigate their risk [253]. Further, physicians can prescribe naloxone to these high-risk patients and teach them/their caregivers to use it at emergency. Naloxone is an opiate antidote for neutralizing the toxicity of opioid overdoses [253, 254]. For patients who are taking long-acting opioids (e.g., oxycodone or methadone) or having hepatic or renal dysfunction, they should be reassessed regularly in order to ensure timely tapering/discontinuing of opioids if necessary [253]. Collectively, existing medical guidelines generally recommend low-dose initiation and gradual titration of opioid therapy and constipation prophylaxis, increased awareness of potential interactions among concurrent medications, as well as close monitoring of treatment responses in patients. It is necessary to provide updated education to health-care providers so as to optimize pain management for older patients with chronic pain.

Other conservative treatments

Although analgesics are the first line treatment for older people with LBP, older people with LBP (especially those with a prolonged history of LBP) may require other conservative treatments to mitigate pain and to restore function. Growing evidence has indicated that some, but not all, conservative treatments can benefit older people with LBP [255, 256].

While the efficacy of various physiotherapy modalities in treating older people with LBP remains controversial [256], a recent meta-analysis has highlighted that Tai Chi, a mind-body exercise therapy, is an effective intervention for older patients with chronic pain (including LBP, osteoarthritis, fibromyalgia, and osteoporotic pain) as compared to education or stretching [255].

Importantly, in addition to pain relief, various systematic reviews on Tai Chi have revealed promising outcomes in improving balance [257], fear of falling [258], lower limb strength [259], physical function [260], hypertension [261], cognitive performance [262], and depression [263] in seniors as compared to no treatment or usual care. Given the high frequency of physical and psychological comorbidity among older adults (e.g., depression, hypertension, and osteoarthritis), Tai Chi appears to be a viable LBP treatment option for older adults with LBP. Future studies should determine the dose response of Tai Chi in treating older people with LBP in community and institutional settings.

Lumbar surgery

Surgical intervention is indicated for older people only if there is a definite diagnosis of lumbar pathology (e.g., degenerative LSS, cauda equine syndrome, or spinal tumor) that needs to be treated by surgery or that is unresponsive to conservative intervention. While there are many different lumbar surgical interventions, the objective of these approaches is to minimize compression of neural tissues and/or enhance spinal stability. Decompression surgery (i.e., laminectomy, laminotomy, and discectomy) is used to partially or completely remove lumbar structures that are impinging neural tissues [264, 265]. Recent evidence suggests that minimally invasive spine surgery techniques have higher success rate than open lumbar decompression surgery [266].

Unlike decompression surgery, spinal fusion surgery utilizes bone grafts (autograft or allograft) or surgical devices to fuse adjacent vertebrae anteriorly, posteriorly, or circumferentially. Such surgery immobilizes the spinal motion segment, in theory removes key pain generating sources and eliminates intersegmental movement of vertebrae that may compress neural structures in order to alleviate symptoms [267]. In general, both simple and complex spinal fusion surgeries are associated with a higher risk of major complications and postoperative mortality as compared to decompression surgery [264]. While decompressive laminectomy/laminotomy with or without spinal fusion is a common surgical intervention for older patients with degenerative LSS [268], isolated decompression without spinal fusion is a preferred choice for older patients with lumbar degenerative spondylolisthesis without severe LBP/instability [269].

However, two recent randomized controlled trials have reported conflicting results regarding the effectiveness of decompression surgery plus spinal fusion versus decompression surgery alone in treating patients with LSS and degenerative spondylolisthesis [270, 271]. Decompression and spinal fusion are also indicated for patients with symptomatic degenerative lumbar scoliosis [272, 273] although these procedures may increase the risk of complications in older adults (especially those with comorbidities) [268, 272, 274276]. Recently, disc arthroplasty has been adopted to restore the mobility of an intervertebral joint by replacing a degenerative disc with an artificial disc and minimizing the risk of adjacent segment degeneration/disease [277]. Although current evidence notes the safety and efficacy of such intervention for indication for cervical spine pathology in comparison to conventional interbody fusion procedures, outcomes for lumbar disc disorders remain under further evaluation.

Percutaneous transpedicular vertebroplasty and balloon kyphoplasty are two minimally invasive techniques for treating patients with painful osteoporotic vertebral compression fracture [278]. These procedures involve the injection of a small amount of bone cement into the collapsed vertebral body to alleviate excruciating pain and stabilize the fractured vertebral body [279]. However, individual studies have found that these procedures may heighten the risk of new vertebral fractures at the treated or adjacent vertebrae, and other complications (e.g., cement leakage into the lungs, veins, and the vertebral body) [280283]. However, a recent meta-analysis reveals that these vertebral augmentation procedures may attenuate pain and correct deformity of patients with osteoporotic vertebral compression fractures without increasing the risk of complications or new vertebral fractures along the spine [278].

In addition, the past decade alone has seen a significant interest in the concept of sagittal alignment and balance with respect to the preoperative planning and predictive outcome analyses of patients with various lumbar spinal disorders and spinal deformities [284, 285]. Novel imaging software has been developed to quantify such parameters, such as pelvic incidence and tilt, and sacral slope, in a semi-automatic fashion [286, 287]. Numerous studies have noted the clinical utility assessing spinal alignment/balance [288292] a field that continues to gain widespread momentum and motivate future research.

Like conservative LBP treatments, some patients may experience persistent LBP (with or without sciatica) even after spinal surgery. The reasons for the failed back surgery syndrome (FBSS) may be ascribed to technical failure, incorrect selection of surgical patients, surgical complications, or related sequelae [267]. Additionally, since spinal surgery may alter the load distribution at vertebral structures adjacent to the operated segments (e.g., sacroiliac joint), this may result in the adjacent segment disease and pain. Because patients with FBSS are unlikely to benefit from revision surgery, spinal cord stimulation has been suggested to manage pain in these patients. Specifically, spinal cord stimulation involves the placement of electrodes into the epidural space and the generation of electrical current by a pulse generator placed subcutaneously. Studies have noted that there is fair evidence to support moderate effectiveness of spinal cord stimulation in attenuating persistent radicular pain of appropriately selected patients with FBSS although device-related complications are also common [267].

It is noteworthy that while surgical intervention may benefit some patients with LBP, clinicians should weigh the risks and benefits of surgery for each individual patient. A recent Cochrane review summarized the evidence regarding the effectiveness of surgical and conservative treatments for patients with LSS [293]. Two of the five included randomized controlled trials reported that patients undergoing spinal decompression with or without fusion had no significant difference in pain-related disability (measured by Oswestry Disability Index) from those receiving multi-modal conservative care at 6 and 12 months although the decompression group demonstrated improved disability at 24 months [294, 295]. Similarly, a small-scale included study found no significant difference in pain outcomes between decompression and usual non-surgical care (bracing and exercise) at 3 months, and 4- and 10-year follow-ups [296].

Another included study revealed that minimally invasive mild decompression was no better than epidural steroid injections in improving Oswestry Disability Index scores at 6 weeks although decompression had significantly better pain reduction but less improvement in Zurich Claudication Questionnaire scores [297]. Conversely, an included trial found that an interspinous spacer was significantly better than usual non-operative care in reducing symptoms and restoring physical function at 6 weeks, and 6 and 12 months [298]. Regardless of the treatment effects, approximately 10 to 24% of participants experienced peri or postoperative complications (e.g., lesion to the dural sac, hematoma, infection, spinous process fracture, respiratory distress, coronary ischemia, stroke, and even death secondary to pulmonary edema) while no side effect was documented for any conservative treatments [293]. Given above, back surgery should be considered carefully for high-risk patients (e.g., older adults with medical comorbidity). High-quality randomized controlled trials are warranted to compare the effectiveness of surgical versus nonsurgical interventions for older patients with LSS.

Future research

While anecdotal evidence and clinical experience suggest that older people appear to have higher rates of LBP with definite pathology (e.g., vertebral osteomyelitis, degenerative spondylolisthesis, and DNDLS), only a few studies have properly evaluated this issue. Given this knowledge gap, future research should quantify the prevalence of various LBP diagnoses so that health care resources can be better allocated to effectively manage the epidemic of LBP in the older population.

Although self-report of LBP is the gold standard for evaluating subjective pain experience, some patients with cognitive impairment may be unable to effectively verbalize their pain. Clinicians (especially those working in the geriatric field) should improve their competence in assessing nonverbal pain expression in patients with cognitive impairment. While multiple observational pain assessment scales have been developed, there is no consensus on the use of a particular assessment tool. Different clinical guidelines have recommended different scales [223, 225]. Given the rapid development and validation of different observational scales in the last decade, it is necessary to update existing guidelines on this issue.

While the scores of several observational pain behavior assessment tools (e.g., the Abbey Pain Scale and Pain Assessment in Advanced Dementia) have been found to be closely related to self-report of pain [299, 300], there is a paucity of research on the interpretation of scale/subscale scores in relation to pain or other psychological comorbidity (e.g., depression). Future studies should establish this relation. Further, most of the existing behavioral observational pain scales have only been validated in the nursing home setting. Future studies are warranted to compare various existing scales and evaluate their responsiveness and sensitivity to changes in pain following treatments in different settings, which can identify best assessment tools for different settings.

Since recent findings suggest that facial expression can provide many useful indirect information of pain, training health-care providers on the recognition and interpretation of facial expression of pain may improve the accuracy and reliability of pain assessment among patients with dementia. Importantly, future studies should adopt computer vision technology to develop automatic, real-time assessment of pain-related facial expression so as to facilitate the evaluation of pain condition in non-communicable patients with LBP [301].

Currently, clinical assessments of LBP among older adults rely heavily on self-report or surrogate report of LBP or manual physical assessments. With recent advances in technology, clinicians can use reliable novel objective measurements (e.g., mechanical spinal stiffness assessments [302304], ultrasonic measurements of paraspinal muscles [305], advanced medical imaging [306, 307], or genetic analysis [308]) to examine patients at affordable costs. Given that age-related physical changes (e.g., sarcopenia or fatty infiltration of paraspinal muscles) in older adults may worsen LBP-related physical changes, the adoption of validated objective measurements may enhance the reliability and sensitivity in detecting physical deficits or monitoring posttreatment improvements of LBP in older adults. For example, ultrasonography may be used to quantify atrophy of lumbar multifidus that can guide clinical treatments (e.g., spinal stabilization exercises). Likewise, computerized spinal stiffness tests can be used to identify patients with LBP who are likely to benefit from spinal manipulation [309].

Novel yet more sensitive imaging, such as chemical exchange saturation transfer, T2 mapping, T1-rho, ultra-short time-to-echo and sodium MRI, may identify the pain-generating source allowing for more targeted therapies [50, 310]. Furthermore, a refinement of some of the imaging phenotypes (e.g., disc degeneration, endplate changes, facet joint changes, paraspinal muscle integrity, and sagittal alignment/balance) or the utility of “phenomics” may further aid in proper diagnosis, management options, and the potential development of novel therapeutics. Knowledge gained from such approaches may enhance the exploration of new pathways of pain and potential treatment options in appropriate animal models. Moreover, the role of pain genetics and its actual utility toward the management of LBP in older individuals needs to be further explored. Taken together, while novel technology may gather new information from patients with LBP, clinicians should integrate these objective outcomes with other clinical findings in order to make proper diagnosis and clinical decision.

Given the multifactorial causes of LBP in older adults, it is necessary to consider the entire spectrum of “omic” approaches (e.g., genomics, metabolomics, phenomics, etc), ethnic variations, and all aforementioned risk factors in order to derive appropriate predictive models for future LBP development or severity of pain. These models can then be used to develop cost-effective and personalized LBP intervention for older adults.


Although LBP is ubiquitous among older adults, the dearth of literature on the trajectories of LBP, determinants of chronic LBP, and effective LBP managements in older adults highlights the research gaps in this area. Given that multiple factors (e.g., dementia, psychiatric and physical comorbidities, maladaptive coping, and age-related physical and psychosocial changes) can modify the LBP experience in older adults, clinicians should incorporate comprehensive subjective, observational, and physical examinations, as well as proxy reports to make accurate diagnosis. For patients with persistent LBP, medical imaging may be ordered to rule out malignant causes of pain. To minimize undertreatment of older adults with LBP, it is necessary to recognize the presence of LBP and to titrate pain medications in accordance with individual needs. Through understanding various factors contributing to severe/chronic LBP in older adults, timely and proper treatment strategies can be formulated. In addition, with the expansive understanding of “omic” technologies, study designs, and findings, new pathways of pain may be identified and novel therapeutics may be developed. As such, it is with a hope that with the understanding of pain being broadened and deepened, the management of older patients with LBP may eventually become more personalized or precise and outcomes optimized, leading to a healthier and productive society.