Helping the elderly to cope with pain

By Lauran Neergaard

MS NBC, May 10, 2002

Acetaminophen— Tylenol in the brand-name version — is a good first choice for certain types of mild to moderate pain, the guidelines say. But people with persistent, severe pain require far stronger drugs, including opiates such as Oxycontin.
       Controversy over that drug because of some highly publicized overdose deaths linked to recreational use shouldn’t limit doctors from prescribing it, the guidelines say.
       “The truth is, ... for lots of patients, probably, opioids are a reasonable choice and are still underprescribed in this population,” said Dr. Bruce Ferrell of the University of California, Los Angeles, who co-wrote the society’s guidelines.
       The society was releasing the guidelines and patient pamphlets Thursday at its annual meeting in Washington.
       Some 86 percent of elderly people have at least one chronic illness that can be painful, and they are more likely than other age group to receive inadequate treatment.

“There are these myths ... that as you get old, you have to expect you’ll have pain and learn to live with it. That isn’t true,” said Keela Herr, a University of Iowa nursing professor who led development of the patient materials.
       But with today’s range of treatments, pain should be controlled at least to a level that doesn’t harm quality of life, Herr stressed. “Be more assertive” in demanding care, and seek a referral to a pain specialist if the regular doctor doesn’t help enough, she advised.
       A key to good treatment is explaining to a doctor just how bad the pain is, where and when it strikes, if it  responds to certain medications and if those therapies cause bothersome side effects.
       So the society created a “daily pain diary” to help patients do just that. It includes a pain scale like those used in hospitals so doctor and patient describe the pain using the same terminology. Such a precise recording also may help doctors better realize the extent of suffering, and thus guide therapy, and can provide a faster way of telling if a prescribed dose isn’t high enough or if it’s time to abandon one drug and try another, Herr said.

Equally novel: the new guide for people who care for patients with Alzheimer’s or other forms of dementia. It’s hard to tell if a dementia patient suffers, the guide explains. They may deny they have “pain,” but ask if they’re “aching” or “hurting,” and the answer might be yes.
     Advanced patients often can’t talk, however, and for them the guide describes how to watch for grimaces, unusual behavior like rocking or pacing, or a change in appetite that may signal pain but too often can be mistaken for simply worsening dementia. For example, sudden pacing might indicate a urinary tract infection, constipation or bed sores.

        NEW GUIDELINES
       Among new guidelines for doctors:
       Screen older patients for persistent pain on their initial visit, any hospital admission, and periodically thereafter. Consider any persistent pain that affects physical or psychological function or quality of life to be a significant problem.
       The use of placebos — sugar pills or other dummy medication — is unethical and should not be done in clinical care. Nobody knows how often doctors today offer placebos outside of studies of experimental medicines, where they’re frequently used to compare the new drug’s effects. But Ferrell cited one California case where a teen-ager with a concussion was given placebos for a week while hospitalized.