Is Dad in pain?

pain assessment in the elderlyThe prevalence of pain is twice as high in the elderly population as it is in individuals less than 60 years old. Some studies show that 25% to 50% of older persons living in the community suffer from pain problems, whereas as much as 85% of nursing home residents suffer from pain. Pain is a serious problem in this population and may lead to multiple complications.

When older persons experience a traumatic event or go through a serious illness, their pain and suffering is often compounded by recent losses of either a spouse or close friends and relatives or loss of their home and independence. The older person’s traditional support system and coping abilities are stripped away. Events or illnesses that lead to pain and suffering may be devastating blows to the individual. Elderly individuals are also at particular risk for abuse and neglect leading to prolonged suffering.

Causes of Chronic Pain in the Elderly

Most chronic pain complaints from the elderly are related to arthritis and musculoskeletal problems such as degenerative arthritis and low back pain. Cancer is also a source of significant pain in the elderly population. Headaches and leg cramps are not uncommon in the elderly but are caused by a variety of ailments. Peripheral vascular disease is a term indicating diseases of the arteries and veins of the extremities. Symptoms may include pain with walking. Problems causing pain with walking, such as arthritis, must be differentiated from arterial insufficiency with associated intermittent pain upon walking and swelling of the lower legs.

Pain Assessment and the Undertreatment of Pain in the Elderly

It may be difficult for healthcare providers to determine if an elderly person is pain (and for the attorney or expert witness to determine this from the medical record.) This difficulty contributes to undertreatment of pain and results in suffering. The American Medical Directors Association lists the following barriers to the recognition of chronic pain in nursing homes. These same barriers apply to the hospitalized elderly.

1. Blunted response – Older people might not exhibit the same signs and symptoms of a younger person. An older person may be less verbal and demonstrative about pain or abuse. When injured or abused, an older person may not report it to anyone. When asked about an injury or abuse, the older person may attempt to diminish the real suffering he or she is experiencing.

2. Cognitive and communication barriers – Older people may not be able to verbally communicate that they are in pain. Nurses may fail to recognize the behaviors that suggest the presence of pain and suffering.

3. Cultural and social barriers – The cultural and social background of the older person, family and caregiver greatly affect communication about pain and the treatment. Racial, ethnic, and gender biases of residents and caregivers may hinder patients from reporting pain and may reduce caregivers’ sensitivity to the signs and symptoms of pain and suffering. For example, males tend to attempt to be more stoic and may be less vocal about their suffering. The British also tend to be more stoic.

4. Co-existing illnesses and multiple medication use – Illnesses such as depression, and multiple medication use can reduce the older person’s ability to interpret or report pain. Multiple medication use may also alter the older person’s response to pain, which, in turn, may decrease the caregiver’s ability to recognize that the older person is in pain or is suffering.

5. Staff training and access to appropriate tools – Caregivers may not have the training and skills to assess pain or use valid tools available to assess for pain.

6. System barriers – Adequate pain assessment and management of pain in nursing homes and hospitals requires a team approach of physicians, nurses, physical therapists, pharmacists and nurse aides. High turnover of direct caregivers, poorly functioning groups or teams of caregivers and insufficient commitment to pain management by leadership in health care facilities may result in a failure to recognize, assess and treat pain sufficiently.

The elderly are at particular risk for undertreatment of pain, particularly those in nursing homes. Two reasons for undertreatment of pain in the elderly are patient beliefs and communication problems. If the elderly and their caregivers believe that pain is a natural part of the aging process then the pain is unlikely to be treated. If an older person has communication problems, due to a stoke or cognitive deficits, it is more difficult for the caregiver to assess the person’s pain and degree of suffering.

There are many misconceptions in our society that may contribute to inadequate assessment and treatment of pain in the elderly. One common misconception is that pain is a natural outcome of growing old. The fact is that pain is not normal in the elderly. Another misconception is that an older person does not feel pain as much as a younger person due to a decreased sensitivity or perception of pain. However, there is no scientific basis for this belief. Many in our society also believe that if the elderly patient does not complain of pain, he or she does not have pain. However, most elderly patients do not complain of pain because of not wanting to worry loved ones, not wanting to bother or anger caregivers and fear of losing their independence. It is wrong to assume that if the elderly patient is busy with activities then he or she is not in pain. Likewise, it is wrong to assume that if the elderly patient is asleep or resting that patient is not in pain. Many older patients use sleep as a coping mechanism. They may also use activities as a short term distraction for their pain.

The determination of presence or absence of pain cannot be based on a patient’s behavior alone. The thought that elderly patients complain of more pain as they age is contradicted in studies that show that elderly patients actually do not report their pain enough. Elderly patients are often very stoic and the degree of pain and suffering they are experiencing may not be readily evident. Pain assessment in the elderly is more complex than in younger patients due the elderly patient’s poor memory, depression and sensory impairment. However, the pathophysiology of pain is essentially the same in the elderly as in younger people.

Yes, Dad could be in pain and no one is recognizing it.
This material is from “Pain and Suffering in the Elderly Population” by Suzanne Frederick MSN RN, in Patricia Iyer (Editor), Medical Legal Aspects of Pain and Suffering.

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