Lucia Gagliese

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.

The measurement of postoperative pain: a comparison of intensity scales in younger and older surgical patients.

&NA; The psychometric properties of pain intensity scales for the assessment of postoperative pain across the adult lifespan have not been reported. The objective of this study was to compare the feasibility and validity of the Numeric Rating Scale (NRS), Verbal Descriptor Scale (VDS), and Visual Analog Scale (horizontal (VAS‐H) and vertical (VAS‐V) line orientation) for the assessment of pain intensity in younger and older surgical patients. At 24 h following surgery, 504 patients, who were receiving i.v. morphine via patient‐controlled analgesia, completed the pain intensity measures and the McGill Pain Questionnaire (MPQ) in a randomized order. They were asked which scale was easiest to complete, the most accurate measure, and which they would most prefer to complete in the future, as an index of face validity. The amount of opioid self‐administered was recorded. Age differences in postoperative pain intensity were not found. However, elderly patients obtained lower MPQ scores and self‐administered less morphine than younger people. Psychometric analyses suggested that the NRS was the preferred pain intensity scale. It had low error rates, and higher face, convergent, divergent and criterion validity than the other scales. Most importantly, its properties were not age‐related. The VDS also had a favourable profile with low error rates and good face, convergent and criterion validity. Finally, difficulties with VAS use among the elderly were identified, including high rates of unscorable data and low face validity. Its use with elderly postoperative patients should be discouraged.

Pathways to distress: The multiple determinants of depression, hopelessness, and the desire for hastened death in metastatic cancer patients

We tested a model in which psychosocial and disease-related variables act as multiple protective and risk factors for psychological distress in patients with metastatic cancer. We hypothesized that depression and hopelessness constitute common pathways of distress, which mediate the effects of psychosocial and disease-related factors on the desire for hastened death. This model was tested on a cross-sectional sample of 406 patients with metastatic gastrointestinal or lung cancer recruited at outpatient clinics of a Toronto cancer hospital, using structural equation modeling. The results supported the model. High disease burden, insecure attachment, low self-esteem, and younger age were risk factors for depression. Low spiritual well-being was a risk factor for hopelessness. Depression and hopelessness were found to be mutually reinforcing, but distinct constructs. Both depression and hopelessness independently predicted the desire for hastened death, and mediated the effects of psychosocial and disease-related variables on this outcome. The identified risk factors support a holistic approach to palliative care in patients with metastatic cancer, which attends to physical, psychological, and spiritual factors to prevent and treat distress in patients with advanced disease.

Longitudinal Study of Depressive Symptoms in Patients With Metastatic Gastrointestinal and Lung Cancer

PURPOSE Although early intervention is increasingly advocated to prevent and relieve distress in patients with metastatic cancer, the risk factors for such symptoms and their trajectory are not well established. We therefore conducted a longitudinal study to determine the course and predictors of depressive symptoms. PATIENTS AND METHODS Patients (N = 365) with metastatic gastrointestinal or lung cancer completed measures of physical distress, self-esteem, attachment security, spiritual well-being, social support, hopelessness, and depression at baseline; physical distress, social support, hopelessness, and depression were subsequently assessed at 2-month intervals. RESULTS Of the sample, 35% reported at least mild depressive symptoms, with 16% reporting moderate to severe depressive symptoms that persisted in at least one third of such individuals. Moderate to severe depressive symptoms were almost three times more common in the final 3 months of life than > or = 1 year before death. Predictors of depressive symptoms included younger age, antidepressant use at baseline, lower self-esteem and spiritual well-being, and greater attachment anxiety, hopelessness, physical burden of illness, and proximity to death. The combination of greater physical suffering and psychosocial vulnerability put individuals at greatest risk for depression. CONCLUSION Depressive symptoms in advanced cancer patients are relatively common and may arise as a final common pathway of distress in response to psychosocial vulnerabilities, physical suffering, and proximity to death. These findings support the need for an integrated approach to address emotional and physical distress in this population and to determine whether early intervention may prevent depression at the end of life.

Pain and Aging: The Emergence of a New Subfield of Pain Research

UNLABELLED The pain and aging subfield has grown dramatically, including a 6-fold increase in publications over the last 2 decades. This subfield is based on the assumption that pain in older and younger adults differs in clinically and theoretically significant ways. If this were not the case, data from younger groups could be generalized to older persons, and the subfield would not be needed. This article considers the evidence for this assumption. Possible interpretations of the discrepant findings of age-related increases, decreases and stability in pain, including methodological limitations, challenges of gerontological research, and the possibility of nonuniform age-related variation, are discussed. Evidence is presented for several unique characteristics of geriatric pain: difficulty using Visual Analog Scales, increased vulnerability to neuropathic pain, decreased vulnerability to acute pain related to visceral pathology, prolonged recovery from tissue and nerve injury, including prolonged hyperalgesia, and differences in the relationships among psychosocial factors important in adjustment to chronic pain. However, without a theoretical framework, it is difficult to integrate these results in a heuristic manner. Further research is needed to elucidate the characteristics of geriatric pain, to examine the mechanisms for age-related patterns, and to develop and test the efficacy of age-tailored interventions. PERSPECTIVE This article reviews the emerging subfield of pain and aging, discusses the interpretation of age-related patterns in pain, and presents several avenues for future research and subfield development. This could contribute to the continued growth of this subfield.

Age differences in postoperative pain are scale dependent: a comparison of measures of pain intensity and quality in younger and older surgical patients

&NA; As the population ages, research into the assessment of postoperative pain in older patients is urgently needed. The reliability and validity of most pain scales for the assessment of acute postoperative pain in the elderly remain to be demonstrated. The present study reports the analysis of age‐related patterns on three pain scales (McGill Pain Questionnaire, MPQ; Present Pain Intensity, PPI; and Visual Analog Scale, VAS) completed by younger (n=95, mean age=56.4±5.8 years) and older (n=105; mean age=66.8±2.7 years) men following radical prostatectomy. All patients received intravenous morphine via patient‐controlled analgesia (PCA) throughout the study. On the first 2 postoperative days (POD), patients completed the pain scales and PCA opioid intake was recorded. An interaction was found between amount of opioid self‐administered and POD. In both groups, less opioid was administered on POD 2 than POD 1, but the decrease over time was greater in younger than older men. On both PODs, older men self‐administered less opioid than younger men. Age differences in pain were dependent on the pain scale used. Older men had significantly lower scores than younger men on the MPQ and PPI but there were no differences on the VAS. Several age differences in the psychometric properties of the scales were evident. On both PODs, the correlation between VAS and MPQ scores was significantly lower in the older than younger group. POD effect sizes did not differ between the scales or age groups suggesting that all three scales have comparable sensitivity within an age group. However, the different results between the scales for the effect of age suggests that the VAS is not sufficiently sensitive to detect age differences. Therefore, age differences in postoperative pain are better captured by verbal descriptions of pain qualities than non‐verbal measures of intensity.

Age Is Not an Impediment to Effective Use of Patient-controlled Analgesia by Surgical Patients

BACKGROUND Obstacles to the use of patient-controlled analgesia (PCA) by elderly surgical patients have not been well-documented. Age differences in preoperative psychological factors, postoperative pain and analgesic consumption, treatment satisfaction, and concerns regarding PCA were measured to identify factors important to effective PCA use. METHODS Preoperatively, young (mean age +/- SD, 39 +/- 9 yr; n = 45) and older (mean age +/- SD, 67 +/- 8 yr; n = 44) general surgery patients completed measures of attitudes toward and expectations of postoperative pain and PCA, psychological distress, health opinions, self-efficacy, and optimism. On the first 2 postoperative days, pain at rest and with movement and satisfaction with pain control were assessed using visual analog scales. Daily opioid intake was recorded. When PCA was discontinued, satisfaction and concerns about it were assessed. RESULTS The older patients expected less intense pain (P </= 0.003) and preferred less information about (P </= 0.02) and involvement in (P </= 0.002) health care than young patients. There were no age differences with regard to pain at rest (P </= 0.22) or with movement (P </= 0.68). The older group self-administered less opioid than the young group (P </= 0.0001) and received PCA for more days than the young group (P </= 0.004). The groups did not differ in concerns about pain relief, adverse drug effects, including opioid addiction, and equipment use or malfunction. Satisfaction with PCA was high and did not differ between the groups. CONCLUSIONS Patient-controlled analgesia use was not hindered by age differences in beliefs about postoperative pain and opioids. Younger and older patients attained comparable levels of analgesia and were equally satisfied with their pain control.

Age differences in nociception and pain behaviours in the rat

Much remains to be learned about the effects of ageing on pain. Studies of life-span changes in nociception and pain behaviours in the rat are equivocal making it difficult to draw firm conclusions. This paper reviews the available data and finds that age differences in nociception may be dependent on the pain test employed. Specifically, reflexive responses to nociceptive stimuli do not change with age while there may be no change or a linear decrease with age on more highly organized tests of nociception. Interestingly, age differences in pain behaviours on models of tissue injury and inflammation may not be linear. It is shown that important changes that begin at mid-life in neuroanatomy, neurochemistry and endogenous pain inhibition may be associated with alterations in pain sensitivity. Several testable hypotheses which might encourage future research in this domain are developed throughout this paper.

Age-related differences in the qualities but not the intensity of chronic pain.

Age differences in the experience of chronic pain remain unclear. A serious barrier to progress in the field of pain and aging arises from the lack of data regarding the psychometric properties of pain scales for use with the elderly. The present study was designed to assess age differences in pain intensity and quality and to compare the psychometric properties of the McGill Pain Questionnaire (MPQ) in young and elderly chronic pain patients. Young (n=139, mean age=42.93±9.41 years) and elderly (n=139, mean age=70.12±7.51 years) pain center patients, matched on primary diagnosis or pain location, duration, and sex, completed the MPQ, numeric ratings (0–10) of pain intensity, a Pain Map, and the Hospital Anxiety and Depression Scale (HADS). A Pain Management Index (PMI) score was calculated for each patient. Age differences on the measure of pain qualities were found. The elderly group had significantly lower MPQ total and sensory scores and chose fewer words than the young group. However, there were no significant differences between the groups on numeric ratings of highest, usual, and lowest pain intensity. Similarly, there were no age differences on PMI, Pain Map, or the HADS Depression or Anxiety Subscales. Finally, the latent structure, internal consistency, and pattern of subscale correlations of the MPQ were very similar in the young and elderly groups. Possible explanations for the discrepancy in the pattern of age differences on measures of pain intensity and quality are explored. The implications of this pattern of age differences for basic pain mechanisms and pain management should be given serious empirical attention.

The desire for hastened death in individuals with advanced cancer: a longitudinal qualitative study.

Research is needed on the desire for hastened death (DHD) in the context of advanced cancer in order to address the clinical, ethical, and legal questions that it raises. The goal of the present qualitative study was to understand the experience of the DHD as expressed by individuals with advanced cancer, and to understand how it evolves over time. Participants were 27 ambulatory patients aged 45-82 years with advanced lung or gastrointestinal cancer. Participants were recruited through theoretical sampling from outpatient clinics at a large cancer center in Toronto Canada, and were asked about the DHD in serial, open-ended interviews until the point of death. A total of 54 interviews were analyzed based on the grounded theory method. The experience of the DHD in the context of advanced cancer was found to be subsumed under three distinct categories: i) DHD as a hypothetical exit plan; ii) DHD as an expression of despair; and iii) DHD as a manifestation of letting go. Each category had unique temporal and qualitative characteristics. The identification of these categories may be important to inform future research on the DHD, the criteria for clinical intervention in individuals who express this desire, and the public debate about physician-assisted suicide and euthanasia for individuals with advanced disease.