Chronic pain in elderly people

Age-related differences in the qualities but not the intensity of chronic pain

Age differences in the experience of chronic pain remain unclear. A serious barrier to progress in the field of pain and aging arises from the lack of data regarding the psychometric properties of pain scales for use with the elderly. The present study was designed to assess age differences in pain intensity and quality and to compare the psychometric properties of the McGill Pain Questionnaire (MPQ) in young and elderly chronic pain patients. Young (n=139, mean age=42.93+/-9.41 years) and elderly (n=139, mean age=70.12+/-7.51 years) pain center patients, matched on primary diagnosis or pain location, duration, and sex, completed the MPQ, numeric ratings (0-10) of pain intensity, a Pain Map, and the Hospital Anxiety and Depression Scale (HADS). A Pain Management Index (PMI) score was calculated for each patient. Age differences on the measure of pain qualities were found. The elderly group had significantly lower MPQ total and sensory scores and chose fewer words than the young group. However, there were no significant differences between the groups on numeric ratings of highest, usual, and lowest pain intensity. Similarly, there were no age differences on PMI, Pain Map, or the HADS Depression or Anxiety Subscales. Finally, the latent structure, internal consistency, and pattern of subscale correlations of the MPQ were very similar in the young and elderly groups. Possible explanations for the discrepancy in the pattern of age differences on measures of pain intensity and quality are explored. The implications of this pattern of age differences for basic pain mechanisms and pain management should be given serious empirical attention.

Psychometric properties of the Pain Attitudes Questionnaire (revised) in adult patients with chronic pain

Previous evidence supports the utility of the newly developed pain attitudes questionnaire (PAQ) for assessing pain-related stoicism and cautiousness in community-dwelling pain-free adults (Yong et al., 2001). A revised questionnaire (PAQ-R) was examined in the present study to determine the generalizability of psychometric properties when used with chronic pain patients. Results from both exploratory and confirmatory factor analyses suggest that the factor-structure of the revised questionnaire was best represented by a five- rather than a four-factor solution, thus, suggesting that chronic pain patients do not conceptualize the questionnaire items, in particular, with respect to the stoicism attitudes, in the same manner as the community-dwelling adults. A satisfactory internal consistency reliability of the PAQ-R was replicated in chronic pain patients. There was also evidence to suggest that chronic pain patients from different age cohorts do apply a similar frame of reference and calibration scale when responding to the items on the questionnaire. However, the cohorts of patients across the age spectrum show some differences in pain attitudes and possible reasons were discussed.

Management of Painful Conditions in the Elderly

Persistent pain conditions in the elderly are most often due to degenerative disorders of the spine, osteoarthritis of the joints, malignant cancer, and vascular disorders. The consequences of persistent pain include depression, anxiety, de-creased socialization, sleep disturbance, impaired ambulation, and increased healthcare utilization. Proper pain assessment is the key to selecting appropriate treatment. Barriers to pain assessment are associated with the patient's perception of pain and the caregiver's attitude towards providing effective treatment. All elderly patients have age-related physiologic changes that affect absorption, distribution, metabolism, and clearance of medications used for pharmacologic treatment. Medications used in pain management include opioids, nonsteroidal anti-inflammatory drugs, gabapentin, nortriptylline, desipramine, and lidocaine 5%patch. Pharmacists have an important role in the monitoring of medications in elderly. As the utilization of prescription medication continues to increase in the elderly, pharmacists are becoming the frontline of healthcare care for this population.

Old people in pain: a comparative study

To investigate the prevalence of pain in older people (75+), compare those in pain to those without regarding demographics, social network, functional limitations, fatigue, sleeping problems, depressed mood and quality of life (QOL), and identify variables associated with pain, a cross-sectional, prospective survey was conducted in an age-stratified sample of 4,093 people aged 75-105 years old. Those reporting pain (n=1,654) were compared with those who did not (n=2,439). Pain was more common with higher age, as were all complaints among those in pain and among those without, except sleeping problems. Lower QOL was found with higher age, as well as with pain. Pain was found to be associated with functional limitations, fatigue, sleeping problems, depressed mood, and QOL. These data highlight the importance of identifying old people in pain. Those who are older and those affected by pain are at greater risk of also being troubled by other problems, such as functional limitations and lowered QOL.

Care Management for Persistent Pain: An Introduction

Persistent pain is a frequently occurring condition with significant economic, clinical, and humanistic implications, for both individuals and society. Current literature, however, points to unresolved issues with regard to its identification, assessment, diagnosis, and treatment, and a number of suggestions have been made for improving the quality of care for pain sufferers. Because persistent pain shares many of the salient features of other chronic conditions such as diabetes and congestive heart failure, it is reasonable to believe that the adoption of a coordinated approach to care management could substantially improve the quality of care. Several strategies--including identification, appropriate referral, education, and planning--can and should be implemented to offer comprehensive, individualized treatment alternatives that are not currently available and that improve patient outcomes, including quality of life.

Efficacy of a self-management group intervention for elderly persons with chronic pain

OBJECTIVES

To assess the efficacy of a self-management group intervention in improving physical functioning, mood, and pain among elderly persons with chronic pain, and to identify factors that may be associated with improvement.

MATERIALS AND METHODS

Forty-five residents of three retirement communities (86% women; mean age, 82.0 years) were assigned randomly to a 7-week pain self-management group or an educational booklet control condition. Participants completed self-report measures of pain, functioning, depression, and pain-related beliefs at baseline, 9 weeks later (after treatment), and 3 months after the post-treatment assessment.

RESULTS

The self-management group showed significantly greater pre- to post-treatment improvement in physical role function (P = 0.04) and characteristic pain intensity (P = 0.02). No significant differences were found between groups on measures of pain-related activity interference, depression, and pain-related beliefs. Improvement in characteristic pain and physical role function was not associated with baseline depression scores, pretreatment expectations, or changes in pain-related beliefs.

DISCUSSION

This study provides preliminary support for the efficacy of a self-management group intervention for older adults with chronic pain and has implications for future studies of such approaches for this and similar populations.

The effects of aging on thermal hyperalgesia and tactile-evoked allodynia using two models of peripheral mononeuropathy in the rat

The effects of aging on the behavioral manifestations of neuropathic and inflammatory pain were investigated using two models of peripheral nerve injury. The left sciatic nerve of young and aged Fischer 344 FBNF1 hybrid rats (4-6 and 24-26 months old, respectively) was ligated using either the chronic constriction injury (CCI) model of Bennett and Xie or the partial sciatic nerve ligation (PSNL) model of Seltzer et al. A plantar analgesic meter was used to assess age-related differences in CCI- or PSNL-induced thermal hyperalgesia, and nerve injury-induced tactile-evoked allodynia was assessed with von Frey filaments. Aged animals subjected to the PSNL procedure developed a more vigorous and longer lasting thermal hyperalgesic response than did aged rats post-CCI. The CCI model incorporates a more prominent peripheral inflammatory component than the PSNL model. These data support the notion that the peripheral inflammatory response is diminished in aged rats.

The assessment and management of pain among older people in care homes: current status and future directions

Pain is highlighted as a significant, yet neglected problem among older people, particularly in long-term care settings. The effects of inadequate assessment and treatment of pain among older people may lead to multiple problems. Problems arise due to cognitive impairment of clients and inadequate assessment by healthcare professionals. Analgesics are under-used and there is a need for improved education of both healthcare professionals and older people regarding attitudes to pain and ageing. Research is needed into the prevalence of pain among older people in United Kingdom (UK) care homes, how best to further educate healthcare professionals regarding pain management and how to enable older people to be facilitative partners in this process.

Age-related differences in endogenous pain modulation: a comparison of diffuse noxious inhibitory controls in healthy older and younger adults

Despite decades of research, hundreds of studies, and a number of recent reviews, the effects of aging on the experience of pain remain poorly understood. Many prior investigators have reported increases in persistent pain conditions and diminished tolerance for certain types of laboratory-induced pain among the elderly. While explanations for these effects often propose senescent decrements in endogenous analgesic systems as a possible contributory mechanism, almost no direct empirical evidence for this hypothesis has yet emerged in human studies. The present investigation was designed to evaluate the existence and nature of these putative age-related differences in endogenous pain inhibition. Groups of healthy younger (n=45, mean age=21.6 years, range=18-25) and older (n=48, mean age=63.1 years, range=55-67) adults participated in a controlled, two-session laboratory assessment of diffuse noxious inhibitory controls (DNIC), a measure of endogenous pain inhibition. In this study, we examined age differences in the effects of concurrent cold pain on ratings of heterotopically presented repetitive noxious thermal stimuli. Interestingly, older adults demonstrated facilitation rather than inhibition of thermal pain during concurrent noxious cold stimulation while younger adults demonstrated some expected DNIC effects (i.e. a reduction in thermal pain ratings during heterotopic stimulation with noxious cold). Collectively, the findings of the present study suggest age-associated decrements in at least one form of endogenous analgesic response. If replicated, such findings of reduced pain-modulatory capacity in the elderly may partially explain age-related differences in the prevalence, severity, and impact of chronic pain.

Interference due to pain following spinal cord injury: important predictors and impact on quality of life

Two studies were designed to examine important predictors of pain following spinal cord injury (SCI), and the impact of pain on self-reported quality of life (QOL). Pain was defined as "interference in day-to-day activities secondary to pain". In order to determine risk factors associated with the development of pain interference, Study 1 examined the predictive validity of multiple demographic, medical, and QOL variables at year 1 post-SCI to self-reported pain interference 2 years post-injury. Results showed that middle age (30-59-year-olds), lower self-reported mental health, and pain interference at 1 year post-SCI were the most important unique predictors of pain interference 2 years post-SCI. In Study 2, participants were separated into four groups; (1) those pain-free at years 1 and 2, (2) those pain-free at year 1 and in pain at year 2, (3) those in pain at year 1 and pain-free at year 2, and (4) those in pain at years 1 and 2. Results showed that only those experiencing a change in pain interference status reported a change in QOL. More specifically, those developing pain interference (group 2) from year 1 to year 2 reported decreased life satisfaction, physical health, and mental health, whereas, those with resolving pain interference from year 1 to year 2 reported an increase in these same domains. Unexpectedly, change in pain interference status was unrelated to change in self-reported handicap. Implications and future directions are discussed.

Prevalence of pain in general practice

OBJECTIVE

The aim of this study is to estimate the prevalence and diagnostic pattern of pain at the primary care level during one year in a group practice. This practice serves the patients of a geographically defined area with approximately 14,000 inhabitants.

DESIGN

Retrospective analysis of all computerised records of a GP group practice during one year, using a combined computerised search technique and manual check-up.

SETTING

Tumba Primary Care District, Stockholm County, Sweden.

SUBJECTS

All records of patients who visited Tumba primary care practice during one year.

MAIN OUTCOME MEASURES

Pain diagnoses, pain duration, analgesic use, pain category, and referrals.

RESULTS

Little less than 30% of the patients, who were treated at a primary care practice, had some kind of medically defined pain problem, requiring the attention of a GP. A little less than half of these patients received a prescription for analgesic drugs. The pain diagnoses at a primary care level showed a predominance of musculoskeletal pain. The patients with pain were much older than population and total practice patients. Among the patients, 37% were in a state of acute pain, 37% suffered from chronic pain, 13% had an intermediate pain duration of 1-3 months, and 11% had a chronic intermittent pain condition (predominantly migraine).

CONCLUSIONS

Painful states of the musculoskeletal system constitute more than 2/3 of painful states in primary care. Viewed from a primary care perspective, pain has a great impact on GPs' day-to-day activities and on health economy in general.

Management of nonmalignant pain in home-dwelling older people: a population-based survey

OBJECTIVES

To investigate use of prescribed analgesic drugs in relation to experience of joint or back pain in a home-dwelling older population, to study changes in the use of analgesic drugs over 10 years, and to investigate concomitant use of protective gastrointestinal drugs with prescribed analgesic drugs in 1999.

DESIGN

Cross-sectional mailed surveys 10 years apart.

SETTING

Helsinki, Finland.

PARTICIPANTS

Random samples of older birth cohorts born in 1904, 1909, and 1914 in 1989 (n = 644) (n=644)-->, and of three separate cohorts born in 1914, 1919, and 1924 in 1999 (n = 3,000).

MEASUREMENTS

Use of various types of analgesic and protective gastrointestinal drugs, prescribed and over the counter. Experience of joint and back pain that interferes with daily functioning.

RESULTS

The response rate of home-dwelling older people was 83% in 1989 and 81% in 1999. Although the use of analgesic drugs as self-treatment increased from 28.5% to 41.4% during the 10 years, in 1999, only 35.5% to 38.2% of those suffering joint or back pain that impaired daily functioning had been prescribed an analgesic drug for regular use. Of those using prescribed medication, 57.5% were on nonsteroidal antiinflammatory drugs (NSAIDs), 20.9% acetaminophen, and 18.5% weak opiates. Only one-fifth of those individuals taking NSAIDs were on a concomitant gastroprotective drug.

CONCLUSIONS

Pain is markedly undertreated in community-dwelling older people, which may have serious implications for their well-being and functioning. Although we noted a tendency for safety in the use of prescribed analgesic drugs, a significant effort must sill be made to implement evidence-based practice. Self-treatment of pain has increased in 1 decade, which may reduce the overall safety of analgesic drug use among older people.

Pain in Older Subacute Care Patients: Associations with Clinical Status and Treatment

OBJECTIVE

To examine the relationship between patient pain levels and clinical status and treatment in older adults.

DESIGN

A correlational study involving patient and nurse ratings of pain and retrospective review of clinical records.

SETTING

A subacute care inpatient facility.

PATIENTS

Seventy-five older adults (mean age: 75.9 years) who met entry criteria for pain, age, and mental status.

MEASUREMENTS

Patients and nurses made independent ratings of pain over a 7-day period. Clinical data included measures of mental status, depression, behavioral signs of discomfort, functional independence, and analgesic medication use.

RESULTS

Nurse ratings of patient pain were uncorrelated with patient ratings and underestimated pain relative to patient reports. Nurse ratings correlated with levels of behavioral discomfort and with doses of opioid medication. Patient ratings were associated with functional limitations, depression, and behavioral signs of discomfort, but were minimally related to administration of opioids or other pain medication. Patient mental status did not appreciably moderate these relationships.

CONCLUSIONS

These findings support a growing literature indicating deficiencies in pain assessment of older patients and suggest inappropriate administration of analgesic medications for these patients. More systematic assessment of pain, including the use of instruments with established psychometric properties for older patients, may improve pain control and enhance functional rehabilitation in this group.

Chronic non-cancer pain in older people: current evidence for prescribing

Chronic pain is a serious problem for many older people, yet its management in this population is often less than satisfactory. The high incidence of toxicity and side effects with some medications and irrational fears of opioid dependence are significant barriers to effective pain management. In this article, the research evidence relating to these issues is examined, and their impact on nurse prescribing considered. More studies are needed to assess the veracity of opposing arguments, and to support effective assessment and prescribing by nurses.

Pain and quality of life among older people with rheumatoid arthritis and/or osteoarthritis: a literature review

The aim of this study was to review the research literature on pain and quality of life (QoL) and the relationship between these variables among people aged 75 years and above with rheumatoid arthritis and/or osteoarthritis. A Medline and CINAHL search was carried out using MeSH terms rheumatoid arthritis, osteoarthritis, QoL and pain in various combinations. Seventeen articles were identified that met the requirements for methodological quality and inclusion criteria. No study focused only on respondents aged 75 years or over. The studies had varying representation of this age group. Pain was common in both groups and was found to increase with age and disease duration among those with rheumatoid arthritis but not among those with osteoarthritis. Increased pain could lead to depression. Pain, functional limitation and increased age were found to decrease QoL among those with rheumatoid arthritis and osteoarthritis alike. Social support was found to buffer against negative effects on QoL among those with osteoarthritis while no moderating effects were found in rheumatoid arthritis. Increased age was found to relate to pain (rheumatoid arthritis) and decrease QoL (both rheumatoid arthritis and osteoarthritis). It is, however, hard to draw any firm conclusions about older people's pain and QoL because of the lack of studies including respondents aged 75 years or over. Thus, research about pain and QoL, especially focusing on the old and the very elderly with rheumatoid arthritis/osteoarthritis, is needed. It also seems justified to say that nursing care should especially focus on older people and that these people should be assessed for their level of pain, functional limitations and QoL especially in the case of having rheumatoid arthritis and/or osteoarthritis.

The significance of saliva during sleep and the relevance of oromotor movements

Saliva is an essential component of the oroesophageal milieu and allows for normal speech, taste, mastication, food bolus formation and swallowing. Saliva has important functions in protecting the hard and soft tissues of the oral cavity from acids and pathogenic microbes. A large number of people suffer either subjective or objective alterations in quantity and/or quality of their saliva that may be secondary to disease, medications, medical treatments or emotional events. Sleep-related xerostomia is a sensation of dry mouth associated with a report of either mouth and/or throat discomfort that induces awakenings for water intake. The prevalence of self-reported dry mouth complaint during sleep (associated with awakening and water intake) in a Canadian survey was estimated at 23%. The biological significance of decreased saliva during sleep is unknown and it is unclear how the oral cavity compensates for this period of relative dryness. The amount of saliva produced is greatest during the waking hours of the day and diminishes dramatically during sleep and may represent another process in the human body that displays a circadian rhythmicity. Salivary secretion during wakefulness is, in part, associated with oromotor activity involving the masticatory muscles. Rhythmic masticatory muscle activity and swallowing are non-disruptive events that occur during normal sleep. We hypothesize herein that lubrication from saliva is necessary during sleep to protect tissue integrity and health of oroesophageal structures.

Supportive therapy of elderly cancer patients

Elderly cancer patients often require supportive care due to the physiologic decline of organs and apparatus linked with the aging process per se, and for the effects of tumor or of anticancer treatments. Pain and nutritional deficits are some clinical aspects requiring supportive care. Lack of studies on these latter topics does not allow an in depth analysis of the problem. The present review deals with literature concerning pain and nutritional problems in the general cancer population with emphasis on aspects typical for elderly cancer subjects. Physiologic and cancer-related changes in body composition, physical function and cognitive capacity of the elderly are presented and, when appropriate, linked with pathogenetic factors of pain and malnutrition, as well as their treatment. Pain demographic data, pain intensity evaluation and currently available techniques to provide pain relief such as etiologic treatment, analgesic pharmacotherapy and invasive analgesic procedures, are extensively discussed. Causes and assessment of malnutrition as well as available nutritional approaches such as oral, enteral and parenteral nutrition are also debated.

Spinal cord stimulation in postherpetic neuralgia and in acute herpes zoster pain

We studied the effects of spinal cord stimulation (SCS) on postherpetic neuralgia (PHN). Data of 28 patients were prospectively investigated over a median period of 29 (quartiles 9--39) mo. In addition, four patients with acute herpes zoster (HZ) pain were studied simultaneously. After intractable pain for more than 2 yr, long-term pain relief was achieved in 23 (82%) PHN patients (median, 70 yr) during SCS treatment confirmed by a median decrease from 9 to 1 on the visual analog scale (P < 0.001). In five cases with serious comorbidity, the initial pain alleviation could not be stabilized. Spontaneous improvement was always confirmed or excluded by SCS inactivation tests at quarterly intervals. Eight patients discontinued SCS permanently because of complete pain relief after stimulation periods of 3--66 mo, whereas 2 reestablished SCS because of recrudescence after 2 and 6 mo. Considerable impairments in everyday life, objectified by the pain disability index, were also significantly improved (P < 0.001). In 4 patients with acute HZ pain, SCS was promptly effective and after periods of 2.5 (quartiles 2--3) months the pain had subsided. SCS seems to offer a therapeutic option for pharmacological nonresponders.

IMPLICATIONS

In many patients with postherpetic neuralgia and acute herpes zoster pain is not satisfactorily alleviated with pharmacological approaches. We report on 23 of 28 patients with postherpetic neuralgia and 4 of 4 with acute herpes zoster whose chronic pain was improved by electrical spinal cord stimulation.

Chronic pain: challenges and assessment strategies

Older adults are a rapidly growing segment of the world population, and long-term care will continue to be a major concern for most health care institutions in this century. Pain management remains at the forefront of long-term care issues, with older patients more subject than younger patients to chronic disease states that predispose them to pain. Assessment and management of chronic pain, however, are impeded by a lack of patient and caregiver education regarding pain, widespread misconceptions about pain in older patients, and special concerns and cautions for appropriate analgesic use in this population. This is the first of a two-part series highlighting issues and strategies related to pain assessment in older adults.

Effects of age on temporal summation and habituation of thermal pain: Clinical relevance in healthy older and younger adults

Although the effects of aging on the experience of clinical pain seem relatively clear, investigations of age-related changes in pain perception using laboratory-based pain assessment procedures have yielded contradictory findings. One potential source of variability in this literature is the type of experimental noxious stimulus that is used. Although thermal pain thresholds are the most commonly reported measure of pain sensitivity, use of suprathreshold stimuli in pain assessment procedures may yield additional, more clinically relevant information concerning the effects of aging on the experience of pain. The present study examined the effects of age on temporal summation of both the intensity and unpleasantness of thermal pain at multiple stimulus temperatures. Specifically, responses to repetitive thermal stimuli delivered to the volar forearm at 47 degrees C, 50 degrees C, and 53 degrees C were assessed in 34 younger (mean age, 22.4 years) and 34 older (mean age, 62.2 years) healthy volunteers. Results suggested that for the 47 degrees C and 50 degrees C stimulus trains, older adults exhibited higher ratings of the intensity and unpleasantness of thermal pain and enhanced temporal summation of thermal pain relative to younger adults. Moreover, thermal pain sensitivity was inversely related to perceptions of general health and to reports of recent clinical pain among younger, but not older, subjects. Collectively these findings may indicate small, although potentially significant, age-related alterations in the plasticity of the central nervous system or endogenous pain-modulatory capacities.

Pain in the nursing home

The treatment of pain in the nursing home setting continues to present several unique and challenging problems. Increasingly, studies are focusing on the large number of elderly with important pain problems in long-term care. The inclusion of pain as an area of clinical focus in the Minimum Data Set has fueled interest in this problem and will provide solid data for future study. Researchers are attempting to establish reliable and valid data using standardized assessment tools previously validated in younger adults and are attempting use of traditional and cutting-edge assessment tools in cognitively impaired patients. Assessment is being linked to innovative interventions in noncommunicative, cognitively impaired residents using primary care nurses who best know these patients to decipher "normal" from "abnormal" behavior. The application of available pharmacologic interventions are more challenging because of the higher incidence of side effects in the elderly; part of this problem is the result of the decreased hepatic metabolism and renal clearance present in older patients. The nursing home environment has limited resources that can create logistical concerns in terms of diagnosis and treatment but also can positively limit overly invasive modalities. This article explores these issues and offers suggestions for the appropriate assessment and management of pain in long-term care residents.

Age-related differences in pain perception and report

The clinical and laboratory-based evidence for age-related differences in pain perception and report are reviewed. Most clinical studies suggest a relative decrease in the frequency and intensity of pain symptoms associated with myocardial complaints, visceral infections, musculoskeletal conditions, and postoperative and malignant pain problems in adults of advanced age. The findings from experimentally controlled laboratory investigations are more equivocal and vary according to the type and intensity of noxious stimulation. Nonetheless, such studies also provide some additional support for the notion of an age-related decrease in pain perception and report. Evidence has not determined whether the observed changes are caused by the aging process or reflect other age-associated effects, including an increased presence of comorbid disease, biocultural cohort effects, or altered psychosocial influences.

Pain management practices of nurses caring for older patients with osteoarthritis

Osteoarthritis is a prevalent chronic illness in older people. Management of the ensuing pain is of critical importance in preventing disability and maintaining independence. This qualitative study explored the pain management techniques used by 10 RNs working in home health nursing. Four categories emerged from the interview data: knowing how to assess, knowing about pain treatments, trying but frustrated, and needing more knowledge. These categories were reduced into two constructs: Understanding Pain and Wanting to Provide Good Nursing Care. Clinical implications included supplementing pain management strategies by adding to the assessment base, expanding pain management techniques, and increasing knowledge about aging processes and pain control.

Assessment and management of chronic pain in elderly people

The ageing process can bring with it an increased incidence of conditions which give rise to chronic pain. Persistent musculoskeletal and/or neuropathic pain due to conditions such as back pain, arthritis, osteoporosis and diabetes in elderly people can lead to a marked deterioration in their quality of life. Pain assessment can be complicated by concomitant disorientation, confusion and communication deficits, leading to the undertreatment of pain in this client group. Pain management can be difficult due to the existence of multiple medical problems and the increased incidence of side-effects related to the treatment. This article aims to update nurses on the assessment and management of pain in the older adult, and will provide a broad overview of pain management strategies suitable for elderly patients.

Age-associated differences in responses to noxious stimuli

BACKGROUND

Although population-based studies typically report age-associated increases in clinical pain, laboratory-based pain assessment procedures generally indicate diminished pain sensitivity with age. The majority of these studies have utilized noxious thermal stimuli as the method of pain induction. However, other pain assessment methodologies, including ischemic pain induction, may have a more meaningful relationship to clinical pain. The present study examined the effects of age on responses to a variety of experimental noxious stimuli. In addition, relationships between cardiovascular measures and pain responses were investigated in both older and younger subjects.

METHODS

Responses to thermal, mechanical, and ischemic pain were assessed in 34 younger (mean age, 22.4 years) and 34 older adults (mean age, 62.2 years). In addition, relationships between resting blood pressure and pain responses were assessed separately for older and younger participants.

RESULTS

Although group differences in thermal and mechanical pain responses did not achieve statistical significance, older individuals demonstrated substantially lower ischemic pain thresholds and tolerances assessed via the modified submaximal effort tourniquet procedure (ps < .01). Overall, higher resting arterial blood pressures were associated with increased pain thresholds and tolerances, although relationships between blood pressure and ischemic pain variables were evident only for the younger group.

CONCLUSIONS

These findings indicate that age-related differences in responses to experimental noxious stimuli vary as a function of the pain induction task, with older individuals showing greater sensitivity to clinically relevant stimuli. In addition, the absence of a relationship between blood pressure and ischemic pain responses in older adults may suggest potential functional decrements in at least one endogenous pain-modulatory system.

Morphine treatment induced calcitonin gene-related peptide and substance P increases in cultured dorsal root ganglion neurons

The mechanism of spinal tolerance to the analgesic effects of opiates is unclear at present. We have reported previously that calcitonin gene-related peptide-like immunoreactivity was significantly increased in primary afferents of the spinal dorsal horn during the development of morphine tolerance, suggesting that changes in the level of pain-related neuropeptides in dorsal root ganglion neurons may be involved [Menard D. P. et al. (1996) J. Neurosci. 16, 2342-2351]. In this study, we investigated if in vitro treatment with morphine can mimic the in vivo findings and induce increases in calcitonin gene-related peptide-like immunostaining in cultured dorsal root ganglion neurons from young (three-month-old) and middle-aged (10-month-old) adult rats. Following a repetitive exposure to morphine sulfate (1, 5, 10 microM) for six days, the number of calcitonin gene-related peptide- and substance P-immunoreactive neurons in cultured dorsal root ganglia from three- and 10-month-old rats was significantly increased. A lower concentration (0.5 microM) of morphine induced these increases only in dorsal root ganglion neurons from middle-aged rats. Morphine treatment was also found to increase the number of calcitonin gene-related peptide-immunoreactive neurons possessing multiple, long branches (i.e. with at least one branch >0.5mm). This apparent increase in the number of calcitonin gene-related peptide- and substance P-immunoreactive neurons observed following morphine treatment was blocked by naloxone, an opiate antagonist, indicating the involvement of genuine opioid receptors. No significant change in the number of neuropeptide Y- or galanin-immunoreactive neurons in cultured dorsal root ganglia was detected following any of these treatments. These data suggest that repeated exposure to morphine rather selectively increases calcitonin gene-related peptide- and substance P-like immunoreactivity in cultured dorsal root ganglion neurons. Moreover, the sensitivity to morphine-induced changes is greater in cultured dorsal root ganglion neurons from 10- compared to three-month-old rats. Hence, cultured dorsal root ganglion neurons can provide a model to investigate the cellular and molecular mechanisms underlying alterations in neuropeptide levels following repeated exposure to opiates and their relevance to the development of opioid tolerance.

Easing elders' pain

Pain is an undertreated, understudied problem in the growing elder population. Clinicians need to consider the compelling evidence that a significant majority of this population experience pain that interferes with quality of life and normal functioning. The barriers to adequate pain management must be addressed and misconceptions corrected. It is critical to identify both acute and chronic pain. Pain assessment and reassessment need to be performed regularly and used in treatment selection. Consideration of physiologic changes that occur in the aged will guide choices of pharmacologic and non-pharmacologic therapies. Pain assessment and treatment must be recognized as fundamental care issues.

Age differences in nociception and pain behaviours in the rat

Much remains to be learned about the effects of ageing on pain. Studies of life-span changes in nociception and pain behaviours in the rat are equivocal making it difficult to draw firm conclusions. This paper reviews the available data and finds that age differences in nociception may be dependent on the pain test employed. Specifically, reflexive responses to nociceptive stimuli do not change with age while there may be no change or a linear decrease with age on more highly organized tests of nociception. Interestingly, age differences in pain behaviours on models of tissue injury and inflammation may not be linear. It is shown that important changes that begin at mid-life in neuroanatomy, neurochemistry and endogenous pain inhibition may be associated with alterations in pain sensitivity. Several testable hypotheses which might encourage future research in this domain are developed throughout this paper.

The impact of age on a patient's perception of pain and ways it can be managed

The elderly population is one of the fastest growing groups in the United States. Pain is a significant problem for community-dwelling elders and for elderly persons in residential facilities. Numerous barriers exist to effective pain management in the elderly. Clinicians, however, can overcome many of these barriers through careful assessments of pain that accommodate many of the physiologic changes that occur with aging. Effective pain management of elderly individuals requires knowledge of the pharmacokinetic and pharmacodynamic changes that occur with aging. Both pharmacologic and nonpharmacologic approaches should be used to manage pain in the elderly.

Nurses' perceptions of pain assessment and treatment in the cognitively impaired elderly. It's not a guessing game

The purpose of the study was to describe nurses' perceptions regarding the assessment and treatment of pain in patients with late-stage dementia. Thirty nurses from six long-term care facilities were interviewed using a semistructured format for this qualitative study. Initial results were presented to a second group for validation and refinement of findings. The most commonly cited behaviors used to indicate discomfort were facial grimacing, restless body movement, change in behavior, moaning, and tense muscles. Psychotropic drugs were perceived to be commonly misused because behavior changes were seen as a psychiatric problem rather than a representation of the patient's unmet need. Nurses had positive feelings about using both narcotics and nonnarcotic analgesics with this population but believed both types of analgesics were underused. The most common concerns regarding the administration of narcotic analgesics to this population were falls, sedation, and constipation.

Partial sciatic nerve ligation induced more dramatic increase of neuropeptide Y immunoreactive axonal fibers in the gracile nucleus of middle-aged rats than in young adult rats

Neuropeptide changes in primary sensory neurons caused by partial nerve injury are likely involved in the development of neuropathic pain. In this study, using immunocytochemistry, we examined neuropeptide Y (NPY) expression in lumbar dorsal root ganglion (DRG) cells of young adult (2-3 months old) and middle-aged (8-10 months old) rats 4 weeks after partial sciatic nerve ligation (PSNL). Significantly higher NPY immunoreactivity was induced in the injured side DRG neurons, the dorsal horn and the gracile nuclei in middle-aged rats than in young rats. Using combined fluorescent dye tracing and NPY immunostaining, we found in middle-aged rats that 46% injured DRG neurons projected to the gracile nucleus and 45% of injured neurons were also NPY-IR, whereas 42% spared DRG neurons projected to the gracile nucleus and 18% of spared neurons were also NPY-IR. Thus PSNL induces NPY up-regulation in spared as well as injured DRG neurons, both contribute to the increased NPY immunoreactivity in the gracile nucleus in the middle-aged rats. The more dramatic increase of NPY in DRG neurons of middle-aged rats after PSNL shows that the responses to partial nerve injury are age-dependent, that suggests a possible relevance to the higher incidence of neuropathic pain in human middle age.

Effective pain management in older patients

Assessing and managing post-operative pain in older adult patients is complex. A baseline preoperative pain assessment provides the necessary data that assist appropriate and effective pain management. Careful monitoring and individualization of patient dosages result in effective older adult patient pain management.

Increased calcitonin gene-related peptide immunoreactivity in gracile nucleus after partial sciatic nerve injury: age-dependent and originating from spared sensory neurons

Following a unilateral chronic constriction injury of the sciatic nerve, calcitonin gene-related peptide (CGRP)-immunoreactive (IR) fiber density increases in the ipsilateral gracile nucleus, and this is more pronounced in aged (16-month) rats where the fibers are dystrophic. In this study we show that a second type of partial sciatic nerve injury, a half-transection, also induces CGRP-IR fibers in the gracile nucleus, but this effect is strongly age-dependent, being much more pronounced in 8- to 10-month-old rats than in 2- to 3-month-old rats. Dystrophic CGRP-IR fibers were rarely observed in 8- to 10-month-old animals, so the increased reaction in aged animals and axonal dystrophy are separate phenomena. Using double-labeling with fluorescent dye tracing for 8- to 10-month-old rats, we showed that neuron profiles in the dorsal root ganglion (DRG) with peripheral axons spared by the partial sciatic nerve injury were 10 times more likely to be CGRP mRNA-positive than profiles with injured peripheral axons, suggesting that spared neurons are more likely to contribute to the increase in CGRP-IR fibers in the gracile nucleus. Using combined fluorescent dye tracing with in situ hybridization for CGRP mRNA or CGRP immunostaining, we further showed that CGRP-expressing DRG neuron profiles with central projections to the gracile nucleus had peripheral axons spared by the partial nerve injury. We conclude that the increased CGRP immunoreactivity in the gracile nucleus following partial sciatic nerve injury originates from primary sensory neurons with axons spared by the injury. These neurons may still transmit cutaneous sensory information and thus the increased CGRP immunoreactive fibers in the gracile nucleus may be involved in the mechanical allodynia characteristic of neuropathic pain syndromes following partial nerve injury.

Can stroke patients use visual analogue scales?

BACKGROUND AND PURPOSE

Visual analogue scales (VAS) have been used for the subjective measurement of mood, pain, and health status after stroke. In this study we investigated how stroke-related impairments could alter the ability of subjects to answer accurately.

METHODS

Consent was obtained from 96 subjects with a clinical stroke (mean age, 72.5 years; 50 men) and 48 control subjects without cerebrovascular disease (mean age, 71.5 years; 29 men). Patients with reduced conscious level or severe dysphasia were excluded. Subjects were asked to rate the tightness that they could feel on the (unaffected) upper arm after 3 low-pressure inflations with a standard sphygmomanometer cuff, which followed a predetermined sequence (20 mm Hg, 40 mm Hg, 0 mm Hg). Immediately after each change, they rated the perceived tightness on 5 scales presented in a random order: 4-point rating scale (none, mild, moderate, severe), 0 to 10 numerical rating scale, mechanical VAS, horizontal VAS, and vertical VAS. Standard tests recorded deficits in language, cognition, and visuospatial awareness.

RESULTS

Inability to complete scales with the correct pattern was associated with any stroke (P<0.001). There was a significant association between success using scales and milder clinical stroke subtype (P<0.01). Within the stroke group, logistic regression analysis identified significant associations (P<0.05) between impairments (cognitive and visuospatial) and inability to complete individual scales correctly.

CONCLUSIONS

Many patients after a stroke are unable to successfully complete self-report measurement scales, including VAS.

Older adults living with chronic pain: an opportunity for improvement

The American Geriatrics Society has recently published clinical practice guidelines addressing chronic pain in older adults. The guidelines identify current provider-based and system-oriented barriers and recommend practice improvements to enhance routine assessment, pharmacological therapy, and nonpharmacological therapy. Recommended organizational improvements focus on facilitating access and delivery of optimal care for all older adults living with chronic pain. Nurses are encouraged to assess older adults routinely for the presence of chronic pain and to advocate for appropriate treatment when indicated.

Emerging concepts in the neurobiology of chronic pain: evidence of abnormal sensory processing in fibromyalgia

Chronic pain often differs from acute pain. The correlation between tissue pathology and the perceived severity of the chronic pain experience is poor or even absent. Furthermore, the sharp spatial localization of acute pain is not a feature of chronic pain; chronic pain is more diffuse and often spreads to areas beyond the original site. Of importance, chronic pain seldom responds to the therapeutic measures that are successful in treating acute pain. Physicians who are unaware of these differences may label the patient with chronic pain as being neurotic or even a malingerer. During the past decade, an exponential growth has occurred in the scientific underpinnings of chronic pain states. In particular, the concept of nonnociceptive pain has been refined at a physiologic, structural, and molecular level. This review focuses on this new body of knowledge, with particular reference to the chronic pain state termed "fibromyalgia."

Empirical evidence of the association between the presence of musculoskeletal pain and physical disability in community-dwelling senior citizens

The proportion of people 65 years of age and older who report musculoskeletal pain and physical disability is high. The main objective of this study was to determine whether physical disability was associated with the presence of musculoskeletal pain in a sample of senior citizens. Self-administered questionnaires were sent to a sample of 1306 community-dwelling senior citizens in London, Ontario, Canada between August and October 1995. The questionnaire included questions about pain, difficulty performing activities, depressive symptoms, chronic conditions, and demographic information. A total of 887 seniors completed the questionnaire (70.7% response rate, aged 65-94, 41.2% men, 58.8% women). Logistic regression analysis, without controlling for potential confounding variables, revealed that those who reported having musculoskeletal pain were seven times more likely to have some difficulty performing three or more activities listed in the questionnaire (OR = 6.91 95% CI 4.92-9.69). When significant confounding variables were controlled in the analysis, seniors who reported musculoskeletal pain were still three times more likely to have some difficulty with three or more activities (OR = 2.93, 95% CI 1.96-4.38). Although no causal relationship can be inferred, thorough pain assessment and pain management may be important in the maintenance of independent living for adults 65 years of age or older.