Pain and the Elderly
The elderly are among those most affected by pain due to a plethora of chronic conditions, end of life issues, and lack of personal resources and yet are often helpless to improve their situation. It is estimated that 40% of elderly cancer patients in nursing homes are in pain.1 Sources of pain in the elderly may be complex and diagnosis is hampered by potential incapacitation. The elderly person who has cancer may also have other causes of pain. Arthritis, cancer, post herpetic neuralgia, osteoporosis, diabetic neuropathy, peripheral vascular disease, vertebral canal stenosis, crush fractures and post stroke syndrome are but a few of the debilitating conditions possible.
Pain in the elderly is often chronic non-malignant pain and is disproportionately under-treated for a variety of reasons. In a survey conducted by Partners Against Pain conducted in 2002,2 about 33% in a sample of 1000 patients had debilitating pain, and often so bad they wanted to die. Many misconceptions abound. Some elderly believe pain is part of aging and they must live with it; health care professionals often believe less pain medication is indicated in treating an elder’s pain. 3 They may fear causing addiction with opiates. Some physicians fear regulatory boards and admonition for writing too many prescriptions for controlled substances. While this is a possibility, adherence to the Model Guidelines makes the admonition highly unlikely.
Standard of Care vs Elder Abuse
A recent California law suit addressed under-treatment of pain by a physician and convicted the physician for elder abuse because of his paucity of pain prescribing and lack of continuing education in current pain prescribing practices.4 In Bergman v. Chin Alameda Co. Superior Court, California, June 13, 2001, the physician was convicted of elder abuse for failure to prescribe adequate pain medication.5 The jury found, by clear and convincing evidence, that the doctor’s conduct constituted abuse of an elder, and further, that such conduct was reckless.
The patient, in severe pain, was brought by his daughter to the hospital on February 16, 1998. He was diagnosed with multiple compression fractures and possible lung cancer. During his 5 day hospital stay, he continued in severe pain, registering 7-10 on a pain scale of 0-10 but was prescribed only as needed Demerol. The patient requested to go home and was prescribed Vicodan, despite difficulty with swallowing. Two days after the patient went home, the hospice nurse found that his pain was out of control and, since the original doctor was unavailable, contacted another doctor. Liquid morphine and duragesic patches were prescribed and thereby, finally, alleviated the patient’s pain the day before he died.
Plaintiff’s experts testified that if treated according to modern standards, the patient should have received around the clock pain medication with extra for break through episodes. Their opinion was that the doctor’s care was appalling and egregious despite the defense experts’ testimony that the doctor’s action was within the standard of care and exercised acceptable judgment on his part. Kathryn Tucker, the director of legal affairs for the Compassion in Dying Federation, stated that “Until recently it would have been difficult to establish that the care provided fell below the standard of care. However, the past decade has brought clinical practice guidelines on pain management from such groups as the World Health Organization, the American Medical Association, the Agency for Health Care Policy and Research and the Joint Commission of Accreditation of Health Care Organizations.”
|Celebrex (cox 2 inhibitor)||200 mg||30 tablets||$88.49|
|Vioxx||50 mg||30 tablets||$129.90|
|Oxycontin||10 mg||30 tablets||$ 90.00|
Special Concerns of the Elderly
End of life issues plague the elderly. Most fear the pain of dying more than dying itself. Hospice care is effective in managing pain at the end of life, but the physician must certify that life expectancy is six months or less in order for Medicare to cover the cost. Not all terminally ill people know of, or seek, hospice care. Further, as occurrences of Alzheimer’s disease and other forms of dementia increase in aging patient populations, many elderly patients have pain but can’t effectivley communicate that pain. Astute observation for variations from the usual behavioral pattern may produce indications that the person with dementia is in pain. Restlessness is often a sign. Treatment for pain should be given in adequate doses to promote maximum comfort.
Another concern of the elderly is financial; lack of money is often a barrier to receiving adequate pain management. Many do not have prescription coverage since Medicare parts A and B do not provide prescription coverage. Medigap policies are expensive and may not pay for the pain medicine that is ordered. A survey of drug prices is presented in Table 1 and illustrates that prices are typically beyond the limited means of the elderly.
Scientific evidence has shown that early intervention and treatment of pain is effective in returning people to a functional way of living. More importantly, early pain treatment may effectively relieve pain that may otherwise become chronic. Physicians must treat pain as an urgent condition. If the patient does not respond, a referral to a Pain Specialist is indicated. The American Academy of Pain Medicine warns that effective pain evaluation and control must occur within a few weeks or months of onset “in order to prevent progressive pain, associated morbidity and increased costs."6
A multidisciplinary treatment plan can be prepared and implemented. With chronic conditions and under-treated pain, an elder’s quality of life may deteriorate, complaints may proliferate and the person may become irritable and unpleasant to be around. Social isolation can result and become progressive and thereby compound the problem.
Modern Standard of Care
The Joint Commission of Accreditation of Hospitals Organization (JCAHO) published new standards for pain control in December 2000.7 JCAHO is a private national accreditation agency that has deemed status by the Federal Government to conduct accreditation surveys on behalf of Medicare. JCAHO surveys and accredits some 19,000 hospitals, health care plans and networks, out patient service centers, home care organizations, nursing homes and long term care facilities assisted living residences and behavioral and mental health care organizations.8