1. Do you know why mortality rates for elderly asthma patients have been rising more rapidly than for younger patients?

No one really knows, but there are several possibilities. When elderly people developed asthma, it used to be diagnosed as emphysema or bronchitis, but now we know that asthma can occur at any age. So it may not be a real increase in incidence, but simply better recognition. Second, as the population has aged in the last several decades, many diseases occur more commonly than they did years ago. We didn’t use to see many 80-year-olds with asthma because there weren’t many 80-year-olds around. When an elderly asthmatic dies, it’s not necessarily from the asthma. There may also be other factors that we don’t know about yet — ambient air quality, second-hand smoke. But I think better recognition is the most important factor.

2. Does asthma tend to be more severe in the elderly due to aging factors?

Again, this is not really known. My guess is that it’s because as people get older, lung function deteriorates. When you put asthma on top of that, patients do get much more symptomatic. Some, but not all, asthmatics get worse and worse over the years because of an excessive decline in lung function. If you live long enough, it’s going to lead to very severe disease. Research is just now being conducted to find out why and how often this happens. In part, it’s aging factors, and partly the chronicity of the asthma itself in some patients.

3. What complications of asthma are specific to elderly patients?

Elderly patients are more likely to develop problems tolerating their drugs, and interactions with other medications. Beyond that, I can’t really say that there are any complications specific to the elderly asthmatic.

4. What is the advantage of the shift to using long-term treatment strategies, especially with regard to the elderly?

Overall, there is much more emphasis on preventive therapy in asthma. Inhaled corticosteroids are anti-inflammatory in the lungs, and can prevent flare-ups, exacerbations and worsening of lung function. This leads to less utilization of the health-care system, fewer emergency-room visits, hospitalizations and so forth. Elderly people don’t perceive their symptoms as well, especially breathing problems, and are more likely to delay going to the hospital until symptoms are severe because they’re reluctant to complain, so anything we can do to prevent worsening of the disease would be advantageous, as it would in any patient with any disease.

5. Can people develop asthma at any age, or is the asthma seen in elderly patients really the continuation of a previous chronic condition?

I’ve seen patients in their 70s, 80s — even a 90-year-old I saw recently — develop asthma for the first time. It’s not known what causes this, but the leading theory is that it’s a viral respiratory disease that just goes haywire. What’s thought is that the inflammation from the acute infection for some reason stays in the lungs and worsens, and this eventually leads to some of the changes of asthma. Which viruses or other organisms are responsible is unclear. Some investigators think it may be a latent virus that’s been dormant in the body for years, even since childhood, until something, perhaps another respiratory virus or some kind of stress to the immune system, triggers a flare-up — as in shingles from chicken pox or fever blisters from the herpes virus. I wish I had more definitive answers, but this is all just conjecture at this point. What’s certain is that much research remains to be done in this field.

Elderly asthmatic patients are prone to the same factors that worsen asthma in younger sufferers: viral respiratory infections, paint and household cleaning product fumes, cold air, exposure to smoke, etc. The pharmacological management of asthma does not differ very much in the elderly from what is used at any age, except in three ways: the elderly are likely to experience significant side effects from medications; they are more likely to develop drug interactions with other medications they may be required to take; and they are more likely to rely on medications over many years.

Because of these factors, another problem arises: elderly patients are less likely to take their medications regularly — or at all — either because of the side effects, or because they simply don’t want to admit to being ill. Furthermore, while some elderly asthmatic patients have only mild and occasional symptoms of wheezing and cough, most have almost continual symptoms. Doctors have been investigating ways to tailor medications to these individual needs.

The two main types of drugs used to treat asthma are bronchodilators, which are used as short-term treatment (a matter of minutes or hours) for symptoms such as wheezing, and anti-inflammatory agents which stop inflammation and are used primarily for prevention. Treatment with either of these classes of drugs has pros and cons that doctors need to weigh when prescribing medications for their elderly patients.

Beta2-adrenergic agents

Taking a beta2-adrenergic agent is the most effective way to open up obstructed airways in a hurry. It works by activating beta2 receptors in the lungs (found on the airway smooth muscle cells or inflammatory cells) resulting in the relaxation of bronchial smooth muscle. Inhaled types are commonly prescribed, including albuterol, bitolterol, salbutamol and terbutaline, to name a few. Long-acting, effective oral treatment, such as bambuterol, is available only in certain countries. So far, there seems to be no particular advantage in taking the oral forms; since the inhaled forms have fewer side effects, they are preferred.

Concerns have been raised recently about the possible effects of long-term use of beta2-adrenergic (also called beta-agonist) drugs, and about the association of their excessive use with high asthma death rates. A Saskatchewan study discovered this latter link, but the key word here is “excessive” — that is, exceeding the recommended dosage is dangerous, possibly because the beta2 receptors become desensitized with excessive use. The additional effect of aging on beta2 receptor responsiveness may also be a factor in long-term beta-agonist use. Some, but not all, investigators have found decreased responsiveness to these agents with advanced age.

Common side effects of these drugs include racing heart (tachycardia), a drop in serum potassium (which can increase cardiac problems) and tremor, all of which cause special problems for elderly patients. In addition, the elderly sometimes have trouble using metered dose inhalers and spacers — such cases make getting the right dose problematic. Instead, for acute asthma attacks, beta2-agonist drugs can be inhaled in wet nebulizer form.

Anticholinergic drugs

Drugs like ipratropium bromide or oxitropium bromide act as bronchodilators by working on different receptors than the beta-agonists. However, because ipratropium bromide is not as rapidly effective a bronchodilator as beta2-agonists, it is not a first-line agent for acute symptoms. It is generally used when side effects prohibit taking beta2-agonists, or when additive therapy is needed for severe, persistent symptoms.

Methylxanthines

The most prescribed oral methylxanthine is theophylline, which is no longer used as first-line asthma therapy. It has a limited scope of action which, in some cases, makes it useful as add-on therapy, especially if patients are not getting good asthma control despite maximum use of anti-inflammatory agents and inhaled bronchodilators. Side effects at lower blood levels include nausea and upset stomach; higher blood levels can produce life-threatening seizures and cardiac arrhythmias, which occur many times more frequently in the elderly than in younger patients.

Corticosteroids

As anti-inflammatory drugs, corticosteroids are extremely effective in the prevention and treatment of asthmatic symptoms. In their inhaled form, they can reduce or eliminate the need for brochodilators and oral corticosteroids. Unfortunately, many elderly patients require oral corticosteroids (prednisone is most common in North America) to control symptoms without interrupting their normal levels of activity. Corticosteroids have numerous side effects when taken in their oral form, including insomnia, emotional disturbances, diabetes mellitus and cataracts. For elderly patients, the risk of rib and vertebral fractures rises dramatically, and osteoporosis is a serious problem that requires aggressive, early preventive treatment using calcium supplements and exercise.

Asthma treatment in the elderly is challenging, especially when complications such as those that can occur with oral corticosteroids become severe and life-threatening. But effective treatment is available. Many studies are currently underway to increase our understanding of asthma — all the better to develop successful drug treatment strategies for the elderly.

When benzodiazepines are prescribed for anxiety and the behavioral disorders of dementia, there is a well-documented risk of dizziness, sedation, falls, fractures subsequent to falls, and cognitive impairment associated with these agents in the elderly. In addition, the concept of disinhibition should be considered as a possible complication of therapy in this population. The release of previously suppressed behavior has been called the disinhibitory effect.

“Benzodiazepines dilute the controlling capacity of the ego, allowing one to lose the intensity of normal control mechanisms,” says Lucy Rea Sarkis, M.D., Executive Director, South Beach Psychiatric Center, Staten Island, NY. “The premorbid personality determines how disinhibition is expressed clinically.” Dr. Sarkis elaborates, “It depends on the normal tendencies of the individual.” For instance, in an elderly individual with a premorbid personality possessing sexual preoccupation, a benzodiazepine may precipitate sexually inappropriate behavior. If an aging adult had a premorbid personality possessing obsessive-compulsive features, an increase in anxiety and ritualistic behavior may follow the introduction of a benzodiazepine. If paranoid thinking and/or tendencies existed premorbidly, a benzodiazepine may induce an increase in verbally abusive behavior and an increase in paranoid thinking and behavior.

Furthermore, “in dementia, the area of compromise is very often the determinant of benzodiazepine response variability,” explains Dr. Sarkis. For instance, she adds, if the cerebellum is compromised, a benzodiazepine may increase the risk of falling; with a compromised hippocampus, the center of emotional response, a benzodiazepine may elicit emotional lability; alternatively, a benzodiazepine used with a compromised frontal lobe may produce significant cognitive impairment.

For treating uncomplicated, generalized anxiety in the elderly, shorter-acting benzodiazepines are recommended with scheduled dosing at lower doses than those for younger patients (Table 3). They are relatively rapid in action and effective in reducing feelings of panic, fear, and tension. They should not, however, be prescribed casually for simple situations resulting in tension and anxiety, or for those who suffer from chronic anxiety. The course of therapy is often short (e.g., up to 4 to 6 weeks) since most bouts of anxiety are short-lived, although recurrent in nature. Discontinuation after extended use is difficult due to psychologic and physical dependence; gradual tapering every few days over 3 to 4 weeks is recommended, as withdrawal may lead to rebound anxiety. In a dying patient who appears uncomfortably anxious, an assessment for treatable causes (e.g., hypoxemia, pain, fear) should be undertaken, and if necessary, a short-acting benzodiazepine is recommended.

An alternative to the benzodiazepines is buspirone, initially dosed at 5 mg BID and usually up to 10 mg BID or TID. Using the slow titration guideline of increasing by 5 mg/day every 2 to 3 days as needed up to 20 to 30 mg/day (maximum daily dose of 60 mg/day) helps to avoid or minimize side effects (e.g., dizziness, drowsiness) while providing adequate dosing for effectiveness. Response to treatment is generally seen within 1 to 2 weeks of continuous therapy, with a maximum effect after 3 to 4 weeks. Although this delay in onset of action may be perceived as a disadvantage to buspirone therapy, it should be noted that there is little potential for abuse with this agent.

Hydroxyzine — due to its potent anticholinergic properties — and meprobamate — due to its highly addictive and sedating properties — are not recommended for use in the elderly. Due to adverse effects associated with the antipsychotic drugs (noted above), they should not be used for anxiety disorders unless frank psychotic symptoms (e.g., paranoia, delusions, hallucinations) are present.

In the elderly with anxiety disorders, for whom the tricyclic antidepressants (TCAs) are indicated, imipramine and nortriptyline are well tolerated (75 mg at bedtime; range 50-150 mg/day). Due to strong anticholinergic and sedating properties, amitriptyline is rarely the TCA of choice in the elderly. The TCAs are contraindicated in patients with narrow-angle glaucoma, a frequent comorbidity in older adults. The selective serotonin reuptake inhibitors (SSRIs), also indicated in anxiety disorders, may be useful in patients at risk for sedation, hypotension, and anticholinergic effects of TCAs.The benzodiazepines are often used adjunctively for anxiety disorders, on an intermittent basis, with the TCAs or SSRIs.

Conclusion

Benzodiazepines have demonstrated their utility in relieving anxiety, including the anxiety that accompanies dementia. However, along with other documented potential adverse effects in this patient population, disinhibition may occur. In disinhibition, inappropriate social behavior such as sexual advances or verbal abuse/pananoid behavior may manifest as a side effect. The best outcome from benzodiazepine use in the elderly is obtained from short-term use (4 to 6 weeks) of smaller doses of shorter-acting benzodiazepines.

Dementia may be the most common cause of anxiety in the elderly, with an increased risk of anxiety seen in patients initially transferred to a long-term care facility from the hospital or from home. Trauma or a stressful event may induce an acute, short-lived, situational anxiety. Anxiety disorders (also known as anxiety and phobic neuroses) are classified as phobic disorders, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and panic disorder (Table 1).

Attempts at alleviating anxiety in the elderly, and especially in those with dementia, should be attempted through nonpharmacologic intervention whenever possible. This may include providing a more structured environment with consistent routines, simplifying everyday tasks, avoiding over- or understimulation in the environment, providing soothing background music, and providing support to caregivers. Testing for adequate hearing and vision is also essential. Supportive psychotherapy, behavioral therapy, biofeedback, relaxation therapy, and paced exercise therapy may be used as nonpharmacologic and adjunctive therapy where appropriate.

Reversible etiologies of anxiety related to adverse drug effects and concomitant medical disorders should not be overlooked. When possible, eliminating medications known to contribute to or induce anxiety and treating medical conditions that may cause anxiety or similar symptoms (Table 2) may help avoid unnecessary intervention with an anxiolytic. For example, eliminating anxiety and agitation secondary to depression with the use of an antidepressant may be sufficient.

Benzodiazepines are often prescribed for elderly dementia patients with behavioral disorders because of a prescriber preference over the antipsychotics that carry a liability of extrapyramidal symptoms (EPS) and tardive dyskinesia (TD). Extrapyramidal reactions are more common in the elderly, with up to 50% of patients developing these reactions after age 60; incidence may be more common in dementia patients. The prevalence rate of tardive dyskinesia in the elderly may be as high as 40%; elderly women are especially at risk. Up to 20% of older adults take benzodiazepines, and their use is more common among women than men. Benzodiazepines are useful in treating general anxiety disorders, panic disorders, and depression, as an adjunct to antidepressants. They are also indicated in insomnia, on a short-term basis. In addition, they are useful for preprocedure/preoperative sedation (e.g., dental procedures, MRI screenings) and in cases of status epilepticus.

Choosing an appropriate dosage form of analgesic drug is essential to successfully manage pain in the older patient. Beyond the clinical recommendations, the pharmacist can be instrumental in providing information on products that will optimize pain relief in this patient population. Swallowing difficulties secondary to other medical conditions, such as Parkinson’s disease, dementia, or stroke, may preclude the use of large tablets or sustained-release medications that cannot be crushed. Liquid medications provide an acceptable alternative for administering analgesics. Unfortunately, few analgesic preparations are available in liquid form. Ibuprofen and naproxen suspensions are the few NSAIDs available as liquids for the relief of mild to moderate pain. For moderate to severe pain, fentanyl patches provide continuous pain relief and are suitable for patients who cannot swallow sustained-release preparations, are tube-fed, or who have difficulty remembering to take their medication. The 72-hour administration interval also reduces the burden of administering medication by nursing staff in long-term care facilities or caregivers at home. The initial dose of the patch may be increased after the first three days of therapy. Additional dose increases should only occur after two cycles of patches have been applied. Morphine sulfate controlled-release capsules may be opened and the pellets mixed in applesauce or administered via a gastrostomy tube without loss of continuous pain relief. Patient controlled analgesia (PCA) through the use of a pump has not been as widely used in elderly patients, particularly those with cognitive impairment, since successful use requires active involvement by the patient.

 

Analgesics that are considered unnecessary drugs with a high potential for significant adverse effects and should be avoided include pentazocine and oral meperidine.

The older patient may be taking numerous medications, some of which may induce similar side effects as pain management therapy. Constipation is frequently a side effect of narcotic analgesic administration, particularly as the dose increases, placing the patient at risk for fecal impaction. Patients may also be taking calcium supplements and psychoactive agents, which can contribute to constipation. A review of bowel management therapy is advised at the time of prescribing narcotics.

According to the World Health Organization guidelines, the basis for current pain management practices, senna is the laxative of choice for managing opiate-induced constipation. Normal peristaltic movement is inhibited by opiates, preventing movement of fecal material through the colon. Irritant laxatives, such as senna, can help stimulate bowel evacuation. Docusate or psyllium-containing products may be of additional benefit to prevent straining or to add bulk. Adequate fluid intake is essential to prevent possible bowel obstruction associated with the use of bulk-forming laxatives.

Health Care Financing Administration (HCFA) Interpretive Guidelines also influence the process of selecting drug therapy for pain management. The use of tricyclic antidepressants, especially amitriptyline and doxepin, is discouraged in elderly patients due to their increased sensitivity to adverse effects, particularly anticholinergic effects and heart rhythm abnormalities. If a tricyclic agent is to be used, particularly for neuropathic pain, nortriptyline is preferred at low doses with careful titration and monitoring. Patients currently receiving amitriptyline should be considered for conversion to nortriptyline in equipotent doses. Documentation of efficacy and absence of adverse effects should be readily available. During medication pass and meal observation, surveyors are instructed to determine whether NSAIDs are administered with a meal. If they are administered on an empty stomach, it is calculated into the facility’s medication error rate.

Analgesics that are considered unnecessary drugs with a high potential for significant adverse effects and should be avoided include pentazocine and oral meperidine. Both drugs have an increased risk of respiratory depression or central nervous system adverse effects, including seizures with meperidine, in patients over 65 years of age. Alternative agents with less serious adverse effects are readily available.

Conclusion

Successful chronic pain management in the senior patient requires the active involvement of the pharmacist in the community as well as the institution. Regulatory requirements have established a framework for a comprehensive approach to pain management and a fundamental right of patients to adequate relief of pain. Overcoming the barriers to adequate pain relief is only one of the challenges facing the patient and the clinician. Multiple opportunities exist for enhancing patient quality of life. The pharmacist can help educate patients, families and staff about pain management, provide the clinical expertise necessary to manage pain, recommend dosage forms and adjunct medications that will enhance therapy, and measure outcomes of pain management programs.

Pharmacologic options for pain management range from simple analgesics, such as acetaminophen or low-dose nonsteroidal anti-inflammatory agents (NSAIDs) for the relief of mild to moderate chronic pain, to opioids for more severe pain (Table 1).

Simple Analgesics: Acetaminophen is useful for the relief of mild to moderate osteoarthritic pain in scheduled, divided doses not exceeding 4 g/day.NSAIDs may also be used in appropriate doses, for short periods of time. COX-2 inhibitors may be less likely to be associated with gastrointestinal bleeding and may be administered once daily, reducing nursing time for medication administration or the likelihood of missed doses. All NSAIDs should be given with a meal to avoid gastrointestinal upset. Periodic monitoring of renal function and blood count should be performed.

Topical Analgesics: Topical analgesics may also be used in the management of chronic pain. Capsaicin cream, derived from red peppers, desensitizes nerve fibers associated with pain by depleting substance P. Regular applications of the cream, beginning with the 0.025% concentration and progressing to the 0.075% formulation, may be helpful in relieving pain. Patients generally report a warming sensation at the site of application. The cream should not be used on broken or irritated skin. Several weeks of therapy may be necessary to determine efficacy. Menthol or methylsalicylate-containing products in the form of liniments, creams, sprays and other formulations may also be effective in relieving joint pain. Topical anesthetics, such as lidocaine ointment or gel, and combination anesthetic ointments or creams may also be of benefit in relieving joint pain or pain in other localized sites.

Table 1

Pharmacologic Management of Pain

Analgesics Acetaminophen Nonsteroidal anti-inflammatory agents Nonselective COX-2 inhibitors Topical analgesics/anesthetics Capsicum/Lidocaine Tramadol Antidepressants Tricyclics SSRIs Anticonvulsants Gabapentin Carbamazepine Narcotic analgesics Adjunct medications Clonidine patches Corticosteroids

Tramadol: Tramadol has been successful in managing pain in patients over the age of 75 years who are unable or unwilling to use opioids at doses of 300 mg or less per day. Doses in renally impaired patients (those with a creatinine clearance [CrCl] of 30 mL/min or less) should be further reduced by decreasing the dosing interval to every 12 hours and a maximum dosage of 200 mg/day. Dosage adjustment is also necessary in patients with hepatic impairment. Tramadol should not be used with opioids, tricyclic anti-depressants, or selective serotonin reuptake inhibitors. Patients taking other medications that lower the seizure threshold or who are at high risk for seizures may experience seizures with the addition of tramadol. Concomitant use of carbamazepine significantly lowers the bioavailability of tramadol, requiring a dose increase. In clinical studies with a majority of patients over the age of 65 years, dizziness, nausea, and vertigo were the most common side effects, reported in up to 46% of patients receiving tramadol for as long as three months.

Tricyclic Antidepressants: Tricyclic antidepressants have been successfully used in managing pain in combination with analgesic agents, particularly for neuropathic pain syndromes. Initiation of therapy at low doses (10­25 mg of nortriptyline) given at bedtime will avoid daytime drowsiness and improve sleep. Limited data exist for the efficacy of the selective serotonin reuptake inhibitors as adjunct pain management, precluding their routine substitution for tricyclic agents.

Anticonvulsants: With relatively few drug interactions in comparison to other anticonvulsants, gabapentin has been shown to be effective as adjunct pain therapy in patients with neuropathic pain. Gabapentin was shown to be as effective as amitriptyline in the management of diabetic peripheral neuropathy. In order to avoid the most common side effect, drowsiness, therapy is initiated at relatively small doses of 100 mg in the evening, with gradual upward titration every five to seven days. In patients with impaired renal function (CrCl>60 mL/min), doses should not exceed 1200 mg/day in divided doses.A maximum dose of 600 mg/day in divided doses is recommended in patients with CrCl 30­60 mL/min. Monitoring of drug serum levels is not indicated with gabapentin.

Narcotic Analgesics: Multiple narcotic analgesics are available as single agents or in combination with other analgesics for the relief of moderate to severe pain. Sustained-release preparations, such as morphine sulfate sustained-release tablets, offer the benefit of once or twice a day administration with continuous pain relief. Short-acting, immediate release formulations should be readily available to the patient for breakthrough episodes of pain. Use of the short-acting agents serves as a method of titration for the sustained-release preparations and as a measure of their efficacy. The timing of the use of immediate-release medications on a prn basis can help determine if pain control is diminished at the end of the dosing interval or if specific times of the day require an increased dose of analgesic. The inclusion of acetamin-ophen or ibuprofen with narcotic analgesics limits their usefulness. Acetaminophen-associated hepatotoxicity and ibuprofen-associated renal and gastrointestinal toxicities limit the total daily dose of the combination products. With gradual dose titration based on patient response, there is no dose limitation with single-agent narcotic analgesics. Oxycodone controlled-release tablets or other narcotic analgesics may be alternatives in patients unable to tolerate morphine sulfate, as intolerance of one agent does not prevent the trial of other narcotic analgesics.

Nonpharmacologic Interventions: Nonpharmacologic interventions have been used, often in conjunction with analgesic or adjunct medications, as part of a comprehensive pain management program (Table 2). Specific modalities may be used alone or in combination, depending on the patient’s condition.

As part of an interdisciplinary team, the pharmacist should ascertain whether all of the patient’s pain needs are being met during or after physical therapy sessions. Patients may refuse therapy sessions because they perceive the sessions as causing pain, or pain exists prior to the therapy visit. Premedication with a relatively rapid onset analgesic one-half to one hour prior to the therapy appointment can significantly reduce discomfort and allow the rehabilitation process to proceed smoothly. Medication after the therapy session can be useful in relieving discomfort or aching experienced by the patient.

Patients may also experience pain during wound care. Routine premedication for dressing changes in patients with a Stage III or IV pressure ulcer or other serious wound is recommended and can reduce the discomfort or pain associated with manipulation of the affected area.

Table 2

Nonpharmacologic Treatment of Pain

Acupuncture Exercise Guided imagery Ice or heat packs Occupational or physical therapy Pastoral or psychological support Transcutaneous electrical nerve stimulation (TENS)

 

Clinical assessment of elderly patients must attempt to ascertain the presence of pain through both verbalized and nonverbalized symptoms.

Selecting an optimal therapy depends on patient-specific criteria, including medical history, previous medications utilized, drug allergies, swallowing ability, and response to therapy. A description of the pain is also useful in determining initial therapy. Nociceptive pain, often the result of chronic or other conditions arising from actual tissue damage as in osteoarthritis, can be described as aching or soreness, rather than sharp pain. Neuropathic pain, arising from damaged nerve tissue, is usually described as burning, stinging or stabbing pain. To adequately manage chronic pain, the clinician should employ a step-therapy approach that uses regularly scheduled doses of medication rather than dependence on a regimen of “prn” doses. This avoids underdosing and its resulting inadequate pain relief. Titrating the dose and managing occasional variations in pain patterns are achieved through the use of rescue analgesics. Adjunct medications and nonpharmacologic interventions enhance the efficacy of analgesics; both are useful in managing chronic neuropathic and nociceptive pain. Adjunct medications may also have a positive effect on accompanying symptoms, including insomnia and depression. Therapy should be initiated in low doses, with gradual upward titration until pain relief is achieved.

Adequate pain management is a cornerstone of both palliative care and hospice care. Palliative care, the active care of a patient whose disease is not responsive to curative treatment, may be long-term. In contrast, a patient who is receiving hospice care has a life expectancy of six months or less. Regardless of the category of care the patient is receiving, appropriate management of pain and other associated symptoms is essential to the patient’s well-being and quality of life.

The lack of recognition and consequent undertreatment of pain in all patient populations has resulted in new standards from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for all levels of care. Organizations seeking JCAHO accreditation or reaccreditation must have a comprehensive pain management program in place. Underlying the new standards is a commitment to every patient’s right to adequate treatment of pain. This is accomplished through the organization’s program of education for all staff, patients, residents, and families; development and use of appropriate tools for pain assessment; care of persons with pain; inclusion of pain management in discharge planning; and incorporating pain management into the institution’s performance improvement program. The pharmacist is considered an essential staff member for a successful pain management program, not only in the educational component, but also in the development of policies and procedures, drug therapy protocols, and outcomes assessment.

To emphasize the importance of routine and ongoing pain assessment, the American Pain Society (APS) has labeled pain as “the fifth vital sign.” Consistent with the JCAHO standards, which the Society endorsed, the APS seeks to provide practical measures in order to make adequate pain management a reality for every patient.

Assessment and Identification of Pain

Clinical assessment of all elderly patients must attempt to ascertain the presence of pain through both verbalized and nonverbalized symptoms. An elderly patient may verbally respond to questions about the presence of pain by stating that he has no pain but may, in fact, be experiencing unrelieved or inadequately relieved pain. In addition to an inability to express the presence of pain due to progressing dementia, aphasia, or language barriers, there may be cultural or societal barriers to articulating pain symptoms. Cultural beliefs that pain is a sign of weakness and that suffering is preferable to accepting pain medication may precondition the patient to deny the presence of pain. The patient, his or her family, and health professionals may have the misconception that narcotic analgesics should not be used because of the potential for physical dependence. Healthcare staff may not be adequately trained in recognizing the signs of pain in the older patient or in assessing pain relief. Staff cultural beliefs about patient perception of pain and treatment may hinder adequate pain management as well.

Pain scales that can be used to assess the intensity of verbally expressed pain include numeric or descriptive scales. The Wong Baker Faces Scale may be especially useful when verbal description is not possible. The patient may be able to indicate which face best demonstrates how he or she feels; if not, staff can match the face to the patient in front of them. Nonverbal cues may indicate the presence of pain in the elderly patient who denies or is unable to indicate the presence of pain. In addition to facial expression, behaviors that can indicate actual unrelieved pain include agitated behavior, pulling away or refusing care, favoring or rubbing a limb or body part, gait disturbances, declining to participate in rehabilitation activities, withdrawing from social activities, loss of appetite with resulting weight loss, insomnia, or symptoms of depression.