HEALTHDoctors urged to do more to control seniors' painGeriatric care guidelines recommend starting with acetaminophen and moving on to COX-2 inhibitors and opioids.By Susan J. Landers, amednews staff. June 3, 2002. Washington -- Physicians can do much to end the persistent pain that plagues many older people. That is the message of new guidelines from the American Geriatrics Society. The recommendations, announced at the AGS' annual meeting last month in Washington, D.C., reflect advances in pain assessment and treatment made since guidelines were last issued four years ago. "We wanted to make them more clinically relevant," said Bruce Ferrell, MD, chair of the panel that drafted the guidelines and an associate professor in the geriatrics division at the University of California, Los Angeles, School of Medicine. Pain is a common complaint among older patients. A Louis Harris telephone survey found that one in five older Americans is taking analgesics several times a week or more, and 63% of those had taken prescription pain meds for more than six months. Yet most experts believe that pain is undertreated, often because physicians and other practitioners don't recognize it in their patients. Panelist Paul Katz, MD, professor of medicine at the University of Rochester School of Medicine and Dentistry, pointed to a recent study that found 25% of cancer patients in nursing homes were not provided any needed analgesic.
1 in 5 seniors takes analgesics regularly.
"So the fact is we do need guidelines," he said. "We're not doing the job." Another reason for the prevalence of pain in the elderly is that many older people believe that it is simply a natural part of aging, said Keela Herr, PhD, RN, who also served on the panel. Elderly patients must be convinced otherwise, she said. The first steps in effective pain assessment include a careful recording of a patient's medical history and a thorough physical examination, said Dr. Herr, a professor of nursing at the University of Iowa College of Nursing. Scales using a thermometer, a series of increasingly distressed faces or simply numbers have been used successfully in many facilities and physicians' offices to help patients describe the level of their pain, she said. Simple scales can even be used for patients with mild cognitive impairments, who often pose more difficult challenges in assessing pain levels. For patients with more severe cognitive impairments, nonverbal clues become important. Increased blinking, heavy breathing, rocking, agitation and changes in interpersonal actions can all be signs of pain, Dr. Herr said. If a withdrawn person becomes uncharacteristically aggressive, or an active person becomes passive, check to see if pain medication brings about a return of more normal behavior. Effective pharmaceuticalsThe first medication to try for mild to moderate pain is acetaminophen, with a starting dosage of 325 mg every four hours and titrating up to 500 mg every six hours, according to the guidelines. For more severe pain, the guidelines recommend using opioids, including Oxycontin, which has gained much notoriety for its addictive potential. Often older patients must be taught not to be afraid of using such drugs, said Perry G. Fine, MD, associate medical director of the University of Utah's Pain Management Center. Dr. Fine helped write the guidelines. While the use of acetaminophen, and even the recommendation that opioids be prescribed, prompted little discussion at the AGS meeting, the guidelines' inclusion of COX-2 inhibitors generated some concern. Some audience members noted that risks have been associated with the use of top-selling pain relievers rofecoxib, or Vioxx, and celecoxib, or Celebrex, and they asked whether cautionary notes should be added to the guidelines. The Food and Drug Administration has warned against using Vioxx if an individual has experienced asthma, hives or another allergic reaction after taking aspirin or other nonsteroidal anti-inflammatory drugs. Dr. Fine defended the society's recommendations, noting that they were based on a careful review of published clinical trials. Dr. Ferrell advised that new data on COX-2 inhibitors are continually being released and that it is important for clinicians to judge this new evidence as it emerges. "These guidelines are not in lieu of clinical judgment," he said. The guidelines do advise against the use of propoxyphene for mild or moderate pain because of its tendency to cause sleepiness. They recommend that methadone only be prescribed by physicians who have considerable experience with its use because of the drug's long and variable half-life. The guidelines also reflect new research that takes into account such age-related bodily changes as alterations in body fat and muscle, gastrointestinal mobility and decreased renal clearance, Dr. Fine noted. There are also common chronic conditions, such as congestive heart disease, arthritis and diabetes, that enter the pharmaceutical picture, said Dr. Fine. The guidelines advise against the use of placebos in the management of pain. It would be unethical to try to fool a patient into thinking he or she is being given a pain-relieving medication when they are given a placebo, said Dr. Fine. Additional approaches to pain relief, such as exercise and patient education, are also recommended. A patient's increased involvement in pleasurable activities, such as gardening or a sport, can be employed along with medications to bring relief from pain, said Jerome J. Epplin, MD, a clinical professor at the Southern Illinois University School of Medicine's Dept. of Family Medicine. While the importance of educating patients cannot be overemphasized, the level of educational material supplied to a patient should be at an appropriate level of understanding, said Dr. Epplin. Physicians were also advised not to ridicule any forms of pain treatment a patient believes might be helpful. Such an approach could undermine a trusting relationship, said Dr. Epplin. ADDITIONAL INFORMATION:Alleviating painMedications listed in the American Geriatric Society's guidelines for pain relief for older patients include: Non-opioids
Opioids
Source: American Geriatric Society WeblinkSummary of the American Geriatrics Society's clinical practice guideline, "The Management of Persistent Pain in Older Persons" (http://www.americangeriatrics.org/education/executive_summ.shtml) Copyright 2002 American Medical Association. All rights reserved.
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