Keela Herr

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.

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 intensity assessment in older adults: Use of experimental pain to compare psychometric properties and usability of selected pain scales with younger adults

Objectives:To determine: (1) the psychometric properties and utility of 5 types of commonly used pain rating scales when used with younger and older adults, (2) factors related to failure to successfully use a pain rating scale, (3) pain rating scale preference, and (4) factors impacting scale preference. Methods:A quasi-experimental design was used to gather data from a sample of 86 younger (age 25–55) and 89 older (age 65–94) adult volunteer subjects. Responses of subjects to experimentally induced thermal stimuli were measured with the following pain intensity rating scales: vertical visual analog scale (VAS), 21-point Numeric Rating Scale (NRS), Verbal Descriptor Scale (VDS), 11-point Verbal Numeric Rating Scale (VNS), and Faces Pain Scale (FPS). Results:All 5 pain scales were effective in discriminating different levels of pain sensation; however the VDS was most sensitive and reliable. Failure rates for pain scale completion were minimal, except for the VAS. Although age did not impact failure to properly use this pain intensity rating scale, but rather those conditions more commonly associated with advanced age, including cognitive and psychomotor impairment did. The scale most preferred to represent pain intensity in both cohorts of subjects was the NRS, followed by the VDS. Scale preference was not related to cognitive status, educational level, age, race, or sex. Conclusion:Although all 5 of the pain intensity rating scales were psychometrically sound when used with either age group, failures, internal consistency reliability, construct validity, scale sensitivity, and preference suggest that the VDS is the scale of choice for assessing pain intensity among older adults, including those with mild to moderate cognitive impairment.

Comparison of selected pain assessment tools for use with the elderly

p AIN IN THE ELDERLY is receiving increasing attention by researchers and practitioners. Given the potential impact of pain on the elderlys activities and quality of life, it is important that health care providers evaluate a pain complaint carefully. Accurate assessment of clinical pain is critical for evaluation of treatments in controlled studies and for implementation and evaluation of interventions in the care of the elderly. However, little attention has been devoted to determining if tools used to assess pain in adults are valid and reliable with elderly populations. Studies that determine the ability, utility, and practicality of measures to evaluate pain are necessary to assist with decision making when selecting a tool for use with the elderly.

Assessment and measurement of pain in older adults

Although the empiric base is still limited when providing clear directions for pain assessment and management in older adults, it is possible to identify recommendations for guiding practice based on consensus and a developing scientific base to support best practice activities. A brief overview of the epidemiology and consequences of pain is offered, followed by a summary of issues and approaches relevant to pain assessment in older adults. Cohort-specific recommendations for comprehensive pain assessment and measurement based on current evidence are then addressed, including strategies for assessment of pain in cognitively impaired older adults.

Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations.

Individuals who are unable to communicate their pain are at greater risk for under recognition and undertreatment of pain. This position paper describes the magnitude of this issue, defines populations at risk and offers clinical practice recommendations for appropriate pain assessment using a hierarchical framework for assessing pain in those unable to self-report. Nurses have a moral, ethical, and professional obligation to advocate for all individuals in their care, particularly those who are vulnerable and unable to speak for themselves. Just like all other patients, these special populations require consistent, ongoing assessment, appropriate treatment, and evaluation of interventions to insure the best possible pain relief. Because of continued advances and new developments in strategies and tools for assessing pain in these populations, clinicians are encouraged to stay current through regular review of new research and practice recommendations.

Evaluation of the faces pain scale for use with the elderly

OBJECTIVE The specific objective for this research was to determine initial psychometric properties of the Faces Pain Scale (FPS) as a measure of pain intensity for use with the elderly. DESIGN The study was descriptive correlational in nature, with nonrandom sampling. A total sample of 168 community subjects (30-121, depending on task completed), aged 65 or older, participated in the research protocol. To determine the validity, reliability, and scaling properties of the FPS, rating and ranking procedures, placement tasks, and test-retest methods were used. RESULTS Response to six Likert-type items indicated that subjects agreed that the FPS represents pain: however, it is clear that the perception of the meaning of the faces can be influenced by the context in which they are presented. Rank ordering tasks for the individual faces demonstrated near-perfect agreement between the actual expected ranking and the ranking produced by the subjects (Kendalls W = .97, p = .00). When subjects placed individual faces along a 1-m-long red wedge indicating the amount of pain represented by each face, statistically significant separation of the faces in the anticipated equal interval position was demonstrated by the lack of overlap of the 95% confidence intervals when all faces were viewed and positioned simultaneously. However, when subjects placed faces independent of others, the expected placement fell outside the 95% confidence limit for three of the five faces placed. In addition, the actual intervals between the five faces placed by subjects demonstrated substantial variances from the 167 mm expected in several instances. Rating a vividly remembered painful experience about the degree of pain perceived using the FPS initially and again 2 weeks later, the FPS demonstrated strong reproducibility over time with a Spearman rho correlation coefficient of .94 (p = .01). CONCLUSION These results provide preliminary support for the construct validity, strong ordinal properties, and strong test-retest reliability of the FPS with a sample of elderly individuals. The equality of intervals in the FPS has not been fully supported in the older adult, but given the complexity of the task used, the results should not be considered to be refuted. Further evaluation of the FPS with experimental and clinical pain conditions and comparison with other standard pain assessment instruments in the elderly population are warranted.

Recent developments in pain in dementia

Epidemiological studies show that, worldwide, the number of people aged over 65 will increase substantially in the next decades and that a considerable proportion of this population will develop dementia.1 Ample evidence shows that ageing is associated with a high rate of painful conditions, irrespective of cognitive status.2 The number of patients with dementia who will experience painful conditions is therefore likely to increase. A key question relates to whether and how patients with dementia perceive pain. Patients with dementia may express their pain in ways that are quite different from those of elderly people without dementia.3 Particularly in the more severe stages of dementia, therefore, the complexity and consequent (frequent) inadequacy of pain assessment leads to the undertreatment of pain. The most commonly used pain assessment instruments seem to be selected primarily according to the communicative capacity of the patient (self report pain rating scales for communicative patients and observation scales for non-communicative patients) instead of according to two main aspects of pain—the sensory-discriminative and motivational-affective aspects. In particular, the motivational-affective aspects of pain are assessed by observation scales, which should therefore be applied to every patient, irrespective of ability to communicate. Distinction between the sensory-discriminative and motivational-affective aspects of pain is of great clinical relevance, as the motivational-affective aspects are particularly likely to reflect pain that needs treatment.4 Moreover, differentiating between these two aspects of pain in relation to the neuropathology of the various subtypes of dementia provides insight into the basis of the alterations in the pain experiences of elderly people with dementia. Future experimental and clinical studies should not only focus on subtypes of dementia but should go a step further and assess pain in disorders in which pain is already present at a stage without cognitive impairment and during the course …

An epidemiologic analysis of pain in the elderly: the Iowa 65+ Rural Health Study

Despite acknowledgment that pain is likely to be a major problem for many older adults, it is difficult to accurately estimate the frequency of pain problems for this population because of the lack of systematic epidemiological investigation. This article reports a study of the prevalence and nature of pain in a population of 3,097 rural persons 65 years and older (the Iowa 65+ Rural Health Study). Of the subjects, 86% reported pain of some type in the year prior to the interview, and 59% reported multiple pain complaints. Joint pain was the most prevalent site of pain reported, followed by night leg pain, back pain, and leg pain while walking. As reported severity of pain increased, there was a corresponding increase in impact on daily activities.

Complexities of pain assessment in the elderly. Clinical considerations.

Establishing a trusting, caring relationship that acknowledges suffering and demonstrates caring is an important first step toward pain management in the elderly. The content of assessing pain in the elderly is similar to that for younger individuals. However, the source of information, manner and timing of assessment, method, and amount of data collected must be adapted to meet the special needs of the elderly individual. Strategies for assessing pain in the elderly must be adapted for those with sensory, cognitive, or psychomotor deficits. Many tools currently available for assessing pain may be effective when adapted to accommodate these changes. Interpreting reports of pain and pain-related behaviors in the elderly is complicated by myths and misunderstandings commonly held by the elderly and many health professionals. Careful consideration must be given to the meaning of pain or lack of pain report, as well as personal biases, which may influence the interpretation of pain behaviors.