Clinical Practice Guidelines Address Problem of Chronic Pain in Older People Recommendations Focus on Improved Assessment and Aggressive Treatment;

UR Medical Students Examine Local Use and Need for Guidelines

May 17, 1999

Chronic pain, a critical issue to the aging population, is often under-recognized and under-treated, according to the American Geriatrics Society (AGS).

"Pain is the most common symptom of disease and the most common complaint in physicians' offices among older patients-the fastest growing segment of the population, and the most likely to suffer from chronic, painful conditions that are often under-treated," said Paul Katz, M.D., associate professor of medicine at the University of Rochester School of Medicine and Dentistry. By 2011, the number of Americans 65 and older will have doubled and the number of adults over 50 is expected to increase by 30 percent. "As the population matures, there is a growing need for medical information about pain management that is specific to older people," Katz says.

Katz served on the AGS Panel on Chronic Pain in Older Persons that developed the first clinical practice guidelines that focus specifically on pain management in older Americans. "The AGS Guidelines on Chronic Pain go a long way in informing both health care professionals and consumers about the importance of recognizing and controlling pain and its impact on quality of life," Katz says.

Katz, along with visiting professor Jurgis Karuza, Ph.D., is leading a work group of first-year medical students at the University of Rochester to examine these guidelines and the topic of chronic pain management on a local level as part of a course in community medicine. Their course work includes conducting an informal survey of area health care providers and HMOs to determine area use of the AGA's guidelines.

"There appears to be a lack of a systematic, consistent approach to addressing chronic pain in the elderly," says Christopher Good, a medical student in the class. "One of the main goals of the guidelines is to educate people on how to recognize and assess their pain and to utilize the many treatments available to manage it. We'd like to increase awareness and use of these guidelines among local health care providers and those with chronic pain."

About Pain Management Guidelines

The AGS guidelines were developed in recognition of several factors that are specific to pain management in the older population. As people age, they are more likely to suffer from conditions that are not readily resolved and are accompanied by mild, moderate or severe pain. These include arthritis, bone and joint disorders and back problems. Older people are also likely to have multiple medical problems requiring different drug regimens that may interact with pain medications.

"Another major barrier for effectively treating pain in older people is their cognitive capability, and their caregiver's attitude towards pain in general," says Rajbala Thakur, M.D., an anesthesiologist specializing in chronic pain at Strong's Pain Treatment Center. "The concept that 'aches and pains come naturally with aging' is common. So, education and involvement of caregivers-be it family members or nursing staff-in evaluation and treatment planning is extremely important to effective pain management for the elderly."

The guidelines suggest the use of several pain-measuring scales. One such pain intensity scale for use with older patients depicts facial expressions that one might make when experiencing varying degrees of pain. Others examples are scales from 1-10, and "no pain" to "worst possible pain" with degrees of pain in between. Documenting pain control over time and monitoring side effects or the use of other treatments are recommended in the guidelines.

Combining Drug and Non-Drug Therapies for Pain

The AGS clinical practice guidelines recommend non-drug pain management strategies including patient and caregiver education, cognitive-behavioral therapy and exercise programs. However, the guidelines note that these often work best when used in combination with appropriate drug regimens.

Analgesics, or painkillers, are the most common way to manage pain. The guidelines emphasize that analgesics should supplement other medications used to treat the underlying disease. The AGS guidelines recommend using acetaminophen, such as Tylenol, under the direction of a health care provider as a first step for mild to moderate musculoskeletal pain-the most common chronic pain conditions in older Americans.

The guidelines advise caution when using nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, for treating intermittent chronic pain. They may have greater side-effects in older adults.

The AGS guidelines also urge regulatory agencies to change policies to improve access to narcotic, opioid analgesic drugs for older patients in pain, and recommend that health systems caring for older people to allow for more aggressive treatment of chronic pain.

Depression, decreased socialization, sleep disturbance, impaired movement, and increased health care utilization and costs have all been associated with the presence of pain in older people.

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