RESEARCH IN CANCER PAIN AND PALLIATIVE CARE

CHALLENGES IN CARING FOR THE ELDERLY IN PAIN

Elderly nursing home residents have pain which must be treated

Ferrell BA. Pain evaluation and management in the nursing home. Ann Intern Med 1995;123(9):681-687.
As many as 45% to 80% of nursing home residents have pain that contributes materially to functional impairment and decreased quality of life. Substantial barriers, including a high frequency of dementia, multiple pain problems, and increased sensitivity to drug side effects often make pain assessment and management more difficult in the nursing home setting. Logistic problems in carrying out diagnostic procedures and management interventions are also common. Pain can be alleviated in nursing homes through the careful use of analgesic drugs combined with nonpharmacologic strategies, including exercise programs and other physical therapies. Elderly nursing home residents are more sensitive to the side effects associated with many analgesic drugs, but this does not justify the failure to treat pain, especially in those who are terminally ill or near the end of life. Structured programs for routine pain assessment and treatment are needed. Physician involvement in pain assessment and management is necessary if pain control is to be improved for nursing home patients.

Instruments to assess pain reviewed

Gagliese L, Melzack R. Chronic pain in elderly people. Pain 1997; 70(1):3-14.
Chronic pain in elderly people has only recently begun to receive serious empirical consideration. There is compelling evidence that a significant majority of the elderly experience pain which may interfere with normal functioning. Nonetheless, a significant proportion of these individuals do not receive adequate pain management. Three significant factors which may contribute to this are (1) lack of proper pain assessment; (2) potential risks of pharmacotherapy in the elderly; and (3) misconceptions regarding both the efficacy of nonpharmacological pain management strategies and the attitudes of the elderly towards such treatments. In this review the most commonly used assessment instruments and patterns of age differences in the experience of chronic pain are described and evidence for the efficacy of psychological pain management strategies for this group is reviewed.


Valid scale allows pain assessment of older cancer patients with cognitive problems

Filbet M, Wary B. Cancer pain assessment in the elderly with cognition impairment: the DOLOPLUS scale validity study [abstract, ICCCC conf.] J Pain Symptom Manage 1999; 18 (5): S12.
Since 1993 Dr. B. Wary and his team have been working on the validation of the DOLOPLUS pain rating scale, a behavioral pain assessment scale which relies on ten different items: somatic, psychomotor and psychosocial reactions. After six years of experimental multicentric studies and statistical methods, the rating scale has been validated. This scale may be used for cancer pain assessment in elderly people. Cancer frequency increases with aging and pain assessment with a Visual Analog Scale (VAS) may become difficult when dementia or cognition impairment occur. Therefore, elderly people do not complain despite severe pain. This Doloplus scale improves cancer pain treatment in elderly people who are usually undertreated.

Nurses ignore pain in the elderly

Stein et al. Cancer pain in the elderly hospice patient. J Pain Symptom Manage 1993; 8: 474-482.
To assess the relationship between subjective pain assessment and other clinical variables in geriatric hospice patients with cancer, we performed a retrospective record review and observation of home visits for patients treated by a community-based hospice with three satellite offices covering the state of Rhode Island. From a sample of 537 patients with terminal cancer admitted during 1990, 239 patients 65 years of age and older were identified. Of the 239 patients, 89% survived 90 days or less, and 21% lived 7 days or less. Upon admission, 55% of the sample reported pain, with 44% reporting pain in the range from discomfort to excruciating. Of those patients not reporting pain upon admission, 55% went on to experience pain that subsequently required medication management. [...] There was a difference between the admission nurse's placement of pain on the problem list and the patients' reporting of pain; although the numbers were small, it was found that a nurse caring for the elderly, but not one caring for a younger patient, was almost twice as likely to incorrectly leave pain off a problem list than to incorrectly ascribe pain to a patient not reporting it at the time of the interview. These data suggest that elderly patients entering hospice with pain require early concentration of pain management services. For patients entering hospice without pain, attention to initial onset of pain requires both appropriate assessment and specific treatment plans to minimize suffering.

Older cancer patients receive less analgesics than younger patients

Goldberg RJ, Mor V, Wieman M, et al. Analgesic use in terminal cancer patients: report from the National Hospice Study. J Chronic Dis 1986; 39: 37-45.
Little systematic research has been reported on analgesic use in terminal cancer patients. This paper presents data from the National Hospice Study on the use of analgesics by a sample of terminal cancer patients served in home-based and hospital-based hospice programs as well as conventional oncological settings. Patients in hospital-based hospice programs were more likely than other patients to have an analgesic prescription and to have consumed analgesics. Patients in hospice settings were more likely to consume analgesia orally and less likely to have 'as needed' analgesic prescriptions. The amount of analgesic consumption was inversely related to age. The paper discusses the implications of these and other findings for the treatment of pain in terminal cancer patients.

Older cancer patients have greater risk of undermedication of pain

Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994;330:592-596.
BACKGROUND & METHODS. Pain is often inadequately treated in patients with cancer. A total of 1308 outpatients with metastatic cancer from 54 treatment locations affiliated with the Eastern Cooperative Oncology Group rated the severity of their pain during the preceding week, as well as the degree of relief provided by analgesic drugs. Their physicians attributed the pain to various factors, described its treatment, and estimated the impact of pain on the patients' ability to function. We assessed the adequacy of prescribed analgesic drugs using guidelines developed by the World Health Organization, studied the factors that influenced whether analgesia was adequate, and determined the effects of inadequate analgesia on the patients' perception of pain relief and functional status. RESULTS. Sixty-seven percent of the patients (871 of 1308) reported that they had had pain during the week preceding the study, and 36 percent (475 of 1308) had pain severe enough to impair their ability to function. Forty-two percent of those with pain (250 of the 597 patients for whom we had complete information) were not given adequate analgesia therapy. Patients seen at centers that treated predominantly minorities were three times more likely than those treated elsewhere to have inadequate pain management. A discrepancy between patient and physician in judging the severity of the patients' pain was predictive of inadequate pain management (odds ratio, 2.3). Other factors that predicted inadequate pain management included pain that physicians did not attribute to cancer (odds ratio, 1.9), better performance status (odds ratio, 1.8), age of 70 or older (odds ratio, 1.5). Patients with less adequate analgesia reported less pain relief and greater pain-related impairment of function. CONCLUSIONS. Despite published guidelines for pain management, many patients with cancer have considerable pain and receive inadequate analgesia.


Daily cancer pain undertreated in older patients

Bernabei R, Gambassi G, Lapane K, Landi F, et al. Management of pain in elderly patients with cancer. JAMA 1998; 279: 23:1877-1882.
CONTEXT. Cancer pain can be relieved with pharmacological agents as indicated by the World Health Organization (WHO). All too frequently pain management is reported to be poor. OBJECTIVE. To evaluate the adequacy of pain management in elderly and minority cancer patients admitted to nursing homes. DESIGN. Retrospective, cross-sectional study. SETTING. A total of 1492 Medicare-certified and/or Medicaid-certified nursing homes in 5 states participating in the Health Care Financing Administration's demonstration project, which evaluated the implementation of the Resident Assessment Instrument and its Minimum Data Set. STUDY POPULATION. A group of 13,625 cancer patients aged 65 years and older discharged from the hospital to any of the facilities from 1992 to 1995. Data were from the multilinked Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database. MAIN OUTCOME MEASURES. Prevalence and predictors of daily pain and of analgesic treatment. Pain assessment was based on patients' report and was completed by a multidisciplinary team of nursing home personnel that observed, over a 7-day period, whether each resident complained or showed evidence of pain daily. RESULTS. A total of 4003 patients (24%, 29%, and 38% of those aged „ 85 years, 75 ot 84 years, and 65 to 74 years, respectively) reported daily pain. Age, gender, race, marital status, physical function, depression, and cognitive status were all independently associated with the presence of pain. Of patients with daily pain, 16% received a WHO level 1 drug, 32% a WHO level 2 drug, and only 26% received morphine. Patients aged 85 years and older were less likely to receive either weak opiates or morphine than those aged 65 to 74 years (13% vs 38%, respectively). More than a quarter of patients (26%) in daily pain did not receive any analgesic agent. Patients older than 85 years in daily pain were also more likely to receive no analgesia (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.13-1.73). Other independent predictors of failing to receive any analgesic agent were minority race (OR, 1.63; 95% CI, 1.18-2.26 for African Americans), low cognitive performance (OR, 1.23; 95% CI, 1.05-1.44), and the number of other medications received (OR, 0.65; 95% CI, 0.5-0.84 for 11 or more medications. CONCLUSION. Daily pain is prevalent among nursing home residents with cancer and is often untreated, particularly among older minority patients.


Age affects opioid response

Mercadante S, Casuccio A, Pumo S, Fulfaro F. Factors influencing the opioid response in advanced cancer patients with pain followed at home: the effects of age and gender. Support Care Cancer 2000 Mar;8(2):123-30
The aim of this study was to evaluate the influence of age and gender on pain characteristics and opioid response in advanced cancer patients followed at home. A perspective study was carried out in a sample of 181 consecutive advanced cancer patients who required opioids in the last 4 weeks before death. Pain intensity and symptoms associated with opioid therapy at weekly intervals for 4 weeks were recorded, as were the previous oncological treatments. Opioid doses increased over time, but remained stable in the last 2 weeks of life, while pain intensity decreased over time despite unchanged use of NSAIDs. A considerable increase in symptom intensity was observed in the last weeks of life, except for nausea and vomiting. Visceral pain was more often reported in women. Male patients more often presented somatic pain mechanisms. Neuropathic pain was associated with higher mean VAS intensity and was equally reported in male and female patients and in the different age groups. Very old patients, who received less chemotherapy, required less opioid doses and reported a lower intensity of some symptoms, while reporting similar pain relief. Dry mouth was more frequent in adults than in very old patients. The identification of specific factors and pain characteristics may be useful in suggesting the likelihood of response in terms of analgesia and opioid-related adverse effects. Age and gender analysis should be included in all cancer pain and symptom control studies, as they may have an influence on cancer pain prognosis.

Education of elderly cancer patients and families can improve pain relief

Ferrell BR, Ferrell BA, Ahn C, Tran K. Pain management for elderly patients with cancer at home. Cancer 1994;74: 2139-2146.
BACKGROUND. Pain is an important problem for patients with cancer and is particularly important for elderly patients with cancer and their family care givers. Increasingly, cancer is managed on an outpatient basis with pain management responsibility assumed by the family at home. This study evaluated a structured pain education program that included three components: basic pain management principles and assessment, pharmacologic interventions, and nondrug treatments.
METHODS. The pain education intervention was implemented across three home visits with two points of follow up evaluation. Outcomes of the 66 elderly patients with cancer completing the educational program included measures of quality of life, patient knowledge and attitudes regarding pain, and use of a self-care log to document drug and nondrug interventions and their effectiveness.
RESULTS. Repeated measurement analysis was used to evaluate the outcomes of the three-part education intervention. Results indicate an improvement in knowledge and attitudes regarding pain as well as the use of drug and nondrug interventions. Outcomes of the quality of life instrument suggest significant effect of pain on all aspects of quality of life, including physical well being, psychological well being, social concerns, and spiritual well being. CONCLUSIONS. The investigators concluded that the pain education intervention provided important support to elderly patients with cancer and family members at home. Structured pain education based on an evolving science of pain relief should become part of the standard health care for pain management. Improved pain management includes quality of life for the elderly patient with cancer as well as for family care givers.

Education of elderly cancer patients can help manage pain

Clotfelter CE.The effect of an educational intervention on decreasing pain intensity in elderly people with cancer. Oncol Nurs Forum 1999: 26(1):27-33.
PURPOSE/OBJECTIVES: To determine if an educational intervention related to pain management could decrease pain intensity in elderly people with cancer. DESIGN: Quasi-experimental pretest/post-test design. SETTING: A private oncology practice in urban west central Florida. SAMPLE: 36 subjects who were 65 years of age or older and had a known cancer diagnosis. METHODS: Visual Analog Scale (VAS) completed by each subject. Subjects were randomized to an experimental or a control group. Experimental group members watched a 14-minute video produced by the investigator that presented information contained in the booklet "Managing Cancer Pain." Experimental group members also received a copy of the booklet. Control group members received pain management instructions from the office staff. Two weeks later, subjects completed the VAS at two different times on that day and mailed them to the investigator. FINDINGS: Analysis of covariance revealed a statistically significant difference in pain intensity between the control group and the experimental group. CONCLUSIONS: Pain management in elderly people with cancer has been underrepresented in the literature and minimally studied. This study indicated that an educational intervention aimed at elderly people with cancer was effective and implies that educational interventions should be a central component in prevention and management of cancer pain in the elderly. IMPLICATIONS FOR NURSING PRACTICE: Every effort should be made to educate elderly people with cancer on prevention and management of pain. Nurses must take a leading role in identifying and implementing educational strategies for cancer pain management and side effect control for their elderly patients.

Education of elderly patients does not improve pain experience

Desbiens NA, Wu AW. Pain and suffering in seriously ill hospitalized   patients. J Am Geriatrics Society 2000; 48 (5 Suppl): S183-186.
BACKGROUND: Previous studies had suggested a high prevalence of pain in hospitalized patients but had not specifically evaluated pain and other symptoms in seriously ill and older hospitalized patients. OBJECTIVE: The SUPPORT and HELP studies were designed to (1) assess the frequency and severity of pain and other symptoms during hospitalization 2 and 6 months later, and before death; (2) identify factors associated with pain and other symptoms; and (3) test an intervention to improve pain. DESIGN: An observational cohort and randomized controlled trial. SETTING: Five major teaching hospitals in the US. PATIENTS: Hospitalized patients aged 80 years and older or with one of nine serious illnesses. INTERVENTION: Education of patients and family members about pain control, monitoring of patients' pain, and feedback about pain with treatment suggestions to nurses and physicians. MEASUREMENTS: Data from the medical record and interview-based information about pain and other symptoms and preferences for care and symptom control from patients and family members. RESULTS: Pain and other symptoms were frequent and often severe in seriously ill and older patients during hospitalization, at follow-up, and before death, even in those with diseases not traditionally associated with pain. There was wide variation in symptom experience across hospitals. Patients' preference for pain control was not associated with symptom experience. The intervention did not improve pain control. CONCLUSIONS:Control of pain and other symptoms remains an important medical and ethical issue. Routine monitoring of pain and other symptoms should be linked to treatment strategies aimed at combinations of symptoms and tested to assuage concerns about side effects.