One of the most frustrating clinical problems health care providers encounter when caring for older adults is pain. Complaints of discomfort are the leading reason for office visits among elderly patients, with many experts suggesting that nearly every older person experiences some degree of pain on a daily basis. In hospitals and other institutions, pain management is an important activity for those who work primarily with geriatric patients.

How can we help older adults achieve comfort when it may not be realistic to establish a goal of total relief? There are several actions you can take, regardless of the setting where you work.

First, educate yourself about geriatric pain. Many health care providers know very little about this topic, and fall prey to stereotypes, such as:

• Older people don't mind pain
• Older people don't get as much pain
• Medications to relieve pain should be given in smaller doses to older adults
• Many older people are chronic complainers and will say they have pain even if it isn't severe

The truth is that older people get more pain than younger persons due to the increased prevalence of painful conditions, such as osteoarthritis, during the later years. While the verdict still isn't in on whether pain threshold is lowered or raised in older adults, elders tend to be stoical in the face of pain. In general, the 65+ generation is characterized by "health optimism" which means they overestimate how well they are doing health-wise.

There is no evidence that medication dosage should be reduced for older adults. Due to the diversity of the aging experience, each individual should be evaluated in light of his or her body size, overall health status, level of pain, and living circumstances prior to deciding how much or how little analgesic to use.

Second, adjust the way you evaluate pain in your older patients. Using a multifocal approach, consider different dimensions of pain that might be unique to elders. For example, when trying to determine severity of pain, keep in mind that some older persons have trouble conceptualizing a Visual Analogue Scale (VAS) which asks them to rate their pain from 1-10. If you plan on using this method, providing a paper version of the scale formatted as below can help overcome difficulty.

Enlarge the scale as needed to enhance readability, and make sure the older person hears and understands your directions on how to use it.

Don't settle for just asking older people to rate their pain. Question whether the level of pain they have today is typical, and whether they had the same kind of pain yesterday. Then go further back and determine whether the discomfort has persisted for more than three months. Acute pain is generally of more recent onset and expected to resolve in a few days or weeks. Chronic pain is that which lasts longer than 3-6 months, or recurs at regular intervals over time. Older people are unique in that they can have both types of pain coexisting, as in the case study below.

The impact of pain is also important to assess. How has the pain effected your patient's daily activities? For example, did they do less than usual in the last 24 hours because of pain, or were there things they wanted to do but couldn't?

These questions will provide you with a richer understanding of your patient's discomfort and can lead into a discussion of what methods he or she has used to deal with the pain. What has worked, and how well has it worked? Inquire about the degree of effectiveness by asking the elder if they obtained total, partial, or no relief from the therapies they used. Establish how frequently they tried a particular strategy, and, if a new approach is reported, find out why it was tried. Older persons with chronic pain are attractive targets for "quick fix" cures, some of which may be dangerous. Determine whether prescribed medications are acceptable (i.e. low side effect profile, affordable, and obtainable) and what has worked or failed in the past.

Don't forget to explore whether the person is currently using any self-care strategies. A study I recently finished showed that every one of the 30+ older patients we interviewed was using at least one complementary therapy to manage pain. The most commonly used remedies in descending order were: prayer, over-the-counter analgesics which they self-prescribed, heat/cold, exercise, ointments, and music. More importantly, the research emphasized the importance of including patients in the treatment plan given their active search for and use of complementary pain control therapies.

Third, after determining the type of pain your patient has and whether the current plan for treating it is working, collaborate with him or her to make adjustments as needed. Although a discussion of specific analgesics and other treatments for both chronic and acute pain is beyond the scope of this article, continuous evaluation of the effectiveness of medications should be undertaken. At this point, it is important to know what your patient's values and goals are. Does he or she want to keep trying different strategies until total relief is obtained, or is the level of comfort they are currently at satisfactory? Some elders report considerable pain, but adamantly refuse to take any medication, preferring to use other therapies, a value that will directly influence the treatment plan.

Document progress or lack thereof on a pain management flow sheet so all members of the team are aware of status of the plan. Give a copy to the patient as well. A sample of this form is below, and can be used to supplement the regular medical record in any setting.

Don't forget the multitude of nonprescription therapies your patients might be using. These include: over-the-counter medications, herbals, homeopathic remedies, natural supplements such as Glucosamine, special diets, ointments or lotions, yoga, heat or cold, acupuncture, exercise, Electromagnetic Field Therapy, massage, distraction, Transcutaneous Nerve Stimulation (TENS), music, prayer, reflexology, and chiropractic. Some of these may offer relief equal or superior to medications.

Fourth, treat each encounter like a new one. Reevaluate whether the current plan is working, any new treatments the patient or another health care provider prescribed, and make adjustments accordingly. Don't assume if patients aren't complaining of pain that they don't have any. By asking, you give the message that the issue is important to you, and that you want to work with them to find a plan that helps.

If the regimen has changed, make sure to reassess effectiveness. Follow-up on acute and new pain should be quicker and more frequent than chronic pain once a level of satisfactory control is achieved.

Case Example

Rose Letterman is 80, and suffers from osteoarthritis in both hips. She has been on a prescribed non-steroidal anti-inflammatory agent for the last two months, and has tolerated it well. When the NSAID was initially prescribed, Rose reported taking it "prn." Since you explained how these medications worked and encouraged her to take it continuously, she has been compliant, and her discomfort has dropped from a "6" to a "3." Rose is happy with her ability to carry out daily activities since starting on the NSAID, and says if she uses a heating pad before bedtime she is usually able to sleep well and not be bothered by discomfort.

One day, Rose comes to you complaining of pain in her right knee. This pain is sharp and localized, rated a "7," and completely different from her hip pain. She first noticed it the previous evening after she returned from an all day shopping trip with her granddaughter.

Before doing a physical exam, you ask a series of questions which reveal that Rose had done an extraordinary amount of walking the day before. She had developed a blister on her left foot, but had continued on, perhaps favoring her right leg. In reconstructing her day, she remembers a point where she lost her balance briefly and slightly twisted her right leg.

To use the specialized pain documentation form, you would write the following about Rose, in addition to those notes made on the medical record.

DATE	PAIN RATING and DESCRIPTION	COMMENTS	CURRENT THERAPIES	CHANGES	HEALTH CARE PROVIDER'S NAME
2/10/00	Pain = 7 "Worst pain I've had in the last 3 months." Pain differentiated from hip pain 2 degree to osteoarthritis.	More activity than usual yesterday, as well as increased stress to right leg. May have injured knee.	NSAID Heating pad prn before bed	X-ray of knee Apply ice to site of pain (knee), rest and elevate leg, additional analgesic for 2-3 days then reevaluate	C. Dellasega

Getting a handle on geriatric pain takes the effort of both you and the patient. Use of a collaborative approach to identify the type of pain and possible therapies for treating it will promote satisfaction on the part of both your patient and yourself.