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Geriatric Pain Management & Nursing Implications

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Pain Management in the Elderly

Pain is a complex, subjective, and unpleasant sensation derived from sensory stimuli and modified by memory, expectations and emotions (Merck & Co., Inc., 1995). It is a multidimensional and universally experienced phenomenon, however, the reactions and sensitivity to pain varies widely among individuals, especially for the geriatric population (65 years and older). Pain is a common experience for many elderly individuals that has negative consequences on their health, functioning and quality of life (Monti & Kunkel, 1998). This is of particular concern because the geriatric population is the fastest growing segment in the United States, and is projected to double to 72 million by the year 2030 (U.S. Census Bureau, 2005). It is estimated that individuals over the age of 65 suffer from pain twice as much as young adults, and the percentage of adults living in long term care that experience chronic pain is 70-80% (U.S. Census Bureau, 2005).

In terms of pain management, the elderly are the most undertreated and ineffectively controlled segment of the population. Due to the prevalence of pain among the elderly, managing it requires special attention to possible cognitive impairment, physiological changes, disease comorbidity and cultural beliefs about pain. This paper examines considerations and effective methods for managing pain among the elderly in a range of health care settings, substantiated by several research studies that provide evidence-based data. Specifically, the research considered looked at the incidence and types of pain experienced among the elderly, barriers to ineffective pain management, assessment of pain in the elderly, pharmacological and non-pharmacological approaches to treatment, and the affect of unrelieved pain on an elder's activities of daily living and overall functioning.

Pain that results from injury, surgery or any break in skin tissue that stimulates peripheral sensory receptors is called nociceptive pain. It can cause acute pain which typically lasts anywhere from a few days up to several weeks, and subsides with healing. Pain that lasts longer than six months is called persistent or chronic pain (Merck & Co., Inc., 1995). This is the type of pain that most geriatric patients experience because they often have more than one disease process present. According to Schofield, it is suggested that 80% of those over the age of 65 suffer from at least one chronic illness (2006). Chronic pain is common in the elderly, and can be exacerbated by, those who have degenerative joint diseases, osteoarthritis, diabetes mellitus, vascular diseases, cancer, infection, ulcers, dementia, eating and feeding impairments, sleep disorders, and gait imbalances (Schofield, 2006). Neuropathic pain is another type of pain seen frequently among elderly patients. It is caused by damage or abnormalities in nerves, spinal cord or brain, and usually felt as a burning or tingling sensation (Merck & Co., Inc., 1995). Regardless of the type of pain that elderly people experience, it can be difficult to describe and often hard to measure.

The consistent trend of unrelieved pain in the elderly population has many factors that influence it, both patient-based and caregiver-based. There are many barriers that limit effective pain management. On the side of the health care provider, nurse or caregiver, often times there is a lack of or insufficient knowledge about pain control and how to assess patients who are experiencing pain (Dawson et al., 2005). Research has also shown that most nurses and caregivers believe that pain is to be expected as part of the normal aging process (Ebersole, Hess, Touhy, & Jett, 2005, p. 345). Contrary to that belief, pain among the elderly is not normal and therefore it should be investigated accordingly.

In terms of patient-based influences, a substantial barrier to unrelieved pain in the elderly stems from various cultural beliefs about the existence of pain, and that in turn influences their willingness to report pain and comply with prescribed regimes (Dawson et al., 2005). Other concerns that older people have about pain, which inhibits them from seeking help includes medication addiction, medication side effects (constipation, sedation and dry mouth), previous health care received, fear of appearing weak or needing diagnostic tests, loss of independence, idea that they will be a "bad patient" or that complaining of pain will distract the doctor from treating the underlying problem (Schofield, 2006; Dawson et al., 2005). The research conducted by Dawson et al. suggests that 85% of the patients in their sample expressed their greatest concern being the addictive effects of taking pain medication, but would be more willing to take the medications if they were told by the doctor that addiction is highly unlikely if taken as prescribed (2005). In addition, almost two-thirds of the sample population stated that pain was an inevitable process that they could not avoid. Because geriatric patients have certain beliefs regarding treatment of pain, failure to report their pain has resulted in ineffective pain management. That coupled with the doctors and nurses inability to educate and treat patients as needed could "unintentionally introduce, reinforce or confirm inaccurate beliefs" on the part of the patient (Dawson et al., 2005).

Effective January 1, 2000, pain is considered to be the fifth vital sign (Board of Registered Nursing, 2007). This indicates that upon assessment of each patient, the level of pain, intensity and duration should be noted, especially for an older individual. Accordingly, self-report is the best indicator of pain and pain is whatever the patient says it is, existing whenever they say it does because there are no definitive objectives or biological markers of pain (American Geriatrics Society, 2002). Nurses are often the first person to hear of a patient's report of pain in the health care setting, therefore it is crucial that they perform a comprehensive pain assessment on elderly individuals based on the data provided previously. It requires that a thorough pain history, medication history and complete physical examination be conducted, followed by any necessary laboratory or diagnostic procedures (Higgins, Madjar, & Walton, 2004; Monti & Kunkel, 1998).

It is important that assessment is done using a standardized pain scale that is research-based and measures a patient's level of pain sufficiently in order to ensure optimal and adequate care. The most common pain scale used in clinical practice rates the intensity of pain based on a number between 0 and 10, where 10 is the most severe amount of pain, and 0 is no pain



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