Musculoskeletal pain and analgesic therapy in a very old population

Pain Perception and Management: Where do We Stand?

BACKGROUND

Pain is often flammable, sharp and sometimes described as an electrical shock. It can be categorized in three different ways as nociceptive, neuropathic and inflammatory. Nociceptive pain always originates in specific situations such as in trauma. Neuropathic pain results in nerve damage. In inflammatory pain, inflammatory mediators are involved in the sensitization of nociceptors. It is important to control the pain as it affects the individual physically, mentally, and socially.

OBJECTIVE

Recognizing pain physiopathology and pain pathways, defining the relationship between receptor and transmitter is critical in developing new treatment strategies. In this review, current information on the definitions, classifications, and physiological and chemical mechanisms involved in pain are reviewed.

METHODS

Various search engines were used to gather related articles/information. Only peer-reviewed journals were considered. Additional, books/chapters of standard publishers were also included in the article.

RESULTS

With a better understanding of the physiological and chemical mechanisms that play a role in pain, significant improvements have been made in pain treatment. Various oral or intravenous drugs, local injection treatments, physical and occupational therapy, electrical stimulation, alternative medicine applications, psychological support, and surgical applications are routinely performed in the treatment, dependent upon the type, severity and cause of the pain.

CONCLUSION

Improved understanding of pain physiopathology will serve as the basis for future improvements in the delivery of efficacious and reliable treatments, and is likely to rely on novel technological innovations.

Chronic musculoskeletal pain in European older adults: Cross-national and gender differences

BACKGROUND

In an ageing Europe, chronic pain is a major public health problem, but robust epidemiological data are scarce. This study aimed to analyse the prevalence of and factors associated with chronic musculoskeletal pain by gender in older adults of 14 European countries.

METHODS

A cross-sectional study was performed from wave 5 of the Survey of Health, Ageing and Retirement in Europe (SHARE). The study included people ≥50 years residing in Austria, Belgium, Czech Republic, Denmark, Estonia, France, Germany, Italy, Luxembourg, the Netherlands, Slovenia, Spain, Sweden and Switzerland. Chronic pain was defined as being bothered by joint and/or back pain for the previous 6 months. Multivariable Poisson regression models with robust variance were performed to analyse prevalence ratio by covariates, stratified by sex.

RESULTS

A total of 61,157 participants were included. Overall prevalence of chronic musculoskeletal pain was 35.7% (28.8-31.7), ranging from 18.6% (17.1-20.1) for Switzerland to 45.6% (43.3-47.8) for France. Prevalence was higher in women than in men: 41.3% (40.2-42.4) versus 29.1% (28.0-30.3). Chronic musculoskeletal pain was lower in men aged >75 years (PR = 0.82; 0.72-0.92) than the younger (50-59) group. Separated/divorced status presented opposite effects among men (PR = 0.85; 0.76-0.96) and women (PR = 1.12; 1.03-1.21) compared with married, and unemployment was a significant factor in men (PR = 1.21; 95% CI 1.02-1.43) compared with employed.

CONCLUSIONS

Musculoskeletal pain in older European adults is very frequent, especially in women, with large differences depending on the country of residence. Health policy makers should prioritize strategies aimed at improving the prevention and management of chronic musculoskeletal pain in Europe.

SIGNIFICANCE

This study provides epidemiological data of chronic musculoskeletal pain in older adults. Reported differences contribute to highlight the relevance of considering a gender perspective in chronic musculoskeletal pain research. Cross-national comparison also offers a map of differences that improves the knowledge of this chronic condition in Europe.

Chronic Pain: How Challenging Are DDIs in the Analgesic Treatment of Inpatients with Multiple Chronic Conditions?

Background

Chronic pain is common in multimorbid patients. However, little is known about the implications of chronic pain and analgesic treatment on multimorbid patients. This study aimed to assess chronic pain therapy with regard to the interaction potential in a sample of inpatients with multiple chronic conditions.

Methods and Findings

We conducted a retrospective study with all multimorbid inpatients aged ≥18 years admitted to the Department of Internal Medicine of University Hospital Zurich in 2011 (n = 1,039 patients). Data were extracted from the electronic health records and reviewed. We identified 433 hospitalizations of patients with chronic pain and analyzed their combinations of chronic conditions (multimorbidity). We then classified all analgesic prescriptions according to the World Health Organization (WHO) analgesic ladder. Furthermore, we used a Swiss drug-drug interactions knowledge base to identify potential interactions between opioids and other drug classes, in particular coanalgesics and other concomitant drugs. Chronic pain was present in 38% of patients with multimorbidity. On average, patients with chronic pain were aged 65.7 years and had a mean number of 6.6 diagnoses. Hypertension was the most common chronic condition. Chronic back pain was the most common painful condition. Almost 90% of patients were exposed to polypharmacotherapy. Of the chronic pain patients, 71.1% received opioids for moderate to severe pain, 43.4% received coanalgesics. We identified 3,186 potential drug-drug interactions, with 17% classified between analgesics (without coanalgesics).

Conclusions

Analgesic drugs-related DDIs, in particular opioids, in multimorbid patients are often complex and difficult to assess by using DDI knowledge bases alone. Drug-multimorbidity interactions are not sufficiently investigated and understood. Today, the scientific literature is scarce for chronic pain in combination with multiple coexisting medical conditions and medication regimens. Our work may provide useful information to enable further investigations in multimorbidity research within the scope of potential interactions and chronic pain.

Pain in Neurodegenerative Disease: Current Knowledge and Future Perspectives

Neurodegenerative diseases are going to increase as the life expectancy is getting longer. The management of neurodegenerative diseases such as Alzheimer's disease (AD) and other dementias, Parkinson's disease (PD) and PD related disorders, motor neuron diseases (MND), Huntington's disease (HD), spinocerebellar ataxia (SCA), and spinal muscular atrophy (SMA), is mainly addressed to motor and cognitive impairment, with special care to vital functions as breathing and feeding. Many of these patients complain of painful symptoms though their origin is variable, and their presence is frequently not considered in the treatment guidelines, leaving their management to the decision of the clinicians alone. However, studies focusing on pain frequency in such disorders suggest a high prevalence of pain in selected populations from 38 to 75% in AD, 40% to 86% in PD, and 19 to 85% in MND. The methods of pain assessment vary between studies so the type of pain has been rarely reported. However, a prevalent nonneuropathic origin of pain emerged for MND and PD. In AD, no data on pain features are available. No controlled therapeutic trials and guidelines are currently available. Given the relevance of pain in neurodegenerative disorders, the comprehensive understanding of mechanisms and predisposing factors, the application and validation of specific scales, and new specific therapeutic trials are needed.

The clinical characteristics of older people with chronic multiple-site joint pains and their utilisation of therapeutic interventions: data from a prospective cohort study

Background

Chronic multiple-site joint pain (MSJP) is common in older people and associated with poor outcomes, yet under-researched. Our aim was to detail the clinical characteristics of people with MSJP and their utilisation of therapies.

Methods

MSJP was defined as pain in at least one large joint and one other joint for >6 weeks in the last three months. A mixed community, primary and secondary care cohort of people >50 years old underwent detailed history and examination by a single clinician. Treatment utilisation was recorded comprehensively.

Results

201 adults were recruited, 82 % women, mean age 63, BMI 31 kg/m². Median number of painful joints per patient was 6 (IQR 4–9; range 2–17); most common painful sites were knee (84 %), lower back (62 %) and shoulder (47 %). 194/201 (96 %) had an osteoarthritis (OA) diagnosis, 155/194 (80 %) also had soft tissue pathology and 72 % had back problems. 85 % had OA at multiple sites. Upper and lower limb weakness was common (90 and 77 % respectively). Lower limb weakness was significantly associated with obesity. Only 26 % had received written information about their joints. Though 79 % had attended physiotherapy, the majority (93 %) had muscle weakness. Only 36 % of overweight participants had accessed weight-loss support. Half of those with foot pain had seen a podiatrist or used appliances. Multiple concurrent pharmacological therapies were used by 47 %.

Conclusion

MSJP represents a combination of OA, back pain and soft tissue disorders; muscle weakness is extremely common. Therapies appear underutilised in people with MJSP. Identifying the reasons for this should guide effective intervention research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1049-0) contains supplementary material, which is available to authorized users.

Prevalence and treatment of pain in non-institutionalized very old population: transversal study at national level

BACKGROUND

In Europe, there is no conclusive data at national level about pain prevalence in non-institutionalized very old population. In USA, it has recently been reported a high prevalence (56 %); however, this data can not be extrapolated to other regions because the known influence of geographical and ethnic differences. Furthermore there are few data on use of treatments for pain in this population.

AIMS

To explore prevalence and considered pharmacological treatments for pain in this population.

METHODS

Transversal study on 551 participants aged 80 or more living in Spain (non-institutionalized). Probabilistic multistage sampling was carried out, stratified by sex and place of residence. All Spanish regions were considered for recruitment process. Pain (last 4 weeks), intensity (Face Pain Scale), localization and pharmacological treatments were evaluated by in-person interviews.

RESULTS

Pain's prevalence was 52.5 % (CI 95 % 48.28-56.80) and 38.5 % experienced pain of at least moderate intensity. The most frequently involved body regions were lower limbs (26.6 %) and dorso-lumbar region (21.9 %). Only 40 % of participants with pain and 43.2 % with moderate or severe pain used analgesics, and paracetamol was less frequently used than non-steroidal anti-inflammatory drugs at any pain intensity. Age was not associated with higher prevalence [odds ratios 0.97 (CI 95 % 0.93-1.02) in females and 0.99 (CI 95 % 0.92-1.06) in males].

CONCLUSIONS

The prevalence of pain in non-institutionalized very old people is high. Pain is probably being undertreated, even moderate or severe pain. Guideline's recommendations are probably not being considered to select the analgesic therapy.

Effective pain management in patients with dementia: benefits beyond pain?

This current opinion aims to provide a literature overview of the associations between pain and neuropsychiatric symptoms and the efficacy of pain management for both pain and neuropsychiatric symptoms in patients with dementia. In addition, international guidelines and recommendations for pain management have been collated, and important developing research areas are highlighted. Pain is, in general, under-recognized and undertreated in people with dementia and may therefore trigger or exacerbate neuropsychiatric symptoms. While there is an abundance of pain assessment instruments intended for people with dementia, few have been adequately tested for their feasibility, reliability and validity. In patients with dementia, vocalizations, facial expressions and body movements may be the only valid expressions of pain. Further, pain has been related to the neuropsychiatric symptoms of agitation, aggression, mood syndrome and sleep problems. Unfortunately, health personnel may misinterpret these symptoms as neuropsychiatric symptoms of dementia. A differential assessment of dementia, its presenting neuropsychiatric symptoms and the potential presence of pain is crucial to provide the correct treatment. To achieve this, use of pain assessment tools that are responsive to change and are validated for use in patients with dementia is a prerequisite. To date, there have been few studies, with inconsistent findings on the association between pain and neuropsychiatric symptoms. To ensure a better differential assessment of pain and neuropsychiatric symptoms, and consequently more accurate treatment for patients with dementia, studies with adequate statistical power and high-quality study designs, including randomized controlled trials, are needed.

Prevalence of pain with advancing age brief report

BACKGROUND

The epidemiology of chronic pain with advancing age remains poorly established. Although most studies have examined somatic (musculoskeletal and joint) pain, visceral pain (such as headache and abdominal pain) has warranted less attention. We present longitudinal data from age 70 to 90 years concerning chronic musculoskeletal/joint pain, abdominal pain, and headache.

METHODS

Data was collected by the Jerusalem Longitudinal Study, which is a prospective study of a representative sample from the 1920-1921 birth-cohort living in West Jerusalem. Participants underwent comprehensive assessment at home in 1990, 1998, 2005, and 2010, at ages 70 (n = 460), 78 (n = 763), 85 (n = 1149), and 90 years (n = 394), respectively, and were directly questioned concerning the presence and location of pain.

RESULTS

The overall prevalence of pain of any kind at ages 70, 78, 85, and 90 years was 73% (n = 336/460), 81.1% (n = 619/763), 56.3% (n = 647/1149), and 31.2% (n = 123/394), respectively. Pain at younger ages only was associated with female gender, lower educational status, functional dependence, physical inactivity, increased body mass index, loneliness, depression, and poor self-rated health. At ages 70, 78, 85, and 90 years, chronic neck/back pain was present among 41.5%, 58.9%, 30.1%, and 14.6% of participants, respectively; chronic joint pain was present among 43.0%, 60.6%, 45.2%, and 25.2%, respectively. In contrast abdominal pain was less common and disappeared among the oldest old: 14.7%, 13.9%, 1.7%, and 1.5%, respectively, with a similar pattern for headache: 43.3%, 33.5%, 2.1%, and 1.3%. While pain was reported at ≥2 sites by 42.3% and 54.6% at ages 70 and 78 years, respectively, by ages 85 and 90 years, pain was most frequently reported at only 1 site.

CONCLUSIONS

Visceral pain (headache and abdominal pain) completely disappeared among the oldest old, in contrast to a far smaller decline in somatic (musculoskeletal and joint) pain.

Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools

BACKGROUND

There is evidence of under-detection and poor management of pain in patients with dementia, in both long-term and acute care. Accurate assessment of pain in people with dementia is challenging and pain assessment tools have received considerable attention over the years, with an increasing number of tools made available. Systematic reviews on the evidence of their validity and utility mostly compare different sets of tools. This review of systematic reviews analyses and summarises evidence concerning the psychometric properties and clinical utility of pain assessment tools in adults with dementia or cognitive impairment.

METHODS

We searched for systematic reviews of pain assessment tools providing evidence of reliability, validity and clinical utility. Two reviewers independently assessed each review and extracted data from them, with a third reviewer mediating when consensus was not reached. Analysis of the data was carried out collaboratively. The reviews were synthesised using a narrative synthesis approach.

RESULTS

We retrieved 441 potentially eligible reviews, 23 met the criteria for inclusion and 8 provided data for extraction. Each review evaluated between 8 and 13 tools, in aggregate providing evidence on a total of 28 tools. The quality of the reviews varied and the reporting often lacked sufficient methodological detail for quality assessment. The 28 tools appear to have been studied in a variety of settings and with varied types of patients. The reviews identified several methodological limitations across the original studies. The lack of a 'gold standard' significantly hinders the evaluation of tools' validity. Most importantly, the samples were small providing limited evidence for use of any of the tools across settings or populations.

CONCLUSIONS

There are a considerable number of pain assessment tools available for use with the elderly cognitive impaired population. However there is limited evidence about their reliability, validity and clinical utility. On the basis of this review no one tool can be recommended given the existing evidence.

Guidance on the management of pain in older people

This guidance document reviews the epidemiology and management of pain in older people via a literature review of published research. The aim of this document is to inform health professionals in any care setting who work with older adults on best practice for the management of pain and to identify where there are gaps in the evidence that require further research. The assessment of pain in older people has not been covered within this guidance and can be found in a separate document (http://www.britishpainsociety.org/pub_professional.htm#assessmentpop). Substantial differences in the population, methods and definitions used in published research makes it difficult to compare across studies and impossible to determine the definitive prevalence of pain in older people. There are inconsistencies within the literature as to whether or not pain increases or decreases in this age group, and whether this is influenced by gender. There is, however, some evidence that the prevalence of pain is higher within residential care settings. The three most common sites of pain in older people are the back; leg/knee or hip and 'other' joints. In common with the working-age population, the attitudes and beliefs of older people influence all aspects of their pain experience. Stoicism is particularly evident within this cohort of people. Evidence from the literature search suggests that paracetamol should be considered as first-line treatment for the management of both acute and persistent pain, particularly that which is of musculoskeletal origin, due to its demonstrated efficacy and good safety profile. There are few absolute contraindications and relative cautions to prescribing paracetamol. It is, however, important that the maximum daily dose (4 g/24 h) is not exceeded. Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in older people after other safer treatments have not provided sufficient pain relief. The lowest dose should be provided, for the shortest duration. For older adults, an NSAID or cyclooxygenase-2 (COX-2) selective inhibitor should be co-prescribed with a proton pump inhibitor (PPI), and the one with the lowest acquisition cost should be chosen. All older people taking NSAIDs should be routinely monitored for gastrointestinal, renal and cardiovascular side effects, and drug–drug and drug–disease interactions. Opioid therapy may be considered for patients with moderate or severe pain, particularly if the pain is causing functional impairment or is reducing their quality of life. However, this must be individualised and carefully monitored. Opioid side effects including nausea and vomiting should be anticipated and suitable prophylaxis considered. Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people who are prescribed opioid therapy. Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain. But, tolerability and adverse effects limit their use in an older population. Intra-articular corticosteroid injections in osteoarthritis of the knee are effective in relieving pain in the short term, with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects. It should be considered in patients who are intolerant to systemic therapy. Intra-articular hyaluronic acid appears to have a slower onset of action than intra-articular steroids, but the effects seem to last longer. The current evidence for the use of epidural steroid injections in the management of sciatica is conflicting and, until further larger studies become available, no firm recommendations can be made. There is, however, a limited body of evidence to support the use of epidural injections in spinal stenosis. The literature review suggests that assistive devices are widely used and that the ownership of devices increases with age. Such devices enable older people with chronic pain to live in the community. However, they do not necessarily reduce pain and can increase pain if used incorrectly. Increasing activity by way of exercise should be considered. This should involve strengthening, flexibility, endurance and balance, along with a programme of education. Patient preference should be given serious consideration. A number of complementary therapies have been found to have some efficacy among the older population, including acupuncture, transcutaneous electrical nerve stimulation (TENS) and massage. Such approaches can affect pain and anxiety and are worth further investigation. Some psychological approaches have been found to be useful for the older population, including guided imagery, biofeedback training and relaxation. There is also some evidence supporting the use of cognitive behavioural therapy (CBT) among nursing home populations, but of course these approaches require training and time. There are many areas that require further research, including pharmacological management where approaches are often tested in younger populations and then translated across. Prevalence studies need consistency in terms of age, diagnosis and terminology, and further work needs to be done on evaluating non-pharmacological approaches.

Assessment and treatment of pain in people with dementia

Many elderly people experience pain and regularly take analgesic medication. Pain is also frequent in people with dementia, particularly those with severe disease. As no robust clinical guidelines are available for the treatment of pain in the context of dementia, the risk of inadequate treatment in individuals with this condition is high. Furthermore, our understanding of the aetiology of pain and the potential role of dementia-associated neuropathology in pain is limited. These issues are important in the clinical management of individuals with dementia, as untreated pain is a major contributor to reduced quality of life and disability, and can lead to increased behavioural and psychological symptoms. Assessment scales to identify pain in people with dementia have been highlighted in recent studies, but there is little evidence for consistency between these tools. Numerous studies have evaluated various approaches for the treatment of pain, including stepped-care protocols and/or administration of paracetamol and opioid medications. In this Review, we summarize the best-available evidence regarding the aetiology, assessment and treatment of pain in people with dementia. Further validation of assessment tools and large-scale trials of treatment approaches in people with dementia are needed to improve clinical guidance for the treatment of pain in these individuals.

Undertreatment of osteoporosis in persons with dementia? A population-based study

In this population-based study of more than 2,600 elderly, people with dementia received less preventive treatment for osteoporosis compared to people without dementia, although osteoporotic fractures were more common in patients with dementia. Thus, our results indicate an undertreatment of osteoporosis in dementia.

INTRODUCTION

This study compares the use of osteoporosis drugs in elderly with and without dementia, taking into account osteoporotic fractures and type of housing.

METHODS

We analyzed data from the baseline examination (2001-2004) of The Swedish National Study on Aging and Care- Kungsholmen (SNAC-K), Stockholm, Sweden. Participants were aged ≥ 66 years (n = 2610). We analysed the use of bisphosphonates, raloxifene, and calcium/vitamin D combinations in relation to clinically based dementia diagnosis. Information about osteoporotic fractures during the previous 4 years was obtained from the Swedish National Patient Register. We used logistic regression to analyze the association between dementia status and use of osteoporosis drugs.

RESULTS

Osteoporosis drugs (mainly calcium/vitamin D combinations) were used by 5% of the persons with dementia and 12% of the persons without dementia. Furthermore, 25% of the persons with dementia and 7% of the persons without dementia had had at least one osteoporotic fracture during the past 4 years. After controlling for age, sex, osteoporotic fractures, and type of housing (own home or institution), persons with dementia were less likely to use osteoporosis drugs than persons without dementia (OR = 0.34; 95% CI, 0.19-0.59).

CONCLUSIONS

Our results indicate an undertreatment of osteoporosis in persons with dementia, although osteoporotic fractures are common among these patients.

Pain Assessment and Treatment Challenges in Patients with Dementia 1This article is a modified version of the article „Pain in patients with dementia: An overview of pain assessment and treatment challenges” that will be printed in the Journal of Norsk Epidemiologi

Pain is likely to be equally prevalent in people with dementia, however, only a small minority are prescribed regular analgesics. This is a key issue since untreated pain leads to reduced quality of life and increases the likelihood of emergence of behavioural and psychological symptoms such as agitation. Better assessment and treatment of pain in this fragile patient group are therefore mandatory. In this context, we reviewed the literature on pain and dementia and summarised the best available evidence regarding the frequency of pain and pain diagnosis. Unfortunately, hardly any randomized, controlled studies of pain treatment efficacy in patients with dementia are available, with the consequence that most pain treatment recommendations are not based on the highest level of evidence.

Pain treatment in elderly persons with and without dementia: a population-based study of institutionalized and home-dwelling elderly

BACKGROUND

Several previous studies have reported an undertreatment of pain in elderly persons with dementia. It has also been suggested that persons with dementia may be at risk for inappropriate treatment of pain with psychotropics.

OBJECTIVES

The objective of this study was to investigate if persons with dementia are as likely as persons without dementia to receive pharmacological pain treatment, after taking into account residential setting and pain-related disorders. We also aimed to investigate whether use of psychotropics is related to pain in persons with and without dementia.

METHODS

We used baseline data from the SNAC-K (Swedish National Study of Aging and Care - Kungsholmen). We analysed use of analgesics and psychotropics, prevalence of pain-related diagnoses, self-reported pain, dementia status and residential setting in 2610 participants aged > 65 years.

RESULTS

Of the persons with dementia, 46% used at least one analgesic drug compared with 25% of those without dementia. Although persons with dementia reported pain less frequently than persons without dementia, the prevalence of pain-related diagnoses was similar. After adjustment for individual factors and residential setting (own home/institution), persons with dementia had a higher probability of use of paracetamol (acetaminophen) and psychotropics, whereas there were no significant differences in use of any analgesic, opioids and NSAIDs. Furthermore, having a pain-related diagnosis was associated with use of psychotropics in persons with dementia.

CONCLUSIONS

Persons with dementia had a higher probability of use of paracetamol and were about as likely as persons without dementia to use any analgesic, opioids and NSAIDs, after adjustment for confounders. This may reflect a recent increased awareness of pain and pain management in persons with dementia, compared with previous studies that have reported an underuse of analgesics in persons with dementia. However, further research is needed to analyse if persons with dementia are appropriately treated for pain with regard to type of analgesic drug, pain intensity, indication, dosage and regimen.

Older Adults’ Ways of Dealing With Daily Life While Living With Long-Term Musculoskeletal Pain at Home

Long-term musculoskeletal pain is a global health problem among older adults. Yet little is known about how these older adults actually deal with daily life. This study’s aim is to describe the ways these older adults dealt with daily life at home. Phenomenography is used to collect and analyze data from semistructured interviews with 19 older adults and to identify the range in which they dealt with daily life. Findings consist of an outcome space that encompassed four categories: ignore, struggle, adjust, and resign. The different ways older adults dealt with daily life when living with long-term pain at home strengthen the importance of individualized plans of care in the home and a holistic perspective. Findings contribute to enhanced understanding of a common health problem among older adults that can be used to promote quality of care and improve the quality of life of older adults.

Manejo del dolor del anciano en Atención Primaria (Estudio ADA)

OBJECTIVE

The main purpose of this study is to obtain information concerning type, clinical evaluation and therapeutic management of pain in elderly people in a Primary Care setting.

METHODOLOGY

Observational prospective study, conducted in the Primary Care setting in elderly patients, who were attended in the doctor's office with pain as main or secondary symptom. A total of 213 physicians and 1120 patients have participated in the study. Demographic data and clinical characteristics, pain intensity (as measured by Visual Analogical Scale -VAS-), diagnostic methods, treatments and sanitary resources used have been collected.

RESULTS

Pain was the main reason for visiting the physician in 86.2% of patients. The main characteristics of pain were: nociceptive pain (80.8%), lower limbs location (43.5%), degenerative etiology (71.8%) and chronic (67,7%). Pain intensity, as measured by VAS, was 7.1 +/- 1.3. Degree of satisfaction with previous analgesic treatments was good/very good in 30% of patients. The analgesics most frequently prescribed in this study were paracetamol (87.4%) and NSAID (51.2%).

DISCUSSION

Chronic nociceptive pain of degenerative etiology, and not very satisfactory response with previous treatments are the main characteristics of the elderly patient with pain that were attended by the Primary Care physician.

Quality of life and symptoms among older people living at home

AIM

This paper reports a study comparing the socio-demographic data, quality of life (QoL) and symptoms of older people living at home with and without help.

BACKGROUND

Despite growing numbers of older people worldwide, little is know about the differences between older people receiving help to live at home and those not receiving this, especially as regards QoL and symptoms. Not only symptoms but also dependency on others per se may reduce older people's QoL. From a nursing perspective, knowledge about such issues is important because the impact of symptoms may be reducible, even when diseases cannot be cured.

METHOD

A postal questionnaire was sent to an age-stratified random sample of 1866 people aged 75 years or over. Of the respondents (n = 1248) 448 received help and 793 did not.

RESULTS

The group receiving help had a significantly higher age, more women, more people widowed and living alone, more children, a higher number of self-reported diseases and symptoms, greater inability to remain alone at home and lower QoL. Loneliness, depressed mood and abdominal pain were significantly related to low QoL in both groups. Living alone, not being able to remain alone at home without help, and fatigue were also predictive of low QoL among those receiving help, and number of diseases and sleep problems in those without.

CONCLUSION

Receiving help with daily living seems to be significantly related to low QoL and goes along with a high number of symptoms that need to be considered in nursing care. Through regular visits, systematic assessment and intervention, especially focusing on older people's symptoms, nurses may contribute to improved QoL for this section of the population.

Pain management among older people in need of help with activities of daily living

The aim of this study was to investigate the use of various pain relief methods among older people in chronic pain and in need of help to manage activities of daily living. People who reported pain and were in need of help to manage activities of daily living were included in the study. The Multidimensional Pain Inventory-Swedish version and a modified version of the Pain Management Inventory were used to study pain and methods of pain relief. The respondents used a variety of methods (median = 3) to relieve their pain; pharmacologic methods, rest, and distraction were the predominant strategies employed. A cluster analysis identified 2 main groups of people: people who used a few well-known methods and were significantly older and people who used a larger repertoire of methods to relieve their pain and reported higher pain severity and interference with daily life. About a third of older people reported inadequate pain relief. These findings stress the need for nurses to inform older people about available methods for pain relief and to do systematic pain assessments to evaluate the effectiveness of various pain relief methods.

Old people in pain: a comparative study

To investigate the prevalence of pain in older people (75+), compare those in pain to those without regarding demographics, social network, functional limitations, fatigue, sleeping problems, depressed mood and quality of life (QOL), and identify variables associated with pain, a cross-sectional, prospective survey was conducted in an age-stratified sample of 4,093 people aged 75-105 years old. Those reporting pain (n=1,654) were compared with those who did not (n=2,439). Pain was more common with higher age, as were all complaints among those in pain and among those without, except sleeping problems. Lower QOL was found with higher age, as well as with pain. Pain was found to be associated with functional limitations, fatigue, sleeping problems, depressed mood, and QOL. These data highlight the importance of identifying old people in pain. Those who are older and those affected by pain are at greater risk of also being troubled by other problems, such as functional limitations and lowered QOL.

Living with persistent pain: experiences of older people receiving home care

BACKGROUND

Although the topic of pain among older people has received increasing interest, little is still known about how pain is experienced or handled by those who no longer manage independently but depend on professionals for help with daily living. Developing pain management for older people requires such knowledge.

AIM

To explore sense of self, sense of pain, daily living with pain, sense of others and ways of handling pain in older people with persistent pain.

METHODS

Interviews with 90 older people receiving home care from nursing auxiliaries in their own homes or in sheltered accommodation were collected from January to June 2000. A typology of older people in persistent pain was developed. Activities for handling pain were examined using content analysis.

FINDINGS

Respondents' experiences of themselves and their pain varied. Two groups of older people, considered as 'competent and proud' and 'confident and serene', expressed satisfaction in spite of pain, while the groups 'misunderstood and disappointed' and 'resigned and sad' expressed dissatisfaction. The most common strategies used were medication, rest, mobility, distracting activities and talking about pain. Respondents chose strategies by balancing the advantages of the activities against the disadvantages these brought for their daily living.

CONCLUSION

This study indicates that characteristics of the older people, such as their way of experiencing themselves, how pain affects their daily life and how they perceive effects and side-effects of pain management are areas that need to be identified when staff assess pain and plan pain management. Caring for older people in pain could be improved by listening to and believing their complaints, evaluating effects and side-effects from medications and nonpharmacological pain management and by emphasising the importance of common everyday activities such as mobility and distraction to relieve pain.

The epidemiology of pain in elderly people

Acute pain probably occurs at much the same rate across all age groups. On the other hand, self-report of chronic pain seems to increase up to, but not beyond, the seventh decade of life. Chronic pain in older people is more often experienced in major joints, the back, legs and feet, whereas visceral pain and headache are reported less often. There is a divergence between an increasing load of pain-associated disease and a plateau of chronic pain complaint in old age that probably reflects impairment in the nociceptive function of the nervous system. However, the contribution of social, behavioral, cognitive, and affective dimensions of the pain experience to this divergence between disease and pain have not been fully evaluated. Most of the answers to these and other questions require longitudinal studies with pain as the predominant focus of attention rather than addressing the symptom of pain as an ancillary measure relevant to other aspects of aging.