Pain and the Elderly

The elderly are among those most affected by pain due to a plethora of chronic conditions, end of life issues, and lack of personal resources and yet are often helpless to improve their situation. It is estimated that 40% of elderly cancer patients in nursing homes are in pain.¹ Sources of pain in the elderly may be complex and diagnosis is hampered by potential incapacitation. The elderly person who has cancer may also have other causes of pain. Arthritis, cancer, post herpetic neuralgia, osteoporosis, diabetic neuropathy, peripheral vascular disease, vertebral canal stenosis, crush fractures and post stroke syndrome are but a few of the debilitating conditions possible.

Pain in the elderly is often chronic non-malignant pain and is disproportionately under-treated for a variety of reasons. In a survey conducted by Partners Against Pain conducted in 2002,² about 33% in a sample of 1000 patients had debilitating pain, and often so bad they wanted to die. Many misconceptions abound. Some elderly believe pain is part of aging and they must live with it; health care professionals often believe less pain medication is indicated in treating an elder’s pain. ³ They may fear causing addiction with opiates. Some physicians fear regulatory boards and admonition for writing too many prescriptions for controlled substances. While this is a possibility, adherence to the Model Guidelines makes the admonition highly unlikely.

Standard of Care vs Elder Abuse

A recent California law suit addressed under-treatment of pain by a physician and convicted the physician for elder abuse because of his paucity of pain prescribing and lack of continuing education in current pain prescribing practices.⁴ In Bergman v. Chin Alameda Co. Superior Court, California, June 13, 2001, the physician was convicted of elder abuse for failure to prescribe adequate pain medication.⁵ The jury found, by clear and convincing evidence, that the doctor’s conduct constituted abuse of an elder, and further, that such conduct was reckless.

The patient, in severe pain, was brought by his daughter to the hospital on February 16, 1998. He was diagnosed with multiple compression fractures and possible lung cancer. During his 5 day hospital stay, he continued in severe pain, registering 7-10 on a pain scale of 0-10 but was prescribed only as needed Demerol. The patient requested to go home and was prescribed Vicodan, despite difficulty with swallowing. Two days after the patient went home, the hospice nurse found that his pain was out of control and, since the original doctor was unavailable, contacted another doctor. Liquid morphine and duragesic patches were prescribed and thereby, finally, alleviated the patient’s pain the day before he died.

Plaintiff’s experts testified that if treated according to modern standards, the patient should have received around the clock pain medication with extra for break through episodes. Their opinion was that the doctor’s care was appalling and egregious despite the defense experts’ testimony that the doctor’s action was within the standard of care and exercised acceptable judgment on his part. Kathryn Tucker, the director of legal affairs for the Compassion in Dying Federation, stated that “Until recently it would have been difficult to establish that the care provided fell below the standard of care. However, the past decade has brought clinical practice guidelines on pain management from such groups as the World Health Organization, the American Medical Association, the Agency for Health Care Policy and Research and the Joint Commission of Accreditation of Health Care Organizations.”

Special Concerns of the Elderly

End of life issues plague the elderly. Most fear the pain of dying more than dying itself. Hospice care is effective in managing pain at the end of life, but the physician must certify that life expectancy is six months or less in order for Medicare to cover the cost. Not all terminally ill people know of, or seek, hospice care. Further, as occurrences of Alzheimer’s disease and other forms of dementia increase in aging patient populations, many elderly patients have pain but can’t effectively communicate that pain. Astute observation for variations from the usual behavioral pattern may produce indications that the person with dementia is in pain. Restlessness is often a sign. Treatment for pain should be given in adequate doses to promote maximum comfort.

Another concern of the elderly is financial; lack of money is often a barrier to receiving adequate pain management. Many do not have prescription coverage since Medicare parts A and B do not provide prescription coverage. Medigap policies are expensive and may not pay for the pain medicine that is ordered. A survey of drug prices is presented in Table 1 and illustrates that prices are typically beyond the limited means of the elderly.

Early Intervention

Scientific evidence has shown that early intervention and treatment of pain is effective in returning people to a functional way of living. More importantly, early pain treatment may effectively relieve pain that may otherwise become chronic. Physicians must treat pain as an urgent condition. If the patient does not respond, a referral to a Pain Specialist is indicated. The American Academy of Pain Medicine warns that effective pain evaluation and control must occur within a few weeks or months of onset “in order to prevent progressive pain, associated morbidity and increased costs."⁶

A multidisciplinary treatment plan can be prepared and implemented. With chronic conditions and under-treated pain, an elder’s quality of life may deteriorate, complaints may proliferate and the person may become irritable and unpleasant to be around. Social isolation can result and become progressive and thereby compound the problem.

Modern Standard of Care

The Joint Commission of Accreditation of Hospitals Organization (JCAHO) published new standards for pain control in December 2000.⁷ JCAHO is a private national accreditation agency that has deemed status by the Federal Government to conduct accreditation surveys on behalf of Medicare. JCAHO surveys and accredits some 19,000 hospitals, health care plans and networks, out patient service centers, home care organizations, nursing homes and long term care facilities assisted living residences and behavioral and mental health care organizations.⁸

JCAHO now requires that every health care facility must periodically assess and treat pain. In hospitals it is a requirement to be done when vital signs are taken.⁹ As a result, the pain assessment is now referred to as the “fifth vital sign." A tenet of JCAHO is that all patients have a right to pain relief.

Pain Evaluation

A thorough history and physical may reveal some of the causes of pain, and treating the cause may improve comfort and function, but the cause is not always treatable. “Obtaining a proper history, including the onset, duration, characteristics and intensity…is the first step in determining appropriate treatment."¹⁰ The quality of pain may give clues as to the origin (see Table 2).

Assessment and Measurement Tools

Assessment tools exist that allow the patient to rate pain. Some use a numerical scale ranging from 0 to 10, where 0 indicates no pain and 10 indicates the worst pain ever experienced. Others use a facial expression scale to rate pain.¹¹ In the former, the patient is asked, “On a scale of zero to ten, zero being no pain and ten being the worst pain imaginable, how do you rate your pain now?” Alternately, one may utilize the Wong Facial Scale to determine the relative level of pain. Each face on the Wong Facial scale represents a different amount of pain, from no pain (smiling) to excruciating, worst pain imaginable (crying), although crying is not a prerequisite in order to rate the pain a 10. Comparison of rating results over time—both during and after treatment—provides a record for the practitioner to compare intensity and assess relief from the pain medicine or therapy. Assessment before and after intervention should be a continuing process. Another numeric pain scale in common usage is the McGill Pain Intensity Subscale questionnaire in which a scale of zero to 5 is used where zero is no pain and 5 is excruciating pain.

Finally, a useful technique that a patient might use to chronicle pain levels while at home is a diary which can then be presented to the practitioner at the next visit. In it, the initial pain level, the intervention and the subsequent result should be recorded to help the both patient and practitioner develop the acceptable level of pain control with the fewest side effects. The diary may be in terms of function (i.e. ‘able to walk today’ or ‘prepare a meal,’ etc.) before and after an intervention and how long the relief lasted. It’s a good practice for the practitioner to ask what makes the pain better or worse since the answer may reveal practices—good or bad—instituted by the patient.

Pain Assessment of the Cognitively Impaired

For those who are cognitively impaired, behavioral manifestations, facial expressions, functional decline, anxiety and physiological signs need to be assessed and compared with the usual behaviors.

The caregiver should be alert for:

• changes in sleep and/or eating

• habits

• vocalizations/verbalizations

• lowered frustration thresholds

• withdrawal from usual activities

• and/or people

• rubbing a knee or other body part

• as though it hurts

• crying

• pacing

• facial expressions

• signs of depression

• aggressiveness

• resisting care.

Long-term Care and Pain Monitoring

Brandywine Nursing Home in Briarcliff Manor, NY was featured by JCAHO as the model in long term care pain management.¹² Brandywine incorporated pain assessment into an instrument that is a mandatory reporting tool in long-term care settings. The instrument is known as minimum data set (MDS). MDS must be done at a minimum of every three months, but is also done on admission, re-admission and with changes in health status as well as with residents’ report of new pain. After giving the resident pain medication or a treatment, the staff member inquires at specified intervals to assure that the intervention was effective and if not, move to other options for pain relief. This example of nursing home pain management indicates that pain management can be accomplished with a systematic approach.

Non-pharmalogic Modalities

Depending on the physical condition of the elderly patient, non-analgesic alternatives to pain relief may be appropriate. Such modalities may include exercise, heat, cold, acupuncture, massage therapy, and music, among others. Support groups in the elderly community help to alleviate isolation and depression.

Pharmacologic Modalities

In a study of 117 people over age 80 who suffered with the pain of cancer, oral morphine—often with adjuvants—was found to be efficacious in relieving pain.¹³ Adjuvants are drugs added to enhance the effect of the pain reliever medication. Through research it has been found that certain types of drugs work best for particular pain syndromes. A multidisciplinary approach is highly desirable when treating pain.

Commonly prescribed drugs are used to treat pain in the elderly include Ibuprofen, Diclophenac, Tiaprophenic acid, Tramadol, Indomethacin.¹⁴ About a third of those treated with these medications experience improved quality of life. However, for moderate pain, especially for cancer pain, opioids are used. NSAIDs are often added to help metatastic bone pain. Anticonvulsants and tryciclics may be effective for neuropathic pain. Tramadol (Ultram) may also be beneficial in a variety of pain conditions. It should be used with caution in those with seizure disorders.¹⁰ For severe pain, or persistent non cancer pain, opioids with sustained release are generally effective, although tolerance may be a consequence. Procedures must be instituted against abuse potential including contractual documents of agreement as to use and monitoring. At end of life, morphine, dilaudid and fentanyl are often used individually, and in combination, for intractable pain.

After giving the resident pain medication or a treatment, the staff member inquires at specified intervals to assure that the intervention was effective and if not, move to other options for pain relief.

End-of-Life Care

Physicians need to dialogue with their elderly patients to learn what their values are relative to what they consider a good death. This helps the physician to prescribe in a way the elder wishes when the end is near. The designated health care proxy should be privy to the desires of the elder in regard to life prolonging treatment as well as comfort measures. The proxy should discuss pain management with both the elder and the physician. If the physician is not trained in pain management, consultation or referral to a pain management specialist to provide consultation for end of life treatment may be desirable. “Respect for autonomous decision-making is a fundamental ethical principle that should be adhered to whenever possible.”¹⁵

The New York Physicians Society as well as the American Academy of Pain Management agree that the proper pain treatment to ameliorate a dying person’s agony might have the double effect of hastening that person’s death.¹⁶ The principle of double effect has its roots in Christian ethics. Essentially, although more complicated than stated here, treatment at end of life is done with the intent of relieving pain but it may have the additional effect of hastening death. “Aggressive palliative care has been justified by the “double effect” principle. According to this concept, consequences that would be wrong if caused intentionally become acceptable, even when foreseen, if the actions creating those consequences were intended for a morally permissible purpose.” Care MUST be used to differentiate this approach from physician assisted suicide. For a discussion, refer to Rob McStay’s “Terminal Sedation: Palliative Care for Intractable Pain, Post Glucksber and Quill.”¹⁷

Health Care Proxy and Living Will

Health care proxy instruments delegate decision making for health care for end of life issues and care of the incapacitated. An aging population, facing the inevitable end of life, fears the pain of dying more than dying itself. A person designated as a health care proxy needs to be aware of the alternatives to treat pain and of the pain management specialty practice. What then, is the impact on the person who is the health care proxy for an incapacitated terminally ill person? Compliance with wishes for pain relief should be honored. A patient generally should die naturally and comfortably in the absence of evidence he would want otherwise.¹⁸

Massachusetts and New York are the only two states that do not recognize the living will.¹⁹ The living will directs what treatment an individual would want if he became incompetent by virtue of illness. In Massachusetts, the health care proxy makes the surrogate decisions for the incapacitated person. “Failure of a medical practitioner to respect a patient’s advance directive is medical battery—a justification for a claim for monetary damages. As a medical battery, the practitioner’s intentional act must have directly or indirectly caused the harm or offensive contact.” Damage has to result from the offensive contact. In Franklin v. US 992 F.2d 1492 (10th Circ. 1993), it was held that a person who is treated without informed consent i.e. the treatment was imposed against the patient’s wishes, is the victim of an intentional tort.

Summary and Recommendations

The physician’s role entails the relief of suffering, in particular to alleviate the fears of the terminally ill that they will be unable to receive adequate pain relief for their suffering.²⁰ The first priority should be relief of pain.

Nurses, in particular, are in a unique position to relieve pain and promote comfort. It’s usually the nurse who asks the JCAHO questions about pain as the fifth vital sign. It is often the nurse who assesses the non-verbal behaviors of the elderly to determine if pain relief is needed. Both nurses and physicians must be familiar with the patient’s bill of rights. “Freedom from pain is a basic human right” postulates Gloria Ramsey, JD, RN, Director of Legal and Ethical Aspects Practice at New York University. “Nurses should not hesitate to administer an effective dose for pain relief. In fact, the proper dose is the dose that is sufficient to relieve pain and suffering.”²¹

Pain relief for elders requires a multidimensional approach. Funding to treat pain may be available when the person is hospitalized or reaches the end of life and is eligible for hospice care, but what of the elder whose life has become isolated and full of suffering? The Department of Justice deals with issues of elder abuse and its prevention, but is it not elder abuse to allow suffering when relief is available? In proactive prevention of elder abuse, health professionals need to consider how best to obtain the resources (monetary and otherwise) to provide the best pain relief that is scientifically available to the elderly.

Elderly patients deserve—and are legally entitled—to be as free from pain as possible so that they can return to a productive and rewarding life or, if terminally ill, die a peaceful death.