The Elderly: Introduction

Pain once was viewed only as a symptom or consequence of illness or trauma. The cause of the pain was always the primary consideration in treatment; the pain itself was secondary. That view has changed. Pain is now considered “the fifth vital sign,” and pain management has become an important element in a treatment plan. This is especially true in elderly patients who have the highest incidence of severe pain.

“Elderly” was the medical classification for people age 65 and over for many years. It was a somewhat arbitrary number that had been used to establish a retirement age when Social Security was enacted in the United States in the 1930’s. One can easily see why the age of 65 might have been considered elderly in the 1930’s, because the average life expectancy at birth for males was 58; for females it was 62. Life expectancy has changed dramatically since then. A male born in 2004 has a life expectancy at birth of 74.7 years. For females it has risen to 79.9. People are staying well and active longer, therefore ages have been re classified:

• 65-70 - late middle age
• 70-75 - young old
• 75-80 - old
• 80-85 - old old
• 85 and over - oldest old

Estimates of how large a segment of the population over 65-which currently numbers around 35 million-suffers chronic or intermittent severe pain vary widely:

• In the general population - 25-50%
• In the nursing home population - 40%-80%

The one constant factor related to pain in the elderly is that it is under treated or not treated at all. This is especially true for elderly women.

There are many reasons for this, some of which are based on long-held and erroneous beliefs that include:

Belief: As we age, we are less sensitive to pain.
Fact: Studies have not shown any age-related differences in sensitivity to pain.

Belief: As we age, we are going to suffer more pain in general.
Fact: Pain is not just a natural part of getting old. If there is pain, it should be treated, no matter how young or old the patient.

Belief: Elderly people just complain more.
Fact: Studies have shown that elderly patients are more likely not to report pain.

This is due to a number of factors, like:

• they, too, believe that pain is just part of getting older.
• they don't want to worry their family or their caregivers.
• they don't want to be seen as a burden.
• they fear that reporting pain is admission of a serious illness or poor prognosis.

Treatment Concerns
Another erroneous belief is that it is not safe to treat the elderly with opioids. One can understand why this misconception is so widespread. Pain management in the elderly can be very complex. As human beings age the heart pumps more slowly, lung capacity is reduced, and lean body mass shrinks. The body becomes increasingly frail. Frailty alone makes it more difficult to treat pain because it is harder to pinpoint exact dosages. It is also harder to predict possible side effects. The basal metabolic rate and renal system slow down and become less efficient, and drugs are retained in the system longer. This can greatly increase the toxicity of drugs with a long half-life.

Opioids can be safely used in treating the elderly, but physicians fear the legal consequences if a patient dies because of a pain medication they prescribe. To alleviate this fear steps have been taken to provide specific guidance in how to use opioids. An excellent example is the “Model Policy for the Use of Controlled Substances for the Treatment of Pain,” adopted by the Federation of State Medical Boards in May, 2004. A copy of the Model is included as Appendix A.

Every manufacturer of pain medication, both opioid and non-opioid, has established guidelines for treatment. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Institute of Health (NIH), the National Cancer Institute (NCI), the American Geriatric Society (AGS) and many other not-for profit organizations have also developed guidelines for pain management and the use of pain medication. A copy of the Executive Summary of the AGS Guideline for the Management of Persistent Pain in Older Persons is included as Appendix B.

In addition, most facilities have rules governing the prescription and use of pain medication. These are valuable resources that should be consulted whenever a new pain medication is prescribed for an elderly patient. The “how” of using these drugs is not the biggest question. It is the “when” and “if” that create the greatest difficulty for physicians. Links to all the treatment guidelines of the above-referenced organizations are included in “Resources” which is at the back of the appendices.

Common causes of pain in the elderly
There are several non-malignant causes of pain in the elderly population:

• Extremities - Peripheral neuropathy, peripheral vascular disease, reflex sympathetic dystrophy, phantom limb pain, radicular pain from back disorders
• Gastrointestinal - Hiatal hernia, acute cholecystitis, irritable bowel syndrome, chronic constipation
• Head, neck - Trigemnial neuralgia, occipital neuralgia, cluster headache, vascular headache
• Heart - Angina
• Spine - Lumbar disk disease, lumbar stenosis, osteoporosis, vertebral body collapse
• Trunk - Postsurgical intercostal neuralgia, diabetic neuropathy, postthoracotomy pain, post-herpetic neuralgia (PHN)

Three of the medical conditions that most often cause pain in the elderly are:

• Cancer
• Arthritis
• Shingles and Post-herpetic Neuralgia (PHN)

Cancer
At least 60% of all new cancer cases are diagnosed in people over 65. This statistic holds true for both genders, although a man stands a higher risk of developing cancer than a woman. Estimates are that a man's chances of developing cancer at some point in his life are one in two, while a woman's is one in three.

Skin cancer is the most common cancer, followed by breast cancer in women and prostate cancer in men. For both sexes, lung cancer is third, and colon/rectal cancer is fourth. Lung cancer accounts for the highest death rate. Currently, a man stands about a 25% higher chance of developing lung cancer than a woman, but this gap is narrowing rapidly given increases in the number of women smokers.

Arthritis
The incidence of both rheumatoid arthritis (RA) and osteoarthritis (OA) is higher in the elderly. RA is a disease of the autoimmune system. The first signs of RA tend to present in individuals from 25 to 50. It can be difficult to diagnose because in the early stages the symptoms are very similar to many other diseases. In the majority of cases blood tests will reveal the rheumatoid factor. RA can lead to deformity of the joints and ultimate disability. It is accompanied by pain that often can be extreme.

OA generally presents in individuals over 60. It is a degenerative disease that primarily affects the weight-bearing joints. There is no diagnostic test available; usually the first sign of the disease is pain in the joints which is eased by resting the joint. Certain types of physical therapy can be helpful, but as the disease progresses, it becomes more painful. Ultimately, it usually requires the addition of pharmaceuticals to the treatment plan.

Shingles and Post-herpetic Neuralgia (PHN)
Shingles (Herpes Zoster) is a very painful condition. It is caused by the same virus that is responsible for chicken pox. Only people who have had chicken pox can develop shingles. The virus lies dormant in the body for years before it presents as shingles. No one knows why or exactly what triggers the virus to become active again. Shingles is more common in people over 60, and nearly 50% of at-risk individuals over 80 will develop the disease.

While shingles itself is very painful, in the population over the age of 70, about three-quarters will develop persistent pain that continues after the shingles rash has healed. This pain is called post-herpetic neuralgia (PHN). PHN is the most common, and most dreaded, complication of shingles. Pain may endure for months or even years.

Assessing Pain
Assessing pain in the elderly can be very difficult. It is not uncommon for older patients to prefer words like “discomfort” instead of “pain” or to use a description of the sensation like “my stomach kind of cramps up some times” instead of saying “it hurts.” In any encounter with an elderly patient, draw them out to get as much information as possible.

Another barrier is that describing pain can be confusing, not unlike trying to explain a noise a car is making to an automobile mechanic.

There are key questions that should be asked in the initial visit of an elderly patient presenting with chronic pain:

• Where does it hurt?
• Is the pain constant, or does it come and go?
• If the pain comes and goes, is there any regular time of the day that it occurs?
• Is it affected by what you eat?
• Can the pain be verbally described (e.g. sharp, shooting, burning, sticking etc.)?

If the patient finds it difficult to describe his/her pain, there are several excellent visual tools available that can help.

One is a body diagram that a patient uses to indicate where the pain occurs. The diagram is accompanied by a list of symbols that can be used to describe the kind of pain:

Appendix C is a copy of a body diagram that can be removed and reproduced.

Another useful visual tool is the Visual Analog Scale (VAS). There are several different types, but the one included as Appendix D involves a straight vertical line running down the middle of the page between a statement at the top that says “The Worst Imaginable Pain” and a statement at the bottom that says “No Pain.” The patient should be shown the scale, and the statements should be read to him/her. Then the patient should mark the place along the line that best represents the severity of the pain.

A numeric scale is very similar to the VAS. It uses the numbers one through ten along a horizontal plane. With the number one representing no pain, the number five representing moderate pain and the number ten representing the worst pain possible, the patient is asked to circle the spot that best describes the severity of the pain. Following is an example of a numeric scale.

A copy of a numeric scale that can be removed and reproduced is included as
Appendix E.

The pain scale used should be signed by the patient, dated and kept in the patient's file. It is recommended that a new assessment be made at each subsequent visit, signed by the patient, dated and kept in the patient’s file.

Another very useful non-verbal scale is the Wong-Baker FACES Pain Rating Scale.³ This scale uses expressions on faces to represent pain. Each face has a caption.

The patient is shown the face and asked to read the appropriate caption, then circle the face that represents the severity of his/her pain. Included as Appendix M is a “Resources” section that lists the Website and mailing address for physicians to download the scale for clinical use.

It can be extremely difficult to assess pain in elderly patients who cannot communicate verbally, or have extreme dementia. The patient must be observed for clues as to whether or not they are in pain. Figure 1 is an example of a tool that was adapted from the pain assessment tool created by the Safe Conduct Team of the Safe Conduct Project, Ireland Cancer Center. The Ireland Cancer Center is a partnership of University Hospitals of Cleveland and Case Western Reserve University. There are other excellent assessment tools for non-communicative patients available, and Internet addresses are provided in our Resources section.

Recording the behaviors that are used to assess pain will change for each individual patient, so it is critical to establish baseline behaviors. In response to a sharp pain one patient might moan, another might twitch, another might pace. The health care provider must determine the patient’s usual behavior so changes can be monitored and evaluated based on the patient’s unique pain expression.

The Legal Aspects
There are a number of legal questions that arise in the face of treating pain in the elderly. One is the issue of patient competence.

What if the patient is not mentally competent and cannot answer pain assessment questions? Or make decisions regarding treatment?

In the absence of advance directives, most states have established a hierarchy of surrogacy to make decisions for an incompetent patient, usually a spouse, child or sibling. If there is no relative, the state will assign a guardian or power-of-attorney to make health care decisions.Like a family member, this person is legally obligated to act in the best interest of the patient.

The physician is legally obligated to follow the dictates of the patient or the patient’s surrogate. That, too, can raise difficult legal and ethical issues. What if the pain medication hastens the patient's death? Is the physician liable for charges of murder or for illegally assisting in a suicide?

The other question that arises is who is responsible for treating the elderly patient when he/she enters a long-term care facility? When does the primary care physician's responsibility end? Further, does it end if there is no formal transfer from the primary care physician to the facility’s attending physician?

As can be seen in the following real life case⁴ of an elderly cancer patient, failure to provide adequate treatment in the face of these questions can have serious ramifications for all health care providers involved.

Case Study
NOVEMBER, 2000. - Mr. Lester Tomlinson was diagnosed with mesothelioma due to occupational exposure to asbestos. The prognosis was terminal and when informed, the patient executed an advance directive that stated he wanted to receive all medication necessary to relieve as much pain as possible, even if the medication might actually accelerate his death. The patient was able to remain at home, and his physician prescribed Vicodin tablets for pain relief.

JANUARY, 2001- HOSPITAL, DAY ONE - In January 2001, he had to be taken to a local hospital by ambulance because of what he described as shortness of breath and increasing discomfort in his chest. He was admitted to the hospital with a diagnosis of pleural effusion. Although he had been given Toradol and Percocet while in the hospital emergency center, his primary care physician's admitting orders included only 1-2 tablets of Vicodin every 4 hours as needed. He was in the hospital for four days, and although the nurses recorded pain levels that at times were as high as 9 on a scale of 10, his medication was never adjusted.

NURSING FACILITY - DAY ONE - He was released from the hospital to a skilled nursing facility. Since his primary care physician did not treat patients in nursing facilities, a physician who did treat nursing home patients assumed his care. When he was admitted to the facility, a nurse recorded a pain level of 6-7 out of 10, but the transfer orders did not include any pain medications. Further, even though the facility's policies required starting a Pain Flow Sheet for him, it was not done.

DAY TWO - The nursing facility physician’s nurse practitioner examined the patient. This was the only time she would see the patient. No pain medication was ordered.

DAY THREE - The day after that the patient's daughter spoke to the nurse practitioner and told her that her father was in pain but had no pain medication. A telephone order for 1-2 Vicodin tablets as needed was recorded, but no medication was administered.

DAY FOUR - The patient received his first pain medication. It was not effective. Facility records indicate the patient moaned and actually yelled from pain all night. The daughter contacted the physician’s office. Office records indicate that a message from the daughter that her father was screaming in pain was received. The physician’s office did nothing.

DAY SIX - Again the daughter contacted the physician’s office. She requested that Fentanyl patches be ordered for her father. The physician ordered a 25 mcg patch by phone. Two days later the daughter contacted the physician’s office to request the medication be increased because the patient’s pain had increased. A 50 mcg patch was ordered.

DAY NINE - The nurse practitioner visited the facility and looked at the patient’s chart, but did not go to see him.

DAY THIRTEEN - The facility faxed the physician a message that the patient’s daughter had requested morphine around the clock due to the patient’s low threshold of pain. Morphine in the form of Roxanol 10 mg tablets was ordered to be given every 6 hours. The facility finally listed pain as a formal problem on his patient care plan.

DAY FIFTEEN - The facility physician saw the patient for the first-and only-time. He ordered “MS Contin oral solution [sic] 10 mg every 4 hours 'as-needed' for breakthrough pain.” (This was an incorrect prescription. First, Ms Contin is a controlled-release tablet. Second, it is a long-lasting morphine preparation that the manufacturer recommends only be taken twice a day-every 12 hours-never prn, and never repeated sooner than 8 hours.⁵) Two days later the physician changed the prescription to MS Contin 5 mg to be be taken every 2 hours prn.

DAY SEVENTEEN - The patient’s daughter faxed a letter to the physician advising that her father had been in severe pain throughout his stay at the facility. His cries and moans were so bad that the other patient in his room had not slept for the past four nights. She inquired if her father should be hospitalized for pain control. The physician issued a direct order to his staff not to communicate with the daughter. Facility records indicate that the patient moaned all night long.

DAY EIGHTEEN - On February 12, nursing notes document pain and anxiety. His family requested that the Roxanol dose be increased. The patient died later that day.

This case took place in California, where the patient’s family would not be able to recover damages for pain and suffering if a malpractice suit was filed because the patient died. Instead, the family sued everyone involved for elder abuse: the primary care and nursing home physicians, the nurse practitioner and the nursing home director. A complaint was also filed against the nursing home physician with the Medical Board of California.

All the defendants settled. The financial terms of the settlements were not made public, but along with making financial restitution to the family, the defendants were required to enroll in pain management education.

Being found guilty of violations that fall under the umbrella “elder abuse” can result in serious legal consequences. In this case, the violations include:

1. Abandonment - A physician has a duty to his/her patient to provide medical care until replacement care has been established. When a patient is transferred to a nursing or other long-term care facility, the primary care physician must maintain contact with the patient and the patient's family or other caregivers to make certain that proper medical care is continued. The physician cannot remove him/herself from caring for the patient until adequate continuing care has been established. Otherwise the physician can be held liable for abandoning the patient.
2. Negligence - Charges of negligence can be-and in this case were-brought against every health care provider involved in the man’s care. Beginning with the physician assigned to his care in the nursing home and his nurse practitioner, both of whom failed to even examine the patient for several days. Each neglected to follow through when the patient’s daughter contacted them, and each clearly failed to abide by the patient’s legally executed advance directive.
3. Breach of Duty - When a physician accepts a patient into his/her care, a legal relationship is created. The physician thereby has accepted a duty to provide reasonable care to the patient. This duty can only be ended through appropriate processes.
4. Failure to Provide the Standard of Care - Simply stated, “The Standard of Care” is the degree of care that a reasonable person should exercise when treating a patient, or the care that a reasonable person would expect to receive in a given situation. Most facilities and institutions have published guidelines for all medical treatment. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) adopted standards for the assessment and management of pain in accredited hospitals and other health care settings in 2001. These standards have been endorsed by the American Pain Society and provide excellent guidelines for all pain management. The JCAHO Internet address is in our Resources section.

Summary
In the year 2000, the US population of adults 65-84 was just over 30 million; by 2050 it will more than double. The population of adults 85 and over was 4.2 million. By 2050 it will more than quadruple to an estimated 21 million. Treating frail elderly patients will become an almost ordinary occurrence. Given the vagaries of age, many patients will require extraordinary care. Complex or unusual circumstances regarding the treatment of pain in the elderly are likely to arise, and clinicians are advised to seek the advice of risk managers and ethics decision-makers. Only in that way can one make certain his/her medical practice is protected.

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