[The Mainz Pain Staging System is also suitable for grading chronic pain in inpatient geriatric patients]. / Das Mainzer Stadienmodell der Schmerzchronifizierung ist auch bei stationären geriatrischen Patienten zur Graduierung chronischer Schmerzen geeignet.

INTRODUCTION: The Mainz Pain Staging System (MPSS), which has been validated primarily in middle-aged and chronic low back pain patients, is designed to predict prognosis and control the use of resources at baseline. In multi-morbid and functionally impaired patients (geriatric patients) with multiple causes of pain, it is unclear whether this instrument can be implemented at all and whether it permits statements to be made on the severity of pain chronification. MATERIALS AND METHODS: Therefore, 173 consecutive patients with pain were classified in the second week of inpatient geriatric treatment according to the MPSS. For validation, the questions from the "Pain interview for geriatric patients" (SgP) were used. In addition, the MPSS was compared with the personal history of the duration of the main pain. RESULTS: With the exception of the questions on medication intake, the items in the MPSS could be collected predominantly by self-assessment. Even with current analgesic therapy, MPSS has significant correlations with sensory, affective, and emotional dimensions of pain from the SgP. The data on duration correlated with only one category of MPSS (spatial aspects of pain). CONCLUSION: MPSS can be used in multi-morbid and functionally impaired elderly patients undergoing inpatient treatment. Chronification features are more pronounced at higher stages than at lower levels. Only one category of the MPSS cannot be collected by self-assessment. The possibilities of prognosis estimation and resource control using the MPSS should be further investigated for these patients.

[Recommendations of the second update of the LONTS guidelines : Long-term opioid therapy for chronic noncancer pain]. / Empfehlungen der zweiten Aktualisierung der Leitlinie LONTS : Langzeitanwendung von Opioiden bei chronischen nicht-tumorbedingten Schmerzen.

BACKGROUND: The second scheduled update of the German S3 guidelines on long-term opioid therapy for chronic noncancer pain (CNCP), the LONTS (AWMF registration number 145/003), was started in December 2018. METHODS: The guidelines were developed by 28 scientific societies and 2 patient self-help organizations under the coordination of the German Pain Society. A systematic literature search in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Scopus databases (up until December 2018) was performed. The systematic reviews with meta-analyses of randomized controlled trials with opioids for CNCP from the previous versions of the guideline were updated. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of the recommendations was established by formal multistep procedures in order to reach a consensus according to the Association of the Medical Scientific Societies in Germany (AWMF) regulations. The guidelines were reviewed by four external pain physicians. Public comments were possible for 4 weeks. RESULTS: Opioid-based analgesics are a drug-based treatment option for short-term (4-12 weeks), intermediate-term (13-25 weeks) and long-term (≥26 weeks) therapy of chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia and low back pain. Contraindications are primary headaches as well as functional somatic syndromes and mental disorders with the (cardinal) symptom pain. Based on a clinical consensus the guidelines list other medical conditions for which a therapy with opioids can be considered on an individual basis. Long-term therapy of CNCP with opioids is associated with relevant risks. CONCLUSION: A responsible administration of opioids requires consideration of possible indications and contraindications as well as regular assessment of efficacy and adverse effects. Opioids remain a treatment option for CNCP if nonpharmacological therapies are not effective and/or other drugs are not effective, are not tolerated or are contraindicated.

[Post-acute geriatric rehabilitation outcomes in fracture patients treated in an orthogeriatric trauma center-A prospective investigation with historical control]. / Outcome von Patienten in der geriatrischen Rehabilitation mit und ohne alterstraumatologische Akutbehandlung.

BACKGROUND: Despite the increasing amount of positive evidence with respect to mortality for the orthogeriatric co-management in a center for geriatric traumatology (CGT), effects on the course after the acute inpatient hospital treatment have been insufficiently investigated. METHODS: Patients over 75 years old who needed rehabilitation following acute inpatient treatment before (retrospective, n = 90) and after (prospective, n = 99) the introduction of a certified CGT were investigated. The two groups were compared with respect to the frequency of discharge into an indication-specific (AHB) and geriatric rehabilitation, mobility performance including the five times sit-to-stand test, short physical performance battery (SPPB) and competence in activities of daily living with the Barthel index (BI). RESULTS: After introduction of a CGT 17.2% (95 % confidence interval [95 % CI]: 10-25%; p < 0.027) of the patients were discharged to a specialized orthopedic inpatient rehabilitation (AHB) vs. 6.7% (95 % CI: 1-12%) before the introduction. Correspondingly less patients needed geriatric rehabilitation (before CGT 93.3 %, 95 % CI: 88.1-98.6 vs. CGT 82.8 %, 95 % CI: 75-90; p < 0.001). The overall outcome of post-acute geriatric inpatient rehabilitation improved in both groups but did not differ. Patients who needed two therapy sessions in the CGT were clearly poorer than those with one therapy session with respect to activities of daily living (BI: 34.1, 95 % CI: 30-37.2 vs. 41.2, 95 % CI: 30.9-51.4) and mobility performance (SPPB: 1.2, 95 % CI: 0.7-1.8 vs. 2.2, 95 % CI: 0.9-3.4; p = 0.048). The differences remained despite improvement of both groups during geriatric rehabilitation. CONCLUSION: The establishment of a CGT enables more patients to be discharged into a less cost-intensive AHB. The more intensive treatment in the CGT offers more severely affected patients the chance for further functional improvement through post-acute inpatient geriatric rehabilitation. A predominantly closing treatment of patients in a CGT is not conceivable in the CGT model presented.

[Treatment of pain in people with dementia]. / Schmerzbehandlung bei Menschen mit Demenz.

The causes of pain must always be clarified, as long as it can be justified. In dementia the placebo effect can be lacking. A treatment on demand is difficult to implement. Correctly applied nonmedicinal treatment has few unwanted effects but mostly needs constant support by personnel. Medications with anticholinergic effects should be used with caution due to the high risk of delirium and falling. With analgesics and coanalgesics the principles of geriatric treatment must also be adhered to: start low, go slow. Complaints that can be triggered by analgesics or coanalgesics should be recorded before starting treatment. Education and clarification by therapists are given priority. Multimorbidity and polypharmacy restrict the analgesic treatment. Strategies of self-efficacy and other psychological procedures have limited implementation. The course of treatment is difficult to monitor.

[Anaesthesiological management of patients with dementia]. / Der demenzkranke Patient--Was ist beim anästhesiologischen Management zu beachten?

The aging society challenges anaesthesiologists with a growing number of patients with dementia. These and their relatives worry about an aggravation of an already existing dementia or even the postoperative evocation of one. Common volatile anaesthetics and propofol are suspected to increase dementia - associated protein tau and amyloid-betalevels in the brain. Perioperative complications such as cognitive dysfunction and delirium occur more frequently in dementia patients. For anaesthesiologists, it seems prudent toassess the grade of dementia in the elderly to adjust anaesthesia drug doses and monitoring intra- and postoperatively. Pharmacological interactions with antidementic andneuroleptic current medications affectanaesthetic and analgesic effects.In dementia, perioperative malfunction of cognition, memory, attention, information processing, communication and social interaction abilities is of profound influence on the perioperative management.This review mentions actual knowledge about dementia forms and symptoms in brief. Recommendations for the anaesthesia care are given in more detail.

[Pain and dementia: what to consider?] / Schmerz und Demenz: Was ist zu beachten?

Pain history should be adapted to their cognitive abilities of people with dementia who can still communicate. With increasing limitations of communication skills, history of a third party and standardized observation instruments increase in importance. Non-drug therapies are hardly investigated for pain therapy in people with dementia. The few data on drug pain therapy prove the effectiveness and good tolerability of paracetamol even in people with dementia. Opioids and coanalgetics have hardly been studied in this group although frequently used. Anticholinergic side effects are especially important in people with dementia.

Long-term opioid therapy for chronic noncancer pain: second update of the German guidelines.

The opioid epidemic in North America challenges national guidelines worldwide to define the importance of opioids for the management of chronic noncancer pain (CNCP). METHODS: The second update of the German guidelines on long-term opioid therapy for CNCP was developed by 26 scientific associations and 2 patient self-help organizations. A systematic literature search in CENTRAL, Medline, and Scopus (to May 2019) was performed. Meta-analyses of randomized controlled trials and open-label extension studies with opioids for CNCP were conducted. Levels of evidence were assigned according to the Oxford Centre for Evidence-Based Medicine classification system. The formulation and strength of recommendations were established by multistep formalized procedures to reach a consensus according to German Association of the Medical Scientific Societies regulations. The guidelines underwent external review by 4 experts and public commentary. RESULTS: Opioids are one drug-based treatment option for short- (4-12 weeks), intermediate- (13-26 weeks), and long-term (>26 weeks) therapy of chronic pain in osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia, and low back pain. Contraindications are primary headaches, functional somatic syndromes, and mental disorders with the (cardinal) symptom of pain. For specified other clinical pain conditions, short- and long-term therapy with opioids should be evaluated on an individual basis. Long-term therapy with opioids is associated with relevant risks. CONCLUSION: Responsible application of opioids requires consideration of possible indications and contraindications, as well as regular assessment of clinical response and adverse effects. Neither uncritical opioid prescription nor general rejection of opioids is justified in patients with CNCP.

Pain assessment in advanced dementia. Validity of the German PAINAD-a prospective double-blind randomised placebo-controlled trial.

Pain in combination with dementia is a common condition that makes pain recognition significantly more difficult. This results in undertreatment of pain in those suffering from dementia. The Pain Assessment in Advanced Dementia (PAINAD) scale currently represents one of the best approaches to pain detection in dementia. In a pilot study, strong inter-rater and retest reliability of the German version (PAINAD-G) was proven. However, the available data concerning the validity of this instrument were insufficient. The aim of the study was to validate the PAINAD-G scale by a double-blind randomised placebo-controlled trial in people with advanced dementia expected to be in pain. A second aim was to examine whether other observational tools (BISAD = Observation Instrument for Assessing Pain in the Elderly with Dementia) (German: Beobachtungsintrument für das Schmerzassessment bei alten Menschen mit Demenz, Checklist of Nonverbal Pain Indicators, Algoplus) were also able to demonstrate a significant difference between the study groups. Surprisingly, the study revealed no difference in "pain reduction" between those treated by oxycodone compared with those treated by placebo. Equally, none of the other 3 observational tools were able to demonstrate a significant difference between the study groups. However, correlations among the 4 observational tools were mostly moderate to high. A number of possible reasons for this observation, such as difficulties regarding sensitivity to change/responsiveness, consistence of the fundamental construct, influence of the early onset study, and efficacy of the analgesic in advanced dementia are discussed.