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Progress in Pain Research and ManagementVolume 35

Pain in Older Persons

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Mission Statement of IASP Press®

The International Association for the Study of Pain (IASP) is a nonprofit, inter-disciplinary organization devoted to understanding the mechanisms of pain andimproving the care of patients with pain through research, education, and communi-cation. The organization includes scientists and health care professionals dedicatedto these goals. The IASP sponsors scientific meetings and publishes newsletters, tech-nical bulletins, the journal Pain, and books.

The goal of IASP Press is to provide the IASP membership with timely, high-quality, attractive, low-cost publications relevant to the problem of pain. These publi-cations are also intended to appeal to a wider audience of scientists and cliniciansinterested in the problem of pain.

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Progress in Pain Research and ManagementVolume 35

Pain in Older Persons

Editors

Stephen J. Gibson, PhD

National Ageing Research Institute, Parkville, Victoria;Department of Medicine, University of Melbourne,Melbourne, Victoria; Caulfield Pain Managementand Research Center, Caulfield, Victoria, Australia

IASP PRESS® • SEATTLE

Debra K. Weiner, MD

Division of Geriatric Medicine, Department of Medicine,University of Pittsburgh; Pain Evaluation and Treatment

Institute, University of Pittsburgh Medical Center,Pittsburgh, Pennsylvania, USA

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© 2005 IASP Press®

International Association for the Study of Pain®

All rights reserved. No part of this publication may be reproduced, stored in a retrievalsystem, or transmitted, in any form or by any means, electronic, mechanical, photocopy-ing, recording, or otherwise, without the prior written permission of the publisher.

Timely topics in pain research and treatment have been selected for publication, but theinformation provided and opinions expressed have not involved any verification of thefindings, conclusions, and opinions by IASP®. Thus, opinions expressed in Pain in OlderPersons do not necessarily reflect those of IASP or of the Officers and Councillors.

No responsibility is assumed by IASP for any injury and/or damage to persons orproperty as a matter of product liability, negligence, or from any use of any methods,products, instruction, or ideas contained in the material herein. Because of the rapidadvances in the medical sciences, the publisher recommends that there should beindependent verification of diagnoses and drug dosages.

Published by:

IASP PressInternational Association for the Study of Pain909 NE 43rd Street, Suite 306Seattle, WA 98105-6020 USAFax: 206-547-1703www.iasp-pain.orgwww.painbooks.org

Printed in the United States of America

Library of Congress Cataloging-in-Publication Data

Pain in older persons / editors, Stephen J. Gibson, Debra K. Weiner.p. ; cm. -- (Progress in pain research and management ; v. 35)

Includes bibliographical references and index. ISBN 0-931092-59-0 (alk. paper)1. Pain in old age. [DNLM: 1. Pain--diagnosis--Aged. 2. Pain--therapy--Aged. WL 704 P14578 2005]

I. Gibson, Stephen J., 1959- II. Weiner, Debra K. III. Series. RB127.P322265 2005

2005052016

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List of Contributing Authors viiForeword ixPreface xi

Part I Overview

1. Epidemiology of Pain in Older PersonsGareth T. Jones and Gary A. Macfarlane 3

Part II Age Differences in Pain

2. The Neurobiology of Aging, Nociception, and Pain: An Integrationof Animal and Human Experimental EvidenceLucia Gagliese and Michael J. Farrell 25

3. Age-Associated Differences in Pain Perception and Pain ProcessingRobert R. Edwards 45

4. Age Differences in Clinical Pain StatesGisele Pickering 67

5. Age Differences in Psychological Factors Related to PainPerception and ReportStephen J. Gibson 87

Part III Pain Assessment in the Older Adult

6. Pain Assessment in the Older Adult with VerbalCommunication SkillsKeela Herr 111

7. Assessing Pain in Older Persons with Severe Limitationsin Ability to CommunicateThomas Hadjistavropoulos 135

8. Functional Assessment of Older Adults with Chronic PainThomas E. Rudy and Susan J. Lieber 153

9. Measuring Mood and Psychosocial Function Associatedwith Pain in Late LifePatricia A. Parmelee 175

Part IV Pain Treatment Modalities

10. Oral Analgesics: Efficacy, Mechanism of Action, Pharmacokinetics,Adverse Effects, Drug Interactions, and Practical Recommendationsfor Use in Older AdultsJoseph T. Hanlon, David R.P. Guay, and Timothy J. Ives 205

Contents

v

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11. Physical Therapy Approaches to the Management of Painin Older AdultsRhonda J. Scudds and Roger A. Scudds 223

12. Cognitive-Behavioral Therapy for Pain in Older AdultsSandra J. Waters, Julia T. Woodward, and Francis J. Keefe 239

13. Interventional Pain Management Procedures in Older PatientsCheryl Bernstein, Bud Lateef, and Perry Fine 263

14. Complementary and Alternative Medicine Approachesto Pain in Older PersonsKaren Prestwood 285

15. Multidisciplinary Pain Management Clinics for Older AdultsBenny Katz, Sam Scherer, and Stephen J. Gibson 309

Part V Common Painful Disorders in Older Adults: Disorder-Specific Approaches to Evaluation and Treatment

16. Low Back Pain and Its Contributors in Older Adults:A Practical Approach to Evaluation and TreatmentDebra K. Weiner and Danelle Cayea 329

17. Clinical Features and Treatment of Postherpetic Neuralgiaand Peripheral Neuropathy in Older AdultsKenneth E. Schmader and Robert H. Dworkin 355

18. Postoperative Pain Management in the Older AdultChris Pasero, Barbara Rakel, and Margo McCaffery 377

19. Cancer Pain and End-of-Life IssuesLinda A. King and Robert Arnold 403

Index 421

vi CONTENTS

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Contributing Authors

vii

Robert Arnold, MD Institute for Doctor-Patient Communication, Section ofPalliative Care and Medical Ethics, Division of General Internal Medicine,University of Pittsburgh, Pittsburgh, Pennsylvania, USA

Cheryl Bernstein, MD Department of Anesthesiology, University of PittsburghSchool of Medicine, Pittsburgh, Pennsylvania, USA

Danelle Cayea, MD Division of Geriatric Medicine, Department of Medicine,University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA;currently Division of Geriatric Medicine, Johns Hopkins University Schoolof Medicine, Baltimore, Maryland, USA

Robert H. Dworkin, PhD Department of Anesthesiology, University ofRochester School of Medicine and Dentistry, Rochester, New York, USA

Robert R. Edwards, PhD Department of Psychiatry and Behavioral Sciences,Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

Michael J. Farrell, PhD Howard Florey Institute and Centre for Neuroscience,University of Melbourne, Melbourne, Victoria; National Ageing ResearchInstitute, Parkville, Victoria, Australia

Perry Fine, MD University of Utah Pain Management Center, Salt Lake City,Utah, USA

Lucia Gagliese, PhD School of Kinesiology and Health Science, YorkUniversity, Toronto, Ontario; Department of Anaesthesia and PainManagement, University Health Network, Toronto General Hospital,Toronto, Ontario; Departments of Anaesthesia and Psychiatry, Universityof Toronto, Toronto, Ontario, Canada

Stephen J. Gibson, PhD National Ageing Research Institute, Parkville,Victoria; Department of Medicine, University of Melbourne, Melbourne,Victoria; Caulfield Pain Management and Research Centre, Caulfield,Victoria, Australia

David R.P. Guay, PharmD Institute for the Study of GeriatricPharmacotherapy, Department of Experimental and ClinicalPharmacology, College of Pharmacy, University of Minnesota,Minneapolis, Minnesota; Partnering Care Senior Services, Health PartnersInc., Minneapolis, Minnesota, USA

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viii CONTRIBUTING AUTHORS

Thomas Hadjistavropoulos, PhD Department of Psychology, University ofRegina, Regina, Saskatchewan, Canada

Joseph T. Hanlon, PharmD, MS Division of Geriatric Medicine, Departmentof Medicine, School of Medicine, and Department of Pharmacy andTherapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh,Pennsylvania; and Center for Health Equity Research and Promotion,Veterans Administration Pittsburgh Health Care System, Pittsburgh,Pennsylvania, USA

Keela A. Herr, PhD, RN, FAAN Adult and Gerontological Nursing, Collegeof Nursing, The University of Iowa, Iowa City, Iowa, USA

Timothy J. Ives, PharmD, MPH Division of Pharmacotherapy, School ofPharmacy, University of North Carolina, Chapel Hill, North Carolina, USA

Gareth T. Jones, PhD The Unit of Chronic Disease Epidemiology, and theArthritis Research Campaign (ARC) Epidemiology Unit, Division ofEpidemiology and Health Sciences, The University of Manchester,Manchester, United Kingdom; currently Epidemiology Group, Departmentof Public Health, University of Aberdeen, Aberdeen, United Kingdom

Benny Katz, MBBS, FRACP, FFPMANZCA Consultant Geriatrician,Austin Health, Heidelberg, Victoria, Australia

Francis J. Keefe, PhD Department of Psychiatry and Behavioral Medicine,Duke University Medical Center, Durham, North Carolina, USA

Linda A. King, MD Section of Palliative Care and Medical Ethics, Divisionof General Internal Medicine, University of Pittsburgh, Pittsburgh,Pennsylvania, USA

Bud Lateef, MD Department of Pain Medicine, University of PittsburghSchool of Medicine, Pittsburgh, Pennsylvania, USA

Susan J. Lieber, MS, OTR/L Department of Anesthesiology and PainEvaluation and Treatment Institute, University of Pittsburgh, Pittsburgh,Pennsylvania, USA

Gary J. Macfarlane, PhD The Unit of Chronic Disease Epidemiology,and the Arthritis Research Campaign (ARC) Epidemiology Unit, Divisionof Epidemiology and Health Sciences, The University of Manchester,Manchester, United Kingdom; currently Epidemiology Group, Departmentof Public Health, University of Aberdeen, Aberdeen, United Kingdom

Margo McCaffery, MS, RN, FAAN Clinical consultant, Los Angeles,California, USA

Patricia A. Parmelee, PhD Emory Center for Health in Aging, EmoryUniversity School of Medicine, and Birmingham/Atlanta GeriatricResearch, Education and Clinical Center, Atlanta Veterans Affairs MedicalCenter, Atlanta, Georgia, USA

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Chris Pasero, MS, RN, FAAN Clinical consultant, El Dorado Hills,California, USA, John A. Hartford Foundation Building Academic GeriatricNursing Capacity Scholar, Iowa City, Iowa, USA; Clinical Consultant,Los Angeles, California, USA

Gisèle Pickering, MD, PhD, DPharm Clinical Pharmacology Center,University Hospital, Medical Faculty, Clermont-Ferrand, France

Karen Prestwood, MD Center on Aging, University of Connecticut HealthCenter, Farmington, Connecticut, USA

Barbara Rakel, RN, PhD John A. Hartford Foundation Building AcademicGeriatric Nursing Capacity Scholar, Department of Nursing Services andPatient Care, University of Iowa Hospitals and Clinics, Iowa City, Iowa,USA

Thomas E. Rudy, PhD Departments of Anesthesiology, Psychiatry, andBiostatistics and Pain Evaluation and Treatment Institute, University ofPittsburgh, Pittsburgh, Pennsylvania, USA

Rhonda J. Scudds, PhD, PT Department of Rehabilitation Sciences, Facultyof Health and Social Sciences, Hong Kong Polytechnic University,Kowloon, Hong Kong; currently Health and Rehabilitation SciencesResearch Institute, Faculty of Life and Health Sciences, University ofUlster, Newtonabbey, County Antrim, Northern Ireland, United Kingdom

Roger A. Scudds, PhD, PT Department of Rehabilitation Sciences, Faculty ofHealth and Social Sciences, Hong Kong Polytechnic University, Kowloon,Hong Kong; currently Health and Rehabilitation Sciences ResearchInstitute, Faculty of Life and Health Sciences, University of Ulster,Newtonabbey, County Antrim, Northern Ireland, United Kingdom

Sam Scherer, MBBS, DGM Pain Management Clinic for the Elderly,Melbourne Health, Parkville, Victoria, Australia

Kenneth E. Schmader, MD Division of Geriatrics, Department of Medicineand the Center for the Study of Aging and Human Development, DukeUniversity Medical Center, Durham, North Carolina; Geriatric Research,Education and Clinical Center, Durham VA Medical Center, Durham,North Carolina, USA

Sandra J. Waters, PhD Department of Psychiatry and Behavioral Medicine,Duke University Medical Center, Durham, North Carolina, USA

Debra K. Weiner, MD Division of Geriatric Medicine, Department ofMedicine, University of Pittsburgh; Pain Evaluation and TreatmentInstitute, University of Pittsburgh Medical Center, Pittsburgh,Pennsylvania, USA

Julia T. Woodward, PhD Department of Psychiatry and Behavioral Medicine,Duke University Medical Center, Durham, North Carolina, USA

CONTRIBUTING AUTHORS ix

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Foreword

The world’s population is aging, and most of the current generation canexpect to survive to the eight or ninth decade or beyond. Future generationscan expect an even longer life, as with each passing year human life expect-ancy increases by another couple of weeks or so. For most of us, longevity isa cherished ambition, but just how old age will be for us personally depends onmany factors—our genetics, lifestyle, socioeconomic status, personal at-tributes, environment, and the presence (or absence) of disease or accidents.Indeed, we carry the seeds of our old age within us, but how they willeventually translate may or may not be how we would anticipate or wish.

Old age can be a mixed blessing. On one hand, it can provide a reflec-tive time, an integration of life experiences, a time of accepting things asthey are instead of how they could have been—the development of wisdom.On the other, a longer lifespan increases susceptibility to chronic, disablingdiseases, many of which are painful. If only we could have the benefits ofwisdom and cultural knowledge that aging is known to foster, without thetroublesome effects of physical decline! In late life, “survivorship” can takeon new meaning, including coping with the challenges of disability and thetrials of chronic pain. In reality, it is very hard to be reflective, perceptive,and wise when organ systems don’t work as they should, everything hurts,and breakdown in one area seems to lead to problems in another! Multiplestudies have shown that those older people who have poorer psychologicaladaptation to aging problems have less life satisfaction and poorer quality oflife and are likely to have a greater burden of disease and disability (Smithand Baltes 1999). Not all diseases in late life are painful, but many are verypainful indeed, and pain is a major contributor to disability and depression(Parmelee 1997). While some studies have shown that older people can livewell and have a reasonable sense of well-being despite illness or disability,virtually none show a similar resilience in older persons with persistent pain.

xi

But no matter how they make you feel, you should always watchelders carefully. They were you and you will be them. You carry theseeds of your old age in you at this very moment, and they hear theechoes of their youth each time they see you.

Kent Nerburn, U.S. theologian, artist, and author. Letters to My Son (1993).

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xii FOREWORD

Pain in old age presents many challenges, not only to those in pain, butalso to their family, social network, and health care providers. Pain hasprofound psychosocial effects that influence the person far beyond any im-mediate physiological impact. Disregarding, denying, or neglecting pain hasadverse consequences, not just physically, but also on psychological adjust-ment, mood state, and quality of life. What should be quality time withfamilies at the end of a long life can become distressing and intolerable.

Pain has different meanings for different people. While some stoicsview aches and pains as an expected consequence of aging, others maysuffer in silence, mistaken in a belief that pain signals a dread disease or thatthey might be admitted to hospital, or worse, an institution. Nor does persis-tent pain in older people just belong to those directly afflicted; it oftenaffects family caregivers who provide instrumental and emotional support,sometimes harming their own mental health. A pain problem can becomeemotionally overwhelming, overshadowing everything else in life, becom-ing a stage for interpersonal and intrapersonal dynamics to be acted out tothe detriment of all involved.

An older person with persistent pain needs to be understood in his or herown biopsychosocial context. It is disease, not aging, that initiates persistentpain. While this may seem self-evident, it is surprising how often pain isthought to be a “normal” part of the aging process by elders themselves, bytheir caregivers, and unfortunately also by their clinicians. Pathology be-comes entwined with physiology as late life progresses, modified in turn bypsychosocial factors, each component influencing the others. A good under-standing of contextual factors increases the individual’s appreciation of thecomplexity of pain and helps the clinician to be more empathic to patients’problems.

Aging and pain are not synonymous. While aging is inevitable, pain inold age is not. Given appropriate knowledge and skills, much is available toalleviate pain and suffering, improving the quality of life for many olderpeople. In recent years, the gerontological literature has been interested in“successful ageing,” defined simply as “doing the best one can with whatone has” (Baltes and Carstensen 1996). Older people have their own ideas asto what they consider “successful ageing,” such as retaining their ability toadapt, focusing on gains rather than losses, and having a sense of psycho-logical well-being and social engagement (Phelan et al. 2004). Older peoplevalue these characteristics far more than maintaining physical or cognitivefunctioning. It is much more likely that older persons will achieve the at-tributes they desire if they are without pain, or if any pain that they have iswell controlled. Thus, the rewards for good management of pain in personsof advanced age are potentially great. The relief of discomfort allows older

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persons to engage more with their families and communities, to have abetter chance of developing a sense of personal well-being, and to be morelikely to gain that much-cherished quality time at the end of their days.

So far, despite acknowledging that increased longevity will be accompa-nied by a concomitant increase in the prevalence of painful diseases, weseem to be focusing little effort on controlling pain in older people. About60–71% of community-dwelling older people report feeling pain somewhere,with over 33% reporting daily persistent pain (Brochet 1998). The extent towhich pain interferes with daily activities increases incrementally with age.Yet while the prevalence of pain may be high in elders, the prevalence ofpain actually treated is shockingly low. This discrepancy is seen in commu-nity-dwelling elders without dementia who are more functional and betterable to articulate their pain (Pitkala et al. 2002), in community-dwellingindividuals with dementia (Mäntyselkä et al. 2004), and especially in institu-tionalized elders (Ferrell 2004).

One fundamental reason for the relative neglect of pain in older peopleis lack of education in the assessment and management of pain in geriatriccurriculae, thus turning out health professionals lacking the knowledge andskills to treat pain in their older patients. Another cause is the unfortunatenihilistic attitudes of some health professionals to pain associated with ag-ing, leading them to undertreat because they believe there is little point. Yetanother involves the numerous myths that abound about pain in older people,such as the notion of presbyalgia or that prescription of regular analgesicsleads to addiction and a lack of long-term efficacy, or the belief that failureto express pain complaints means they do not exist. Pain is complex, but sois aging. That is why the current volume on Pain in Older Persons is sonecessary and timely. We need to educate, to dispel the myths, to highlightthe important issues, to explore the intricacy of the relationship betweenpain and aging, and to provide information on the practicalities of painmanagement.

A mere intellectual acknowledgement of the issues related to pain andaging, including epidemiology, notable age differences, and methods of as-sessment and treatment, may still be viewed as a limited response to themassive problem of pain and suffering in old age. Knowledge and empathyare not enough without a commitment for action, but they are an importantstart. As Nerburn reminds us so significantly: “You should always watchelders carefully. They were you and you will be them. You carry the seedsof your old age in you at this very moment.”

Not only does each one of us carry the seeds of our own old age, butcollectively, health professionals interested in the management of persistentpain carry the kernels of knowledge about optimal pain management for the

FOREWORD xiii

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aged. Pain in Older Persons has been written to help us cultivate that knowl-edge so that we can develop a suitable climate of professional consideration,compassion, and commitment to allow those seeds to germinate and grow.

REFERENCES

Baltes M, Carstensen L. The process of successful aging. Ageing Soc 1996; 16:397–422.Brochet B, Michel P, Barberger-Gateau P, Dartigues J. Population-based study of pain in elderly

people: a descriptive survey. Age Ageing 1998; 27:279–284.Ferrell BA. The management of pain in long-term care. Clin J Pain 2004; 20(4):240–243.Mäntyselkä P, Hartikainen S, Louhivuori-Laako K, Sulkava R. Effects of dementia on perceived

daily pain in home-dwelling elderly people: a population-based study. Age Ageing 2004;33:496–499.

Parmelee P. Pain and psychological function in late life. In: Mostofsky D, Lomrantz J (Eds).Handbook of Pain and Aging. New York: Plenum Press, 1997, pp 207–226.

Nerburn K. Letters to My Son: Reflections on Becoming a Man. San Rafael, CA: New WorldLibrary, 1993.

Phelan E, Anderson L, Lacroix A, Larson E. Older adults’ views of “successful aging.” How dothey compare with researchers’ definitions? J Am Geriatr Soc 2004; 52:211–216.

Pitkala KH, Strandberg TE, Tilvis RS. Management of nonmalignant pain in home-dwellingolder people: a population-based survey. J Am Geriatr Soc 2002: 50(11):1861–1865.

Smith J, Baltes P. Profiles of psychological functioning in the old and oldest old. Psychol Aging1997; 12:458–472.

PAMELA S. MELDING, MB, CHB, FFARCS, FRANZCP, DIPHSMSenior Lecturer in Psychiatry of Old AgeDepartment of Psychological MedicineFaculty of Medical and Health SciencesUniversity of AucklandConsultant in Psychiatry of Old AgeWaitemata District Health BoardNorth Shore HospitalTakapuna, AucklandNew Zealand

xiv FOREWORD

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xv

Preface

The average human life expectancy continues to rise with falling mor-tality in infancy and childhood as well as advances in social policy, publichealth measures, and improved medical care across the adult lifespan. Forthe first time in history the number of older persons now exceeds the num-ber of children in many developed countries. A prolonged lifespan has muchmerit and provides many new opportunities, but longevity is only a blessingif one can maintain reasonable health. Bothersome or chronic pain is a majorproblem in older segments of the population because it can have a profoundnegative impact on physical functioning, psychosocial health, and quality oflife, and it is one of the most prevalent health problems affecting olderpersons. The IASP recognized the importance of this topic with the timelyrelease of a volume entitled Pain in the Elderly in 1996. This publication,edited by Bruce and Betty Ferrell, had an international team of contributorsand comprised 11 chapters. In the 10 years since the IASP’s first volume onthe problem of pain and aging, the field has flourished with an accumulationof new knowledge regarding the neurophysiology and neurobiology of painin older adults, further testing of age differences in pain perception andreport, the development of age-appropriate pain assessment tools, new waysof treating pain disorders common in advanced age, and the identification ofareas that require more study in order to further improve the care of olderpain patients.

Pain in Older Persons attempts to update our understanding of theseareas and highlight the major accomplishments that have occurred since thefirst IASP publication on this topic. The book comprises 19 chapters, di-vided into five main sections. Part I provides an introduction to the fieldthrough discussion of the epidemiology of common painful disorders fromwhich older adults suffer. The four chapters in Part II focus on age differ-ences in pain, including differences in the neurobiology of pain processingand behavior in animals and humans, the unique aspects of clinical painstates as manifested in older adults, studies on pain threshold and age differ-ences in the sensitivity to experimental pain stimuli, and age-related psycho-logical and cognitive differences in pain and its impact. This section providesimportant background material to aid in understanding pain as it affectsolder persons.

Part III includes four chapters that critically review the literature onpsychometric and behavioral pain assessment as it specifically relates to

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xvi PREFACE

older adults. Many assessment tools are developed in young adult popula-tions and are then applied to older segments without formal validation orconsideration of age-specific needs. The authors review the age-appropriateevidence base regarding valid approaches to the assessment of pain severityin cognitively intact and cognitively impaired older persons, the assessmentof pain-related physical functioning, and the monitoring of psychosocialaspects of chronic pain. Part IV presents pain-related treatment modalitiesthat apply to a wide range of pain conditions, including oral analgesics,physical therapy techniques and exercise, cognitive-behavioral therapy,interventional pain management procedures, complementary and alternativemedicine applications, and multidisciplinary pain management clinics. Onceagain, the emphasis is on a critical evaluation of age-appropriate treatmentmodalities with due consideration to the specific needs of older persons withbothersome pain. Part V includes four chapters that discuss evaluation andtreatment approaches to various pain conditions common in advanced age,including low back pain and its contributors (osteoarthritis, fibromyalgia,myofascial pain, osteoporosis, and sacroiliac joint syndrome), neuropathicpain, postoperative pain, and cancer pain. Bothersome pain in older personsrepresents a major public health problem for our society, and this problemwill become even more pressing with the demographic shift in the agecomposition of the world’s population. It is our hope that this volume notonly will help to update the field as a whole, but will stimulate new thinkingand contribute to new developments in this critical area of investigation.

STEPHEN J. GIBSON, PHD DEBRA K. WEINER, MD

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135

7

Pain in Older Persons, Progress in PainResearch and Management, Vol. 35, editedby Stephen J. Gibson and Debra K. Weiner,IASP Press, Seattle, © 2005.

Assessing Pain in Older Personswith Severe Limitations in Ability

to Communicate

Thomas Hadjistavropoulos

Department of Psychology, University of Regina,Regina, Saskatchewan, Canada

The assessment of the pain patient is a comprehensive task that shouldinvolve information about a wide variety of areas of functioning includingpain intensity, mood, diagnosis, results of physical examinations, social con-text, personal history, coping strategy usage, and other related domains. Thischapter focuses primarily on the aspect of pain assessment that concernsitself with pain detection and pain intensity.

It is widely agreed upon that pain in seniors is undertreated (Ruda 1993;Jones et al. 1996; Kapp 1996; Ferrell et al. 2001; Weiner et al. 2001), andthis concern becomes especially salient when one considers seniors whohave serious limitations in ability to communicate due to dementia (e.g.,Marzinski 1991; Malloy and Hadjistavropoulos 2004). It is believed that theundertreatment of pain among seniors with severe dementia is partly due todifficulties in detecting pain in this population (e.g., Feldt 2000;Hadjistavropoulos et al. 2001; Herr and Garand 2001; Martin et al., in press).Studies have confirmed that pain problems are often missed by physicianswhen traditional pain evaluation approaches are employed with dementiapatients (Cohen-Mansfield and Lipson 2001; Sengstaken and King 1993).

ASSESSMENT THROUGH A COMMUNICATIONSMODEL OF PAIN

The challenges involved in assessing pain among seniors with cognitiveimpairments can be conceptualized through a communications model of

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136 T. HADJISTAVROPOULOS

pain (e.g., Prkachin and Craig 1995; Hadjistavropoulos and Craig 2002;Hadjistavropoulos et al. 2004). The model, based on earlier formulations byRosenthal (1982), describes an A → B → C process whereby the internalstate (A; pain) may be encoded in features of expressive behavior (B) thatallow an observer to draw inferences (C) about a patient’s internal experi-ences. The model also construes the complex response to tissue injury asvarying with respect to reflexive automaticity and cognitive executive me-diation (Hadjistavropoulos and Craig 2002). That is, self-report proceduresfor assessing pain, which are generally easy for an observer to decode, relyon higher mental processes. The ability to comprehend a question and (usu-ally) the ability to respond verbally or in writing are required. Often, thepatient must be able to represent the pain along a 10-cm line or throughother representational modes. In persons with dementia, such abilities de-cline along with abstract reasoning, language skills, and other cognitivecapacities. In contrast to self-report procedures, observational methods ofassessing pain tend to rely on more automatic forms of pain expression andcommunication (e.g., grimaces or the reflexive withdrawal of a limb). Theseautomatic forms of pain communication are sometimes more difficult todecode and interpret than self-report information. On the other hand, due totheir reflexive automaticity, nonverbal behaviors are more likely to be pre-served in situations where higher mental processes are compromised. Assuch, nonverbal behaviors are a primary focus of this chapter.

SELF-REPORT OF PAIN AMONG SENIORS WITH DEMENTIA

During the early to middle stages of the dementing process (i.e., mild tomoderate dementia), the patient’s communicative abilities tend to remainsufficient for the verbal communication of the pain experience (see Chapter6 for more information on assessment procedures suitable for seniors whocan communicate verbally). In fact, early to mid-stage dementia patients canoften provide valid responses to a variety of self-report assessment tools(e.g., Hadjistavropoulos et al. 1998; Scherder and Bouma 2000; Chibnalland Tait 2001). There is little question, however, that as the dementiaprogresses, patients become less likely to self-report pain complaints (e.g.,Parmelee et al. 1993; Hadjistavropoulos et al. 1997), despite a lack of differ-ences in the prevalence of painful conditions between people with and with-out cognitive impairments (Proctor and Hirdes 2001).

Self-report measures have been found to differ with respect to theirpsychometric properties when used with seniors suffering from varying de-grees of dementia. In attempting to determine the lowest level of impairment

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240 S.J. WATERS, J.T. WOODWARD, AND F.J. KEEFE

CONCEPTUAL FRAMEWORK

Cognitive-behavioral approaches to pain are guided by a biopsychosocialmodel (see Fig. 1). This model maintains that pain is a complex phenom-enon that is influenced by underlying biological factors (e.g., diseases thatcause tissue damage) as well as psychological and social factors. Cognitive-behavioral researchers have identified a number of key psychological factors(e.g., cognitions, emotions, and behaviors) and social factors (e.g., socialsupport, solicitous or critical spousal responses) that can influence pain anddisability. A hallmark of the cognitive-behavioral model is that the relation-ships between biopsychosocial factors and pain are reciprocal. Thus,biopsychosocial factors can directly influence pain and disability, and changesin pain and disability can, in turn, influence important biopsychosocial fac-tors. These reciprocal interrelationships have important implications for treat-ment. For example, a surgical treatment (e.g., a knee replacement surgeryfor a patient having osteoarthritic knee pain) can produce substantial reduc-tions in pain and disability and can influence related biological factors (e.g.,

Biological Factors

Psychological Factors

• Medical Comorbidities • Sensory Changes • Cognitive Changes

• Depression • Anxiety • Fear of Pain • Helplessness • Cognitive Distortions • Self-Efficacy

• Social Support • Access to Treatment

Socio-Environmental

Factors

Fig. 1. Recursive cognitive-behavioral model of pain.

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COGNITIVE-BEHAVIORAL THERAPY 241

by improving joint mechanics and physical conditioning), psychological fac-tors (e.g., by boosting self-efficacy and reducing depression), and socialfactors (e.g., by reducing caregiver strain). Thus, the impact of one factor onanother may be modified with the use of CBT.

Cognitive-behavioral therapy can be characterized by examining bothits process-related and content-specific characteristics (Beck 1976; Beck etal. 1979; Dobson and Shaw 1995; see J.S. Beck 1995 for a detailed descrip-tion of CBT characteristics and techniques). From a process standpoint,CBT is often delivered as a brief intervention (e.g., 8–12 sessions) with anemphasis on current functioning and behaviors. CBT therapists take a direc-tive role in early sessions in order to orient the client to therapy and intro-duce basic concepts, then transition to a more collaborative stance that in-volves clients in setting the session’s agenda, developing homeworkassignments, and providing ongoing feedback to the therapist. Within eachsession, CBT therapists follow a structured sequence in which they:(1) assess the client’s current mood; (2) set an agenda; (3) review materialcovered in the previous session; (4) review the previous homework assign-ment; (5) introduce a new skill or concept; and finally, (6) establish a home-work assignment that will allow for practice and consolidation of the new skill.

Cognitive-behavioral therapy also can be understood by examining itscontent-specific characteristics (A.T. Beck 1976; Beck et al. 1979; J.S. Beck1995; Dobson and Shaw 1995). In general, early in treatment patients areprovided with a rationale for treatment and informed about the efficacy ofCBT in treating their symptoms. Next, the link between cognitions andemotion is established, and patients begin to appreciate the role of distortedcognitions in driving their emotional distress. Throughout the treatment pe-riod, patients are taught a variety of specific skills (e.g., identifying auto-matic thoughts, challenging cognitive distortions) that help them to ratio-nally evaluate and modify thinking (Beck 1995). Challenging the veracity ofnegative thoughts decreases patients’ propensity to accept them as fact andmoves patients toward recovery. Finally, the last phase of treatment empha-sizes anticipation of potential setbacks and specific steps for relapse preven-tion.

When patients receive CBT to address their chronic pain, their cognitiveexperiences become a primary focus of treatment (Thorn 2004). Negativethinking leads chronic pain patients to believe that their life cannot improveand that they are victims of pain that will never remit. Thus, the generalprinciples of CBT are particularly effective in this population when thefocus is appropriately placed on the pain-related negative cognitions. Fur-ther, patient outcome is improved by also providing patients with requisitepain-coping skills training (e.g., relaxation, activity pacing, and pleasant

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242 S.J. WATERS, J.T. WOODWARD, AND F.J. KEEFE

activity scheduling) to enhance self-efficacy for dealing with pain. Suchtraining typically begins with education about the complex nature of pain(e.g., the gate control theory of pain; Melzack and Wall 1965), followed byintroduction of specific cognitive and behavioral skills that have demon-strated efficacy in improving patient’s ability to cope with their pain. Pa-tients become empowered to actively manage their pain when they are pro-vided with a repertoire of coping skills that can be applied during stressfulperiods or during pain flares. Table I lists specific skills typically includedin pain-coping skills protocols (for a more complete description see Beck1995; Waters et al. 2004). The final phase of pain-coping skills trainingfocuses on methods of maintaining coping skills practice and dealing withpotential setbacks and relapses.

SPECIAL CHALLENGES AND OPPORTUNITIES IN WORKINGWITH OLDER ADULTS: A BIOPSYCHOSOCIAL PERSPECTIVE

A number of challenges and opportunities arise when using cognitive-behavioral interventions to manage persistent pain in older adults. These canbe grouped into three basic categories: biological, psychological, and social,

BehavioActivity

Pleasantsched

Social re

Time-comedic

CognitivCognitiv

Problem

Distracti

Relapse

Source:

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336 D.K. WEINER AND D. CAYEA

AXIAL AND APPENDICULAR OSTEOARTHRITIS

Background and epidemiology. Degenerative disk and facet disease isnearly universal in people 65 and older, regardless of pain status. One smallstudy demonstrated that 100% of 35 older adults who were pain free and hadno history of LBP had radiographic evidence of degenerative disk and/orfacet disease (Weiner et al. 1994). Degenerative lumbar spinal stenosis,according to another small study, occurs not uncommonly in pain-free indi-viduals, with a prevalence rate of 21% in adults 60 and older; 36% of theseasymptomatic individuals showed herniated nucleus pulposus (Boden et al.1990).

Because of the generalized nature of OA, non-lumbosacral degenerativepathology such as knee and hip arthritis must be taken into account whenevaluating the older adult with LBP. Gait alterations caused by painful lower-extremity arthritis may lead to a variety of adverse consequences includingstrain of the SI joint and surrounding structures, pain of the tensor fascialata/IT band, postural instability associated with a risk of falling, and physi-cal disability (Thomas et al. 2004). Thus, clinicians should routinely exam-ine the hips and knees when evaluating the older adult with LBP and/orlower-extremity pain.

Approach to evaluation. Clinical history, physical examination, andassessment of pain and functional status lie at the core of evaluating olderadults with axial and appendicular OA. For patients with hip or knee OA,the American College of Rheumatology (ACR) also recommends X-rays inthe setting of worsening pain and/or functional status if none have beenperformed during the prior 3 months (Pencharz and MacLean 2004). Asmentioned above, the evaluation of lumbosacral degenerative disease shouldbe even more conservative, focusing on a thorough history and physicalexamination. Basic radiographs should be obtained if non-degenerative pa-thology is suspected (e.g., an osteoporotic compression fracture). Advancedimaging should be avoided unless red flags are uncovered at the time of thehistory, or if surgery is being contemplated, as the specificity of MRIs islow, with some estimates as low as 72% (Jarvik and Deyo 2002). Investiga-tors have attempted to develop non-radiographic procedures to assist withthe diagnosis of lumbar spinal stenosis. One such procedure, the two-stagetreadmill test, has been shown to have excellent test-retest reliability (Deenet al. 2000); it correctly classifies patients with lumbar spinal stenosis 76.9%of the time (Fritz et al. 1997).

Approach to treatment. Treatment of both axial and appendicular OAshould be approached in a step care manner, as illustrated in Fig. 2, ascheme that we use to guide treatment at our pain management center forolder adults. Details on the pharmacokinetics, dosing, side effects, and drug-

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LOW BACK PAIN 337

drug and drug-disease interactions of oral analgesics can be found in Chap-ter 10 and in guidelines published by the American Geriatrics Society Panelon Persistent Pain in Older Persons (2002).

Step 1. At the foundation of OA treatment is patient education as well asprescription of weight loss, exercise, and assistive devices. The AmericanGeriatrics Society Panel on Exercise and Osteoarthritis recently publishedguidelines on exercise prescription for older adults with OA (2001). Foradditional information on the benefits of exercise, the reader is also referredto Chapter 11.

Step 2 (injections). (a) For appendicular OA, if the source of pain iswell-localized and easily accessible (e.g., in the knee or finger), we feel thatcorticosteroid injection should be seriously considered as the next step. Whilestudies indicate that corticosteroid efficacy is relatively modest and short-lived (Dieppe et al. 1980; Raynauld et al. 2003), their low side-effect profileand sometimes prolonged efficacy supports their use early on in the courseof treatment. The use of local corticosteroids also has scientific underpin-nings because of data indicating the underlying inflammatory pathogenesisof OA (Martel-Pelletier et al. 1999; Abramson et al. 2001; Pincus 2001;Hedbom and Hauselmann 2002; Sowers et al. 2002; Haywood et al. 2003).Intra-articular injection of hyaluronic acid has met with mixed results (Brandtet al. 2000; Felson and Anderson 2002). (b) For axial OA, the value ofinjection procedures for degenerative lumbosacral pathology has not been

Education, Exercise, Weight Loss, Assistive Devices

Injections

Acetaminophen

Non-acetylated salicylates

Strong Opioids

Surgery

Topical Preparations,Cognitive-Behavioral Therapy,

Interdisciplinary Pain Rx,CAM Modalities

Other NSAIDs, Weak Opioids

Education, Exercise, Weight Loss, Assistive DevicesEducation, Exercise, Weight Loss, Assistive Devices

Injections

Acetaminophen

Non-acetylated salicylates

Strong OpioidsStrong Opioids

SurgerySurgery

Topical Preparations,Cognitive-Behavioral Therapy,

Interdisciplinary Pain Rx,CAM Modalities

Other NSAIDs, Weak Opioids

Fig. 2. Stepped care approach to the treatment of axial and appendicular osteoarthritis.CAM = complementary and alternative medicine.

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