Thomas Hadjistavropoulos1 & Una E. Makris2 1 Department of Psychology and Centre on Aging and Health, University of Regina, Saskatchewan, Canada 2 University of Texas Southwestern Medical Center, Dallas, Texas, USA Pain affects people of all ages with epidemiological studies reporting exceedingly high prevalence rates of pain in general community samples and even higher rates in institutional settings. The absolute prevalence figures for persistent pain in the general population vary widely and depend upon the sample being examined (community, hospital, outpatient settings etc), the severity of pain to classify a case (i.e. any, bothersome, disabling, significant), the time interval sampled (i.e. right now, past week or months, etc.), the time in pain during this interval (i.e. every day, most days, or any pain during the period), and the sampling technique (i.e. telephone survey, interview, questionnaire etc) (e.g. [1, 2]). Specifically for older adults, the prevalence of bothersome pain over the last month in a sample of over 7,000 adults 65 years of age or older was estimated as being greater than 52%; 74% of those with pain endorsed multiple pain sites [3]. Patel et al. [3] also showed that pain reports were strongly associated with decreased physical function. Examining chronic pain (defined as duration for at least three months), Larsson et al. [4] estimated a 38.5% prevalence in people who were at least 65 years of age. Pain in long‐term care environments appears to be even more common. Although estimates vary from study to study, they have been found to be as high as 83% [5, 6]. Females are more likely to suffer from pain than males, although the magnitude of gender difference may decrease in very old age. When considering the high prevalence of pain in later life and the potentially taxing implications for health service delivery, it is important to understand that not all persistent pain will be bothersome or of high impact. Indeed, many older adults will not seek treatment for pain and will manage pain symptoms without help. That said, a survey of members of the American Academy of Pain Medicine and the American Pain Society [7] identified the undertreatment of pain among older adults and the inadequate pain assessment among persons with dementia as being among the most pressing ethical concerns for pain clinicians. More recent evidence suggests that the issue of pain undertreatment in the general older adult population continues to be an issue [8, 9] although better quality studies assessing the extent of pain undertreatment in community dwelling dementia patients are still needed [10]. Pain undertreatment appears to be substantial for patients with cognitive impairments who reside in long‐term care (LTC) facilities [11]. Specifically, it has been demonstrated in several studies that patients with cognitive impairments tend to receive considerably less pain medication than their cognitively intact counterparts, despite a similar prevalence of pain problems [12, 13]. A Canadian study suggests that patients with pain, who have cognitive impairments, are often likely to be prescribed psychotropic rather than analgesic medications [14]. It is noted, however, that recent investigations from Denmark and Norway suggest that the frequency of pain undertreatment may be decreasing in those countries [15, 16]. In addition to challenges that are common among most age groups, the assessment of older adults is complicated further by the entrenched but misleading notion that having pain is “natural” in old age [17, 18]. While pain problems are frequent in this population, if we think of pain as being “natural” for this age group, we would be less likely to treat it than we would be for younger persons. Pain results from pathology rather than from old age per se and, as such, should not be considered to be natural. Other factors that have been cited as contributing to the undertreatment of pain among older adults include sensory (e.g. a patient may not be able to hear staff questions about his or her functioning due to hearing loss) and cognitive impairments that affect some older individuals, concerns about the risk of addiction to opioids and a possible stoicism may make many older adults less likely to report pain [18, 19]. Moreover, nurses identify insufficient access to available assessment methodologies, inadequate pain education, and insufficient time as being barriers to adequate pain management in older adults [18, 20], despite advances of pain assessment methodologies for seniors with dementia [21–23]. Other research has raised concerns about inadequate communication between long‐term care facility nurses and family physicians of patients with some physicians not having adequate trust in LTC nurses for making decisions about narcotics and other pain medications [24]. Experimental studies have shown small, although somewhat inconsistent, increases in pain threshold with advancing age (i.e. a reduced sensitivity to faint pain) [25–27]. Age‐related threshold changes may be specific to certain stimulus modalities. For example, El Tumi et al. [28] found age‐related reductions in pressure pain thresholds but no age differences in contact heat thresholds. Recent meta‐analytic research has casted doubt on earlier claims that there are age‐related reductions in ability to tolerate pain [27]. Moreover, there are inconsistencies in findings regarding the role of dementia in the pain experience, especially in experimental research [29]. Studies that rely on self‐report, and are reporting lower levels of pain in dementia, are confounded by the limitations in ability to provide self‐report that can result from the dementing process. Nonetheless, neuroimaging research on central nervous system processing revealed significantly greater pain‐related activations in patients with Alzheimer’s disease (i.e. dorsolateral prefrontal cortex, mid cingulate cortex and insula; [30]) and some research focusing on nonverbal pain reactions suggested that people with dementia may react with more vigor to painful situations [31]. It is, nonetheless, difficult to reconcile the disparate findings. Pain perception with the progression of dementia remains unclear and further research is needed in order to answer this important question. At the present time, there is no convincing evidence that dementia results in clinically significant reductions in pain‐related suffering. The successful treatment of pain always relies on appropriate assessment. Regardless of whether pain is acute or persistent, it is important to assess all factors that may contribute to the pain as well as the prospect of remedial or curative actions. With persistent pain, a more comprehensive approach is required, including the evaluation of physical functioning (disability, interference with daily activities), psychosocial function (mood, interpersonal relationships, sleep, cognitive function), beliefs and attitudes to pain (fear of harm, ability to cope, meaning of symptoms) and general quality of life. Each of these aspects of a comprehensive assessment provides information that is essential to development of a tailored pain management program consistent with the specific needs of the older individual [22, 23]. Importantly, understanding the multiple potential contributors and often multifactorial pathway that results in persistent pain is critical in older adults [32]. The first vital step in pain assessment should be by patient self‐report whenever possible and may include a structured history that ascertains onset, location, intensity, periodicity, quality, aggravating and relieving factors, and impact of pain [23]. The older adults should be given every opportunity to provide this history and the person taking the history should be a skilled communication partner. Sufficient time, adequate proximity, lighting and sensory assistive devices (i.e. glasses, hearing aid) should be utilized when required. The medical components of an assessment should include making a diagnostic formulation for the cause of pain and this can be more difficult in an older person as they often have pathology in several bodily systems (e.g. musculoskeletal, vascular, neurological) that may contribute to the pain through a variety of different mechanisms. In addition, it is important to evaluate all medications that the patient is already taking, especially in the context of renal or hepatic disease, alertness, cognitive impairment, issues with balance and general frailty, since these problems may restrict the available pharmacological pain treatment options. The use of psychometric tools can help to provide a standardized assessment of pain and related suffering. Numerous unidimensional and multidimensional self‐report measures of pain have been developed and, in general, tools with demonstrated merit in younger adult populations are also thought to be useful with older adults. Several different types of self‐report scales exist, including verbal descriptors (i.e. none, mild, moderate, severe), numeric ratings (i.e. 0–10), visual analogue scales, complex qualitative word lists (i.e. McGill Pain Questionnaire; [33]), and more graphic representations, such as the pain thermometer, colored analogue scales or pain faces scales. Several studies directly compare different self‐report pain measurement tools and suggest that the verbal descriptor scales are most preferred by older persons and have the strongest evidence of utility, reliability and validity (e.g. [34]). Other acceptable measures include numeric rating scales, the multidimensional McGill Pain Questionnaire [33] and Brief Pain Inventory [35, 36] . There is less uniform support for visual analogue scales and several authors raise concerns when using this measure with older adults ([36] for a discussion of this issue). That said, some research has shown good success with horizontally‐presented visual analogues scales that can include changes in color and shape to indicate increasing amounts of pain (e.g. [37]). However, it is important to note that there is no one best measure of pain and a failure to complete one type of scale does not preclude success with other pain assessment tools. In clinical practice it may be best to select tools that are consistent with the personal preference of the individual when it is known, or to try several different types of scales before giving up on the use of self‐report tools. The longer that bothersome pain persists, the greater the probability that the older adult will become depressed, socially withdrawn, and somatically preoccupied. Anger, frustration, loss of ability to cope and increased anxiety also occur as the person tries and fails with a variety of medical and non‐medical therapies. As a result, the measurement of mood disturbance and social impacts are now considered as an integral component of any comprehensive clinical evaluation and should be incorporated as a routine part of the assessment plan. There are a number of standardized tools that have demonstrated reliability and validity for use in older adults (i.e. Geriatric Depression Scale [38,39], Spielberger State‐Trait Anxiety Inventory [40,41]). The initial assessment can also include evaluation of other common psychological associations and mediators of pain, including anger, cognitive and behavioral coping strategy use, beliefs and attitudes, psychological strengths (e.g. resilience), stoicism, sleep, spousal bereavement and suicide risk. Developing a better understanding of the persons’ social situation, beliefs, attitudes and current coping strategies in relation to their pain, provides an important starting point toward individualizing the eventual management plan and should be considered as a routine part of the clinical assessment. Chronic pain has a major impact on function and is likely to interfere with many of the activities of daily life. A number of options exist for the measurement of activity levels or disability, ranging from objective measures of uptime/movement and direct observation of activity task performance, through to self‐report psychometric questionnaires and activity dairies. The psychometric scales typically used to measure function in geriatric populations such as the Barthel Index and the, Katz ADL scale [42, 43] may be useful to monitor the basic and instrumental activities of daily living in the older adult with chronic pain, although they tend to lack sensitivity and fail to measure the more discretionary activities that are mostly affected by chronic pain (i.e. leisure and pastimes, home maintenance and social interactions). One must also exercise some care with the interpretation of activity measures because activity restriction can also occur as a consequence of a change in social circumstances, medical factors or other concurrent disease states rather than as a consequence of pain. Moreover, regardless of whether measures are via self‐report or objective markers, activity performance is highly dependent upon motivational factors and the context in which measurement is undertaken. As a result, studies of chronic pain populations have tended to focus on measures of perceived pain‐related interference in activity or self‐rated measures of perceived disability (i.e. SF‐36, Pain Disability Index [44], Oswestry Disability Questionnaire [45], the Sickness Impact Profile [46]) rather than documenting the actual levels of activity performance. Older adults with chronic pain often respond more dramatically with respect to improvements in function than in pain intensity following an efficacious treatment plan and functional outcomes are often considered as the most important outcome by the older person. For this reason, the measurement of disability and perceived interference should become an essential component of any routine comprehensive assessment. In recent years, we have seen a proliferation of research focusing on the development and validation of observational tools designed to assess pain in persons with cognitive impairments. A detailed review of these is beyond the scope of this chapter but some of the most researched and recommended ones include the Pain Assessment Checklist for Seniors with Limited Ability to Communicate scales (PACSLAC and PACSLAC‐II [47, 48]; the DOLOPLUS‐II [49] and the Pain in advanced Dementia Scale (PAINAD; [50]). The DOLOPLUS‐II has the disadvantage that a considerable portion of its items require knowledge of the patient which may make it more difficult to use in acute situations. The PACSLAC, which is a check list of 60 behaviors, takes less than five minutes to complete and, unlike most other tools of its kind, covers all of the assessment domains that have been recommended by the American Geriatrics Society as being useful in the assessment of older persons. The PACSLAC‐II (31 items) is a shorter version of the PACSLAC with psychometric properties that appear to be stronger than the original PACSLAC [47]. With this in mind, we recommend several practical steps in the assessment of older adults with dementia. These steps are adaptations of earlier recommendations by a variety of groups (e.g. [23, 51]). In addition to taking into account patient history and physical examination results, we recommend the determination as to whether Mini Mental Status Examination scores [52] are available or can be obtained. This would facilitate determination of patients’ ability to provide valid self‐report since research suggests that patients with scores of 13 or lower are unlikely to be able to provide valid self‐report whereas patients with scores of 18 or higher can typically respond to basic self‐report scales such as verbal rating scales [53,54
Chapter 40
Pain in older adults: a brief clinical guide
Epidemiology
The Undertreatment of Pain Among Older Adults
Age‐related Change in Pain Sensitivity and Nociceptive Processing
The Clinical Pain Assessment of the Cognitively Intact Older Adult
A Clinical Approach to Pain Assessment in Adults with Dementia
General guidelines:
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