Pain in the Elderly: Listen to the Patient's Voice

by Gretchen Henkel

SAN DIEGO--Pain research has burgeoned in the last three decades, producing advancements in genetics and molecular biology to better explain pain genesis, and yielding more sophisticated treatments for acute, chronic, and terminal cancer pain. But there's still work to be done if clinicians are to successfully address and treat elderly patients' pain, agreed researchers and workshop presenters at the recent 10th World Congress on Pain, hosted here by the International Association for the Study of Pain (IASP).

North American research suggests that pain is still undertreated in older adults, including those in institutional settings, according to M. Gail Woodbury, PhD, Adjunct Professor in the Department of Epidemiology and Biostatistics at the University of Western Ontario in London, Canada." The literature identifies the need for more descriptive, self-report, and longitudinal research to direct efforts to improve delivery of pain services to this population," she noted recently from her office in Canada.

Accordingly, Woodbury's colleagues Maggie Gibson, PhD, a psychologist and researcher with the Veterans Care Program at St. Joseph's Health Care in London, Ontario, designed a clinical study to assess self-reported pain over time in a sample of elderly Canadian war veterans living in a chronic care facility. Among the conclusions, which Dr. Gibson presented during a poster session at the World Congress, is that the first step toward optimum pain management in the elderly depends upon appropriate and comprehensive assessment. Slightly over half of the 33 war veterans participating in the study reported having pain at regular follow-up assessments, which occurred at quarterly intervals over a two-year time frame. In most instances, reported Dr. Gibson, patients' pain "predated their admission to the facility," reflecting the high prevalence of chronic pain conditions such as arthritis in the elderly.

The results of their study, which was funded by a research grant from the Parkwood Hospital Foundation in London, Ontario, underscore the complexities of diagnosing and treating pain in the heterogeneous elderly population. For example, although the patients in this study did not exhibit significant levels of cognitive impairment, many found it difficult to describe pain quality, while others described combined patterns of "dull, aching, throbbing" or "sharp, shooting, burning" pains.

Multiple Assessments

Inclusion criteria for the St. Joseph's Health Care facility study were straightforward: participants needed to be able and willing to consent to participation, and to be admitted to the facility from September, 1998 through October, 1999. More than half (57%) of newly admitted residents met inclusion criteria, and 59% of the eligible residents agreed to participate. They were then followed for a two-year period, or until discharge from the facility or death.

At admission, enrolled participants verbally completed a structured interview conducted by a research assistant. The interview included five measures: Pain Beliefs Questionnaire, Geriatric Depression Scale, Standardized Mini-Mental Status Examination, Anxiety Measure, and Delighted-Terrible Quality-of-Life Scale (see box at right). Patients who reported having pain also completed the Comprehensive Pain Assessment.

At each subsequent assessment, patients were again queried about their pain, its impact, and the types of pain-relief methods used for treatment. For most of the patients reporting pain, the researchers found, onset had occurred during older adulthood, and was mostly somatic (as opposed to neuropathic) in origin.

Patients reported expressing their pain in several forms, including verbalizations, nonverbal vocalizations (e.g., moaning), behaviors (e.g., grimacing), and requests for medications. At least 60% and sometimes as many as 100% (depending on which three-month interval) of those in pain reported that they experienced physical limitations due to their pain. Patients' pain intensity was often exacerbated by either motor activity or restriction of activity.

Patients identified a variety of pain-control methods that they used to manage their pain, including pharmacologic as well as non-pharmacologic approaches. The interdisciplinary staff of the Veterans Care Program develops care plans in collaboration with patients, explained Dr. Gibson . "In this observational study, patients themselves identified high usage of both pharmacological and non-pharmacological interventions, which provides indirect support that pain was commonly recognized as a clinical concern by staff in this setting."

Patient-Centered Approach

The assessments performed for the purposes of this study are in alignment with best-practice recommendations included in the clinical practice guidelines (CPGs) for pain management in older persons formulated by the American Geriatrics Society and published last June in the Journal of the American Geriatrics Society (2002;50:S205-S224). During an educational workshop at the World Congress entitled "Recent Developments in the Study, Treatment, and Assessment of Pain in Older Persons," presenter Bruce A. Ferrell, MD, a Professor in the Division of Geriatrics, UCLA Medical School, and Chairman of the AGS' CPG committee, highlighted the problem of undertreatment of pain in the elderly." The literature," he noted, "is replete with examples of sub-populations of elderly people who tend to have poor pain management. Both observational studies and epidemiological studies suggest that older patients with cancer pain receive poorer care than patients who are younger with cancer pain." The same holds true, said Dr. Ferrell, for postoperative pain management in older people.

The AGS guidelines, an update of the 1998 version, recommend that all patients coming into a facility be screened for the presence of chronic or persistent pain. For patients who are cognitively intact, as were the patients participating in the St. Joseph Health Care study, the panel found that research supports the use of direct inquiry.

Interestingly, the AGS panel's literature search revealed, said Dr. Ferrell, that "elderly people often don't like to use the word 'pain.' They like to use other words. They describe [the pain sensation] as a discomfort, or a soreness, or an aching." If clinicians do not use similar words, he said, they may not discover their patients' real pain problems.

Comprehensive, individualized pain assessment, maintain Drs. Woodbury and Gibson, will most likely contribute to improvements in pain management for older adults in institutions. "In essence," said Dr. Gibson, "what we are advocating is a 'patient-centered' approach to pain management." Further research is now planned in collaboration with other Veterans Care facilities across Canada through the VET-LINK research network that Dr. Gibson is spearheading.

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