Undertreatment of pain in older adults: an application of beneficence

Pain management inequities by demographic and geriatric-related variables in older adult inpatients

BACKGROUND

Pain is ubiquitous, yet understudied. The objective of this study was to analyze inequities in pain assessment and management for hospitalized older adults focusing on demographic and geriatric-related variables.

METHODS

This was a retrospective cohort study from January 2013 through September 2021 of all adults 65 years or older on the general medicine service at UCSF Medical Center. Primary exposures included (1) demographic variables including race/ethnicity and limited English proficiency (LEP) status and (2) geriatric-related variables including age, dementia or mild cognitive impairment diagnosis, hearing or visual impairment, end-of-life care, and geriatrics consult involvement. Primary outcomes included (1) adjusted odds of numeric pain assessment versus other assessments and (2) adjusted opioids administered, measured by morphine milligram equivalents (MME).

RESULTS

A total of 15,809 patients were included across 27,857 hospitalizations with 1,378,215 pain assessments, with a mean age of 77.8 years old. Patients were 47.4% White, 26.3% with LEP, 49.6% male, and 50.4% female. Asian (OR 0.75, 95% CI 0.70-0.80), Latinx (OR 0.90, 95% CI 0.83-0.99), and Native Hawaiian or Pacific Islander (OR 0.77, 95% CI 0.64-0.93) patients had lower odds of a numeric assessment, compared with White patients. Patients with LEP (OR 0.70, 95% CI 0.66-0.74) had lower odds of a numeric assessment, compared with English-speaking patients. Patients with dementia, hearing impairment, patients 75+, and at end-of-life were all less likely to receive a numeric assessment. Compared with White patients (86 MME, 95% CI 77-96), Asian patients (55 MME, 95% CI 46-65) received fewer opioids. Patients with LEP, dementia, hearing impairment and those 75+ years old also received significantly fewer opioids.

CONCLUSION

Older, hospitalized, general medicine patients from minoritized groups and with geriatric-related conditions are uniquely vulnerable to inequitable pain assessment and management. These findings raise concerns for pain underassessment and undertreatment.

Clarification of ethical principle of the beneficence in nursing care: an integrative review

BACKGROUND

Ethics-based nursing practice can transform health care practices. As the biggest human capital in the health care system, nurses are obliged to follow ethical principles in this field. One of these ethical principles; is beneficence, which is considered the core of nursing care. This study aimed to investigate clarification of the principle of beneficence in nursing care and its related challenges.

METHODS

This integrative review was conducted using the Whittemore & Knafl method in 5 stages, including problem identification, searching the literature, evaluating primary sources, analyzing data, and presenting the results. Databases like SID, Irandoc, Magiran, Google Scholar, Web of Science, PubMed, and Scopus were searched using the keywords; "beneficence", "ethic", "nursing" and "care" in English and Persian in the time range of 2010 to 10 February, 2023. After applying inclusion criteria and assessing the articles using Bowling's Quality Assessment Tool, finally, 16 papers were included from 984.

RESULTS

After reviewing and evaluating the qualified articles, the findings were classified into four main categories: (1) nature, (2) applicability, (3) Relevant and influential factors, and (4) challenges related to the ethical principle of beneficence in nursing care.

CONCLUSION

Based on the results of this review it seems that paying attention to clarification the principle of beneficence in nursing care can provide positive outcomes for patients to benefit from this principle and finally, it leads to increasing the well-being and health of patients, reducing their mortality rate, increasing satisfaction and maintaining the respect and human dignity of patients.

The concept of vulnerability in aged care: a systematic review of argument-based ethics literature

BACKGROUND

Vulnerability is a key concept in traditional and contemporary bioethics. In the philosophical literature, vulnerability is understood not only to be an ontological condition of humanity, but also to be a consequence of contingent factors. Within bioethics debates, vulnerable populations are defined in relation to compromised capacity to consent, increased susceptibility to harm, and/or exploitation. Although vulnerability has historically been associated with older adults, to date, no comprehensive or systematic work exists on the meaning of their vulnerability. To fill this gap, we analysed the literature on aged care for the meaning, foundations, and uses of vulnerability as an ethical concept.

METHODS

Using PRISMA guidelines, we conducted a systematic review of argument-based ethics literature in four major databases: PubMed, Embase®, Web of Science™, and Philosopher's Index. These covered biomedical, philosophy, bioethical, and anthropological literature. Titles, abstracts, and full texts of identified papers were screened for relevance. The snowball technique and citation tracking were used to identify relevant publications. Data analysis and synthesis followed the preparatory steps of the coding process detailed in the QUAGOL methodology.

RESULTS

Thirty-eight publications met our criteria and were included. Publication dates ranged from 1984 to 2020, with 17 publications appearing between 2015 and 2020. Publications originated from all five major continents, as indicated by the affiliation of the first author. Our analyses revealed that the concept of vulnerability could be distinguished in terms of basic human and situational vulnerability. Six dimensions of older adults' vulnerability were identified: physical; psychological; relational/interpersonal; moral; sociocultural, political, and economic; and existential/spiritual. This analysis suggested three ways to relate to older adults' vulnerability: understanding older adults' vulnerability, taking care of vulnerable older adults, and intervening through socio-political-economic measures.

CONCLUSIONS

The way in which vulnerability was conceptualised in the included publications overlaps with distinctions used within contemporary bioethics literature. Dimensions of aged care vulnerability map onto defining features of humans, giving weight to the claim that vulnerability represents an inherent characteristic of humans. Vulnerability is mostly a value-laden concept, endowed with positive and negative connotations. Most publications focused on and promoted aged care, strengthening the idea that care is a defining practice of being human.

Perioperative Pulmonary Support of the Elderly

Purpose of Review

With the projected increase in the geriatric patient population, it is of the utmost importance to understand and optimize conditions in the perioperative period to ensure the best surgical outcome. Age-associated changes in respiratory physiology affect the surgical management of geriatric patients. This review focuses on perioperative pulmonary management of elderly individuals.

Recent Findings

The physiological changes associated with aging include both physical and biochemical alterations that are detrimental to pulmonary function. There is an increased prevalence of chronic lung disease such as COPD and interstitial lung disease which can predispose patients to postoperative pulmonary complications. Additionally, elderly patients, especially those with chronic lung disease, are at risk for frailty. Screening tools have been developed to evaluate risk and aid in the judicious selection of patients for surgical procedures. The concept of "prehabilitation" has been developed to best prepare patients for surgery and may be more influential in the reduction of postoperative pulmonary complications than postoperative rehabilitation. Understanding the age-associated changes in metabolism of drugs has led to dose adjustments in the intraoperative and postoperative periods, reducing respiratory depression and lung protective ventilation and minimally invasive procedures have yielded reductions in postoperative pulmonary complications.

Summary

The perioperative management of the geriatric population can be divided into three key areas: preoperative risk mitigation, intraoperative considerations, and postoperative management. Preoperative considerations include patient selection and thorough history and physical, along with smoking cessation and prehabilitation in a subset of patients. Operative aspects include careful selection of anesthetic agents, lung protective ventilation, and choice of surgical procedure. Postoperative management should focus on selective use of agents that may contribute to respiratory depression and encouragement of rehabilitation.

Pharmacokinetics of 2 oral paracetamol formulations in hospitalized octogenarians

AIMS

It is currently unclear how paracetamol should be dosed in order to increase its efficacy while warranting safety in very old adults. The objective was to evaluate the pharmacokinetics of 2 oral paracetamol formulations and its metabolites in hospitalized octogenarians.

METHODS

Geriatric inpatients aged 80 years and older received a 1000-mg paracetamol tablet or granulate at 08.00, 14.00 and 20.00. After at least 4 consecutive gifts, plasma samples were collected around the 08.00 dose (trough, +0.5, +1, +2, +4, +5 and +6 h). Plasma concentrations of paracetamol and its metabolites were determined and individual pharmacokinetic parameters were derived. The Edmonton Frail Scale was used to assess frailty. An analgesic plasma target was defined as an average plasma concentration (C_avg ) of 10 mg/L.

RESULTS

The mean (±standard deviation) age was 86.78 (±4.20) years. The majority (n = 26/36, 72%) received the tablet, 10 (28%) the granulate. Thirty patients (85%) were classified with moderate to severe frailty. Seven (21%) patients had a C_avg above 10 mg/L. The median [interquartile range] time to reach the peak concentration was 50.5 [31.50-92.50] and 42.50 [33.75-106.75] min for the tablet and granulate, respectively. The coefficient of variation was 95% for time to reach the peak concentration and 30% for C_avg of paracetamol. A correlation of C_avg of paracetamol was observed with female sex and total serum bilirubin.

CONCLUSION

Large interindividual differences were found for pharmacokinetic parameters of oral paracetamol in frail inpatients after multiple dosing. Female sex and higher total serum bilirubin concentrations were associated with paracetamol exposure. No significant differences were observed between the tablet and granulate.

Experimentally evoked pain in Alzheimer's disease

BACKGROUND

Pain continues to be underrecognized and undertreated in Alzheimer's disease (AD) while existing guidance about pain assessment and management in dementia is not widespread. Brain regions involved in pain processing and modulation are damaged during AD, and the pain experience in AD is not well understood. Experimental pain studies using psychophysics can further our understanding of the pain experience in AD, which may lead to improved assessment and management of pain in people living with AD.

OBJECTIVE

A systematic review was conducted to explicate the current understanding of experimentally evoked pain in AD from primary research using psychophysical methods.

DATA SOURCES

Peer-reviewed publications were found via PubMed, CINAHL, and PsycINFO. A total of 18 primary research, peer-reviewed full articles that met inclusion criteria were included, representing 929 total participants.

CONCLUSIONS

Experimentally evoked pain in people with AD demonstrates that despite cognitive impairment and a reduced ability to effectively communicate, individuals with AD experience pain similar to or more unpleasant than cognitively intact older adults. This may mean amplified pain unpleasantness in people with AD.

IMPLICATIONS FOR PRACTICE

Our current best practices need to be widely disseminated and put into clinical practice. Self-report of pain continues to be the gold standard, but it is ineffective for noncommunicative patients and those unable to understand pain scales or instructions because of memory/cognitive impairment. Instead, pain treatment should be ethically initiated based on patient reports and behaviors, caregiver/surrogate reports, review of the medical record for painful conditions, analgesic trials, and regular reassessments.

The Association of Persistent Low Back Pain With Older Adult Falls and Collisions: A Longitudinal Analysis

Mobility-related injuries associate with reduced quality of life, greater functional dependence, and quicker mortality in older adults-warranting prevention efforts. One factor elevating injury risk may be persistent low back pain, which can negatively affect cognitive and physical functions essential for safe mobility. Among older adults obtaining license renewal (n = 1,127), this study examined the association between persistent low back pain and incidence of falls and motor vehicle collisions (MVCs) for up to 15 years. Overall, older adults with persistent low back pain were more likely to have a fall (odds ratio [OR] = 1.54, 95% confidence interval [CI] = [1.34, 1.77]) or MVC (OR = 1.38, 95% CI = [1.07, 1.77]) than those without back pain. Furthermore, the number of falls and MVCs was lower for people with better lower limb and visuospatial function, respectively. Ameliorating pain and functioning in persistent lower back pain might contribute to improved mobility and a reduction of injury-related risk in later life.

["Emergency anesthesia" in geriatric patients]

BACKGROUND

The share of elderly patients undergoing emergency surgery is constantly increasing. Their postoperative outcome remains poor, even if surgery itself is survived in the short or medium term.

OBJECTIVES

Important aspects of anesthesiologic care for older emergency patients based upon recent literature and guideline recommendations are presented.

METHODS

Selective review of the literature, considering national and international guidelines, meta-analysis and Cochrane reviews.

CONCLUSION

Anesthesiologic care can significantly influence the perioperative outcome of elderly emergency surgery patients. In this context, emergency anesthesiology exceeds mere anesthesia itself and applies to the overall perioperative management.

Older people's use of non-pharmacological interventions for chronic, non-cancer pain and comfort

BACKGROUND

Many older people experience chronic pain, so increased comfort and pain relief are important for older residents in assisted and/or supported-living environments. While several studies have found that people using non-pharmacological interventions without taking pain medication experienced significant differences in pain, the effect of non-pharmacological interventions on comfort and chronic pain in older people has not been studied.

AIM

To assess differences in comfort and pain among older people in assisted and supported-living facilities who had chronic, non-cancer pain and who used or did not use non-pharmacological interventions.

METHOD

A descriptive, comparative, cross-sectional pilot study with a convenience sample of 82 participants from 11 assisted and supported-living facilities. Three questionnaires were used to obtain data on the independent variable of use/non-use of non-pharmacological interventions and the dependent variables of perceived comfort and pain. Multivariate analyses of variance were computed to measure differences between the use/non-use groups, and Roy-Bargmann stepdown analyses were computed to further subdivide and analyse the groups who were using and not using pain medication.

RESULTS

No significant differences were found in chronic pain and perceived comfort between participants who did or did not use non-pharmacological interventions if they were not also taking pain medication. However, when participants were also taking pain medication, chronic pain and perceived comfort scores were significantly affected by the use of non-pharmacological interventions. The most common non-pharmacological interventions were exercise, heat therapy, spiritual activity/religion and listening to music.

CONCLUSION

Older people using non-pharmacological interventions and taking pain medication had higher perceived comfort scores and lower pain scores than those using pain medication only. Relationships between non-pharmacological interventions and comfort should be explored further. With minor changes, this pilot study design could be used with a larger sample.

Assessment and Management of Postoperative Pain among Nurses at a Resource-Constraint Teaching Hospital in Ghana

Background

Postoperative pain remains one of the greatest concerns for patients following surgical procedures. Nurses play an essential role in postoperative pain assessment and management, especially within the first few days after surgery.

Objective

The study investigated how nurses in a resource-constraint hospital in Ghana assessed and managed postoperative pain.

Methods

This was an explorative qualitative study involving 12 registered nurses practising in the largest referral hospital in Ghana. Data was gathered using a semistructured interview guide. Demographic characteristics of participants were summarized using descriptive statistics. Data were analysed using Kvale's three phases for analysing qualitative data. First, the entire text was read again to identify meaning units which were then condensed. Second, the condensed texts were read again and interpreted. Finally, the condensed data containing similar meaning were coded and then sorted into subthemes.

Results

It was found that some nurses have never used any pain assessment tool due to lack of standard tool for assessing postoperative pain. The majority of nurses reported that managing pain by using medication was the norm especially in the first 24 hours after surgery.

Conclusion

Although participants may have some knowledge of assessing and managing postoperative pain, this knowledge was not largely used to manage postoperative pain effectively, partly because of resource constraints. Therefore, there is the need for adequate training and with provision of resources, it is imperative that the use of standardized pain assessment scales could help in the proper assessment and management of postoperative pain in this setting.

Frailty is associated with pain and cognitive function in older people in post-acute care settings

BACKGROUND

To describe pain, cognitive function, and frailty of older people in post-acute care settings and examine the association between the three elements.

METHODS

This cross-sectional study involved 142 participants from a rehabilitation ward and a geriatric day centre. Pain, cognitive function and frailty were assessed using Brief Pain Inventory, Abbreviated Mental Test, and 5-item Frail Scale respectively.

RESULTS

Participants were mostly women (51.7%) with a mean age of 76.5 (SD 7.8). Mean scores for pain, cognition, and frailty were 9.0 ± 1.0, 4.0 ± 2.8, and 2.2 ± 1.2, respectively. Cognition had a significant inverse association with frailty (β = -0.160, p = 0.047), and pain had a significant positive association with frailty (β = 5.122, p < 0.001). This linear regression model explained a variance of 0.269.

CONCLUSIONS

The study demonstrated the association between pain, cognitive function, and frailty. In predicting frailty, however, more studies are required to determine the predictive value and cut-off points for pain and cognitive measures.

Oligoanalgesia in Adult Colles Fracture Patients Admitted to the Emergency Department

Pain is a complex symptom to assess properly and it is often poorly managed in the Emergency Department. The majority of research has focused on exploring oligoanalgesia in samples of patients with heterogeneous injuries. The occurrence of oligoanalgesia in a homogeneous injury, such as Colles fracture, has yet to be explored. A retrospective chart review was conducted to determine the incidence of oligoanalgesia in adults with Colles fractures admitted to two urban Emergency Departments in Western Canada. Data were collected from one hundred fifty charts from a 5-year period (2009-2014). Age and gender predicted of pain assessment (p = .019), but were not significantly associated with receipt of an opioid or pain reassessment. Pain reassessment was only completed in 47% of patients who received an initial pain assessment; this was significantly different from current best practice standards (p = .0002).

Establishing a Research Agenda on Mobile Health Technologies and Later-Life Pain Using an Evidence-Based Consensus Workshop Approach

The rapid growth of mobile health (mHealth) devices holds substantial potential for improving care and care outcomes in all patient populations, including older adults with pain. However, existing research reflects a substantial gap in knowledge about how to design, evaluate, and disseminate devices to optimally address the many challenges associated with managing pain in older persons. Given these knowledge gaps, we sought to develop a set of practice-based research priorities to facilitate innovation in this field. We employed the Cornell Research-Practice Consensus Workshop Model, an evidence-based approach to generating research priorities. Sixty participants attended the conference, where stakeholder groups included older adults with pain and their caregivers, behavioral and social scientists, healthcare providers, pain experts, and specialists in mHealth and health policy. Participants generated 13 recommendations classified into 2 categories: 1) implications for designing research on mHealth among older adults (eg, conduct research on ways to enhance accessibility of mHealth tools among diverse groups of older adults with pain, expand research on mHealth sensing applications), and 2) implementation of mHealth technology into practice and associated regulatory issues (eg, promote research on ways to initiate/sustain patient behavior change, expand research on mHealth cybersecurity and privacy issues). PERSPECTIVE: This report highlights a set of research priorities in the area of mHealth and later-life pain derived from the joint perspectives of researchers and key stakeholder groups. Addressing these priorities could help to improve the quality of care delivered to older adults with pain.

Emergency nurses' knowledge and self-rated practice skills when caring for older patients in the Emergency Department

BACKGROUND

Older adults are high users of emergency department services and their care requirements can present challenges for emergency nurses. Although clinical outcomes for older patients improve when they are cared for by nurses with specialist training, emergency nurses' knowledge and self-assessment of care for older patients is poorly understood.

AIM

To assess emergency nurses' knowledge and self-rating of practice when caring for older patients.

METHODS

A cross-sectional self-report survey of emergency nurses (n=101) in Melbourne, Australia.

RESULTS

Mean scores were 12.7 (SD 2.66) for the 25-item knowledge of older persons questionnaire, and 9.04 (SD 1.80) for the 15-item gerontic health related questions. Scores were unaffected by years of experience as a registered nurse or emergency nurse. More than 80% of nurses rated themselves as 'very good' or 'good' in assessing pain (94.9%), identifying delirium (87.8%), and identifying dementia (82.8%). Areas with a 'poor' ratings were identifying depression (46.5%), assessing polypharmacy (46.5%) and assessing nutrition (37.8%).

CONCLUSIONS

There was variation in knowledge and self-rating of practice related to care of older patients. The relationship between knowledge and self-ratings of practice in relation to actual emergency nursing care of older people and patient outcomes warrants further exploration.

Impact of prescription drug monitoring programs (PDMPs) on opioid utilization among Medicare beneficiaries in 10 US States

BACKGROUND AND AIMS

Prescription Drug Monitoring Programs (PDMPs) are a principal strategy used in the United States to address prescription drug abuse. We (1) compared opioid use pre- and post-PDMP implementation and (2) estimated differences of PDMP impact by reason for Medicare eligibility and plan type.

DESIGN

Analysis of opioid prescription claims in US states that implemented PDMPs relative to non-PDMP states during 2007-12.

SETTING

Florida, Louisiana, Nebraska, New Jersey, Vermont, Georgia, Wisconsin, Maryland, New Hampshire and Arkansas, USA.

PARTICIPANTS

A total of 310 105 disabled and older adult Medicare enrolees.

MEASUREMENTS

Primary outcomes were monthly total opioid volume, mean daily morphine milligram equivalent (MME) dose per prescription and number of opioid prescriptions dispensed. The key predictors were PDMP status and time. Tests for moderation examined PDMP impact by Medicare eligibility (disability versus age) and drug plan [privately provided Medicare Advantage (MAPD) versus fee-for-service (PDP)].

FINDINGS

Overall, PDMP implementation was associated with reduced opioid volume [-2.36 kg/month, 95% confidence interval (CI) = -3.44, -1.28] and no changes in mean MMEs or opioid prescriptions 12 months after implementation compared with non-PDMP states. We found evidence of strong moderation effects. In PDMP states, estimated monthly opioid volumes decreased 1.67 kg (95% CI = -2.38, -0.96) and 0.75 kg (95% CI = -1.32, -0.18) among disabled and older adults, respectively, and 1.2 kg, regardless of plan type. MME reductions were 3.73 mg/prescription (95% CI = -6.22, -1.24) in disabled and 3.02 mg/prescription (95% CI = -3.86, -2.18) in MAPD beneficiaries, but there were no changes in older adults and PDP beneficiaries. Dispensed prescriptions increased 259/month (95% CI = 39, 479) among the disabled and decreased 610/month (95% CI = -953, -257) among MAPD beneficiaries.

CONCLUSIONS

Prescription drug monitoring programs (PDMPs) are associated with reductions in opioid use, measured by volume, among disabled and older adult Medicare beneficiaries in the United States compared with states that do not have PDMPs. PDMP impact on daily doses and daily prescriptions varied by reason for eligibility and plan type. These findings cannot be generalized beyond the 10 US states studied.

[Patients with pain in outpatient care. A nationwide cross-sectional survey with path model]

BACKGROUND

There is limited knowledge on the degree of pain and pain-related impairments in home care clients. This study was carried out to provide data on the prevalence of pain and pain-related impairments in home care patients and to investigate the impact on activities of daily living and on classification into the three levels of care as defined by the statutory German long-term care insurance.

MATERIAL AND METHODS

In 2012 a representative cross-sectional multicenter study was conducted among clients of 100 German home care services. The stepwise sampling procedure included a random selection of 9 home care services in each of the 16 federal states and a randomized sampling among the clients of the participating home care services. The total sample consisted of 878 home care clients (inclusion criteria ≥ 18 years). The subjective pain intensity was measured using an 11-step Likert scale ranging from 0 (no pain) to 10 (most severe pain). Pain-related impairments were rated on a 6-step Likert scale (0 = no impairments to 5 = complete impairment) assessing the level of independence in household chores, mobility, personal hygiene, dressing and social participation. Furthermore, multimorbidity (number of diagnoses) and level of care according to the current classification in the German long-term care insurance were registered. The predictive significance of latent variables was determined by structural equation modelling.

RESULTS

Of the subjects surveyed 68.5 % (n = 672) reported suffering from pain. The average intensity of pain was 2.9 (standard deviation SD 2.8) and pain-related impairments had the greatest effect on mobility (78.2 %). Path analysis revealed that a higher degree of pain-related impairments (β = + 0.31) and a higher number of diagnoses (β = + 0.19) were associated with classification to higher levels of care as defined in the German long-term care insurance. However, stronger pain and higher age were related to a classification to a lower level of care (β = - 0.21). No relevant gender differences were identified except for the finding that old age in women had no significant effect on the classification to the level of care, whereas in men both old age and pain intensity did have an impact.

CONCLUSION

Even though the majority of home care clients in this representative study suffered from pain, the degree of pain intensity only becomes an issue in home care if it concurs with impairments in daily living and a corresponding classification to higher levels of care dependency. These findings suggest that pain and pain management should receive more attention in home care, irrespective of observable impairments in daily living. In practice, nurses in home care services should regularly assess the level of pain intensity among home care clients and the results of these regular pain assessments should be taken into account for the identification of individual care needs.

The ethics of postoperative pain management: Mapping nurses' views

AIM

We explored the positions of nurses working in hospitals regarding the acceptability of refusing to give a repeat dose of painkiller to a postoperative patient who requested it. These positions were compared with that of lay people, physicians, and other health professionals.

DESIGN AND METHODS

Factorial design was used to assess the impact of 6 situational factors: the patient's age, the current level of pain as assessed by the nurse, the number of requests, the level of risk associated with the administration of a repeat dose, the outcome of surgery, and the giving of alternative mild analgesics. We implemented a combination of scenario technique and of cluster analysis. Data were collected from April 2013 to December 2015.

PARTICIPANTS

138 registered nurses, 32 nurse's aides, 33 physicians, 23 psychologists, and 169 lay people participated in the study.

RESULTS

We found 4 qualitatively different meaningful positions. A plurality of participants (57% of nurses) considered that refusing was not acceptable, irrespective of circumstances. A substantial minority of participants (but 52% of physicians) considered that refusing was acceptable only if the level of pain was low and the risk was high. Other participants (mostly lay people) considered that refusing was always acceptable each time a risk of side effects, either serious or simply mild, was present.

The impact of multimorbidity on quality of life among midlife women: findings from a U.S. nationally representative survey

BACKGROUND

Little is known about the prevalence and cumulative burden of coexisting health conditions including chronic joint and muscular pain, urinary incontinence (UI), depression, osteoporosis risk, moderate/severe vasomotor symptoms, and vulvar/vaginal atrophy (VVA). We surveyed a nationally representative U.S. sample of midlife (age 40-64 years) women to ascertain the prevalence, general health-related quality of life (HRQoL), and health-seeking behaviors associated with these six conditions.

METHODS

This cross-sectional, telephone survey collected data from a sample of English- and Spanish-speaking U.S. women. The survey contained demographic and menopausal status questions, and also five condition-specific symptom/disease risk-screening instruments. The EuroQol 5 dimensions (EQ-5D) questionnaire was used to measure HRQoL. Health-seeking behavior was measured based on clinician discussion of and recent treatment for each condition.

RESULTS

Three thousand fifty eight women (mean age 53.4 years) completed the survey. The majority were white (75.6%), married (60.5%), employed full- or part-time (59.0%), and postmenopausal (69.8%; based on self-report). The prevalence [95% confidence interval] of 0, 1, 2, and ≥3 conditions was 35.2% [33.5-36.9], 34.2% [32.5-35.9], 17.9% [16.6-19.3], and 12.7% [11.5-13.9], respectively. Osteoporosis risk (30.6%) was most prevalent, followed by VVA (27.8%) and UI (26.6%). UI and VVA coexisted most frequently (11.3%), followed by osteoporosis risk and VVA (9.8%). EQ-5D scores decreased with increasing number of illnesses (0, 1, 2, and ≥3 conditions, means: 0.92, 0.87, 0.77, 0.61, respectively; p<0.01). Health-seeking behavior varied by condition.

CONCLUSION

Over 25% of women surveyed had multiple coexisting conditions. Lower HRQoL was associated with multiple conditions and with each added condition.

Pharmacotherapy in the ageing patient: The impact of age per se (A review)

A literature search was carried out to review the influence of 'ageing' on pharmacotherapeutic decision-making, specifically how 'age' is defined and considered in the utilisation of medication. Embase, Medline, International Pharmaceutical Abstracts, and Google scholar were canvassed in a three-tiered search according to pre-established inclusion criteria. In tier 1, a total of 22 studies were identified highlighting the underutilisation of medication in elderly patients, with a particular focus on warfarin. Four studies highlighted an age-bias in medication-prescribing for elderly patients, specifically in relation to medicines for rheumatoid arthritis, angina, and hypertension. Tier 2 identified diverse definitions for 'elderly', including biological age, chronological age, physiological age, as well as various descriptions of 'elderly' in clinical trials and guidelines. Finally, medication optimisation tools were identified through the third tier, emphasising the use of chronological age to describe the 'elderly'. Old age influences pharmacotherapeutic decision-making at various levels, however, what complicates the situation is the absence of a comprehensive definition of 'elderly'. Clinical recommendations need to be based more on objective factors known to affect medication effectiveness and safety.

Occupational therapists' pain knowledge: a national survey

PURPOSE

This study surveyed Canadian occupational therapists to identify whether their pain knowledge is current or if the gaps identified in past studies have remained the same. The findings will provide information to guide the development of targeted pain knowledge translation strategies for occupational therapists.

METHOD

A self-report survey, including demographic questions and part of the City of Boston's Rehabilitation Professionals' Knowledge and Attitude Survey (COBS), was disseminated electronically to all members of the Canadian Association of Occupational Therapists.

RESULTS

A total of 354 therapists, most came from Ontario, Alberta and Nova Scotia and working in the community, acute care and private practice, participated. Over 50% had 10 years or less of experience. Deficit knowledge areas were identified in pediatric pain, chronic versus acute pain, pain assessment and medications. These findings are largely consistent with deficits identified in pre-2000 studies.

CONCLUSIONS

Pain knowledge gaps persist among Canadian occupational therapists and this can, and should, be addressed within the occupational therapist (OT) curriculum and in professional development initiatives. It is concerning that this study identified similar knowledge gaps as those identified in previous studies of OT students and clinicians. Pain is a growing and complex issue with negative impact on occupational performance across the lifespan. Knowledge dissemination of occupational therapy pain assessment and management approaches should be a priority for the profession.

IMPLICATIONS FOR REHABILITATION

Pain is a prevalent condition in all age groups of occupational therapists' clients. There appear to be gaps in occupational therapists' evidence-based knowledge of aspects of pain. Occupational therapy training programs and occupational therapy associations should provide education with a particular focus on identified pain knowledge gaps.

Shoulder symptoms and function in geriatric patients

BACKGROUND AND PURPOSE

Musculoskeletal problems, including shoulder pain, are common in the general population and are often cited as reasons for physician visits. Although many risk factors for shoulder pain are postulated, the effects of shoulder pain on functional level and perceived quality of life are poorly characterized in older adults. In this study, we set out to determine the prevalence and impact of shoulder symptoms and dysfunction in an older adult veteran population.

METHODS

A chart review, cross-sectional survey, and examination were performed. A sample of 93 individuals, aged 60 years or older, was recruited from a primary clinic outpatient waiting room at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin. Patients were asked about shoulder symptoms and self-assessed health and completed the Stanford Modified Health Assessment Questionnaire. A series of 3 shoulder maneuvers was used to assess shoulder mobility and pain. The presence of diabetes and statin use was documented. A more thorough chart review was performed on individuals who reported shoulder pain and disability.

RESULTS

Severe shoulder pain was common in the study group, reported by 31% of all participants. Functional limitation measured by the Modified Health Assessment Questionnaire and answering "yes" to greater difficulty performing daily tasks was associated with reduced internal rotation, which was present in almost 36% of all participants. Symptoms were often bilateral. No statistically significant risk factors emerged in this small sample, but suggestive trends were apparent. Interestingly, few patients reported discussing these problems with their providers, and shoulder-related problems were documented in only 10% of corresponding problem lists of symptomatic patients.

CONCLUSIONS

With an aging population, the high prevalence of shoulder pain may have considerable impact on public health. It will become increasingly important to define risk factors, delineate etiologies, and devise new management strategies for patients with symptomatic shoulder disease.

Breakthrough pain in elderly patients with cancer: treatment options

The prevalence of pain is high in the elderly and increases with the occurrence of cancer. Pain treatment is challenging because of age-related factors such as co-morbidities, and over half of the patients with cancer pain experience transient exacerbation of pain that is known as breakthrough pain (BTP). As with background pain, BTP should be properly assessed before being treated. The first step to be taken is optimizing around-the-clock analgesia with expert titration of the painkiller. Rescue medication should then be provided as per the requested need, while at the same time preventing identified potential precipitating factors. In the elderly, starting treatment with a lower dose of analgesics may be justified because of age-related physiological changes such as decreased hepatic and renal function. Whenever possible, oral medication should be provided prior to a painful maneuver. In the case of unpredictable BTP, immediate rescue medication is mandatory and the subcutaneous route is preferred unless patient-controlled analgesia via continuous drug infusion is available. Recently, transmucosal preparations have appeared in the medical armamentarium but it is not yet known whether they represent a truly efficient alternative, although their rapid onset of activity is already well recognized. Adjuvant analgesics, topical analgesics, anesthetic techniques and interventional techniques are all valid methods to help in the difficult management of pain and BTP in elderly patients with cancer. However, none has reached a satisfying scientific level of evidence as to nowadays make the development of undisputed best practice guidelines possible. Further research is therefore on the agenda.

The influence of health care professional characteristics on pain management decisions

OBJECTIVE

Evidence suggests that patient characteristics such as sex, race, and age influence the pain management decisions of health care providers. Although this signifies that patient demographics may be important determinants of health care decisions, pain-related care also may be impacted by the personal characteristics of the health care practitioner. However, the extent to which health care provider characteristics affect pain management decisions is unclear, underscoring the need for further research in this area.

METHODS

A total of 154 health care providers (77 physicians, 77 dentists) viewed video vignettes of virtual human (VH) patients varying in sex, race, and age. Practitioners provided computerized ratings of VH patients' pain intensity and unpleasantness, and also reported their willingness to prescribe non-opioid and opioid analgesics for each patient. Practitioner sex, race, age, and duration of professional experience were included as predictors to determine their impact on pain management decisions.

RESULTS

When assessing and treating pain, practitioner sex, race, age, and duration of experience were all significantly associated with pain management decisions. Further, the role of these characteristics differed across VH patient sex, race, and age.

CONCLUSIONS

These findings suggest that pain assessment and treatment decisions may be impacted by the health care providers' demographic characteristics, effects which may contribute to pain management disparities. Future research is warranted to determine whether findings replicate in other health care disciplines and medical conditions, and identify other practitioner characteristics (e.g., culture) that may affect pain management decisions.

The Nurse Practitioner and Policy in End-of-Life Care

The focus of this column is the interface between policy and end-of-life care, particularly as provided by advanced nurse practitioners. The complexities of end-of-life along with barriers in practice can diminish quality of life for patients and their families. Changes in policy are needed to enable nurse practitioners their full scope of practice in a way that benefits patients and families at end-of-life. Three areas particularly relevant to policy for nursing practitioners and end-of-life care are addressed: scope of practice, reimbursement, and prescribing practices. Other recommendations for policy and end-of-life care are discussed.

The influence of sex, race, and age on pain assessment and treatment decisions using virtual human technology: a cross-national comparison

PURPOSE

Studies in the United States have found that patients' sex, race, and age influence the pain assessment and treatment decisions of laypeople and medical professionals. However, there is limited research as to whether people of other nationalities make pain management decisions differently based on demographic characteristics. Therefore, the purpose of the following study was to compare pain assessment and treatment decisions of undergraduate students in Jordan and the United States as a preliminary examination of nationality as a potential proxy for cultural differences in pain decisions.

METHODS

Virtual human (VH) technology was used to examine the influences of patients' sex (male or female), race (light-skinned or dark-skinned), and age (younger or older) on students' pain management decisions. Seventy-five American and 104 Jordanian undergraduate students participated in this web-based study.

RESULTS

American and Jordanian students rated pain intensity higher in females and older adults and were more likely to recommend medical help to these groups, relative to males and younger adults. Furthermore, Jordanian participants rated pain intensity higher and were more likely to recommend medical help for all patient demographic groups (ie, sex, race, age) than American participants.

CONCLUSION

This is the first cross-national study that compares pain decisions between undergraduate students. The results suggest that sex, race, and age cues are used in pain assessment and treatment by both Americans and Jordanians, with Jordanians more likely to rate pain higher and recommend medical help to patients. Additional research is needed to determine the cultural determinants of these differences.