Benny Katz

An interdisciplinary expert consensus statement on assessment of pain in older persons

This paper represents an expert-based consensus statement on pain assessment among older adults. It is intended to provide recommendations that will be useful for both researchers and clinicians. Contributors were identified based on literature prominence and with the aim of achieving a broad representation of disciplines. Recommendations are provided regarding the physical examination and the assessment of pain using self-report and observational methods (suitable for seniors with dementia). In addition, recommendations are provided regarding the assessment of the physical and emotional functioning of older adults experiencing pain. The literature underlying the consensus recommendations is reviewed. Multiple revisions led to final reviews of 2 complete drafts before consensus was reached.

Pain in older persons

Chronic pain is more prevalent in older persons than in young adults. In this review the physiological, pathological, and psychological reasons for altered pain sensibility in older persons are explored and strategies for the management of pain in older persons described. The evidence suggests that altered physiology of peripheral and central pain mechanisms combine with psychological attitudes, such as stoicism and reluctance to confirm the presence of pain, to raise pain threshold. However, once pain is experienced, older persons describe the same severity, quality, and psychological disturbance as younger persons. There is some evidence to suggest that the complaint of pain in the presence of pathology is reported less often in older persons. On the other hand, the presence of persistent or recurrent clinical pain may have a greater impact on the psychological, social, and physical function of older adults. It is also clear, however, that further empirical studies are required in order to delineate the...

The impact of dementia on the pain experience

&NA; Advancing age is associated with an increased risk of illness. Investigating the influence of ageing on the experience of pain must take account of this association, as well as the impact of past experience of life. Dementia, which is almost exclusively restricted to older people, is an illness where the effects of past experience and future life anticipation are severely curtailed. The influence of dementia on the experience of pain has received little attention and many questions remain unanswered. This review draws upon this literature to describe current knowledge of the area. Suggestions for further research are made.

The aged care pain chart : an innovative approach to assessing, managing and documenting pain in older people.

This article presents the development and initial testing of a comprehensive pain chart for the assessment, management and documentation of pain in older people in subacute and residential aged care. The pain chart was developed from existing assessment scales and pain indicators, and is targeting needs of older people in residential care and geriatric hospital settings with high prevalence of cognitive impairments. The chart is based on self‐report of pain but allows for observation of pain‐related behaviours for those unable to report pain. The chart consists of one evaluative and one documentation dimension, and was evaluated by a group of clinicians in geriatric hospital care (n = 15) and residential aged care (n = 6). The chart was found to be content valid, informative and easy to use, facilitating clinical assessments and monitoring, and assisting visual readings of patients’ temporal pain trends.

Management of Chronic Nonmalignant Pain in the Elderly

A multidisciplinary pain management clinic for older persons was established in Melbourne, Australia, during 1988. Areas of clinical expertise represented in the clinic include medicine (neurology, geriatric medicine), nursing, psychology, physiotherapy, occupational therapy, and pharmacy. In this chapter, we outline the rationale for, and function of, the clinic, describe the characteristics of referred patients, and detail clinical outcomes according to measures of pain, mood, and activity. In general, patients referred to the clinic improve according to these measures. The rationale for pain management clinics specifically for the elderly is discussed, and problems associated with long-term audit of patients in this setting are outlined.

Survey of Australasian geriatricians' satisfaction with, and preferences for, continuing professional development.

Continuing professional development (CPD) is an obligation for all Australasian geriatricians; however, there are no systematic data regarding Australian and New Zealand geriatricians’ satisfaction with, and preferences for, CPD.

Innovations in Aged Care: The aged care pain chart: An innovative approach to assessing, managing and documenting pain in older people

This article presents the development and initial testing of a comprehensive pain chart for the assessment, management and documentation of pain in older people in subacute and residential aged care. The pain chart was developed from existing assessment scales and pain indicators, and is targeting needs of older people in residential care and geriatric hospital settings with high prevalence of cognitive impairments. The chart is based on self‐report of pain but allows for observation of pain‐related behaviours for those unable to report pain. The chart consists of one evaluative and one documentation dimension, and was evaluated by a group of clinicians in geriatric hospital care (n = 15) and residential aged care (n = 6). The chart was found to be content valid, informative and easy to use, facilitating clinical assessments and monitoring, and assisting visual readings of patients’ temporal pain trends.

Multivitamin supplement interaction with warfarin therapy

We have recently completed an audit in the secondary prophylaxis of osteoporotic fractures in our orthogeriatric service. Counties Manukau District Health Board serves a population of nearly half a million with a busy orthopaedic service and a well-established orthogeriatric service. The mainstay of treatment of osteoporosis is bisphosphonates, alendronate in particular; however, few compliance data are available. The aims of our audit included assessing the efficacy of our initiative of identifying those eligible for starting alendronate early in their stay and the number of patients compliant with treatment at 2 years.

Chronic pain medication management of older populations: Key points from a national conference and innovative opportunities for pharmacy practice

Objective: Inappropriate use of pain medication has serious consequences for older populations. Experts in the field have noted an increase in opioid prescriptions, and opioid‐related hospitalisations and deaths among this vulnerable population. In the pursuit of educating pharmacists, physicians, allied healthcare professionals, researchers, academics and the public facing the challenges of chronic pain medication management, ‘The Inaugural Monash University School of Public Health and Preventive Medicine (SPHPM) Best Practice in Chronic Pain Medication Management Day Conference’ was held in December 2016 at the Alfred Medical Research and Education Precinct (Melbourne, Australia). Methods: Fifteen experts presented on aspects of chronic pain epidemiology and current analgesic use in older Australians, and discussed current practice and associated challenges. Results: Presenters highlighted the dramatic increase in opioid prescribing, development of tolerance and withdrawal symptoms, problems with abuse and addiction, increased risk of death from overdose or suicide, potentiation of sedative effects with concurrent use of anxiolytics/hypnotics, and medication diversion. Conclusions: Pharmacists are very accessible to patients and are crucial members of medication management teams. They have the necessary medication expertise to review medication regimens and provide patient education. Towards addressing chronic pain medication management of older populations, pharmacists can contribute in several ways, such as being aware of relevant guidelines and completing further training, contributing to policy and guideline development, participating in multidisciplinary panels, working groups and pain management teams, collaborating on research projects, and educating the community. With regards to opioid medication management, pharmacists are in an ideal position to: monitor prescription dispensing and potential misuse, provide education about overuse, and, if appropriate, provide access to naloxone. In order to fulfil these roles and responsibilities, allied healthcare professionals should be educated and informed, and opportunities for continuing professional education should be available and utilised. Pharmacists should have the necessary knowledge and skills to optimise chronic pain management, and to both deliver and inform policies and guidelines on pharmacological management of chronic pain in older people.

Comment On: Geriatricians: The Super Specialist

To the Editor: In a recent publication, John Morley highlights how geriatric medicine has improved the quality of life of older persons through the development of wide ranging interprofessional programs. Despite evidence that geriatricians are the most satisfied of physicians and enormous demand for geriatricians that the aging of the population is bringing about, there has been a decline in board-certified geriatricians in the United States since 1996. Morley proposes a number of strategies to reverse this trend, including electronic referral systems; advertising on prime time television, radio, and social media; and a return to a 2-year fellowship program. Faced with a similar shortfall of geriatricians and recruitment of trainees into the geriatric medicine program in Victoria, Australia, the Australian and New Zealand Society for Geriatric Medicine adopted a different approach. All stakeholders involved in specialist training in Victoria agreed to collaborate to form a statewide geriatric medicine training program. Rather than competing for a limited number of trainees, the focus shifted to expanding the number of trainees. All hospitals agreed to release trainees for half a day per week for statewide training and other educational activities that could be delivered at a higher standard than any single hospital could provide. Professional-quality training was embedded in the scientific curriculum. Satisfied trainees became ambassadors for recruitment of junior doctors into the 3-year training program. The number of trainees in Victoria increased from 26 in 2007 to 89 in 2017. The number of specialist geriatricians in Victoria, with a population of 6 million people, increased from 99 to 209 over this time. The model of the Victorian Geriatric Medicine Training Program has now been successfully adopted in other Australian states and also by other specialties that had been experiencing difficulty recruiting.