Chronic Pain in Cognitively Impaired Elderly: Challenges in Assessment, Diagnosis, and Treatment
Siciliano, Paula, Forum on Public Policy: A Journal of the Oxford Round Table
One of the greatest challenges facing health care today is the provision of proper pain management in elderly patients suffering from both acute and chronic pain. The task of caring for suffering individuals is magnified when those patients are inflicted with cognitive impairments. Approximately 4 1/2 million Americans suffer from Alzheimer's disease and it is estimated that around 14 million will have the disease by the year 2050 if a cure is not found. With the possible exception of depression, the mental disorder constituting the greatest health problem in the older age group is organic brain syndrome of varying etiology and severity. Elders with dementing illness receive fewer pain medications and interventions aimed at relieving discomfort than those elders without brain syndromes. The purpose of this paper is to provide information regarding the enormity of the problem, discuss assessment tools available for use when identifying the pain in this group, list usual and unusual manifestations of pain in patients with dementia, identify the most common differential diagnosis causing pain symptoms and suggest treatment methodologies for treating pain in this special population.
One of the greatest challenges facing healthcare today is the provision of proper pain management in elderly patients suffering from acute and/or chronic pain. This vital component of medical care becomes even more difficult when those elders are also dealing with cognitive impairments in addition to their pain. It is important that professional and lay caregivers learn as much as they can about assessment and treatment of pain and examine their own feelings and prejudices towards pain management. Pain is not normal and pain management needs to be a priority in the care of this vulnerable population.
The American Geriatric Society (AGS) Panel on Chronic Pain in Older Persons gathered statistics from examining multiple studies and summarized the data in an article originally published in 1990, again in 1998, and in 2002. The findings of their work highlight the following information: 25-50% of community-based elders have pain, up to 85% of residents in long-term care report pain, and from 45-80% of that pain is under treated. Seventy-five percent of hospitalized medical patients say pain was excruciating. When PRN (as needed) opioid medications are ordered for postoperative patients, more than half of them have unrelieved pain due to under treatment. One in five older Americans are taking analgesic medications regularly (several times a week or more), and 63 percent of those had taken prescription pain medication for more than six months. Older persons are more likely to suffer from arthritis, bone and joint disorders, back problems, and many other painful chronic conditions. (1)
It is interesting to note, that only 1% of the 4,000 articles on pain published annually and listed in the National Library of Medicine database Medline, are related to pain management in older persons. (6) Despite the prevalence of pain among older adults, pain is inadequately recognized, therefore under treated, especially in those with severe cognitive impairment. Studies demonstrate that older adults with cognitive impairment receive less pain medication than their counterparts who are able to communicate. (2) Horgan and Tsai3 examined a sample of 339 (295 women and 44 men) nursing home residents with a mean age of 87 years old (range 66-104). Forty-six percent of the sample had diagnosed cognitive impairment, and 55% had at least one painful condition. The results indicated that cognitively impaired nursing home residents are prescribed and administered significantly less analgesic medication, both in number and in dosage of pain drugs than their more cognitively intact peers. After analysis, it was found that the more disoriented and withdrawn the resident, the less analgesics prescribed by physicians and the less analgesia administered by nursing staff. …