US Pharm. 2009;34(5):21-25.
Around the country, seniors are discharged from ambulatory surgery centers and hospitals into the care of their loved ones. These caregivers take on many tasks, including medicating a postsurgical patient for the relief of pain after procedures such as a hernia repair, gallbladder removal, and joint repair or prosthetic replacement. Others are discharged with a chronic illness that may progress in severity and require close monitoring and appropriate pain management for persistent pain. Caregivers, many of whom are spouses or adult children of patients, are faced with challenges that may be overwhelming; many may be seniors themselves.
Whether a new analgesic medication is dosed on an as-needed or scheduled basis, it must be carefully incorporated into the current medication regimen. Specific administration directions (e.g., timing and separation of doses) and the avoidance of drug interactions may be confusing for caregivers of elderly patients with comorbidities and complex medication regimens. Furthermore, many caregivers have age-related impairments (e.g., vision loss, physical limitations, cognitive decline) or low health literacy, which may complicate performing their role.
Senior patients may have difficulty with effectively communicating their needs for pain relief to a family caregiver on a number of levels, including the dynamics of family roles and interactions, guilt about burdening the family, embarrassment about their inability to tolerate pain, and lack of understanding about their condition. Assessing pain may be especially challenging in seniors with dementia, sensory impairments, and disability.1 For example, there may be a barrier to communication between a caregiver and a nonverbal senior patient and/or one contending with dementia, a hearing impairment, or a developmental disability.
Pain and Physical Functioning
While seniors are more likely to suffer from arthritis and bone and joint disorders causing persistent pain, changes in the patient's condition should not be overlooked.1-3 Caregivers should be made aware that acute pain may indicate a new condition that is distinguishable from an exacerbation of persistent pain and should be evaluated by a physician.1 A careful examination of the site of pain is necessary to evaluate if pain is being referred to other areas; the focus of the examination should be on the musculoskeletal and neurological systems; and attention should be paid to any weakness and dysesthesia.2 When pain becomes persistent, assessing its impact on physical functioning is recommended. If pain reaches the level at which it has a negative effect on physical function or quality of life, it should be clearly identified as a significant problem.4
Persistent pain in seniors is often accompanied by an increase in pain intensity secondary to movement; often, this will result in a limitation of such movements or activities (e.g., walking, climbing stairs) that exacerbate the pain.5 Interestingly, reducing the intensity of the pain by only 25% has been associated with a 50% improvement in functional status.5 When increased motility is achieved through the treatment or reduction of pain intensity, improvement may result not only in physical functioning but also in psychosocial functioning, allowing for an increase in social engagement.1 Pain is associated with depression, distress, and a decline in social activities, so that a key outcome factor, other than reduced pain intensity, is improvement in physical and psychosocial functioning.5 Since factors that exacerbate and relieve pain vary from individual to individual, ongoing assessment of pain intensity is required to deliver quality of care.
Pain-Intensity Scales
According to the American Geriatrics Society, self-reports of pain provide the most accurate and reliable evidence of pain presence and intensity.1 Since there may not be a single optimal pain intensity instrument that is appropriate for all older adults, an individualized approach is recommended.1 In clinical practice, the most commonly assessed aspect of pain is the intensity or severity.5 A 10-point pictorial pain-assessment scale (see Reference 6 online) provides the opportunity to respond by pointing to the words (e.g., no pain; nagging, uncomfortable, troublesome pain; distressing miserable pain, etc.), numbers (i.e., 1 through 10), or pictures (facial expressions), providing a broad spectrum of intensity.6 Pain intensity should be routinely assessed; it has been suggested that seniors in all practice settings, including primary care (e.g., physicians' offices, clinics, and adult day care), would benefit from routine assessment for the presence and severity of persistent pain.5
Assessment in Cognitively Impaired and
Nonverbal Seniors
In nonverbal or cognitively impaired patients, pain assessment is conducted by direct observation or history from caregivers.2
Self-Reporting: Pain intensity can be self-reported by mild to moderately impaired seniors.5 It is hypothesized that, depending upon the extent and location of neuronal disability, cognitively impaired seniors may have an altered ability to interpret and report pain even though there is no evidence supporting a reduction in their ability to feel pain.5 Compared with seniors who are cognitively intact, cognitively impaired patients self-report less pain.5
Reporting by Proxy: There may be inconsistency between a caregiver rating and a patient rating of pain intensity due to family caregiver overestimation as compared with physician and nursing staff underestimation in this population.4,5 Despite some inherent difficulties, caregivers can be instrumental in assessing and managing persistent pain in those who are unable to communicate pain for themselves.5
Direct Observation: While it is important to remember that many elderly patients may demonstrate a lack of behavior when in pain, pain-associated behaviors may nevertheless be used to assess pain in some patients.4 Studies indicate that facial expression of pain is one of the most sensitive and reliable behavioral indicators of pain.7,8 Data support the utility of facial grimacing in the assessment of pain in both cognitively intact and cognitively impaired individuals.8 Based on findings, the specificity of rubbing and guarding as indicators of pain in persons with cognitive impairment has been called into question; rubbing is considered a stereotypical movement in persons with cognitive impairment.8 Although not adequately tested for practical, clinical use, several observational methods have been developed and tested to assess pain in noncommunicative older adults with severe dementia; the literature supports indicators of inadequately treated pain (TABLE 1).5 The presence of these clues may also indicate that a series of changes are occurring, such as constipation, hunger, thirst, depression, and infection; ruling out potential causes is imperative.2,5
Assessing Pain in Severe Dementia: In addition to self-reporting, reporting by proxy, and direct observation, an algorithm may be used as a guide for assessing persistent pain in patients with severe dementia5:
• Assess for pain behaviors during movement.
• If noted, consider 1) premedicating the patient before any movement, 2) strategies to decrease pain, and 3) reassurance while continuing to observe for pain-indicating behaviors.
• If no pain behaviors are noted during movement yet the patient exhibits other behaviors that may be indicative of pain, then assessment for basic comfort measures (e.g., toileting, thirst, hunger) or underlying disorders (e.g., constipation, depression, infection) should be performed.5
• Finally, provide treatment for the identified cause or consider a trial of empiric analgesic therapy. Reduced pain behaviors have been associated with initiated analgesic therapy with acetaminophen 500 to 1,000 mg three times a day.5 Timing of a pain assessment should be at the peak of medication effectiveness; the use of a more potent dose or agent may be necessary to relieve more severe pain and alterations in behavior, since pain cannot be quantified in terms of intensity in patients with severe dementia.5
Role of the Pharmacist
The likelihood that a family member will be facing the scenario of caregiving for a senior relative is ever increasing as the nation's baby boomers begin to reach age 65 in 2011; as the senior population continues to expand, one in five Americans will be age 65 by 2030.9 Since pharmacists have experience in communicating with individuals from a variety of patient populations, each analgesic prescription filled for a senior and every discharge counseling session with a senior patient who is undergoing physical rehabilitation carries with it an opportunity to counsel the patent and/or caregiver about assessing pain so that appropriate treatment may be provided. Patients and caregivers should be counseled about the usefulness of pain scales to assess the level of pain experienced; they should also understand the subjective nature of pain and how the use of pain-assessment tools can assist them with proper dosing to provide comfort and relief. Pharmacists can provide caregiver guidance through education about pain scales, referral for pain management, appropriate dosing and monitoring for adverse effects of analgesic therapy, and avoidance of drug interactions. Pharmacists should embrace the role of patient advocate and provide information about the benefit of a hospice program for palliative care at the end-of-life stage when appropriate.2 Although beyond the scope of this article, the prevention and treatment of constipation should be discussed with patients receiving opioids for pain management. In long-term opioid use, more than 40% of patients develop constipation secondary to delayed gastric emptying time, prolonged stool transit, and decreased peristalsis.10 When opioids are necessary, clinicians often follow guidelines recommending an increase in daily fluid intake and fiber, and the initiation of a stimulant laxative (e.g., senna), a stool softener (e.g., docusate sodium), and/or lactulose or sorbitol.11
Conclusion
It can be difficult for a spouse or adult child to become a caregiver for their family member when the patient is experiencing pain associated with a surgical procedure, acute trauma, or conditions that are chronic or terminal. Pharmacists may help caregivers feel empowered to provide appropriate care by educating them on the use of pain scales and observational clues for the assessment of pain in seniors.
REFERENCES
1. The management of persistent pain in older persons. American Geriatrics Society (AGS) Panel on Persistent Pain in Older Adults. 2002. www.americangeriatrics.org/
2. Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics. 5th ed. New York, NY: McGraw-Hill Inc; 2004:57-70,129-145,266-277,
3. Zagaria ME. Consequences of persistent pain. US Pharm. 2008;33(5):28-30.
4. Ferrell BA, Chodosh J. Pain management. In: Hazzard WR, Blass JP, Halter JB, et al, eds. Principles of Geriatric Medicine and Gerontology. 5th ed. New York, NY: McGraw-Hill Inc; 2003:303-321.
5. McLennon SM. Persistent pain management. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core; 2005 Aug. 58 p. [174 references]. National Guideline Clearing House. Updated April 6, 2009. www.guidelines.gov/summary/
6. Miller KE, Miller MM, Jolley MR. Challenges in pain management at the end of life. Am Fam Physician. October 1, 2001. www.aafp.org/afp/20011001/
7. Hadjistavropoulos T, LaChapelle DL, MacLeod FK, et al. Measuring movement-exacerbated pain in cognitively impaired frail elders. Clin J Pain. 2000;16:54-63.
8. Shega JW, Rudy T, Keefe FJ, et al. Validity of pain behaviors in persons with mild to moderate cognitive impairment. J Am Geriatr Soc. 2008;56(9):1631-1637. www.medscape.com/viewarticle/
9. Retooling for an aging America: building the health care workforce. Institute of Medicine. www.iom.edu/CMS/3809/40113/
10. Pain Management in the Long-Term Care Setting. American Medical Directors Association. Columbia, MD: AMDA; 2003.
11. Lobson NL. Providing Medication Therapy Interventions for Patients with Chronic Constipation. Alexandria, VA: American Society of Consultant Pharmacists; 2009. Clinical Consult.
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