US
Pharm. 2006;5:30-36.
Pain is the most common
reason that patients seek medical care; each year, millions of Americans seek
assistance from their health care providers for the relief of pain.1,2
Despite advances in medicine, pharmaceuticals, and scientific technology, the
undertreatment of pain remains a major public health problem in the United
States (table 1).3 It has been documented that about 40% of nursing
home residents with cancer and 25% without cancer are not treated with
analgesics, even though they experience pain daily.4-6 In addition,
research indicates that many people fear dying in pain more than they fear
death itself.1,3,7
There are numerous consequences of
pain in older adults, including impaired ambulation, anxiety, depression,
sleep disturbance, decreased socialization, and increased health care
utilization and costs.8 Clearly, a complaint of pain should be
recognized as a significant problem if it has an impact on physical function
or quality of life.9
Defining Persistent Pain
Classification of
pain in terms of nociceptive and neuropathic pathways provides a
better understanding of acute and persistent pain (table 2).10
According to The American Geriatric Society (AGS) Panel on Persistent Pain in
Older Persons 2002, 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.8 The guideline
notes that while the terms persistent and chronic have long been
used interchangeably in literature, chronic pain has become a negative
label, associated with such issues as longstanding psychiatric problems,
treatment failure, malingering, or drug-seeking behavior.8 The AGS
panel chose to replace the term chronic with persistent to help
shift the attitudes of older persons, their loved ones, and health care
professionals toward more effective pain management.8 Patients with
persistent pain may experience pain exacerbations, known as breakthrough
pain.2 Breakthrough pain is experienced by 19% to 95% of all
patients with pain; incidence varies according to the population surveyed and
the definition of breakthrough pain that is used.11
The Pain Assessment Process
Accurate pain
assessment begins when the clinician believes the patient and takes his or her
complaint of pain seriously.9 Pain is experiential; therefore, the
best way to assess pain is to believe and listen to the patient.1
This concept is supported by the Agency for Healthcare Research and Quality in
their guideline for cancer pain management, which makes the following
recommendations for the assessment of pain: (1) Health care professionals
should inquire about the pain and believe the patient's report; (2) As part of
the initial pain evaluation, a thorough pain history that includes
descriptions of pain intensity and characteristics should be conducted (tables
2, 3); (3) Pain rating scales that are easy to administer (figure 1) should be
used to assess pain and document the efficacy of pain management plans; and
(4) The development of new pain or changes in pain patterns should trigger a
diagnostic evaluation and modification of the treatment plan.12
The AGS panel recommends that upon
the initial presentation of any older person to any health care service, a
health care professional assess the patient for evidence of persistent pain.
8 This is important due to the large number of neuropathic pain
syndromes (table 2) seen in the senior population that are frequently
difficult to treat. In addition, the pain reported in these neuropathic
conditions often is not evident from examining physical findings.10
Questioning patients about their use of complementary and alternative
therapies should not be overlooked, since patients may be reluctant to report
their use.1 If language is a barrier, an interpreter should be
involved in the assessment process.13 Assessment and treatment
strategies should be sensitive to cultural and ethnic diversity.
Assessing Pain in Nursing
Home Residents and Cognitively Impaired Seniors
Pain is a
commonly reported problem among elderly persons in nursing homes, with the
prevalence of persistent pain between 49% and 84%.14 Additionally,
analgesics are most often prescribed for pain on an as-needed basis, despite
guidelines suggesting the use of standing orders for pain management.15
Improving pain management in nursing homes has become a priority for the
Centers for Medicare and Medicaid Services and the Joint Commission on
Accreditation of Healthcare Organizations, which has standards for pain
assessment and treatment that formally acknowledge pain control as a patient
right and an organizational responsibility.1,16,17
Often, patients who are
cognitively impaired or have profound aphasia can provide reliable and
accurate answers to "yes-no" questions during sensitive and skillful
interviewing.9 When elderly patients are evaluated, their family
members, caregivers, and health care staff should be questioned whenever
possible to provide information such as medical history, medication use,
behaviors, and interventions that have successfully reduced or alleviated
pain. Clinicians should keep in mind that family members and caregivers may
not always be accurate and reliable sources and that physicians and nurses
have often been found to underestimate pain intensity, which has led to the
provision of inadequate pain medication.9
The AGS panel guideline
provides an algorithm for assessing pain in individuals who are cognitively
impaired, to determine the presence of pain-associated behaviors during
physical movement (e.g., grimacing, guarding, groaning during personal care,
ambulation, or transfers) or non–movement- specific behaviors suggestive of
pain (e.g., agitation, reclusiveness, insomnia, diminished appetite) (table 4).
8 While it is important to remember that many elderly patients may
demonstrate a lack of behavior when in pain, pain-associated behaviors may be
used to assess pain in some patients.9 In fact, pain behavior is
helpful for assessing all patients, and its utility should not be limited to
only those patients who cannot communicate.18
A recent report described the
experimental Pain Medication Appropriateness Scale (PMAS) as a useful tool to
assess the suitability of pain management prescribing practices in nursing
homes, to determine whether interventions to improve prescribing behaviors are
effective.17 PMAS scores were better for residents who were not in
pain and in homes where the nurses' knowledge of pain assessment and
management improved or stayed the same during the intervention. The
researchers concluded that the PMAS is useful for assessing the prescribing
practices of pain medication in nursing homes and elucidates why so many
residents have poorly controlled pain.17
Assessment in Outpatient Pain
Management
Cost is often a
factor in the management of breakthrough pain in the outpatient setting.2
The impact of breakthrough pain on quality of life and productivity must also
be considered as part of the assessment process in order to balance the
overall pain management equation. Uncontrolled pain is a common cause of
hospital admissions and has been shown to account for many emergency
department visits and admissions.2 Patient education initiatives
have been associated with a reduction in pain severity, anxiety, fear of
addiction, and an increase in skills to cope with pain.19
Periodic Reassessment as
a Key Element of Pain Control
Persistent pain
may fluctuate with time, which presents a further challenge to the successful
evaluation of pain. Acute pain due to an inflammatory flare-up (e.g., gout) or
an injury (e.g., trauma) can be easily overlooked in an individual with
persistent pain.9 This potential pitfall can be avoided by
including focused and detailed questioning as an integral part of the
comprehensive evaluation. A description of pain should include information
about the location, duration, pattern, and character of the pain problem (
tables 2, 3).9 An astute clinician will probe for descriptions that
may not include the word pain and will utilize these descriptions in the
initial assessment and in subsequent follow-up evaluations.9
Patients with persistent
pain should be reassessed regularly for signs of improvement, deterioration,
or complications.8 The same pain assessment rating scales should be
used for the initial and follow-up assessments. The use of a pain log or diary
may assist clinicians if patients record entries on a regular basis and
include pain intensity, medication use, mood, response to treatment, and
associated activities. The reassessment should be comprehensive and include an
evaluation of pharmacologic and nonpharmacologic interventions, adverse
effects, and adherence issues. The clinician should not overlook patient
preferences in assessment and treatment modifications.
Conclusion
For many seniors,
the thought of dying in pain is more frightening than that of dying itself.
Health care professionals should recognize that a complaint of pain is a
significant problem if it has an impact on physical function or quality of
life. Any older person presenting initially to a health care practitioner
should be assessed for evidence of persistent pain. Patients with
persistent pain should be reassessed regularly for signs of improvement,
deterioration, or complications. Sensitivity to cultural and ethnic diversity
is an important element in the delivery of effective pain management and
should not be overlooked.
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