Bruce A. Ferrell

The management of persistent pain in older persons

Pain is an unpleasant sensory and emotional experience. 1 Pain is a complex phenomenon derived from sensory stimuli or neurologic injury and modified by individual memory, expectations, and emotions. 2 Pain is usually associated with injury or a pathophysiologic process that causes an uncomfortable experience and is usually described in such terms. Although there are no objective biologic markers of pain, an individual’s description and selfreport usually provides accurate, reliable, and sufficient evidence for the presence and intensity of pain. 3 Persistent pain can be defined as a painful experience that continues for a prolonged period of time that may or may not be associated with a recognizable disease process. The terms persistent and chronic are often used interchangeably in the medical literature. Unfortunately for many elderly persons, chronic pain has become a label associated with negative images and stereotypes often associated with longstanding psychiatric problems, futility in treatment, malingering, or drug-seeking behavior. The term persistent pain may foster a more positive attitude by patients and professionals for the many effective treatments that are available to help alleviate suffering. 4 The clinical manifestations of persistent pain are commonly multifactorial. Because of the complex interplay among these factors across several domains (physiologic, psychologic, and social), discriminating which factors are most important for the purpose of treatment can be very challenging. Further complicating this task is the fact that pain expression and hence the importance of specific factors commonly vary, not only across individuals but also over time in one individual. Elderly persons have been defined by demographers, insurers, and employers as those aged 65 years and over. In healthcare discussions, the elderly persons often described are those who are most frail, with health and disability problems typically encountered in the older population. By age 75 many persons exhibit some frailty and chronic illness. In the population above age 75, morbidity, mortality, and social problems rise rapidly, resulting in substantial strains on the healthcare system and societal safety nets. This group represents the fastest growing segment of the total population. 5 The greatest challenges in geriatric medicine are represented by the oldest, sickest, and most frail patients with multiple medical problems and few social supports. The guideline panel focused its attention on this group as it prepared this update. Persistent pain is common in older people. 6 A Louis Harris telephone survey found that one in five older Americans (18%) are taking analgesic medications regularly (several times a week or more), and 63% of those had taken prescription pain medications for more than 6 months. 7 Older people are more likely to suffer from arthritis, bone and joint disorders, back problems, and other chronic conditions. This survey also found that 45% of patients who take pain medications regularly had seen three or more doctors for pain in the past 5 years, 79% of whom were primary care physicians. Previous studies have suggested that 25% to 50% of community-dwelling older people suffer important pain problems. 6,8,9 Pain is also common among nursing home residents. 10,11 It has been estimated that 45% to 80% of them have substantial pain that is undertreated. Studies of both the community-dwelling and nursing home populations have found that older people commonly have several sources of pain, which is not surprising, as older patients commonly have multiple medical problems. A high prevalence of dementia, sensory impairments, and disability in this population make assessment and management more difficult. The consequences of persistent pain among older people are numerous. Depression, anxiety, decreased socialization, sleep disturbance, impaired ambulation, and increased healthcare utilization and costs have all been found to be associated with the presence of pain in older people. Although less thoroughly described, many other conditions are known to be worsened potentially by the presence of pain, including gait disturbances, slow rehabilitation, and adverse effects from multiple drug prescriptions. 12 Psychosocial factors affect and are affected by pain in older patients. It has been shown that older adults with good coping strategies have significantly lower pain and This guideline was developed and written under the auspices of the American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons and approved by the AGS Board of Directors on April 8, 2002.

Pain in cognitively impaired nursing home patients.

Pain is an understudied problem in frail elderly patients, especially those with cognitive impairment, delirium, or dementia. The focus of this study was to describe the pain experienced by patients in skilled nursing homes, which have a high prevalence of cognitive impairment. A random sample of 325 subjects was selected from ten community skilled nursing homes. Subjects underwent a cross-sectional interview and chart review for the prevalence of pain complaints, etiology, and pain management strategies. Pain was assessed using the McGill Pain Questionnaire and four unidimensional scales previously utilized in younger adults. Thirty-three percent (33%) of subjects were excluded because they were either comatose (21%), non-English speaking (3.7%), temporarily away (sick in hospital) (4.3%), or refused to participate (3.7%). Of 217 subjects in the final analysis, the mean age was 84.9 years, 85% were women, and most were dependent in all activities of daily living. Subjects demonstrated substantial cognitive impairment (mean Folstein Mini-Mental State exam score was 12.1 +/- 7.9), typically having deficits in memory, orientation, and visual spatial skills. Sixty-two percent reported pain complaints, mostly related to musculoskeletal and neuropathic causes. Pain was not consistently documented in records, and pain management strategies appeared to be limited in scope and only partially successful in controlling pain. None of the four unidimensional pain-intensity scales studied in this investigation had a higher completion rate than the Present Pain Intensity Scale of the McGill Pain Questionnaire (65% completion rate). However, 83% of subjects who had pain could complete at least one of the scales. We conclude that cognitive impairment among elderly nursing home residents present a substantial barrier to pain assessment and management. Nonetheless, most patients with mild to moderate cognitive impairment can be assessed using at least one of the available bedside assessment scales.

Pain in the Nursing Home

Pain is an understudied problem in geriatric medicine and especially among nursing home residents. The focus of this study was to describe the scope of the problem of pain in a long‐term care facility. Ninety‐seven subjects from a 311‐bed multilevel teaching nursing home were interviewed, and charts were reviewed for pain problems and management strategies. Functional status, depression, and cognitive impairment were also evaluated. Results indicate that 71% of residents had at least one pain complaint (range, 1–4). Of subjects with pain, 34% described constant (continuous) pain and 66% described intermittent pain. Of 43 subjects with intermittent pain, 51% described pain on a daily basis. Major sources of pain included low back pain (40%), arthritis of appendicular joints (24%), previous fracture sites (14%), and neuropathies (11%). Moderately strong correlations were found between pain and infrequent attendance at recreational and social activities (r = .50). However, little correlation was observed between pain and the Yesavage Depression Scale, the Folstein Mini‐Mental State Scale, or basic ADLs measured by the Katz Scale. Pain‐management strategies consisted of analgesic drugs, physical therapy, and heating pads. Only 15% of patients with pain had received medication within the previous 24 hours. The findings suggest that pain is a major problem in long‐term care. Strategies for pain management appear to be limited in scope and application in this setting. Important barriers were identified that influence the reporting and management of pain in this setting.

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.

Fatigue in an Older Population

OBJECTIVES: Fatigue is a common symptom that has not been studied well in the older populations. The purpose of this pilot study was to examine the epidemiology of fatigue symptoms in relation to demographic and medical characteristics of older patients in a long‐term care setting.

The geriatric Pain measure : Validity, reliability and factor analysis

BACKGROUND: Pain is a multidimensional experience that should be evaluated beyond an estimate of intensity. A multidimensional pain measure has not been developed for older persons undergoing comprehensive geriatric assessment.

Development and implementation of a pain education program

Pain is a significant problem for cancer patients and is of particular concern for the elderly. This article reports on the development and implementation of a pain management educational intervention for elderly cancer patients and their family caregivers. This patient education program was developed within a research study funded by the American Cancer Society.

The Quality of Medical Care Provided to Vulnerable Older Patients with Chronic Pain

Objectives: To assess the quality of chronic pain care provided to vulnerable older persons.

Pressure Ulcers Among Patients Admitted To Home Care

CONTEXT: Pressure ulcers are an understudied problem in home care.

Adherence to Pressure Ulcer Prevention Guidelines: Implications for Nursing Home Quality

OBJECTIVES: This study aims to assess overall nursing home (NH) implementation of pressure ulcer (PU) prevention guidelines and variation in implementation rates among a geographically diverse sample of NHs.