Pain in nursing home residents: management strategies

Systematic review of 29 self-report instruments for assessing quality of life in older adults receiving aged care services

BACKGROUND

Quality of life (QoL) outcomes are used to monitor quality of care for older adults accessing aged care services, yet it remains unclear which QoL instruments best meet older adults', providers' and policymakers' needs. This review aimed to (1) identify QoL instruments used in aged care and describe them in terms of QoL domains measured and logistical details; (2) summarise in which aged care settings the instruments have been used and (3) discuss factors to consider in deciding on the suitability of QoL instruments for use in aged care services.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, Cochrane Library and CINAHL from inception to 2021.

ELIGIBILITY CRITERIA

Instruments were included if they were designed for adults (>18 years), available in English, been applied in a peer-reviewed research study examining QoL outcomes in adults >65 years accessing aged care (including home/social care, residential/long-term care) and had reported psychometrics.

DATA EXTRACTION AND SYNTHESIS

Two researchers independently reviewed the measures and extracted the data. Data synthesis was performed via narrative review of eligible instruments.

RESULTS

292 articles reporting on 29 QoL instruments were included. Eight domains of QoL were addressed: physical health, mental health, emotional state, social connection, environment, autonomy and overall QoL. The period between 1990 and 2000 produced the greatest number of newly developed instruments. The EuroQoL-5 Dimensions (EQ-5D) and Short Form-series were used across multiple aged care contexts including home and residential care. More recent instruments (eg, ICEpop CAPability measure for Older people (ICECAP-O) and Adult Social Care Outcomes Toolkit (ASCOT)) tend to capture emotional sentiment towards personal circumstances and higher order care needs, in comparison with more established instruments (eg, EQ-5D) which are largely focused on health status.

CONCLUSIONS

A comprehensive list of QoL instruments and their characteristics is provided to inform instrument choice for use in research or for care quality assurance in aged care settings, depending on needs and interests of users.

The Influence of Pain on Frailty among the Elderly: Based on Korea Health Panel

Background:

Interests between pain and frailty have been increasing in aging or aged societies. This study aimed to identify the prevalence of pain and frailty and to find the influence of pain on frailty.

Methods:

Subjects were selected with aged 65 yr or older among pooled Korea Health Panel data from 2009 to 2013. The prevalence of pain was determined by combining some pain and extreme pain and also, frailty was defined when subjects had at least one of the following 6-domain frailty: physical inactivity, mobility reduction, dependence of daily life, depression, multimorbidity, and disability.

Results:

The prevalence of pain and frailty was 56.1% and 59.8%. It was significantly higher in female (66.1% and 65.2%) and the oldest-old (69.4% and 71.8%). After adjusting for gender, age group, spouse, illiteracy, and economic activity, odds ratios of frailty for some pain and extreme pain were 2.8 (95% CI 2.6–3.0) and 10.5 (95% CI 8.0–13.8) in total subjects. The odds ratios of each 6-domain frailty for some and extreme pain were also significant. Among them, mobility reduction was 5.1 (95% CI 4.5–5.8) and 16.5 (95% CI 13.6–20.1), and dependence of daily life was 3.9 (95% CI 3.5–4.5) and 12.4 (95% CI 10.2–15.1).

Conclusion:

Among the elderly, prevalence of frailty (59.8%) was somewhat higher than that of pain (56.1%). Female and oldest-old had higher prevalence of pain and frailty. In addition, some pain and extreme pain had a decisive influence on frailty and each 6-domain frailty. Therefore, pain control is essential to prevent or manage frailty.

Efficacy and Practicality of Opioid Therapy in Japanese Chronic Noncancer Pain Patients

BACKGROUND

Many Japanese adults suffer from chronic pain. However, 50% of these individuals discontinue treatment despite the persistence of pain. Both clinicians and patients in Japan tend to be concerned about the safety and efficacy of opioid therapy, and the use of opioids in chronic non-cancer pain remains less common in Japan than elsewhere.

AIMS

This study examined the effects of opioid therapy on the daily lives of patients with chronic noncancer pain in Japan, where use of opioids for this type of pain remains uncommon.

DESIGN

Prospective cross-sectional questionnaire study.

SETTING

Data were collected over two periods, between March and April 2014 at one hospital, and between February and April 2015 at the other hospital. Subjects were recruited at the respective clinics by the study interviewer between March 1, 2014 and April 15, 2014 and between February 1, 2015 and April 15, 2015.

PARTICIPANTS/SUBJECTS

This study included 34 outpatients with chronic non-cancer pain who were being treated with opioid analgesics at pain clinics in two hospitals in Sapporo.

METHODS

Thirty-four Japanese patients receiving opioid medications for chronic noncancer pain in outpatient pain clinics were enrolled. Participants underwent interviews and completed the Japanese versions of the Short Form 36 (SF-36v2) and the Coping Strategies Questionnaire (CSQ).

RESULTS

Sleep disruption, claiming compensation for work-related accidents, and current pain level were negatively correlated with opioid effectiveness (p < .05). Additionally, opioid effectiveness was negatively correlated with the catastrophizing subscale of the CSQ (r = -0.50, p < .01). The effects of opioid therapy had a low positive correlation with the emotional functioning role subscale of the SF-36v2 (r = 0.38, p < .05). Daily equivalent morphine dose was positively correlated with opioid therapy duration, interference with appetite, and current pain intensity. Morphine dose was also positively correlated with scores for the catastrophizing subscale of the CSQ (r = 0.36, p < .05) and negatively correlated with scores in all subdomains of the SF-36v2.

CONCLUSIONS

It is important to focus on adaptive, cognitive, and emotional factors, such as emotional role functioning, to determine the efficacy of opioid treatment for chronic noncancer pain. Moreover, patients with catastrophizing significantly increased their morphine doses, resulting in an increased risk of overdose.

Do Nursing Home Residents With Dementia Receive Pain Interventions?

This study compares pain interventions received by nursing home residents with and without dementia. Secondary data analyses of cross-sectional data from 50,673 nursing home residents in New York State were collected by the Minimum Data Set 3.0. Frequency distributions and bivariate analyses with χ2 tests were used to organize and summarize the data. Logistic regression analyses were performed to quantify the relationship between dementia and pain interventions. Our results show that residents with dementia had significantly fewer pain assessments and less reported pain presence than their counterparts. After adjusting for covariates, the results indicate that residents with dementia were significantly less likely to receive pro re nata and nonmedication pain intervention. However, there were no significant differences in scheduled pain medication between the 2 groups. To address the gap, we need more research to design a pain assessment tool that can differentiate severity of pain so that appropriate interventions can be applied.

Nonmalignant Pain Symptom Subgroups in Nursing Home Residents

CONTEXT

Despite many nursing home residents experiencing pain, research about the multidimensional nature of nonmalignant pain in these residents is scant.

OBJECTIVES

To identify and describe pain symptom subgroups and to evaluate whether subgroups differed by sex.

METHODS

Using Minimum Data Set 3.0 data (2011-2012), we identified newly admitted nursing home residents reporting pain (n = 119,379). A latent class analysis included 13 indicators: markers for pain (i.e., severity, frequency, impacts sleep, and function) and depressive symptoms. Sex was evaluated as a grouping variable. Multinomial logistic models identified the association between latent class membership and covariates, including age and cognitive impairment.

RESULTS

Four latent subgroups were identified: severe (15.2%), moderate frequent (26.4%), moderate occasional with depressive symptoms (26.4%), and moderate occasional without depressive symptoms (32.0%). Measurement invariance by sex was ruled out. Depressed mood, sleep disturbances, and fatigue distinguished subgroups. Age ≥75 years was inversely associated with belonging to the severe, moderate frequent, or moderate occasional with depressive symptoms subgroups. Residents with severe cognitive impairment had reduced odds of membership in the severe pain subgroup (adjusted odds ratio [aOR]: 0.84; 95% confidence interval [CI]: 0.78-0.90) and moderate frequent pain subgroup (aOR: 0.60; 95% CI: 0.56-0.64) but increased odds in the moderate occasional pain with depressive symptoms subgroup (aOR: 1.12; 95% CI: 1.06-1.18).

CONCLUSION

Identifying subgroups of residents with different patterns of pain and depressive symptoms highlights the need to consider physical and psychological components of pain. Expanding knowledge about pain symptom subgroups may provide a promising avenue to improve pain management in nursing home residents.

Effect of Exercise on Behavioral Symptoms and Pain in Patients With Dementia Living in Nursing Homes

OBJECTIVES

Examine the effects of a 6-month exercise intervention on neuropsychiatric symptoms, pain, and medication consumption in older people with dementia (PWD) living in nursing homes (NH).

METHODS

Ninety-one older PWD living in NH performed a 6-month structured exercise intervention (n = 44) or a social activity intervention (n = 47). Neuropsychiatric symptoms were measured by the neuropsychiatric inventory (NPI), pain was assessed using the Algoplus scale, and dementia-related drug prescriptions were obtained for all participants.

RESULTS

Between-group analysis found a nonsignificant difference that could be of clinical relevance: a 4-point difference in the NPI and 1.3-point difference in the reduction of the number of medications favoring exercisers. No significant differences were found for pain, and a trend was found for an increase in medication consumption in the social group.

CONCLUSION

Exercise effects did not differ from social intervention effects on neuropsychiatric symptoms, pain, and medication consumption in older PWD living in NH.

Proportion of neuropathic pain in the back region in chronic low back pain patients -a multicenter investigation

Neuropathy can contribute to low back pain (LBP) in the region of the back. Our study investigated the proportion of neuropathic pain (NP) in low back region in chronic LBP patients from multicenter and clinics in China and identified associated factors. Assessment was made using a questionnaire and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS, only tested in low back region), as well as Quantitative Sensory Testing (QST, merely applied to the low back region), the Hospital Anxiety and Depression Scale (HADS) and the Oswestry Disability Index (ODI). Our questionnaire collected demographic information, behavioral habits and medical records. 2116 outpatients over 18 years old complaining of LBP lasting more than 3 months were enrolled in this study. The NP proportion in low back region in chronic LBP patients was 2.8%. Multivariable logistic regression analysis showed that histories of lumbar surgery, abdominal or pelvic surgery, and drinking alcohol were independent positive predictors for LBP of predominantly neuropathic origin (LBNPO), while history of low back sprain and frequently carrying weight as independent negative predictor. Using these parameters may help the identification of patients with chronic LBP likely to develop NP leading to improved treatment outcomes.

Multidimensional Frailty and Pain in Community Dwelling Elderly

Objective

To examine the relationship between frailty and pain, particularly to analyze whether pain predicts physical, psychological and social frailty, after controlling for the effects of life-course determinants and comorbidity.

Design

Cross-sectional.

Methods

A nonprobabilistic sample of 252 community dwelling elderly was recruited. Frailty and determinants of frailty were assessed with the Tilburg Frailty Indicator and pain was measured with the Pain Impact Questionnaire. Hierarchical and logistic regression analyses were conducted.

Results

In this study, 52.4% of the participants were aged 80 years and over, and 75.8% were women. Pain and frailty were higher in women, and physical frailty was higher in those aged ≥80 years. After controlling for the effects of the determinants and comorbidity, pain predicted 5.8% of the variance of frailty, 5.9% of the variance of physical frailty, and 4.0% of the variance of psychological frailty, while the prediction of social frailty was nonsignificant. Overall, a greater pain impact score was associated with the presence of frailty (odds ratio 1.06; 95% CI 1.03–1.10; P < 0.001).

Conclusion

Frailty was independently predicted by pain, emphasizing the importance of its treatment, potentially contributing to the prevention of vulnerability, dependency, and mortality. Nonetheless, longitudinal studies are required to better understand the possible association between pain and frailty.

Spinal Compression Fracture Management: A Review of Current Treatment Strategies and Possible Future Avenues

STUDY DESIGN

Narrative review.

OBJECTIVE

Despite the numerous treatment options for vertebral compression fractures, a consensus opinion for the management of patients with these factures has not been established. This review is meant to provide an up-to-date overview of the most common treatment strategies for compression fractures and to suggest possible routes for the development of clearer treatment guidelines.

METHODS

A comprehensive database search of PubMed was performed. All results from the past 30 years were obtained and evaluated based on title and abstract. The full length of relevant studies was analyzed for level of evidence, and the strongest studies were used in this review.

RESULTS

The major treatment strategies for patients with compression fractures are conservative pain management and vertebral augmentation. Despite potential adverse effects, medical management, including nonsteroidal anti-inflammatory drugs, calcitonin, teriparatide, and bisphosphonates, remains the first-line therapy for patients. Evidence suggests that vertebral augmentation, especially some of the newer procedures, have the potential to dramatically reduce pain and improve quality of life. At this time, balloon-assisted kyphoplasty is the procedure with the most evidence of support.

CONCLUSIONS

Based on current literature, it is evident that there is a lack of standard of care for patients with vertebral compression fractures, which is either due to lack of evidence that a procedure is successful or due to serious adverse effects encountered with prolonged treatment. For a consensus to be reached, prospective clinical trials need to be formulated with potential new biomarkers to assess efficacy of treatment strategies.

Demographics, Pharmacoeconomics, Assessment, and Treatment of Pain in the Elderly

The burden of pain in the elderly population of our society is observed by the greater numbers of the aged who suffer from pain as compared to their younger counterparts. The elderly present difficult challenges for pain clinicians in terms of the ability to assess for pain, amid other medical and pain problems, due to cognitive, sensory, and functional impairment. Treatment with pharmaceuticals may be altered by the impact of aging. Finally, the elderly suffer financial restraints that often prevent optimal treatment of pain even if pain is identified. Principles of pain management in the elderly are reviewed in the context of special attention to assessment tools for the elderly, the evaluation of comorbid factors in the presentation of pain, and pharmacokinetic/pharmacodynamic concerns in the aging. Pharmacologic and nonpharmacologic treatment strategies are described relative to the elder.

Pain in older adults: development of a tool for measuring knowledge of residential aged care staff

OBJECTIVE

To develop a psychometrically sound tool for measuring the knowledge of nursing and care staff about the experience, assessment and management of pain in older people (including people with dementia) for use in the residential aged care setting.

METHODS

The Pain in Older Adults Knowledge Survey (POAKS) was developed and tested in two phases. Phase 1 involved developing an initial item pool with good content validity based on a review of the research literature and a modified Delphi technique involving national and international experts. A pool of 24 items was developed for testing. Initial testing of the psychometric properties of the POAKS with 30 university employees led to refinement and final wording of items. Phase 2 involved testing of the psychometric properties of the POAKS with 279 respondents, including first year (n = 176) and third year (n = 70) nursing students and staff in a residential aged care service (n = 33).

RESULTS

Results established the content validity and internal consistency of the POAKS and supported its use as an instrument to measure nursing staff knowledge about the experience, assessment and management of pain in older people.

CONCLUSIONS

The POAKS will enable residential aged care facilities to measure the level of knowledge among nursing and care staff about pain in older people (including people with dementia). The measure provides a basis for the development and implementation of educational interventions to address knowledge gaps that may impact on the quality of care provided.

Fear of falling assessments in older people with dementia

Fear of falling (FoF) is a common condition in older age. However, there is a paucity of research on its prevalence, impact and treatment in older people with dementia. People with dementia have an increased risk of falls which present a significant threat to their independence, as well as having a significant economic impact on health and social services. This review outlines the key issues in relation to FoF, current guidelines and assessment tools and their use for people with dementia. Further research needs to be completed in both addressing the specific assessment barriers that people with dementia may face regarding the use of current FoF tools, with further exploration surrounding the individual's experience of FoF and how this may be impacting upon their quality of life and functionality. Until a well-validated method has been developed, clinicians need to utilize available tools as guidelines, seek the assistance of proxies at all stages of the care journey, and use clinical judgement to assess FoF in patients with dementia.

Pain Assessment Strategies in Home Care and Nursing Homes in Mid-Norway: A Cross-sectional Survey

The prevalence of pain ranges from 27.8% to 86.5% in nursing homes and 42% to 50% in home care. Pain assessment is the first step toward effective pain management. The aim of this study was to explore the use of pain assessment strategies (verbal, numeric, and observation rating scales and standardized questions) in home care and nursing homes. The study was a descriptive cross-sectional survey. Health care providers who were responsible for the patients' medications replied to a questionnaire. In-home care and nursing homes in 11 randomly selected municipalities in Mid-Norway were included. Three hundred ninety-two individuals were included in this study (70% response rate): 271 (69%) from nursing homes and 121 (31%) from home care. The respondents working in home care had a higher educational level than those in working in nursing homes. Pain assessment instruments were not used frequently in nursing homes and home care. Verbal and numeric rating scales were used significantly more frequently in home care than in nursing homes. Registered nurses (RNs) in nursing homes used standardized questions significantly more often than did RNs in home care. RNs and social educators in home care self-reported less competence in treating the patients' total pain experience than did those in nursing homes. Workplace (working in home care) and regular training in the use of pain assessment tools explained more than 20% of the variation in the use of pain assessment tools. Regular training in the use of pain assessment tools is needed for health care workers in home care and nursing homes.

Pharmacological management of pain in Australian Aged Care Facilities

BACKGROUND

up to 80% of residents in aged care facilities (ACFs) experience pain, and previous studies have found that older patients with pain are often undertreated. Few studies have been conducted in Australia evaluating the use of analgesic therapy in ACF residents.

OBJECTIVE

to explore the use of analgesics among ACF residents, including independent predictors of analgesic use, evaluate analgesic use against pain management guidelines and identify potential medication management issues.

METHODS

a retrospective analysis of 7,309 medicines reviews conducted on Australian ACF residents was undertaken. Medication use was compared with published guidelines relating to the management of pain in elderly patients or ACF residents. Multiple variable logistic regression was used to identify independent predictors of analgesic use.

RESULTS

nearly 91% of residents were prescribed analgesics. Of those, 2,057 residents were taking regular opioids (28.1%). Only 50% of those taking regular opioids received regular paracetamol at doses of 3-4 g/day. The concurrent use of sedatives was high, with 48.4% of those taking regular opioids also taking an anxiolytic/hypnotic.

CONCLUSION

there is a need to optimise the prescribing and administration of regular paracetamol as a first line and continuing therapy for pain management in ACF residents, to potentially improve pain management and reduce opioid requirements. Furthermore, with the risk of falls and fractures increased by concurrent use of opioids and sedatives, the widespread use of these drugs in a population already at high risk was concerning, indicating a need for better education of health professionals in this area.

Pain characteristics and pain control in European nursing homes: cross-sectional and longitudinal results from the Services and Health for Elderly in Long TERm care (SHELTER) study

OBJECTIVE AND DESIGN

Few studies have compared cross-national characteristics of residents with pain in European long term care facilities. The SHELTER project, a cross-national European study on nursing home residents, provides the opportunity to examine this issue. The present study aimed to evaluate key figures about pain and compare them with seven European countries and Israel.

SETTING, PARTICIPANTS, AND MEASUREMENTS

A total of 3926 nursing home residents were assessed by the interRAI instrument for Long Term Care Facilities (interRAI LTCF). Prevalence of pain, frequency, intensity, consistency, and control were estimated and compared cross-nationally. Correlates between patient-related characteristics and inadequate pain management were tested using bivariate and multivariate logistic regression models.

RESULTS

Overall, 1900 (48.4%) residents suffered from pain. Pain prevalence varied significantly among countries, ranging from 19.8% in Israel to 73.0% in Finland. Pain was positively associated with female gender, fractures, falls, pressure ulcers, sleeping disorders, unstable health conditions, cancer, depression, and number of drugs. It was negatively associated with dementia. In a multivariate logistic regression model, all associations remained except for sleeping disorders. Clinical correlations varied considerably among countries. Although in 88.1% of cases, pain was self-rated by the residents as sufficiently controlled, in only 56.8% of cases was pain intensity self-rated as absent or mild. Pain control and intensity improved within 1 year.

CONCLUSION

Pain prevalence is high and varies considerably across Europe. Although most residents considered pain as adequately controlled, a closer look confirmed that many still suffer from high pain intensities. Analyzing the reasons behind these differences may help to improve pain management.

Clinical characteristics and pain management among patients with painful peripheral neuropathic disorders in general practice settings

Alleviating chronic pain is a global healthcare priority. Understanding the medical profile and current treatment patterns in patients with painful neuropathic disorders (PNDs) is crucial to the development of effective pain management strategies. Thus, our objective was to describe the demographic and clinical characteristics of persons with PNDs and their use of pain medications. Using the general practice research database, we categorized PNDs in two ways: Pure PNDs (which include diabetic neuropathy, postherpetic neuralgia, etc.; N=16,690) and Mixed PNDs (which include back/neck pain with neuropathic involvement; N=14,309). On average, PND patients were 55 years old (Pure, 55.4 [SD=16.9] years; Mixed, 54.3 [SD=16.4] years). Over a third had other chronic pain-related (Pure, 37.5%; Mixed, 37.1%) and nearly a quarter had non-pain related (Pure, 28.1%; Mixed, 24.1%) comorbidities. Use of medications with clinically demonstrated efficacy in PNDs was higher among patients with Pure PNDs (tricyclic antidepressants [Pure, 16.6%; Mixed, 10.1%]; 2nd generation antidepressants [Pure, 11.0%; Mixed, 9.7%]; and antiepileptics [Pure, 12.2%; Mixed, 2.6%]), whereas use of NSAIDs (Pure, 43.1%; Mixed, 65.2%) and opioids (Pure, 8.5%; Mixed, 14.3%) was higher among patients with Mixed PNDs. Average daily doses of select neuropathic pain-related medications among PND patients (Pure and Mixed) were lower than those recommended for neuropathic pain. Among both Pure and Mixed PND patients, use and doses of evidenced-based neuropathic pain-related medications was low, and lower than the use of NSAIDs (a medication class with no proven efficacy for PNDs) in each group, suggesting possible sub-optimal neuropathic pain management among these patients.

Culture change in long-term care: participatory action research and the role of the resident

PURPOSE

This study's purpose was to advance the process of culture change within long-term care (LTC) and assisted living settings by using participatory action research (PAR) to promote residents' competence and nourish the culture change process with the active engagement and leadership of residents.

DESIGN AND METHODS

Seven unit-specific PAR groups, each consisting of 4-7 residents, 1-2 family members, and 1-3 staff, met 1 hour per week for 4 months in their nursing home or assisted living units to identify areas in need of improvement and to generate ideas for community change. PAR groups included residents with varied levels of physical and cognitive challenges. Residents were defined as visionaries with expertise based on their 24/7 experience in the facility and prior life experiences.

RESULTS

All PAR groups generated novel ideas for creative improvements and reforms in their communities and showed initiative to implement their ideas. Challenges to the process included staff participation and sustainability.

IMPLICATIONS

PAR is a viable method to stimulate creative resident-led reform ideas and initiatives in LTC. Residents' expertise has been overlooked within prominent culture change efforts that have developed and facilitated changes from outside-in and top-down. PAR may be incorporated productively within myriad reform efforts to engage residents' competence. PAR has indirect positive quality of life benefits as a forum of meaningful social engagement and age integration that may transform routinized and often ageist modes of relationships within LTC.

Concept analysis of nurses' identification of pain in demented patients in a nursing home: development of a hybrid model

Pain is a subjective feeling, with no known biologic markers. Proof of its presence and measurement of intensity rely entirely on self-reporting by the patient. The hampered or abrogated ability of demented patients to report their pain is a major difficulty in pain assessment and management. The purpose of this study was to clarify and conceptualize pain identification in demented patients by nurses. The hybrid model of concept development was used in the development of a conceptual structure of pain in demented patients. Data were collected by literature review (theoretical phase) and among nurses caring for demented patients in three nursing homes in South Korea (fieldwork phase). The 13 nurses involved each reported >3 years' nursing home experience. In a hybrid model, pain identification in demented patients by nurses constituted an active daily process of integrating patient expressional cues during periods of pain and pain relief and involving three dimensions: identification schemes based on the stage and type of dementia, connecting assessments after each intervention, and cognitive efforts to establish the origin of pain. Identification of pain in demented patients by nurses is a complex process. More research is needed to formulate an assessment tool and pain management strategies for patients with dementia.

Nursing home staffing and training recommendations for promoting older adults' quality of care and life: Part 1. Deficits in the quality of care due to understaffing and undertraining

Caught between the inability or unwillingness of nursing home corporations and owners to redistribute revenue and the reluctance of federal and state agencies to increase payments to nursing homes, the nation's most vulnerable older adults are not receiving the care they deserve. Widespread recognition of substandard care and quality of life of older adults in nursing homes has existed for decades. In addition, there is substantial evidence that poor quality of care is related to inadequate numbers and training of nursing staff. Still, policy makers and nursing home owners have failed to take needed action. In the first article of this two-part series, major deficits in the care of older adult nursing home residents are reviewed, and research documenting the relationship between nursing home staffing and the quality of care and life of residents is summarized.

Treatment of chronic non-malignant pain in the elderly: safety considerations

Non-malignant pain in the elderly is frequently under-treated, with physicians appearing to be uncertain concerning how best to achieve optimum management of this common problem in individual cases. The aim of this review is to provide a brief overview and discuss the variety of interacting factors that contribute to the continuing under-treatment of chronic non-malignant pain in the older population. The central objective is to encourage safer and more effective pain management in a population that is highly vulnerable to painful conditions and to the consequences of poorly treated pain. Under-treatment of pain as experienced by the elderly is largely a consequence of uncertainties that arise within a complex environment that is underscored and exacerbated by the progressive and rapid aging of the global population. Uncertainties include the optimum management of pain in geriatric syndromes, frailty and dementia, and their impact on diagnosis, pain assessment and choices of treatment modalities. There is an inadequate evidence base for pharmacological interventions in older persons with respect to pharmacokinetic and pharmacodynamic changes that occur with aging. In this review, the prevalence of chronic pain and the incidence of adverse drug reactions are identified as factors that encourage conservatism in prescribing, as are major predictors of adverse drug reactions, i.e. aging, inappropriate combinations of medications and polypharmacy. The major classes of analgesic drugs are summarized with reference to their mechanisms of action, analgesic properties and known adverse effects. Although all medications have associated risks, the use of analgesics in managing persistent pain in elderly people is widely supported and guided on the basis of clinical experience and consensus among specialists in geriatrics and pain management. It is concluded that the absence of trial data, specific to the elderly, is substantially offset by information based on clinical experience and expert consensus statements. Used appropriately, analgesic and adjuvant treatments can and should be employed to relieve persistent pain in the expanding elderly population.

Methadone: an effective, safe drug of first choice for pain management in frail older adults

OBJECTIVE

Frail older adults have a high prevalence of chronic pain with major effects on function and quality of life. Many analgesics, including opioids, have adverse effects on older adults with multiple co-morbidities. Methadone has been increasingly used for analgesia in the last 10 years. However, a number of adverse events such as sleep-disordered breathing, methadone-induced torsades de pointes arrhythmias, as well as the "addiction stigma," have made people reluctant to use this medication.

SETTING AND PATIENTS

This article uses examples of five cases of pain in frail older adults living in a skilled nursing facility.

RESULTS

Safe and effective use of methadone is illustrated with these cases. The pharmacology of methadone in frail elders is reviewed to demonstrate the specific benefits of the drug in older adults and how adverse events can be minimized.

CONCLUSION

Methadone is an excellent choice for pain in frail older adults.

Pharmacological management of renal colic in the older patient

Renal colic affects up to 12% of the population. Initial management of most patients is expectant. Acute symptom management of renal colic is best accomplished with a combination of parenteral opioids and NSAIDs. The elderly patient with a kidney stone should be screened for contraindications to NSAID therapy, such as renal failure or previous peptic ulcer disease. Use of parenteral opioids is often necessary during the acute setting, and downward-adjusted doses and monitoring are necessary to prevent associated confusion and respiratory depression. Novel therapy with desmopressin may also be effective for symptom control at the initial presentation, without the adverse effects of opioids or NSAIDs. However, use of desmopressin in the elderly must be undertaken cautiously, given the potential adverse effects of this agent. Many small, distal ureteral stones are treated initially with watchful waiting for the first 2-4 weeks after presentation. The patient should have effective, non-parenteral analgesics for use at home. Included in these agents are oral or suppository NSAIDs and oral opioids. Medical expulsion therapy with alpha-adrenoceptor antagonists or calcium channel antagonists is efficacious. alpha-Adrenoceptor antagonists such as the alpha(1A/)(1)(D)-selective tamsulosin are well tolerated in the elderly and increase the rate of spontaneous stone passage by approximately 50% for small distal stones. These agents also appear to decrease the severity of renal colic. Corticosteroids and calcium channel antagonists are also effective but their use in the elderly is not recommended as first-line therapy.

Arthritis pain

Arthritic pain is a common and disabling problem for many older adults. There is widespread evidence that despite its prevalance and debilitating effects on the physical, emotional and cognitive status of older adults, arthritic pain remains under-treated in those age 65 and older. This condition significantly and negatively impacts older adults' quality of life and is a critical problem that requires the attention of gerontological social work. This chapter provides a brief summary of arthritic pain in older adults. It also discusses the treatment efficacy of cognitive-behavioral therapy and psycho-educational programs for older adults with this type of pain.

Research on persistent pain in late life: current topics and challenges

Older women often experience pain in their daily lives. This article provides an overview of topics addressed in the geriatric pain research published between 1999 and 2004. New areas of emphasis of research have emerged such as the recognition of body mass and weight as a factor in persistent pain, while other areas have expanded, including the focus on pain among elders with cognitive impairments and the use of alternative treatment approaches. Understanding of pain in late life is hindered by study samples that lack diversity, treatment approaches that are narrowly focused, and a lack of attention to quality of life issues.

Economic impact of shifting the locus of care for neuropathic pain from specialists to general practitioners

We developed a decision-analytic model to examine the economic impact of shifting the locus of care for patients with painful neuropathies from specialists to GPs. The impetus for such a shift was assumed to be a formal education program, focusing on the recognition and treatment of neuropathic pain, conducted for GPs. In the model, all patients with neuropathic pain were assumed to initiate care with their GPs and then be referred to specialists and, ultimately, pain clinics as required for adequate pain control. Two alternative scenarios were examined--the "current" arrangement in which most patients were assumed to be referred for treatment by specialists and pain clinics and a "hypothetical" arrangement in which GPs were assumed to play an expanded role in the treatment of neuropathic pain and which, therefore, often precluded the need for referral. The model was populated with clinical, epidemiologic, and economic data from Norway. A total of 34,951 persons in Norway were estimated to seek care for painful neuropathies each year. The formal education program was assumed to cost 1.5 million Kroner (NOK). Shifting the locus of care from specialists to GPs would result in 4,715 additional GP visits, but 12,123 fewer specialist visits and 7,967 fewer visits to pain clinics. This change would result in estimated savings to the Norwegian health-care system in 2004 of 74.1 million NOK (approx. US $11.9 million). A partial shift in the locus of care of painful neuropathies from specialists to GPs may result in substantial cost savings to the Norwegian health-care system.

The Search and Selection of Assisted Living Facilities by Elders and Family

BACKGROUND

In this study, we examine factors associated with the search, selection, and satisfaction of residents and family members in assisted living.

METHODS

Data were collected from 375 residents of 25 assisted living facilities matched with 375 family members. We conducted face-to-face interviews with the residents to determine: (1) the principal decision maker; (2) the process of searching for a facility; (3) the factors crucial to facility selection; (4) the time frame from the relocation decision to relocation; and (5) satisfaction with selection. Similar questions were asked of family members, using a mail survey.

RESULTS

Residents described themselves as extremely influential in 39% of cases when searching for a facility, and in 27% of cases when selecting a facility. Quality, cost, and location were the most influential factors for both residents and family members in selecting a facility. Almost all residents and family would use different search and selection processes if they had to select a facility again, and almost all were dissatisfied with the sources of information available.

CONCLUSIONS

Consumers and policy makers both favor the use of assisted living settings; but, the information available to choose a setting is far from ideal, and may represent a barrier to both consumer and policy makers' agendas.

Pain syndromes after missile-caused peripheral nerve lesions: part 1--clinical characteristics

OBJECTIVE

To report on the clinical characteristics of pain and factors influencing pain intensity in patients with missile-caused nerve injuries.

METHODS

The prospective study included 326 patients with clinically significant pain syndromes including complex regional pain syndrome Type II, deafferentation pain, reinnervation pain, and neuralgic pain. Diagnostic procedures were analyzed, factors influencing the pain intensity were identified, and the patients' characteristics, pain characteristics, and other clinical symptoms and signs were compared between different types of pain syndromes.

RESULTS

The rate of painful injuries ranged from 17.3 to 22.9% for mixed nerves and from 2.6 to 4.6% for motor nerves. Peripheral nerve block and sympathetic block were useful and safe adjuvant diagnostic procedures, obtaining pain relief in 66.7% of patients with neuralgic pain and in 90.1% of patients with complex regional pain syndrome Type II. Pain started 2.6 days after injury in patients with complex regional pain syndrome Type II and 11.9 days after injury in patients with painful nerve adhesions (analysis of variance, P < 0.001). Permanent pain was more frequent (79.1%) than paroxysmal pain, superficial pain was more frequent (55.2%) than deep pain, and burning pain was the most frequent pain descriptor (43.6%). Ten factors were found to significantly influence the pain intensity (binary logistic analysis), including three independent predictors (multivariate analysis): type of pain syndrome (P < 0.001), multiple nerve damage in the injury site (P = 0.022), and onset of pain in the first two days after injury (P = 0.031).

CONCLUSION

Pain syndromes after missile-caused nerve injury differ significantly regarding time of pain onset, pain characteristics, and other symptoms and signs. The type of pain syndrome, multiple nerve damage, and early onset of pain are independent predictors of initial pain intensity. Although medical history and physical examination are the main diagnostic keys, nerve exploration preceded by a nerve block and sympathetic block are safe and useful adjuvant diagnostic procedures.

Cognitive function impairment in patients with neuropathic pain under standard conditions of care

The objective of this study is to analyze the prevalence to cognitive function impairment (CI) in a pragmatic cohort of subjects with different types of neuropathic pain under standard conditions of care by means of a cross-sectional baseline analysis of a sample of patients with NeP enrolled in a pragmatic, prospective, multicenter study evaluating the effectiveness of gabapentin. A total of 1519 patients (58.8% women), aged > or =18 years (mean [SD]=56.0 [13.7]), with neuropathic or mixed neuropathic and nociceptive pain for a mean (SD) of 1.1 (2.8) years were enrolled in the study. Pain was assessed with the short form of the McGill Pain Questionnaire, and cognitive function was measured with the Mini-Mental State Examination (MMSE). A score < or =24 on the MMSE was considered as CI. Multivariate logistic regression models were used to estimate CI prevalence. CI prevalence was substantially higher in patients with NeP than that reported in the general Spanish population, and significantly higher than in patients with mixed neuropathic and nociceptive pain: 11.4% (8.5%-14.3%) vs. 6.4% (4.6%-8.7%), P=0.006 (adjusted odds ratio=1.88 [1.21-2.91]). Prevalence significantly increased with age, up to 32.2% (20.6%-45.6%) in those with NeP, and to 28.2% (15.0%-44.9%) in those with mixed syndromes, for the age group > or =75 years, P<0.001 within age groups. Symptoms of anxiety and obesity, and to a lesser extent, symptoms of depression, were also factors associated with a higher prevalence rate of CI. This analysis showed that, after adjusting for confounding factors, the prevalence of CI was substantially higher in patients with NeP than those with mixed pain and the reference general population. Age, anxiety, depression, and obesity were factors found to be significantly associated with CI.

An Interdisciplinary Expert Consensus Statement on Assessment of Pain in Older Persons

This paper represents an expert-based consensus statement on pain assessment among older adults. It is intended to provide recommendations that will be useful for both researchers and clinicians. Contributors were identified based on literature prominence and with the aim of achieving a broad representation of disciplines. Recommendations are provided regarding the physical examination and the assessment of pain using self-report and observational methods (suitable for seniors with dementia). In addition, recommendations are provided regarding the assessment of the physical and emotional functioning of older adults experiencing pain. The literature underlying the consensus recommendations is reviewed. Multiple revisions led to final reviews of 2 complete drafts before consensus was reached.

Hospice Care in Nursing Homes: Does It Contribute to Higher Quality Pain Management?

PURPOSE

The purpose of this study was to investigate pain management among 42 hospice and 65 non-hospice residents in two proprietary nursing homes.

DESIGN AND METHODS

In this prospective, anthropological, quantitative, and qualitative study, we used participant observation, event analysis, and chart review to obtain data. The Medication Quantification Scale was used in order to account for the prescription and administration of all analgesic medications.

RESULTS

Although 72% of residents experienced pain, we found no statistically significant differences in the proportion of hospice versus non-hospice residents (a) who had been prescribed opioids and co-analgesics, and (b) whose medication was administered around the clock or as needed. Limited physician availability, lack of pharmacologic knowledge, and limitations of nursing staff hindered pain management of both groups of residents.

IMPLICATIONS

Although hospice care is of some benefit, pain management and high-quality end-of-life care is dependent upon the context in which it is provided. Given that between 1991 and 2001 Medicare expenditures for nursing home-based hospice care increased from dollar 8.6 million to dollar 21.8 million, the effectiveness of hospice-care programs in nursing homes warrants further study.

A record review of reported musculoskeletal pain in an Ontario long term care facility

BACKGROUND

Musculoskeletal (MSK) pain is one of the leading causes of chronic health problems in people over 65 years of age. Studies suggest that a high prevalence of older adults suffer from MSK pain (65% to 80%) and back pain (36% to 40%). The objectives of this study were: 1. To investigate the period prevalence of MSK pain and associated subgroups in residents of a long-term care (LTC) facility. 2. To describe clinical features associated with back pain in this population. 3. To identify associations between variables such as age, gender, cognitive status, ambulatory status, analgesic use, osteoporosis and osteoarthritis with back pain in a long-term care facility.

METHODS

A retrospective chart review was conducted using a purposive sampling approach of residents' clinical charts from a LTC home in Toronto, Canada. All medical records for LTC residents from January 2003 until March 2005 were eligible for review. However, facility admissions of less than 6 months were excluded from the study to allow for an adequate time period for patient medical assessments and pain reporting/charting to have been completed. Clinical data was abstracted on a standardized form. Variables were chosen based on the literature and their suggested association with back pain and analyzed via multivariate logistic regression.

RESULTS

140 (56%) charts were selected and reviewed. Sixty-nine percent of the selected residents were female with an average age of 83.7 years (51-101). Residents in the sample had a period pain prevalence of 64% (n = 89) with a 40% prevalence (n = 55) of MSK pain. Of those with a charted report of pain, 6% (n = 5) had head pain, 2% (n = 2) neck pain, 21% (n = 19) back pain, 33% (n = 29) extremity pain and 38% (n = 34) had non-descriptive/unidentified pain complaint. A multivariate logistic regression analysis revealed that osteoporosis was the only significant association with back pain from the variables studied (P = 0.001).

CONCLUSION

Residents with back pain represent 13.6% (n = 19) of the sample population studied. This is as frequent as other serious conditions commonly found in LTC. Of the variables studied, only osteoporosis and the self-report of back pain were found to be associated. The back pain resident in this facility can typically be described as female, osteoporotic, with mild to moderate dementia, an independent or assisted walker having low levels of depression. Further research using other sites is needed to determine the overall prevalence of this condition and its impact on quality of life issues. The results of this study should inform future research in this area.

Analyses of nursing home residents with cancer at admission

The objective of the study was to profile nursing home residents with cancer at admission to the nursing facility. We used all admission assessments in the Minimum Data Set recorded throughout the United States during 2002 to identify 61,890 residents with cancer, or 11.3% of all admissions. Nursing home residents with cancer were significantly older and more likely to be male than other residents at admission. Large proportions of nursing home residents with cancer were activities of daily living dependent and about 55% used a wheelchair as their primary mode of locomotion. More than 37% of residents with cancer experienced at least moderate daily pain at admission and almost 26% had a diagnosis of depression. At admission, more than half of residents with cancer had an unstable health condition, 21% were judged to be in their final 6 months of life, and 19% received hospice care. More than 40% of residents with cancer had no advance directives recorded at admission. Compared to other residents at admission, larger proportions of residents with cancer require heavy care. Staff at nursing facilities need to address depression, pain management, and the implementation of advance directives to improve the quality of life for residents with cancer.

Chemotherapy-induced emesis in elderly cancer patients: the role of 5-HT3-receptor antagonists in the first 24 hours

OBJECTIVE

This review highlights the need to optimize 5-HT3-receptor-antagonist-based antiemetic therapy for elderly cancer patients, particularly during the first 24 h after receiving chemotherapy, based on knowledge of the chemotherapeutic regimen, comorbidity, polypharmacy, dosing convenience and age-related health.

BACKGROUND

The proportion of elderly people (over 65 years of age) in the general population is increasing. Compared with the general population, elderly people have a greater risk of serious diseases, such as cancer and cardiovascular disease. Their chemotherapy can be compromised by factors including comorbidity, declining organ function, polypharmacy, drug-drug interactions and cognitive impairments. The use of aprepitant in this elderly population with many concomitant medications is not discussed. Many chemotherapeutic regimens are highly emetogenic, and nausea and vomiting are rated among the most distressing side effects of chemotherapy. The emetogenic potential of various chemotherapy regimens is reviewed, demonstrating clear differences in severity and time of symptom onset. Such differences are particularly important during the first 24 h after administration, when control of emetic symptoms can help to prevent the occurrence of subsequent episodes. The matter is further complicated by inter-patient differences in susceptibility to nausea and vomiting resulting from multiple factors including gender, age and alcohol intake. Individual patient evaluation is essential to identify those patients most at risk. Elderly patients may also be particularly sensitive to the serious physiological and physical effects of nausea and vomiting. Education about symptom management needs to recognize specific learning barriers in the elderly, such as declining sensory perception or cognitive impairment. 5-HT3-receptor antagonists have long been the gold standard for treating chemotherapy-induced nausea and vomiting. Pharmacological differences between 5-HT3-receptor antagonists suggest the need for careful consideration of individual patient characteristics. Selection of the most appropriate agent will optimize antiemetic therapy for elderly cancer patients.

CONCLUSION

Chemotherapy-induced emesis in elderly cancer patients needs optimal control by a 5-HT3-receptor antagonist with uncomplicated 24-hour efficacy and good tolerability. Choosing a 5-HT3-receptor antagonist with a long duration of action, low risk of drug-drug interactions and once-daily dosing is important to ensure effective prophylaxis against nausea and vomiting in the elderly and simplify management for patients with cognitive impairment, declining organ function and comorbidity.

Potential Drug—Disease Interactions in Frail, Hospitalized Elderly Veterans

BACKGROUND:

Drugs can improve quality of life for many older people, but they may cause adverse health outcomes (eg, drug—disease interactions) if used inappropriately.

OBJECTIVE:

To determine the prevalence of potential drug—disease interactions as defined by explicit criteria and examine associations between sociodemographic and health status variables and potential drug—disease interactions.

METHODS:

The study design was cross-sectional. We evaluated 397 frail elderly inpatients from the Geriatric Evaluation and Management trial conducted at 11 Veterans Affairs Medical Centers. Drug—disease interactions were defined using explicit criteria from consensus expert panels of geriatricians from the US and Canada.

RESULTS:

Overall, 159 (40.1%) patients had one or more potential drug—disease interaction. The most common potential interactions were calcium-channel blockers and heart failure (12.3%) and β-blockers and diabetes (6.8%). Multivariable logistic regression analyses revealed that age ⩾75 years (adjusted OR 2.43; 95% CI 1.52 to 3.88), being married (adjusted OR 1.77; 95% CI 1.11 to 2.82), comorbidity index defined by Charlson method (adjusted OR 1.19; 95% CI 1.05 to 1.34), and use of multiple prescription drugs (5–8: adjusted OR 4.17; 95% CI 1.96 to 8.88, ⩾9: adjusted OR 9.22; 95% CI 4.26 to 19.95), were significantly (p < 0.05) associated with having one or more potential drug—disease interaction.

CONCLUSIONS:

Potential drug—disease interactions are common in hospitalized elderly patients and are related to specific sociodemographic and health status factors. Further research is needed to examine the relationship between health outcomes and drug—disease interactions.

Practical considerations in the assessment and treatment of pain in adults with physical disabilities

Adults aging with physical disabilities experience a variety of pain disorders that affect their functionality and QOL. It is important that clinicians caring for this population be knowledgeable about this common symptom and be able to perform a thorough history and physical examination. In addition, it is imperative to have a good working knowledge of the strengths and limitations of the treatments available.

Pain assessment and management in persons with dementia

Pain is a significant problem for older adults, and it has the potential to negatively impact their independence, functioning, and quality of life. In order for pain to be managed effectively, it first must be assessed carefully and systematically. Pain assessment in patients with dementia should start with self-report of pain, but must incorporate assessment of nonverbal pain behaviors. Pain treatment in older adults should be tailored to the individual. Pain medications can be used safely in elders, and they may be more effective when combined with nonpharmacological treatment. Despite the preponderance of research on pain, relatively few investigations have focused on pain in older adults in general, and on persons with dementia specifically. Better strategies for assessing pain, using observational methods, are the cornerstone of effective pain management in persons with dementia. Practitioners must be knowledgeable about pain treatment, and use both pharmacological and nonpharmacological strategies to relieve pain. Moreover, clinicians must be aware of the barriers to effective pain management and work to overcome them. In so doing, they may make significant contributions to managing pain in patients with dementia, and in improving the quality of life of this vulnerable population of elders.

Pharmacological treatments for persistent non-malignant pain in older persons

Persistent non-malignant pain is common, often neglected and under-treated among older persons. Some older adults do not complain because they consider chronic pain to be a characteristic of normal aging. Physicians have concerns regarding adverse effects of pharmacological treatment. The model of the World Health Organization for treatment of cancer pain is generally accepted and also recommended for persistent non-cancer pain. Furthermore, non-pharmacological treatment should complement drug treatment whenever possible. An initial assessment and possible treatment of underlying causes of pain are pertinent. Modern pharmacological pain management is based on non-opioid and opioid analgesics. NSAIDs are among the most widely prescribed class of drugs in the world. The new cyclo-oxygenase-2 inhibitors such as celecoxib and rofecoxib offer an alternative for the treatment of mild-to-moderate pain in patients with a history of gastric ulcers or bleeding. Paracetamol (acetaminophen) is being used widely for the management of mild pain across all age groups as it has moderate adverse effects at therapeutic dosages. For moderate pain, a combination of non-opioid analgesics and opioid analgesics with moderate pain relief properties (e.g. oxycodone, codeine, tramadol and tilidine/naloxone) is recommended. For severe pain, a combination of non-opioid analgesics and opioid analgesics with strong pain relief properties (e.g. morphine, codeine) is recommended. The least toxic means of achieving systemic pain relief should be used. For continuous pain, sustained-release analgesic preparations are recommended. Drugs should be given on a fixed time schedule, and possible adverse effects and interactions should be carefully monitored. Adjuvant drugs, such as antidepressants or anticonvulsants, can be very effective especially in the treatment of certain types of pain, such as in diabetic neuropathy. Effective pain management should result in decreased pain, increased function and improvement in mood and sleep.

Complementary and Alternative Approaches to the Treatment of Persistent Musculoskeletal Pain

OBJECTIVE

To review common complementary and alternative treatment modalities for the treatment of persistent musculoskeletal pain in older adults.

METHODS

A critical review of the literature on acupuncture and related modalities, herbal therapies, homeopathy, and spinal manipulation was carried out. Review included 678 cases within 21 randomized trials and 2 systematic reviews of herbal therapies: 798 cases within 2 systematic reviews of homeopathy; 1,059 cases within 1 systematic review of spinal manipulation for low back pain, and 419 cases within 4 randomized controlled trials for neck pain. The review of acupuncture and related modalities was based upon a paucity of well-controlled studies combined with our clinical experience.

RESULTS

Insufficient experimental evidence exists to recommend the use of traditional Chinese acupuncture over other modalities for older adults with persistent musculoskeletal pain. Promising preliminary evidence exists to support the use of percutaneous electrical nerve stimulation for persistent low back pain. While some herbals appear to have modest analgesic benefits, insufficient evidence exists to definitively recommend their use. Drug-herb interactions must also be considered. Some evidence exists to support the superiority of homeopathic remedies over placebo for treating osteoarthritis and rheumatoid arthritis. The benefits of spinal manipulation for persistent low back and neck pain have not been convincingly shown to outweigh its risks.

DISCUSSION

While the use of complementary and alternative modalities for the treatment of persistent musculoskeletal pain continues to increase, rigorous clinical trials examining their efficacy are needed before definitive recommendations regarding the application of these modalities can be made.

Laxative use in the community-dwelling elderly

BACKGROUND

Constipation, a common and sometimes severe problem in the elderly, is often treated with laxatives.

OBJECTIVE

The purpose of this study was to determine the prevalence of laxative use and identify determinants of such use among representative black and white community-dwelling elderly persons.

METHODS

This was a cross-sectional survey of 4136 participants at baseline (1986-1987) in the Duke University Established Populations for Epidemiologic Studies of the Elderly. Data on demographic characteristics, health status, health service use, and use of prescription and over-the-counter drugs were collected in participants' homes. Use of the following types of laxatives was examined: bulking, hyperosmotic, lubricant, stimulant, stool softener, saline, and miscellaneous agents.

RESULTS

It was found that 10.2% of participants used > or =1 laxative. Stimulants and bulking agents were the most commonly used classes. Only 11.6% of laxative users reported concurrent consumption of > or =2 laxatives. Multivariate logistic regression analyses indicated that laxative use was more likely in women (adjusted OR, 1.78; 95% CI, 1.34-2.37), those with >4 physicians visits in the previous year (adjusted OR, 1.72; 95% CI, 1.16-2.53), those unable to walk a half mile (adjusted OR, 1.44; 95% CI, 1.11-1.87), and those using > or =4 over-the-counter nonlaxative medications (adjusted OR, 2.09; 95% CI, 1.15-3.81). A nonsignificant association was seen between laxative use and the use of anticholinergic agents (adjusted OR, 1.38; 95% CI, 1.00-1.89).

CONCLUSIONS

Laxative use is common among community-dwelling elderly persons and is related to specific factors concerning sociodemographics, health status, and access to health care. Studies are needed that examine the impact of laxative use on bowel function and quality of life in the elderly.

Demographics, assessment and management of pain in the elderly

The prevalence of pain increases with each decade of life. Pain in the elderly is distinctly different from pain experienced by younger individuals. Cancer is a leading cause of pain; however, other conditions that cause pain such as facet joint arthritis (causing low back pain), polymyalgia rheumatica, Paget's disease, neuropathies, peripheral vascular disease and coronary disease most commonly occur in patients over the age of 50 years. Poorly controlled pain in the elderly leads to cognitive failure, depression and mood disturbance and reduces activities of daily living. Barriers to pain management include a sense of fatalism, denial, the desire to be 'the good patient', geographical barriers and financial limitations. Aging causes physiological changes that alter the pharmacokinetics and pharmacodynamics of analgesics, narrowing their therapeutic index and increasing the risk of toxicity and drug-drug interactions. CNS changes lead to an increased risk of delirium. Assessment among the verbal but cognitively impaired elderly is satisfactorily accomplished with the help of unidimensional and multidimensional pain scales. A comprehensive physical examination and pain history is essential, as well as a review of cognitive function and activities of daily living. The goal of pain management among the elderly is improvement in pain and optimisation of activities of daily living, not complete eradication of pain nor the lowest possible drug dosages. Most successful management strategies combine pharmacological and nonpharmacological (home remedies, massage, topical agents, heat and cold packs and informal cognitive strategies) therapies. A basic principle of the pharmacological approach in the elderly is to start analgesics at low dosages and titrate slowly. The WHO's three-step guideline to pain management should guide prescribing. Opioid choices necessitate an understanding of pharmacology to ensure safe administration in end-organ failure and avoidance of drug interactions. Adjuvant analgesics are used to reduce opioid adverse effects or improve poorly controlled pain. Adjuvant analgesics (NSAIDs, tricyclic antidepressants and antiepileptic drugs) are initiated prior to opioids for nociceptive and neuropathic pain. Preferred adjuvants for nociceptive pain are short-acting paracetamol (acetaminophen), NSAIDs, cyclo-oxygenase-2 inhibitors and corticosteroids (short-term). Preferred drugs for neuropathic pain include desipramine, nortriptyline, gabapentin and valproic acid. Drugs to avoid are pentazocine, pethidine (meperidine), dextropropoxyphene and opioids that are both an agonist and antagonist, ketorolac, indomethacin, piroxicam, mefenamic acid, amitriptyline and doxepin. The type of pain, and renal and hepatic function, alter the preferred adjuvant and opioid choices. Selection of the appropriate analgesics is also influenced by versatility, polypharmacy, severity and type of pain, drug availability, associated symptoms and cost.

Physician variability in the management of acute postoperative and cancer pain: a quantitative analysis of the Michigan experience

BACKGROUND

Little is known about physician attitudes, goals, or satisfaction regarding acute postoperative and cancer pain management.

OBJECTIVES

To provide quantitative data regarding the status of acute postoperative and cancer pain management by Michigan physicians. To measure physician confidence, preference, and satisfaction as well as identify their pain care goals for acute postoperative and cancer pain management. To evaluate variability in acute postoperative and cancer pain decision making based upon physician demographic characteristics, knowledge, and attitudes.

RESEARCH DESIGN

A cross-sectional survey, which included two cancer and three acute postoperative pain vignettes.

SUBJECTS

A randomly-selected sample of three hundred sixty-eight licensed Michigan physicians who provide clinical care for acute postoperative and cancer pain patients.

RESULTS

The majority of respondents (>50%) reported providing acute postoperative pain care frequently, while a minority (<20%) reported doing so for cancer pain. The majority of the physicians (>75%) reported goals of at least adequate pain relief without distress for both acute postoperative and cancer pain. Physicians more frequently chose the optimal pain management response for men following prostatectomy (56.2%) than for women following myomectomy (42%). They also chose the optimal response for metastatic prostate cancer more frequently (16.3%) than for metastatic breast cancer pain management (10.7%).

CONCLUSION

These data highlight physician variability in acute postoperative and cancer pain management decision making. Further study of the physician variable is necessary to improve the management of acute postoperative and cancer pain.

Essential Components of a Medical Student Curriculum on Chronic Pain Management in Older Adults: Results of a Modified Delphi Process

OBJECTIVE

The purpose of this study was to develop expert-based guidelines for a medical student curriculum on chronic pain evaluation and management in older adults.

METHODS

A modified Delphi approach was used to survey an interdisciplinary panel (N = 12) with expertise in pain assessment, pharmacological and nonpharmacological pain management, and medical student education. A list of core knowledge/attitudes/skills (KAS) competency items was developed based upon a comprehensive literature review and clinical experience. The expert panel was then asked to consider the degree to which each item should be included in a pain education curriculum, using a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree with inclusion of item). Items with a mean>4.0 (agree) and a standard deviation (SD) <1 were retained, while others were discarded. Retained items were refined, and new items were added based upon panel suggestions. The new KAS list was again scored by the expert panel, and items with a mean <4.0 and SD <1 were discarded.

RESULTS

The original KAS list contained eight pain assessment knowledge, seven pain management knowledge, 12 pain attitudes, and 14 skills/abilities items. The final list, presented in this paper, consisted of 11 pain assessment knowledge, seven pain management knowledge, 12 pain attitudes, and 12 skills/abilities items.

DISCUSSION

We have developed curriculum content guidelines for educating medical students about the evaluation and management of chronic pain in older adults. Once curricula are developed, their efficacy, in particular their influence on patient outcomes, must be evaluated.

Use of inappropriate prescription drugs by older people

OBJECTIVES

To determine the prevalence and predictors of inappropriate drug prescribing defined by expert national consensus panel drug utilization review criteria for community-dwelling older people.

DESIGN

Survey.

SETTING

Five adjacent urban and rural counties in the Piedmont area of North Carolina.

PARTICIPANTS

A stratified random sample of participants from the fourth (n = 3,234) and seventh (n = 2,508) waves of the Duke Established Populations for Epidemiological Studies of the Elderly.

MEASUREMENTS

The prescribing appropriateness for digoxin, calcium channel blockers, angiotensin-converting enzyme inhibitors, histamine(2) receptor antagonists, nonsteroidal antiinflammatory drugs (NSAIDs), benzodiazepines, antipsychotics, and antidepressants as determined by explicit criteria (through Health Care Financing Administration expert consensus panel drug utilization review criteria for dosage, duplication, drug-drug interactions and duration, and U.S. and Canadian expert consensus panel criteria for drug-disease interactions). Multivariable analyses, using weighted data adjusted for sampling design, were conducted to assess the association between inappropriate prescribing and demographic, health-status, and access-to-healthcare factors cross-sectionally and longitudinally.

RESULTS

We found that 21.0 of the fourth wave and 19.2 of the seventh wave participants who used one or more agents from the eight drug classes had one or more elements identified as inappropriate. The therapeutic classes with the most problems were benzodiazepines and NSAIDs. The most common problems were with drug-disease interactions and duration of use. Longitudinal multivariable analyses found that participants who were white (adjusted odds ratio (AOR) = 1.67, 95 confidence interval (CI) = 1.28-2.17), were married (AOR = 1.40, 95% CI = 1.01-1.93), had arthritis (AOR = 1.74, 95% CI = 1.27-2.38), had one or more physical function disabilities (AOR = 1.42, 95% CI = 1.02-1.96), and had inappropriate drugs prescribed at wave 4 (AOR = 6.87, 95% CI = 5.11-9.22) were more likely to have inappropriate prescribing at wave 7.

CONCLUSION

These results indicate that inappropriate prescribing is common among community-dwelling older people and persists over time. Longitudinal studies in older people are needed to examine the impact of inappropriate drug prescribing on health-related outcomes.