The elderly are significantly underserved in pain treatment despite the data suggesting that community dwelling elders suffer from a high rate of pain conditions and that pain under-treatment is even greater among nursing home residents, with an estimated 45% to 80% of residents suffering from pain although a very low percentage receives analgesia.¹ This is alarming since failure to address pain management in this population has health consequences involving disturbed sleep, poor nutritional intake, depression and anxiety, agitation and decreased activity.

For the most part, barriers to the pain treatment in this population are similar to the barriers in the general population. Yet, evidence suggests that shifts in particular attitudes are necessary for appropriate pain management among the elderly.² In particular, changes to restricting attitudes such as the assumption that pain is an acceptable part of aging, that minority groups experience and report pain in an emotional manner, and that health care providers know more about the patient's pain than the patient themselves are important. Further complicating the assessment of pain in this population is a high incidence of cognitive and sensory impairments (approximately 50% among nursing home residents), making elders who suffer from dementia or Alzheimer’s disease a critically underserved population in pain management.³

Dementia causes particular barriers to pain assessment in that symptoms of dementia such as aggressiveness may overlap with the expression of pain. Also due to limitations in abstract thinking, typical measures of pain intensity are not appropriate for this population. Methods of assessing pain within this population have focused on non-verbal reports and behavioral observations. According to the American Geriatric Society, the general categories of pain behaviors to be assessed are: facial expressions, verbalizations and vocalizations, body movements, changes in interpersonal interactions, changes in activity patterns or routines, and mental status changes.¹ Behavioral changes include changes in appetite, physical activity, sleep mobility and body language.

Physiological measures have also been used to assess pain among this population including blood pressure and heart rate. While behavioral assessments often include such physiological measures, these physiologic assessments are unreliable.⁴ Recent research has focused on the development of tools for monitoring pain behaviors among cognitively impaired individuals. In Zwakhalen and colleagues³ review of pain assessment measures, the first major review in this field, 12 measures were assessed for their reliability, validity and utility with a cognitively impaired population. Of the measures reviewed, only two are recommended, the DOLOPLUS2⁵ and the Pain Assessment Check List for Seniors with Limited Ability to Communicate (PACSLAC)⁶ Another measure highly rated by the AGS⁷ is the Pain Assessment in Advanced Dementia scale (PAINAD).⁸

Featured Course

A Review of Pain Screening Instruments for Medical and Mental Health Providers: Assessment and Coordination of Care of the Pain Patient

(5 CEs) by Ann C. Jorn, Ph.D.

Nine in 10 Americans suffer from pain, making pain is the most common reason for visits to primary care physicians.⁹ Some 25 million Americans experience acute pain, some 50 million live with chronic pain and pain accounts for the majority of long-term disability cases. The prevalence rate for chronic pain disorders has been estimated to range from 20% to 60%.¹⁰ For example, 25% to 40% of community dwelling elders present with chronic pain.¹¹ An estimated 30% of the population experience low back pain¹² and approximately 15% suffer migraines.^{13, 14} Further, one national survey found that of those meeting criteria for Major Depression or Dysthymia, 63% had co-morbid chronic pain conditions.¹⁵

In 2001, the Joint Commission on Accreditation of Hospital Organizations not only identified pain as a major health problem, but also highlighted the under-treatment of pain and its consequences.¹⁶ Under-treated pain can not only lead to other serious physiological health consequences, such as pneumonia and deep vein thrombosis, but can be associated with significant disability, under employment, absenteeism, and psychological distress – causing patients and families unnecessary grief and costing society an estimated 100 billion a year.^{16, 17}

In light of these statistics, it is important that health care professionals understand how to identify and assess for pain conditions in their practice. Unfortunately, while there is an increase in the number of medical and mental health practitioners trained in pain management many providers do not understand the ease and utility of gathering initial and ongoing data of psychological and behavioral functioning and the operationalism of findings for treatment planning. Moreover, it is imperative that clinicians working in the pain context are prepared to individually tailor a comprehensive pain management plan for each patient to account for age-related (e.g., cognitive impairment) and other barriers (e.g., non-verbal) and work within an interdisciplinary model to facilitate coordination of care. This course will present health professionals with the information necessary to achieve these goals. Specifically, a detailed review of assessment tools for the reliable identification of the patients’ pain experience and its impact on activities of daily living and psychosocial functioning is provided and the recommended method of administration given patient characteristics (e.g. ethnicity, age, cognitive functioning, culture) is presented. Assessment results are discussed in terms of treatment coordination between medical and psychological providers.