- Institute of Ageing, Keele University

Pain is one of the commonest symptoms in older patients but it has been relatively neglected by both clinicians and researchers.

Steered by Prof Crome, the Institute of Ageing at Keele University organised a study day on the topic, as part of its annual continuing medical education programme.

The day started with a detailed review of both local and international epidemiology of pain by Prof Peter Croft and Dr Lindsay Harris, both from Keele’s Institute of Primary Care Sciences. The evidence for trends in the prevalence of persistent pain in the decades beyond 70 years of age was reviewed. Not surprisingly, persistent pain is found to increase with age. A systematic review of the prevalence of pain in later life concluded that one of the major issues hampering epidemiological and therapeutic research is the absence of a standard age-sensitive definition of pain. Additionally, and not surprisingly, there is a dearth of studies in the considerably older person, as there is in common but rather unglamorous conditions such as osteoarthritis of the hand.

Dr Duncan Forsythe, from Cambridge, explained how to overcome the difficulties of assessing pain in patients with cognitive impairment, including the use of simple pain scales and awareness of non-verbal cues. Since pain not only causes distress, but depression, disability and potential deterioration in cognition, it is imperative that all those treating older people become more proficient in dealing with it.

Dr Tim Hunt, also from Cambridge, reported the results of a pilot study, comparing evaluation and treatment of pain in a palliative care unit with that of an older person’s unit. The study highlighted the absence of pain management in the older person’s unit, along with inappropriate use of medication. Dehydration, with resulting increased adverse effects of opiates, was also more common. He suggested the need for better education of pain management in this age group. These results are rather salutary since many geriatricians believe that they are as good as palliative care specialists in the management of pain in later life.

The afternoon started with a comprehensive overview of the subject by Dr Bruce Ferrell from the UCLA School of Medicine, who chaired the American Geriatrics Society Panel on Persistent Pain in Older Persons. The panel’s activities culminated in the production of national guidelines which have been published in the Journal of the American Geriatrics Society (JAGS 50:S205-S224, 2002). The panel’s recommendations were developed by a multidisciplinary group, consisting not only of geriatricians and pain management experts, but it also included pharmacists, psychiatrists and family practitioners. The Guidelines are divided into four sections: Assessment of Persistent Pain, Pharmacological Treatment, Non-Pharmacologic Strategies and Recommendations for Health Systems that Care for Older Persons. The publication of the Guidelines was widely reported in the press and on local and national television, as well as through older people’s networks.

A lively panel discussion ensued on how the management of pain in older people could be improved. Most people thought that the best approach would be the development of national guidelines, supplemented by an action plan at local level. It was disappointing to note that there is nothing specific about pain in the National Service Framework for Older People, but perhaps clinical champions could take forward the implementation of any guidelines. Lead clinicians would also play an important part in the teaching and use of guidelines with junior medical staff. It is felt that pain management should be included in the education of all healthcare professionals. The guidelines could provide a useful framework for teaching.

There was a divergence of view as to where the assessment and initiation of treatment of persistent pain should be undertaken. Whilst some people felt that primary care was an obvious starting place, others felt that secondary care had more resources and “experts”. An interesting point was also raised, that enquiring about pain during multi-disciplinary team meetings, could, and should become as commonplace as discussion about mobility and continence. It was thought, by several members of the audience, that there should be a research programme assessing the efficacy of alternative therapies in the management of persistent pain in the older age group.

We were fortunate that Dr Beverley Collett, President of the Pain Society was present. A collaboration between her organisation and the British Geriatrics Society has been suggested, as an effective method of tackling this common, distressing and disabling problem. We look forward to the fruits of such a joint venture.

Lisa Youngman and
Peter Crome