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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