Older patients have a variety of chronic illnesses that may result in pain. However, the daily presence of pain often goes unrecognized and, therefore, untreated in both the community-dwelling and institutionalized elderly. Chronic pain may be the result of comorbidities, including osteoarthritis, osteoporosis, cancer, peripheral vascular disease, or neuropathies secondary to complications of diabetes. Procedures such as surgery, open wounds and pressure ulcers can also be a source of pain. Identifying and adequately managing pain in the elderly patient presents unique challenges for the pharmacist and the entire healthcare team.
The lack of recognition and consequent undertreatment of pain in all patient populations has resulted in new standards from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for all levels of care. Organizations seeking JCAHO accreditation or reaccreditation must have a comprehensive pain management program in place. Underlying the new standards is a commitment to every patient’s right to adequate treatment of pain. This is accomplished through the organization’s program of education for all staff, patients, residents, and families; development and use of appropriate tools for pain assessment; care of persons with pain; inclusion of pain management in discharge planning; and incorporating pain management into the institution’s performance improvement program. The pharmacist is considered an essential staff member for a successful pain management program, not only in the educational component, but also in the development of policies and procedures, drug therapy protocols, and outcomes assessment.
|New JCAHO standards commit to every patient’s right to adequate treatment of pain.|
To emphasize the importance of routine and ongoing pain assessment, the American Pain Society (APS) has labeled pain as “the fifth vital sign.” Consistent with the JCAHO standards, which the Society endorsed, the APS seeks to provide practical measures in order to make adequate pain management a reality for every patient.
Assessment and Identification of Pain
Clinical assessment of all elderly patients must attempt to ascertain the presence of pain through both verbalized and nonverbalized symptoms. An elderly patient may verbally respond to questions about the presence of pain by stating that he has no pain but may, in fact, be experiencing unrelieved or inadequately relieved pain. In addition to an inability to express the presence of pain due to progressing dementia, aphasia, or language barriers, there may be cultural or societal barriers to articulating pain symptoms. Cultural beliefs that pain is a sign of weakness and that suffering is preferable to accepting pain medication may precondition the patient to deny the presence of pain. The patient, his or her family, and health professionals may have the misconception that narcotic analgesics should not be used because of the potential for physical dependence. Healthcare staff may not be adequately trained in recognizing the signs of pain in the older patient or in assessing pain relief. Staff cultural beliefs about patient perception of pain and treatment may hinder adequate pain management as well.
Pain scales that can be used to assess the intensity of verbally expressed pain include numeric or descriptive scales. The Wong Baker Faces Scale may be especially useful when verbal description is not possible. The patient may be able to indicate which face best demonstrates how he or she feels; if not, staff can match the face to the patient in front of them. Nonverbal cues may indicate the presence of pain in the elderly patient who denies or is unable to indicate the presence of pain. In addition to facial expression, behaviors that can indicate actual unrelieved pain include agitated behavior, pulling away or refusing care, favoring or rubbing a limb or body part, gait disturbances, declining to participate in rehabilitation activities, withdrawing from social activities, loss of appetite with resulting weight loss, insomnia, or symptoms of depression.