Principles of perioperative pain management in older adults.

The consequences of poor planning for pain management during surgery of geriatric patients not only affect the immediate well-being of the patient but also have terrible socioeconomic implications. Delays in rehabilitation, increases in hospital lengths of stay, and increased comorbidity can be expected if interventions for pain management are either inadequate or excessive without appropriate monitoring. During surgery, seniors are likely to suffer from acute and chronic pain that must be addressed aggressively in the postoperative period to ensure a rapid functional recovery. New pain scales have been developed with seniors in mind, and greater testing of older scales in elderly populations have helped to identify measures of pain more suited to frail seniors. This article is designed to help clinicians to strategically implement optimal pain management principles and techniques and, thus, help to fulfill the obligation to relieve pain and suffering in patients in the perioperative period, which will ensure the greatest chance of recovery to optimal independence for patients.     

Innovations in Aged Care: The aged care pain chart: An innovative approach to assessing,managing and documenting pain in older people

This article presents the development and initial testing of a comprehensive pain chart for the assessment, management and documentation of pain in older people in subacute and residential aged care. The pain chart was developed from existing assessment scales and pain indicators, and is targeting needs of older people in residential care and geriatric hospital settings with high prevalence of cognitive impairments. The chart is based on self‐report of pain but allows for observation of pain‐related behaviours for those unable to report pain. The chart consists of one evaluative and one documentation dimension, and was evaluated by a group of clinicians in geriatric hospital care (n = 15) and residential aged care (n = 6). The chart was found to be content valid, informative and easy to use, facilitating clinical assessments and monitoring, and assisting visual readings of patients’ temporal pain trends.     

Cruise ship care: a proposed alternative to assisted living facilities

Options for elderly patients who can no longer remain independent are limited. Most choices involve assisted living facilities, 24-hour caregivers, or nursing homes. State and federal assistance for payment for individual care is limited, and seniors usually pay for most costs out of pocket. For those patients who have the means to afford assisted living centers or nursing homes, "cruise ship care" is proposed. Traveling alongside traditional tourists, groups of seniors would live on cruise ships for extended periods of time. Cruise ships are similar to assisted living centers in the amenities provided, costs per month, and many other areas. This article begins with an examination of the needs of seniors in assisted living facilities and then explores the feasibility of cruise ship care in answering those needs. Similarities between cruise ship travel and assisted living care, as well as the monetary costs of both options, are defined. A decision tree with selections for non-independent care for seniors was created including cruise ship care as an alternative. Using a Markov model over 20 years, a representative cost-effectiveness analysis was performed that showed that cruises were priced similarly to assisted living centers and were more efficacious. Proposed ways that cruise ship companies could further accommodate the needs of seniors interested in this option are also suggested. Implementation for cruise ship care on the individual basis is also presented. Ultimately, it is wished to introduce a feasible and possibly more desirable option to seniors who can no longer remain independent.     

Clin-STAR corner: 2021 update in musculoskeletal pain in older adults with a focus on osteoarthritis-related pain

Chronic musculoskeletal (MSK) pain remains a leading cause of disability and functional impairment among older adults and is associated with substantial societal and personal costs. Chronic pain is particularly challenging to manage in older adults because of multimorbidity, concerns about treatment-related harm, as well as older adults' beliefs about pain and its management. This narrative review presents data on nine high-quality, peer-reviewed clinical trials published primarily over the past two years that focus on MSK pain management in older adults, of which four were comprehensively reviewed. These studies address contributors to knee osteoarthritis (OA) pain (insomnia), provide evidence for digital delivery or artificial intelligence driven behavioral interventions and potentially more efficient/equally effective modes of delivering glucocorticoids for OA; each of the selected studies have potential for scalability and meaningful impact in the care of older adults.     

Co-Learning With Home Care Aides and Their Clients: Collaboratively Increasing Individual and Organizational Capacities

Changes in health care provide unprecedented opportunities for collaboration across research, education, and practice for the common goal of enhancing the well-being of older adults and their caregivers. This article describes how a pilot project, Promoting Seniors’ Health with Home Care Aides, has synergistic education, research, and practice effects that enhance individual and organizational capacities. This pilot is an innovative partnership with home care aides to deliver a safe physical activity program appropriate for frail seniors in a real-life public home care program. The intervention and research occur in older adults’ homes and thus provide rare opportunities for the research team and partners to learn from each other about dynamics of home care in older adults’ life contexts. Co-learning is essential for continuous quality improvement in education, research and practice. The authors propose to establish “teaching home care” to ensure ongoing co-learning in gerontology and geriatrics.     

Developing a comprehensive interdisciplinary senior healthcare practice

The PeaceHealth Senior Health and Wellness Center (SHWC) provides primary care coordinated by geriatricians and an interdisciplinary office practice team that addresses the multiple needs of geriatric patients. The SHWC is a hospital outpatient clinic operated as a component of an integrated health system and is focused on the care of frail elders with multiple interacting chronic conditions and management of chronic disease in the healthier older population. Based on the Chronic Care Model, the SHWC strives to enhance coordination and continuity along the continuum of care, including outpatient, inpatient, skilled nursing, long-term care, and home care services. During its development, a patient-centered approach was used to identify senior service needs. The model emphasizes team development, integration of evidence-based geriatric care, site-based care coordination, longer appointment times, "high touch" service qualities, utilization of an electronic medical record across care settings, and a prevention/wellness orientation. This collection of services addresses the interrelationships of all senior issues, including nutrition, social support, spiritual support, caregiver support, physical activity, medications, and chronic disease. The SHWC provides access in an environment sensitive to the special needs of seniors, with a staff trained to meet those needs. The SHWC business model attempts to improve access and quality of care to seniors in a mostly noncapitated healthcare setting, while also attempting to remain financially viable.     

The quality of medical care provided to vulnerable older patients with chronic pain

OBJECTIVES: To assess the quality of chronic pain care provided to vulnerable older persons. DESIGN: Observational study evaluating 11 process-of-care quality indicators using medical records and interviews with patients or proxies covering care received from July 1998 through July 1999. SETTING: Two senior managed care plans. PARTICIPANTS: A total of 372 older patients at increased risk of functional decline or death identified by interview of a random sample of community dwellers aged 65 and older enrolled in these managed-care plans. MEASUREMENTS: Percentage of quality indicators satisfied for patients with chronic pain. RESULTS: Fewer than 40% of vulnerable patients reported having been screened for pain over a 2-year period. One hundred twenty-three patients (33%) had medical record documentation of a new episode of chronic pain during a 13-month period, including 18 presentations for headache, 66 for back pain, and 68 for joint pain. Two or more history elements relevant to the presenting pain complaint were documented for 39% of patients, and at least one relevant physical examination element was documented for 68% of patients. Treatment was offered to 86% of patients, but follow-up occurred in only 66%. Eleven of 18 patients prescribed opioids reported being offered a bowel regimen, and 10% of patients prescribed noncyclooxygenase-selective nonsteroidal antiinflammatory medications received appropriate attention to potential gastrointestinal toxicity. CONCLUSION: Chronic pain management in older vulnerable patients is inadequate. Improvement is needed in screening, clinical evaluation, follow-up, and attention to potential toxicities of therapy.     

Evaluating and managing acute low back pain in the primary care setting

Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected. For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician. When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations.     

Effect of depression treatment on depressive symptoms in older adulthood: the moderating role of pain

OBJECTIVES: To investigate whether pain severity and interference with normal work activities moderate the effects of depression treatment on changes in depressive symptoms over time in older adults in primary care. DESIGN: Patient-randomized, clinical trial. SETTING: Multisite: three clinics located in Veterans Affairs Medical Centers. PARTICIPANTS: Adults aged 60 and older (n=524) who screened positive for depression and participated in the Primary Care Research in Substance Abuse and Mental Health for the Elderly Study. INTERVENTION: Integrated care versus enhanced specialty referral care. MEASUREMENTS: Pain severity, the degree to which pain interferes with work inside and outside of the home, and depressive symptoms were examined at baseline and 3, 6, and 12 months. RESULTS: Intention-to-treat analyses revealed that both treatment groups showed reduced depressive symptoms over time, although self-reported pain moderated reductions in depressive symptoms. At higher levels of pain severity and interference with work activities, improvements in depressive symptoms were blunted. Furthermore, pain interference appeared to have a greater effect on depressive symptoms than did pain severity; in individuals with major depression, pain interference fully accounted for the moderating effects of pain severity on changes in depressive symptoms over time. CONCLUSION: Pain and its interference with functioning interfere with recovery from depression. Findings highlight the importance of addressing multiple domains of functioning (e.g., physical and social disability) and the degree to which pain and other forms of physical comorbidity may hinder or minimize treatment-related improvements in depressive symptoms.     

Perceived barriers to trying self-management approaches for chronic pain in older persons

OBJECTIVES: To examine older persons' willingness to participate in exercise and relaxation programs for managing chronic pain, to identify characteristics associated with willingness to participate, and to ascertain their barriers to participation. DESIGN: Cross-sectional survey. SETTING: A geriatric ambulatory care practice located in New York, New York, and the General Clinical Research Center of Weill Cornell Medical College. PARTICIPANTS: Sixty-eight English-speaking patients aged 70 and older with chronic pain. MEASUREMENTS: Participants' level of willingness to participate in the programs was assessed using 5-point Likert scales, and information regarding their demographic, clinical, psychological, and pain status was obtained. Qualitative methods were used to ascertain participants' perceived barriers to participation. RESULTS: Participants had a mean age+/-standard deviation of 81.9+/-7.0 and were mostly white (85%) and female (68%). Although only 16% of participants reported current use of exercise as a pain-management strategy, 73% reported a willingness to try the exercise program. Four percent reported current use of relaxation methods; 70% reported an interest in learning these techniques. Moderate correlations were found between increasing days of restricted activity due to pain and greater willingness to participate. Seventeen unique barriers were identified; the mean number of barriers reported per person was 2.9+/-1.8 for exercise and 2.2+/-1.4 for relaxation. Commonly reported barriers to participating in either program included time conflicts, transportation, treatment efficacy concerns, and fear of pain or injury. CONCLUSION: Older primary care patients with chronic pain are willing to try exercise and relaxation therapies to help manage pain but report a substantial number of barriers to participating in these programs. Addressing patient-level barriers could improve engagement in and adherence to exercise and relaxation therapies for managing pain in older persons.     

The quality of emergency department pain care for older adult patients

OBJECTIVES: To determine whether there are differences in emergency department (ED) pain assessment and treatment for older and younger adults. DESIGN: Retrospective observational cohort. SETTING: Urban, academic tertiary care ED during July and December 2005. PARTICIPANTS: Adult patients with conditions warranting ED pain care. MEASUREMENTS: Age, Charlson comorbidity score, number of prior medications, sex, race and ethnicity, triage severity, degree of pain, treating clinician, and final ED diagnosis. Pain care process measures were pain assessment and treatment and time of activities. RESULTS: One thousand thirty‐one ED visits met inclusion criteria; 92% of these had a documented pain assessment. Of those reporting pain, 41% had follow‐up pain assessments, and 59% received analgesic medication (58% of these as opioids, 24% as nonsteroidal anti‐inflammatory drugs (NSAIDs)). In adjusted analyses, there were no differences according to age in pain assessment and receiving any analgesic. Older patients (65–84) were less likely than younger patients (18–64) to receive opioid analgesics for moderate to severe (odds ratio (OR)=0.44, 95% confidence interval (CI)=0.22–0.88) and were more likely to more likely to receive NSAIDs for mild pain (OR=3.72, 95% CI=0.97–14.24). Older adults had a lower reduction of initial to final recorded pain scores (P=.002). CONCLUSION: There appear to be differences in acute ED pain care for older and younger adults. Lower overall reduction of pain scores and less opioid use for the treatment of painful conditions in older patients highlight disparities of concern. Future studies should determine whether these differences represent inadequate ED pain care.     

Development and Initial Validation of the PEG, a Three-item Scale Assessing Pain Intensity and Interference

BACKGROUND  Inadequate pain assessment is a barrier to appropriate pain management, but single-item “pain screening” provides limited information about chronic pain. Multidimensional pain measures such as the Brief Pain Inventory (BPI) are widely used in pain specialty and research settings, but are impractical for primary care. A brief and straightforward multidimensional pain measure could potentially improve initial assessment and follow-up of chronic pain in primary care. OBJECTIVES  To develop an ultra-brief pain measure derived from the BPI. DESIGN  Development of a shortened three-item pain measure and initial assessment of its reliability, validity, and responsiveness. PARTICIPANTS  We used data from 1) a longitudinal study of 500 primary care patients with chronic pain and 2) a cross-sectional study of 646 veterans recruited from ambulatory care. RESULTS  Selected items assess average pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G). Reliability of the three-item scale (PEG) was α = 0.73 and 0.89 in the two study samples. Overall, construct validity of the PEG was good for various pain-specific measures (r = 0.60–0.89 in Study 1 and r = 0.77–0.95 in Study 2), and comparable to that of the BPI. The PEG was sensitive to change and differentiated between patients with and without pain improvement at 6 months. DISCUSSION  We provide strong initial evidence for reliability, construct validity, and responsiveness of the PEG among primary care and other ambulatory clinic patients. The PEG may be a practical and useful tool to improve assessment and monitoring of chronic pain in primary care.     

Instruments for the assessment of pain in older persons with cognitive impairment

Pain in older persons with cognitive impairment is often unrecognized and inadequately treated. A major problem associated with this undertreatment is the challenging nature of pain assessment and in particular the selection of accurate and useful assessment instruments. The purpose of this study was to review pain measurement instruments for acute and chronic pain suggested for use with cognitively impaired older persons and to summarize available evidence on their reliability and validity. A systematic search for pain instruments was conducted using several bibliographic databases, supplemented by a manual search of the bibliographies of retrieved articles and review chapters and by articles received from experts and clinicians in the field. Instruments were retained for review when the pain instrument was used or recommended for use with older persons with cognitive impairment. Thirty-nine instruments were reviewed; nine were excluded for various reasons. Of the remaining 30, 18 were self-report and 12 were staff administered. There were no instruments for which all major tests of reliability or validity were reported. Reliability and validity data were basic or unavailable for many instruments. One instrument had excellent validity but no reliability data. The remaining instruments had weak or adequate reliability and validity. The authors conclude that there is a need for further rigorous development and testing of pain instruments for use with cognitively impaired older persons. An adequate instrument would be one component of an effective program for assessment and management of pain in this population.     

Care-needs certification in the long-term care insurance system of Japan

The introduction of Japan's long-term care insurance (LTCI) system in April 2000 has made long-term care an explicit and universal entitlement for every Japanese person aged 65 and older based strictly on physical and mental status. At the start of the program, more than two million seniors were expected to apply for services to approximately 3,000 municipal governments, which are the LTCI insurers. The LTCI implementation required a nationally standardized needs-certification system to determine service eligibility objectively, fairly, and efficiently. The current computer-aided initial needs-assessment instrument was developed based on data collected in a large-scale time study of professional caregivers in long-term care institutions. The instrument was subsequently tested and validated by assessing data of 175,129 seniors involved in the national model programs before the start of LTCI. The computer-aided initial assessment (an 85-item questionnaire) is used to assign each applicant to one of seven need levels. The Care Needs Certification Board, a committee of medical and other professionals, reviews the results. Three years after implementation, the LTCI system and its needs-assessment/certification system have been well accepted in Japan. Despite the overall successes, there remain challenges, including area variations, growing demands for services, and the difficulty of keeping the needs certification free of politics. The LTCI computer network that links municipalities and the central government is instrumental in continuously improving the needs-certification system. Future challenges include promoting evidence-based system improvements and building incentives into the system for various constituencies to promote seniors' functional independence.     

National and Regional Differences in Preparation for Future Care Needs: A Comparison of the United States and Germany

Planning for future care needs is likely to be influenced by both policy and culture. We compared attitudes regarding the usefulness of planning ahead for future care needs, processes of preparation for these needs (becoming aware of the risk of future care needs, gathering information about available options, deciding on preferences, concrete planning), and outcomes of preparation (e.g., knowledge about services) in 294 East German, 288 West German, and 590 American seniors. American respondents had higher preparation scores. Compared to the size of national differences, differences between East and West German seniors were generally smaller. East Germans made fewer decisions on preferences and engaged in less concrete planning. Most of the national and regional differences in preparation for future care needs were reduced or eliminated by controlling for differences in the perceived usefulness of planning.