US Pharm 2011;36(1):21-25
Clinicians have an ethical and moral obligation to prevent unnecessary suffering and provide effective pain relief. But who actually determines which medication or modality is most effective with respect to pain relief? And what level of pain relief is used to evaluate the outcome of therapy? Further, what level of cognitive impairment, secondary to analgesic therapy, is acceptable in exchange for pain relief when potent agents at high doses are necessary to deliver that pain relief?
These questions may be best addressed by further questioning whether traditional care, in which the patient tends to take a passive role, is acceptable, or whether a collaborative care approach would be more appropriate and acceptable to today's seniors. Collaborative patient care--in which a partnership is established between clinicians and the patient--enables the health care professional to facilitate and guide therapeutic care rather than dictate treatment. This column will describe some of the pain management issues confronting seniors and present the philosophy underlying the concept of collaborative care for pharmacists to consider when serving older adults with pain.
Defining Pain
Through the centuries, the definition of pain has evolved significantly. The word is derived from Latin (peone) and Greek (poine), meaning “penalty” or “punishment.”1,2 One concept, classifying pain as a passion of the soul, where the heart served as the processing center of pain, was developed by Aristotle and predominated for 2,000 years.1,2 It wasn't until the 19th century that the concepts of neuroreceptors, nociceptors, and sensory input were hypothesized.1,2
Today, pain is defined as a feeling of distress, suffering, or agony caused by stimulation of specialized nerve endings.3 It is considered a state of physical (sensory), emotional, or mental lack of well-being or uneasiness associated with actual or potential tissue damage.2,4,5 Pain has also been referred to as a lack of equilibrium in the physical or mental functions (as through disease).4 Pain may range from mild discomfort or dull distress to acute, often unbearable agony; it may be generalized or localized.4 Many clinicians regard pain as defined by the patient. The U.S. Congress has addressed the issue of pain, based on the huge amount of attention it has received, by passing a law designating the period 2001-2011 as “The Decade of Pain Control and Research” (www.ampainsoc.org/
Pain in Seniors
Pain Perception: Age-related changes in the nervous system (i.e., changes in pain receptors, peripheral nerves, and the central nervous system) may alter pain perception.6 Certain conditions may mask pain complaints, including concurrent illnesses, cognitive impairment, sensory neuropathies, and visual and hearing impairment, making communication of pain complaints more difficult.6 Further, cognitive and behavioral functions can modify a patient's perception of pain (Table 1).6
Complex medication regimens, rife with drug interactions and the potential for serious adverse effects (e.g., cognitive impairment), are often encountered by older adults who are more likely to be in poorer health than the general population and to use more medications.7 These issues are some of the reasons a different approach to pain management is required in seniors than in younger individuals (Table 2).
Persistent Pain: Elderly patients are more likely to suffer from arthritis or bone and joint disorders that cause persistent pain.8-10 In particular, chronic or persistent pain is associated with significant environmental or family issues (e.g., impaired family life, interpersonal relationships, and social productivity) and is commonly associated with insomnia, depression, and psychological factors related to coping skills, quality of life, and disability.1,11 Rather than curing, the treatment goal in patients with persistent pain is restoring or maintaining the ability to function.12
The management of persistent pain often requires a multimodal approach including pharmacologic strategies and nonpharmacologic measures, such as meditation, and usually demands frequent monitoring and dosage adjustments.6,13 With a better understanding of the issues and nuances surrounding older adults with persistent pain, pharmacists may more readily support a comprehensive approach to therapy when developing pharmaceutical care plans, providing recommendations to professionals, and guiding patients with regard to chronic-disease self-management programs (see Resources).
With regard to persistent pain, knowledge, skills, and strategies are of particular importance when serving patients near the end of life, so that needless suffering is avoided. In an era when technology has been developed to provide sophisticated pain formulations, delivery systems, and tailored administration regimens, there should, theoretically, be no reason for a patient to suffer. Even if and when economic restraints do not allow for the availability of advanced devices or cost-prohibitive formulations, pharmacists should be available to develop a pharmaceutical care plan that utilizes cost-effective measures (e.g., pharmaceuticals, nonpharmacologic approaches) as part of the overall interdisciplinary care plan to provide appropriate and optimum pain relief for their patients. For a discussion on patient control in end-of-life decision making, the living will, and durable power of attorney, see Reference 14.
Pain Assessment: According to Baumann and Strickland, one of the key concepts of pain management is the importance of asking patients with pain, whenever possible, to identify the source of pain and to assess the characteristics of their pain.2 Important aspects of the physical examination in the assessment of pain include: 1) examination of the site of pain and common sites of pain referral; 2) focus on the musculoskeletal and neurological systems, such as for weakness and dysesthesia; 3) an observation of physical function; and 4) assessment of psychological and cognitive function.9 When a patient with severe dementia exhibits unusual behavior, a pain assessment is warranted to determine if pain is a potential cause of the behavior.9 Pain assessment in nonverbal and cognitively impaired individuals is carried out by direct observation or by history from caregivers.9 Cognitively impaired seniors and those with severe dementia should be observed for pain-related behaviors (Table 3). For more on assessing persistent pain and pain in patients with severe dementia, refer to Reference 10 and Resources.
Collaborative Care
Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective, according to Boult and Weiland, advocates of a comprehensive primary care approach.15 Further, according to Rejeski et al, the recognition that patients should be treated as active agents in their health care is a significant development in medicine.16 The authors note that in collaborative patient care, the relationship between the patient and the health professional is one of shared expertise with active patients. That is to say, the role of the professional is one of expert about disease and medication, while the role of the patient is one of expert about his or her own life.16 The principal caregivers are the patient and the professional, sharing responsibility for both problem solving and outcomes.16 According to this model, patients and professionals share the responsibility for the development of therapeutic care plans. While the professional helps the patient make informed choices, it is the patient who sets goals; the problem of goal non-achievement is addressed by the modification of strategies.16
Rejeski et al indicate that problems are identified and defined by the patient--e.g. pain or the inability to function--and by the professional, with internal motivation on the part of the patient serving as the mechanism by which patients gain understanding and confidence to acquire new behaviors. While patients are responsible for actual problem solving, it is the professional who teaches the patient problem-solving skills; therefore, medication nonadherence is considered a shared problem that needs to be solved, rather than a dysfunctional patient problem, as it would be viewed in a traditional patient care model.16
Educational materials for use by both consumers and health professionals, together with patient education programs--such as workshops covering appropriate use of medications--are available for specific chronic diseases. Current literature regarding disease self-management programs (e.g., for arthritis; see Resources) emphasizes the importance of establishing collaborative partnerships between health care professionals and patients.15
Conclusion
Pain is a common complaint among older adults. While pain management information and guidelines are readily available, pharmacists and pharmacy students are encouraged to develop an understanding of the nuances of an older patient in pain. When serving seniors with persistent pain, the provision of a comprehensive, multimodal collaborative approach to patient care offers an opportunity for health care professionals to strive for optimum care.
REFERENCES
1. Stimmel B. Pain, Analgesia, and Addiction: The Pharmacology of Pain. New York, NY: Raven Press, 1983:1,2,63,241-245,259,266.
2. Baumann TJ, Strickland J. Pain management. In DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York, NY: McGraw-Hill, Inc; 2008:989-1003.
3. Dorland's Pocket Medical Dictionary. 28th ed. Elsevier Saunders; 2009.
4. Definition of pain. Merriam-Webster.com. www.merriam-webster.com/
5. Turk DC, Okifuji A. Pain terms and taxonomies of pain. In: Loeser JD, Butler SH, Chapman CR, et al, eds. Bonica's Management of Pain. Philadelphia, PA: Lippincott Williams & Wilkins; 2000:17-25.
6. Ferrell BA, Charette SL. Pain management. In: Halter JB, Ouslander JG, Tinetti ME, et al, eds. Hazzard's Geriatric Medicine and Gerontology. 6th ed. New York, NY: McGraw-Hill, Inc; 2009:359-371.
7. Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medication use in the community-dwelling elderly. JAMA. 2001; 286:2823-2829.
8. AGS clinical practice guideline: pharmacological management of persistent pain in older persons (2009). Executive summary. www.americangeriatrics.org/
persistent_pain_executive_
9. Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics. 5th ed. New York, NY: McGraw-Hill, Inc; 2004:57-58.
10. Zagaria ME. Assessing pain in the cognitively impaired. US Pharm. 2009;34(5):21-25.
11. Jacobson L, Mariano AJ. General considerations of chronic pain. In: Loeser JD, Butler SH, Chapman CR, et al, eds. Bonica's Management of Pain. Philadelphia, PA: Lippincott Williams & Wilkins; 2000:241-254.
12. Turk DC, Okifuji A. Psychological factors in chronic pain: evolution and revolution. J Consult Clin Psychol. 2002;70(3):678-690.
13. Brown CA, Jones AK. Meditation experience predicts less negative appraisal of pain: electrophysiological evidence for the involvement of anticipatory neural responses. Pain. 2010;150(3):428-438.
14. Zagaria ME. The dying patient: choices, control, and communication--end-of-life care. US Pharm. 2009;34(10):32-34.
15. Boult C, Weiland GD. Comprehensive primary care for older patients with multiple chronic conditions: “Nobody rushes you through.” JAMA. 2010;304(17):1936-1943.
16. Rejeski WJ, Brawley LR, Jung ME. Self-management of health behavior in geriatric medicine. In: Halter JB, Ouslander JG, Tinetti ME, et al, eds. Hazzard's Geriatric Medicine and Gerontology. 6th ed. New York, NY: McGraw-Hill, Inc; 2009:325-341.
To comment on this article, contact rdavidson@uspharmacist.com.
