Include elderly in pain management programs
Does your pain management program meet the complex needs of elders?
"Pain in older persons goes minimized, underreported, undertreated, or untreated, yet if left unmanaged or inappropriately controlled, pain will increase patients’ depression, diminish function, exacerbate cognitive impairments, disturb sleep as well as increase health utilization and cost" says Terry Fulmer, PhD, RN, FAAN, professor and director of nursing at New York University and one of the developers of Nurses Improving Care to the Hospitalized Elderly (NICHE), a national initiative assisting hospitals to meet needs of acutely ill elders. (See related story about NICHE, p. 10.)
What makes pain management for the elderly different from other acute care patients? Fulmer, who wrote NICHE’s pain management protocols, shared her insights with Patient-Focused Care and Satisfaction:
1. Prevalence and effect of pain.
"More than 80% of all elderly persons suffer from painful chronic diseases such as arthritis and peripheral vascular disease," she says. "Patients over 60 suffer twice as much from pain than younger patients."
Such pain can prevent elderly people from adequately managing activities of daily living. "This, in turn, can affect the quality of life which begins a downward spiral of functional decline," Fulmer explains.
2. Underreporting of pain.
Older patients, who believe pain is a normal part of aging, may not report pain to their caregivers and accept it as second nature. "They don’t want to be labeled bothersome, or hypochondriac, so they may not mention it during a workup for the acute problem," she says.
3. Physiology of aging.
Not only do elders absorb, metabolize, distribute, and excrete medications differently than younger patients, making them at risk for adverse drug reactions, but their physiology makes administration difficult.
For example, an elder may be unable to swallow a pill because of a decreased ability to manufacture saliva. "Lemon-glycerin swabs, while appropriate for younger patients, may actually increase drying of the mouth," Fulmer says.
Or a pill may become lodged in ill-fitting dentures but be recorded as having been taken.
An elder’s poor circulation or wasting muscles can also interfere with injection. "A viable alternative may be rectal administration for some medications," she says.
4. Lack of scientific literature.
"Although the AHCPR’s guidelines are excellent, they don’t provide the specific focus on aging for those who work with this population," she explains.
5. Ageist attitudes and lack of geriatric education.
"Misperceptions such as Old people are unreliable pain reporters’ or Old people can’t cooperate with complex therapies’ can impede assessment and intervention," Fulmer says.
Fear of elderly patients’ adverse reactions to medication can also influence a nurse’s willingness , or unwillingness, to administer pain relief, she adds.
6. Special assessment tools.
Elders may have difficulty using a 10-point scale, she points out. "The four-point Pain Effect Faces Scale has proven to be reliable and quick with elders."
7. eed for alternative practices.
A pain management program for elders should contain noninvasive strategies, stresses Fulmer. "After the acute episode has subsided, alternative therapies such as relaxation, herbal remedies, and therapeutic touch should be explored," she says.
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