CHAPTER 31 PAIN IN THE OLDER PERSON Ronald Kanner, MD, FAAN, FACP 1. What is meant by “the older person”? Of interest, most medical dictionaries do not give a definition for “old” or “older person.” The International Dictionary of Medicine and Biology, Stedman’s Medical Dictionary, and the Mosby Medical, Nursing, and Allied Health Dictionary omit the word “old” and define “elder” as “sambucus” (the elderberry). The American Association of Retired Persons (AARP) accepts people over the age of 50; most “senior communities” have a minimum age of 55; New York State provides housing help for those over the age of 60. The most commonly used working definition of the older person is over 65. However, most aging studies that began with people 65 and older now have a large cadre of people over 85. New definitions are emerging rather rapidly. “Old” is now generally taken to mean ≥75, and the “old old” is now ≥80. Most physicians, however, see octogenarians who are athletic, fit, and active. 2. Why is it important to address pain in the older person? The over-85 population is proportionally the fastest-growing segment in American society. Approximately 34 million people in the United States are aged 65 or older. This is expected to increase to 70 million by the year 2030. As older patients represent an increasingly larger proportion of the population, their health care needs assume a much greater role. Furthermore, the prevalence of pain in the older person is probably double what it is in younger adults. This number grows even larger in institutionalized older patients. Some of the common painful diseases, such as arthritis and cancer, are also more prevalent in the older patient. Furthermore, relatively few studies address the needs and specific problems of the aged population. 3. How common are pain complaints in the older patient? Acute pain occurs with similar frequency in the older patient as it does in the young. However, the incidence of chronic pain appears to increase up to about age 70. After that, it levels off. Older patients are more likely to experience pain in the major joints, back, legs, and feet. Headaches, in general, appear to be less common in the older patient population than in the young. Of older patients living independently, 20% to 50% percent suffer from pain. The incidence of untreated pain may be as high as 85% in long-term care facilities. 4. An 80-year-old woman complains of pain in both shoulders and hips, as well as a generalized aching feeling. What diagnoses should be considered? Polymyalgia rheumatica is a disease of the older patient characterized by aching pain in the shoulders and hips, along with a general feeling of malaise. The erythrocyte sedimentation rate is elevated (usually >80), and the pain responds readily to low doses of oral steroid medications. This syndrome is sometimes associated with temporal arteritis, which requires much higher doses of steroids and carries the risk of sudden blindness. Although fibromyalgia is usually considered a disease of younger people, rheumatologists have been recognizing it in a progressively older population. Whenever an older person experiences a chronic, diffuse pain syndrome, an underlying metabolic or neoplastic cause should be sought. 5. What are the impediments to accurate pain assessment in the older patient? Pain is a truly subjective phenomenon. Its assessment requires careful, detailed communication between sufferer and health care practitioner. Older patients are more likely to underreport pain than are younger patients, possibly because of their desire to be perceived as “good patients.” In a study of patients with duodenal ulcer or myocardial infarction, older patients reported milder pain than younger patients. They tend to have more faith in the medical system and more respect for physicians. Cognitive impairment, a fairly common problem in the older patient, may render patients unable to use appropriate descriptors for pain. Impaired hearing and vision also may cause communication difficulties. In such cases, behavioral signs can be used to assess pain; however, they are often less accurate than good verbal reports. Although the precise severity of pain may be difficult to assess, even patients with significant cognitive impairment can report the presence of pain. Unfortunately, there are relatively few well-validated scales for the older patient. The verbal and visual analogue scales used in younger patients do not have the same degree of validation in the older person. 6. What impact does chronic osteoarthritis have on quality of life in the older person? Compared to their peers with no chronic illnesses, older patients with osteoarthritis, with and without additional comorbidities, have a significantly worse quality of life. Some of this is due to the pain itself and some is related to analgesia consumption. Interestingly, one study showed that a better quality of life was associated with noncompliance, fewer visits to the physicians, and taking oral nonsteroidal antiinflammatory drugs (NSAIDs). 7. What scales are available for assessment of pain in patients with dementia? The Discomfort Scale for Patients with Dementia of the Alzheimer Type (DS-DAT) is difficult to validate because it was generated from the impressions of nursing staff caring for demented patients. It lists a series of items that, in the staff’s opinion, indicate that a patient is in pain. Examples include noisy breathing, negative vocalization, sad versus content facial expression, frightened facial expression, frown, tense versus relaxed body language, and fidgeting. As its name indicates, the DS-DAT is a discomfort scale and may not assess pain directly. It is unclear whether distress, discomfort, or pain is being assessed. Behavioral methods of pain assessment may be valid for the presence or absence of pain, but they do not assess the intensity of pain. Certain facial expressions are common with intense pain, but they are not necessarily graded responses. 8. Are patients with cognitive impairment capable of using a self-assessment scale? Generally, patients with mild to moderate cognitive impairment can still complete some short self-assessment scales. Up to 30% of severely impaired patients can still complete at least one assessment scale. An attempt should always be made to allow an older patient to report pain in his or her own words and to produce a rating of intensity that can be reassessed. Investigators have recently developed a “pain thermometer” to be used not only for older patients but also for very young patients. 9. Are patients with Alzheimer’s disease likely to report more or less pain than cognitively intact patients? It appears that patients with Alzheimer’s disease tend to experience less intense pain than unaffected patients and may also have less of the affective component associated with pain. However, it is not clear that analgesic intake differs between the groups, and special attention must be paid to the side effects that may occur in a cognitively impaired population. 10. Are NSAIDS safe in older patients? Only gold members can continue reading. 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CHAPTER 31 PAIN IN THE OLDER PERSON Ronald Kanner, MD, FAAN, FACP 1. What is meant by “the older person”? Of interest, most medical dictionaries do not give a definition for “old” or “older person.” The International Dictionary of Medicine and Biology, Stedman’s Medical Dictionary, and the Mosby Medical, Nursing, and Allied Health Dictionary omit the word “old” and define “elder” as “sambucus” (the elderberry). The American Association of Retired Persons (AARP) accepts people over the age of 50; most “senior communities” have a minimum age of 55; New York State provides housing help for those over the age of 60. The most commonly used working definition of the older person is over 65. However, most aging studies that began with people 65 and older now have a large cadre of people over 85. New definitions are emerging rather rapidly. “Old” is now generally taken to mean ≥75, and the “old old” is now ≥80. Most physicians, however, see octogenarians who are athletic, fit, and active. 2. Why is it important to address pain in the older person? The over-85 population is proportionally the fastest-growing segment in American society. Approximately 34 million people in the United States are aged 65 or older. This is expected to increase to 70 million by the year 2030. As older patients represent an increasingly larger proportion of the population, their health care needs assume a much greater role. Furthermore, the prevalence of pain in the older person is probably double what it is in younger adults. This number grows even larger in institutionalized older patients. Some of the common painful diseases, such as arthritis and cancer, are also more prevalent in the older patient. Furthermore, relatively few studies address the needs and specific problems of the aged population. 3. How common are pain complaints in the older patient? Acute pain occurs with similar frequency in the older patient as it does in the young. However, the incidence of chronic pain appears to increase up to about age 70. After that, it levels off. Older patients are more likely to experience pain in the major joints, back, legs, and feet. Headaches, in general, appear to be less common in the older patient population than in the young. Of older patients living independently, 20% to 50% percent suffer from pain. The incidence of untreated pain may be as high as 85% in long-term care facilities. 4. An 80-year-old woman complains of pain in both shoulders and hips, as well as a generalized aching feeling. What diagnoses should be considered? Polymyalgia rheumatica is a disease of the older patient characterized by aching pain in the shoulders and hips, along with a general feeling of malaise. The erythrocyte sedimentation rate is elevated (usually >80), and the pain responds readily to low doses of oral steroid medications. This syndrome is sometimes associated with temporal arteritis, which requires much higher doses of steroids and carries the risk of sudden blindness. Although fibromyalgia is usually considered a disease of younger people, rheumatologists have been recognizing it in a progressively older population. Whenever an older person experiences a chronic, diffuse pain syndrome, an underlying metabolic or neoplastic cause should be sought. 5. What are the impediments to accurate pain assessment in the older patient? Pain is a truly subjective phenomenon. Its assessment requires careful, detailed communication between sufferer and health care practitioner. Older patients are more likely to underreport pain than are younger patients, possibly because of their desire to be perceived as “good patients.” In a study of patients with duodenal ulcer or myocardial infarction, older patients reported milder pain than younger patients. They tend to have more faith in the medical system and more respect for physicians. Cognitive impairment, a fairly common problem in the older patient, may render patients unable to use appropriate descriptors for pain. Impaired hearing and vision also may cause communication difficulties. In such cases, behavioral signs can be used to assess pain; however, they are often less accurate than good verbal reports. Although the precise severity of pain may be difficult to assess, even patients with significant cognitive impairment can report the presence of pain. Unfortunately, there are relatively few well-validated scales for the older patient. The verbal and visual analogue scales used in younger patients do not have the same degree of validation in the older person. 6. What impact does chronic osteoarthritis have on quality of life in the older person? Compared to their peers with no chronic illnesses, older patients with osteoarthritis, with and without additional comorbidities, have a significantly worse quality of life. Some of this is due to the pain itself and some is related to analgesia consumption. Interestingly, one study showed that a better quality of life was associated with noncompliance, fewer visits to the physicians, and taking oral nonsteroidal antiinflammatory drugs (NSAIDs). 7. What scales are available for assessment of pain in patients with dementia? The Discomfort Scale for Patients with Dementia of the Alzheimer Type (DS-DAT) is difficult to validate because it was generated from the impressions of nursing staff caring for demented patients. It lists a series of items that, in the staff’s opinion, indicate that a patient is in pain. Examples include noisy breathing, negative vocalization, sad versus content facial expression, frightened facial expression, frown, tense versus relaxed body language, and fidgeting. As its name indicates, the DS-DAT is a discomfort scale and may not assess pain directly. It is unclear whether distress, discomfort, or pain is being assessed. Behavioral methods of pain assessment may be valid for the presence or absence of pain, but they do not assess the intensity of pain. Certain facial expressions are common with intense pain, but they are not necessarily graded responses. 8. Are patients with cognitive impairment capable of using a self-assessment scale? Generally, patients with mild to moderate cognitive impairment can still complete some short self-assessment scales. Up to 30% of severely impaired patients can still complete at least one assessment scale. An attempt should always be made to allow an older patient to report pain in his or her own words and to produce a rating of intensity that can be reassessed. Investigators have recently developed a “pain thermometer” to be used not only for older patients but also for very young patients. 9. Are patients with Alzheimer’s disease likely to report more or less pain than cognitively intact patients? It appears that patients with Alzheimer’s disease tend to experience less intense pain than unaffected patients and may also have less of the affective component associated with pain. However, it is not clear that analgesic intake differs between the groups, and special attention must be paid to the side effects that may occur in a cognitively impaired population. 10. Are NSAIDS safe in older patients? Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Neuroimaging in the Patient with Pain Pharmacologic Management Tension-Type Headache Sympathetic Neural Blockade Cancer Pain Syndromes Temporary Neural Blockade Stay updated, free articles. Join our Telegram channel Join Tags: Pain Management Secrets Jun 14, 2016 | Posted by admin in PAIN MEDICINE | Comments Off on Pain in the Older Person Full access? Get Clinical Tree
