PATIENT COMPLIANCE - PharmXpert Academy

TherapeuticPractical Pain Management in Older PeopleIntroductionPain relief, whether acute, chronic or related to surgery, isan issue throughout the world. However, as a result of achanging population demographic in countries like the UK,the proportion of older patients is increasing, which posesunique challenges when considering analgesia. We have apotential aging ‘time bomb’ and we need to prepare ourservices to meet the needs of this older age group ensuringtheir dignity and their well-being not compromised. Hence,five years ago the British Pain Society worked with theBritish Geriatrics Society & the Royal College of Physicians,reviewed the evidence and produced national guidance tohelp all practitioners in assessing pain in older people with asimple algorithm in October 2007 (Ref. 1 & Appendix 1). Thepurpose was to provide professionals with a set of practicalskills to assess pain as the first step towards its effectivemanagement.To put the effects of pain in the elderly in perspective,national UK statistics have indicated that pain or discomfortwas reported by about half of those over 65 years old, and56% of men and 65% of women aged 75 years and over.Higher prevalence estimates are obtained from samples ofinstitutionalised older people, where 45–83% of patientsreport at least one current pain problem.Pain AssessmentCompared to young adults some of the challenges arecognitive impairment, communication, language and culturalbarriers. Box 1 in that report lists the key components like:direct enquiry, observations of signs, description (sensory,affective & its impact), measurement & cause of pain. Theirtable 1 & 2 describe the observational changes associatedwith pain & various scales for assessing pain.Assessment of pain may be carried out by normal methodsand conventional numerical or graphical methods work well.However, impairment of higher intellectual functions maymean that observational techniques may also be needed.Key components of an assessment of pain include directenquiry about the presence of pain and observation forsigns of pain, especially in older people with cognitive /communication impairment. Description of pain shouldinclude the sensory dimension, the affective dimension(e.g. fear, anxiety or depression) and impact on the patient.Measurement of pain should ideally use standardised scalesin a format that is accessible to the individual. Of course theaim of history, examination and investigation is to establishthe cause of pain, in order to effect treatment (Box 1).Observational changes associated with pain can also bemore marked (or subtle) in the elderly, including autonomicchanges, facial expressions and body movements. Aggressiveverbalisations / vocalisations and altered interpersonalinteractions can sometime be the presenting complaint ofthose with pain, especially if there is preceding cognitiveimpairment. Changes in activity patterns and mental statuschanges can sometimes also occur (Table 1).Our experience at NELTCWe at NELTC have standardised the process along theentire surgical care pathway (from pre-assessment, throughadmission on the wards, theatre & recovery to dischargehome and follow up) with a Coloured Visual Analogue Scale(Appendix 2). Pain maps are sometimes used to get moredetails on localisation as in some patients with chronic pain(Appendix 3). Our numeric rating scale from 0 to 10 is used40 Journal For Patient Compliance Strategies to enhance Adherence and Health OutcomesVolume 2 - Issue 4