Patricia M. Clark, MSN, RN, CS, AOCN®
Pain management continues to be a primary
concern for cancer patients, their families, and oncology nurses. At least 90%
of cancer patients report at least moderate pain at some time during the course
of their disease, and at least 42% of elderly cancer patients have reported
unrelieved pain.[1] The elderly cancer patient is the norm rather than the
exception, because at least half of all cancers are diagnosed in patients over
the age of 65 years.[2] The number of people over 65 years old in the United
States is expected to reach 64.3 million by 2030,[3] making it inevitable that the problem of
pain management for cancer patients will become more prevalent. Oncology nurses
were urged at the 26th Congress of the Oncology Nursing Society to "Look
Before You Leap!"[2] when managing pain in the elderly cancer patient.
How do we know when we are old?
Definitions of old have traditionally started at age 65 years. People in the
65- to 75-year age group are usually termed the "younger old"; those
in the 75- to 85-year age group are the "older old," and those over
85 years of age are termed the "oldest old" or "elite old."[4] All these groups are expected to
increase in size. The 2000 US census reported 4.2 billion citizens older than
85 years.[5] It has been predicted that by 2050, 1.2 million people
will be alive at 100 years of age.[2]
Pain is not an uncommon symptom in the
elderly. Trouble with pain has been reported by 25% to 50% of elders living in
the community[6] and in as many as 80% of nursing home residents.[7] What makes pain in the elderly different
from pain in other cancer patients? Jeannine Brant, RN, MS, AOCN®, Oncology Clinical Nurse Specialist and
Pain Consultant at Saint Vincent Hospital in Billings, Montana, and Rita
Wickham, RN, PhD, AOCN®, Associate Professor of Nursing and Clinical Nurse
Specialist in Pain and Palliative Care at Rush-Presbyterian St. Luke's Medical
Center in Chicago, Illinois, answered this question in their presentation.[2]
Patient beliefs about pain can be barriers
to management. Geriatric cancer patients may have a desire to be "good
patients," or may regard pain as just another part of aging. They may be
afraid that admitting to pain will take the clinician's focus away from more
critical health problems. Fear of addiction to opiates and passive acceptance
of pain as part of a cancer diagnosis also contribute to inadequate pain
control in this population. The perception of clinician apathy also prevents
patients from reporting pain. As Wickham stated in the presentation,
"Patients don't want to be seen as bothersome or hypochondriacal so they
don't tell us [about pain] sometimes. If they get an apathetic response from
their physician or nurse...and we tell them in our words or in our actions that
'well, you have to live with a little pain' they are much less likely to tell
us again that they do have pain. On the other hand, if they perceive that their
caregivers respect their reports of pain, they will probably be much more likely
to tell us."[2]
Culture can play a big role in attitudes
about pain control and palliative care. In some cultures, there can be a
mistaken notion that palliative care is given only immediately before death and
that the clinician has "given up" on the patient.[8]
In a session on cultural influences in
palliative care, Guadaloupe Palos, RN, LMSW, DPh(c), Cancer Project Specialist,
Department of Anesthesiology and Critical Care at the University of Texas, MD Anderson
Cancer Center, Houston, Texas, used the example of Dona Maria, a 54-year-old
Mexican-American woman with metastatic breast cancer to the bone. She had
extreme pain in her back and hip that was unrelieved by self-care measures.
Dona Maria had trouble using the 0 to 10 pain scale to describe her pain
because she was accustomed to using descriptors. She explained to clinicians
that she knew she was going to die very soon, and she showed them a picture of
her coffin and invited them to her funeral. She believed that her suffering
would end when she died.
The staff
thought that Dona Maria was ready to talk about palliative, end-of-life care
because she had showed them pictures of her coffin. Unfortunately, when the
staff approached this subject, the patient and her family assumed that her care
team was giving up. After careful investigation, it was determined that Dona
Maria was not taking her pain medication because she felt it would not help.
She believed that a neighbor's curse had doomed her to constant pain. Dona
Maria asked her healthcare team to bless her house so that she would feel
comfortable dying at home. Once the blessing was complete, Dona Maria felt her
pain decrease and agreed that perhaps her disease was also causing her pain.
She gradually accepted the pain team's efforts to treat her pain.
Palos explained that through the Priority
Pain Relief Education for Minority Outpatients (PREMO) program at MD Anderson
Cancer Center, clinicians learned that pain might be at a level 9 or 10 before
some patients will notify the clinician because they didn't want to be
perceived as complaining or bothering the provider. In both African Americans
and Hispanics, the concepts of "being strong" and "not leaning on
pain medications" can be very important. While it should be remembered
that not all members of an ethnic group share the same beliefs, it is equally
important to ask about beliefs regarding pain and its treatment.[8]
Brant explained that family members who
think that pain is part of the aging process or that it may be related to
worsening disease also can be barriers to pain control. Family members may also
hesitate to bring up pain control because they don't want to
"distract" the clinician from treating the cancer, or they may fear
addiction.[2]
Clinician
bias may be caused by age bias that has not been dispelled by education in
geriatric care. Some clinicians overestimate the extent of adverse reactions to
pain medication and believe that elderly clients cannot accurately report their
pain if they are cognitively impaired. Clinicians may think that a patient who
can sleep and be distracted can't possibly be in pain.[2]
Healthcare
systems may unknowingly erect their own barriers to pain control in the elderly
cancer patient. Lack of standard assessments of geriatric patients, inadequate
treatment protocols, and fragmented care are a few of the institutional
barriers that may block effective pain management in geriatric cancer patients.
The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) has
implemented pain standards that may overcome some of these barriers and
establish consequences for poorly managed pain.[9]
Just as there are patient, family,
clinician, and institutional barriers to pain control, there are barriers to
pain assessment. In general, the same principles of assessment used for younger
patients should be used for cognitively intact elderly patients. However, it is
important for the clinician to allow additional time when assessing the
elderly. As with any assessment, a quiet, private place will help the clinician
obtain an accurate history, as will optimizing communication by making sure
that the patient's hearing aids are working and that dentures and glasses (if
worn) are in place during the interview.[4]
Pain
presentation may be different in the elderly. The location of the pain may be
affected not only by cancer but also by other chronic conditions. When assessing
pain severity, the usual 0 to 10 pain scale may be shorted to a 0 to 5 scale
for ease of use. The faces scale may also be used to rate pain.[2] This scale uses pictures of facial
expressions to rate pain. Assessment should include quality of pain and
aggravating and alleviating factors. If analgesics have been used, the
clinician should ask about their effectiveness and any adverse events
experienced. Most important, a list of all current medications (both
prescription and over-the-counter) should be obtained. The elderly client
should also be assessed for depression or other affective responses to pain.
Psychosocial
concerns include where the patient lives and with whom, the presence or absence
of a caregiver, and the extent of caregiver burden. This is especially
important in elderly couples when a partner who is older than the patient is
trying to provide care.
Examination
of the painful part of the body should include functional assessment, if
appropriate. This assessment may include gait and balance, motor strength,
peripheral sensation, and cranial nerves.
Cognitive impairment is a primary concern
for healthcare providers who assess and treat pain in the elderly. Delirium and
dementia are common syndromes of cognitive impairment in the elderly, but they
have different causes and manifestations (Table 1).
|
Characteristic |
Delirium |
Dementia |
|
Onset |
Acute |
Insidious |
|
Course |
Fluctuates |
Steadily progressive |
|
Consciousness/orientation |
Clouded/disoriented |
Clear until late stages |
|
Attention/memory |
Inattention/poor short-term memory |
Attentive/poor short-term memory |
|
Psychosis |
Common |
Less common |
The risk for
delirium increases in terminally ill patients and puts patients at risk for
mismanagement because of communication difficulties. Risk factors for delirium
include [2]:
·
Dementia
·
Advanced age
·
Infection/sepsis
·
Hospitalization
·
Isolation in unfamiliar surroundings
·
Surgery
·
Myocardial infarction
·
Congestive heart failure
·
Acute blood loss
Cognitive impairment does not alter an
elder's ability to state that they have pain and indicate its location. Use of
simpler pain scales (0 to 5) and the faces scales may be easier for the
cognitively impaired patient. Additional time should be given for a response.
If the patient is nonverbal, look at behavioral indicators, especially the
classic furrowed brow as a sign of pain.[2]
When choosing medications for pain relief
in the elderly, the American Geriatric Society has suggested the following
guidelines[10]:
·
Use the least invasive route to give medication.
·
Start low and go slow.
·
Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with
caution due to side effects; acetaminophen is the drug of choice for mild pain.
·
Opioid analgesics are effective for relieving moderate to severe pain.
·
Adjuvant medications are appropriate for certain pain syndromes.
·
Pharmacologic therapy is most effective when combined with
nonpharmacologic approaches.
Brant and Wickham emphasized the effects
of physiologic changes associated with aging on drug metabolism. Kidneys become
smaller with age, and there is decreased blood flow contributing to decrease in
glomerular filtration rate. The liver becomes smaller as functional tissue is
replaced by fat. Effects on the liver and kidney may be exacerbated by disease,
treatment, or environmental factors. The half-life of drugs and their toxic
effect may be extended, depending upon kidney and liver function.
The route of
administration of drugs may also be affected by aging. Decreased saliva may
hamper swallowing, and injections may be difficult to give due to decreased
muscle mass. Oral drugs may be poorly absorbed due to changes in stomach
acidity. Lipid-soluble drugs may have delayed onset and accumulate, while
water-based drugs may have early peak and onset of action.
Brant explained the effects of aging on
common classifications of analgesic drugs using the World Health Organization
analgesic ladder from the Agency for Health Care Policy and Research (AHCPR)
guidelines.[11]
NSAIDs. NSAIDs are protein bound. Since older
patients have more fat than protein and lower serum albumin levels, serum NSAID
levels will be higher, producing a higher incidence of side effects. When bone
and/or joints are involved, NSAIDs may be useful but gastrointestinal
prophylaxis is important, especially in NSAIDs with a low cyclo-oxygenase
(COX)-2/COX-1 inhibitor ratio. Examples of these drugs include naproxen,
indomethacin, and piroxicam. NSAIDs with a high COX-2/COX-1 ratio include
etodolac, meloxicam, celecoxib, and rofecoxib. These drugs have fewer
gastrointestinal side effects. Patients on NSAIDs should be monitored for side
effects, and electrolytes should be drawn 2 weeks after the initiation of
therapy and intermittently thereafter to monitor renal function.[12]
Opioid
analgesics. Opioid analgesics are useful in the elderly, but certain drugs should
be avoided. Avoid agonist-antagonist preparations, merperidine,
and propoxyphene, which have active metabolites and are central nervous system
stimulants. Opioids should be started at doses 25% to 50% lower than those
given to young adults due to high fat-to-protein ratios. There is increased
sensitivity to the peak effect of short-acting opioids in the elderly, so it is
advantageous to stabilize pain with long-acting medications and give lower
rescue doses. Rescue doses should be 5% of total daily dose and should be given
every 4 hours.[12]
Morphine is a
useful opioid in the elderly, but care must be taken in the event of renal
insufficiency. Metabolites M3G and M6G can accumulate in this setting and cause
excitation of the central nervous system and myoclonus, as well as an increase
in the usual side effect of sedation.[2] Oxycodone has no toxic metabolites and
is a preferred opioid in the elderly because of its short half-life and the
availability of both short- and long-acting forms.[2]
Transdermal
fentanyl is also a preferred opioid in the elderly. Patients seem to like the
idea of a patch, and there is anecdotal evidence suggesting that constipation
is less common with this drug and dosage form.[2] However, the drug should not be used in
opioid-naive patients or in patients with low serum albumin or recurrent
infections. Toxicity may result from increased uptake from the skin reservoir
or from increased free drug.[12] The half-life of this drug is longer; 50% of the drug
remains in the skin reservoir 24 hours after patch removal.
Hydromorphone
is also useful in the elderly. It has no known toxic metabolites, high
solubility, and a short half-life. Under close observation, it can be used to
convert a patient who has had toxic effects from other opioids. [2]
Methadone is
the least expensive of the opioids but is not recommended for
use in the elderly because it has a long and variable half-life, multiple
drug-drug interactions, and can cause sedation, confusion, and delirium.[2]
Adjuvant
pain medications. Adjuvant medications for pain relief include tricyclic
antidepressants, anticonvulsants, and benzodiazepines. Tricyclic
antidepressants (imipramine, doxepin, clomipramine, desipramine, nortriptyline)
may be used to treat neuropathic pain as well as sleep disturbance. In the
elderly, it is suggested that the dose begin at 10 mg orally at bedtime and be
titrated to a therapeutic level (50 mg to 150 mg in divided doses).[12] These drugs can cause orthostatic
hypotension and cardiovascular side effects (atrioventricular heart block), so
patients should be monitored carefully.[2]
Anticonvulsants
used as adjuvant pain medications include gabapentin, carbamazepine, and
phenytoin. These medications are used to treat neuropathic pain. Gabapentin is
preferred in the geriatric population because it has few side effects, but it
still may increase sleepiness and dizziness and cause ataxia and peripheral
edema.[2]
While benzodiazepines can be used as adjuvant drugs for pain relief, in older
patients they often cause sedation and patient falls and they tend to mask
rather than relieve pain.[2]
Medicare currently does not cover the cost
of oral pain medication, which poses an economic burden for seniors who are on
limited, fixed incomes. Many seniors try to save money by using mail-order
pharmacies (which are sometimes mandated in managed care environments), but
there can be delays in receiving medication that compound the problem of pain
control. While some opioids are cheaper than others (methadone is cheaper than
morphine), the least expensive drug is often not the drug of choice for elderly
cancer patients.[2]
Brant and Wickham reminded their nursing
colleagues that, "Oncology nurses must be diligent, astute, and persistent
to meet the needs of the elderly in pain."[2] Pain control in elderly cancer patients continues
to challenge oncology nurses. Pain is twice as likely to be present in cancer
patients over the age of 60 years.[2] In addition to pain, the elderly cancer patient
experiences physical and cognitive changes that are part of the aging process.
While cognitive impairment and agitation are often blamed on analgesic intake,
they are actually more likely to be related to pain.[2] Pain assessment in the elderly is a
complicated process requiring patience and focus. The oncology nurse must take
into account physiologic changes in metabolism, absorption, and excretion of
drugs when suggesting pharmacologic methods of pain control. Consistent
monitoring for relief of pain and adverse effects of pain medication is
essential to providing quality care for the elderly patient.
1.
Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA.
1998;279:1914-1915.
2.
Brant JM, Wickham R. The challenges of pain assessment and management in
the elderly: look before you leap. Program and abstracts of the 26th Congress
of the Oncology Nursing Society; May 17-20, 2001; San Diego, California.
Discussion Session.
3.
Gliford DM. The Aging Population in the Twenty-First Century:
Statistics for Health Policy. Washington, DC: National Academy Press;
1988.
4.
Duthie EH. History and physical examination. In: Duthie EH, Katz PR,
eds. Practice of Geriatrics. 3rd ed. Philadelphia, Pa: WB
Saunders and Co; 1998.
5.
US Government Census 2000. Available at:
http://www.census.gov/prod/cen2000/dp1/2kh00.pdf. Accessed May 26, 2001.
6.
Ferrell BA. Pain management in elderly people. J Am Geriatr Soc.
1991;29:64-73.
7.
Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am
Geriatr Soc. 1990;38:409-414.
8.
McCarthy HC, Powe BD, Palos G, Simpson MR. The influence of culture on
palliative care. Program and abstracts of the 26th Congress of the Oncology
Nursing Society; May 17-20, 2001; San Diego, California. Instructional Session.
9.
Joint Commission on Accreditation of Health Care Organizations. Pain
standards for 2001. Available at: http://www.jcaho.org/standard/pm.html.
Accessed May 26, 2001.
10. American Geriatrics Society Clinical
Practice Committee. Management of cancer pain in older patients (clinical
practice guidelines). J Am Geriatr Soc. 1997;45:1273-1276.
11. Agency for Health Care Policy and
Research. Management of cancer pain. AHCPR Publication No. 940-592; 1994.
12. Abrahm JL. Advances in pain management
for older adult patients. Clin Geriatr Med. 2000;16:260-311.
Edward E.
Rylander, M.D.
Diplomat American
Board of Family Practice.
Diplomat American
Board of Palliative Medicine.