The Pain Clinic for Older People.

OBJECTIVE: Multidisciplinary pain clinics have an established role in the management of persistent pain, but there is little evidence to support this approach in an older population. This study describes the characteristics and pain outcomes of patients attending a pain clinic designed exclusively for older people. METHODS: A retrospective audit was performed of outcomes of the Pain Clinic for Older People (PCOP) in 2015-2019. Response to treatment was determined by change in Brief Pain Inventory (BPI) scores at initial attendance and after a treatment program. Clinically meaningful improvement was defined by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus criteria of ≥30% improvement in average pain and one-point improvement in pain interference. Results were compared with the national benchmark collated by the electronic Persistent Pain Outcomes Collaboration (ePPOC), which reports the combined results from 67 participating Australian and New Zealand pain services. RESULTS: Patients attending the PCOP had a mean age of 80.5 years and had high rates of frailty (84%), cognitive impairment (30%), and multimorbidity. Significant reductions in BPI average pain and BPI pain interference scores were achieved. Clinically meaningful improvement in BPI average pain was achieved in 63% of patients attending the PCOP who were 65-74 years of age and in 46% of patients who were ≥75 years of age, which met the national benchmark set by ePPOC of 40% for both age groups. Clinically meaningful improvement in BPI pain interference was achieved in 69% of those attending the PCOP who were 65-74 years of age and in 66% of those who were ≥75 years of age, comparable to the ePPOC benchmark of 71% and 65% for the respective age groups. CONCLUSION: PCOP clients achieved significant and meaningful improvements in their pain outcomes that satisfied the national benchmark. Advanced age, cognitive impairment, frailty and multimorbidity should not be regarded as barriers to benefit from a pain clinic specifically designed for older people.

Resuscitation planning on a subacute geriatric evaluation and management ward.

OBJECTIVES: To describe the use of acute resuscitation plans (ARPs) among patients on a subacute geriatric ward and to identify factors associated with use of ARPs in these patients. METHODS: The hospital records of all patients admitted to the geriatric medicine ward in 2016 were retrospectively audited. RESULTS: An ARP was completed before separation for 333/442 (75.3%) admissions. In the event of arrest, 240 (54.3%) patients had an ARP specifying "care of the dying", 93 (21.0%) had an ARP specifying "cardiopulmonary resuscitation" and 109 (24.7%) had no resuscitation plan. Age 85-94 years (OR 1.65, P = 0.04) and ≥95 years (OR 9.59, P = 0.003), as well as Charlson index of comorbidity ≥2 (OR 3.4, P < 0.001), Australian-born (OR 2.09, P = 0.002) and admission during October-December (OR 3.81, P < 0.001) were independently associated with increased use of ARPs. CONCLUSIONS: Acute resuscitation plan use was associated with older age, higher comorbidity, birth in Australia and admission later in the year.

Chronic pain medication management of older populations: Key points from a national conference and innovative opportunities for pharmacy practice.

OBJECTIVE: Inappropriate use of pain medication has serious consequences for older populations. Experts in the field have noted an increase in opioid prescriptions, and opioid-related hospitalisations and deaths among this vulnerable population. In the pursuit of educating pharmacists, physicians, allied healthcare professionals, researchers, academics and the public facing the challenges of chronic pain medication management, 'The Inaugural Monash University School of Public Health and Preventive Medicine (SPHPM) Best Practice in Chronic Pain Medication Management Day Conference' was held in December 2016 at the Alfred Medical Research and Education Precinct (Melbourne, Australia). METHODS: Fifteen experts presented on aspects of chronic pain epidemiology and current analgesic use in older Australians, and discussed current practice and associated challenges. RESULTS: Presenters highlighted the dramatic increase in opioid prescribing, development of tolerance and withdrawal symptoms, problems with abuse and addiction, increased risk of death from overdose or suicide, potentiation of sedative effects with concurrent use of anxiolytics/hypnotics, and medication diversion. CONCLUSIONS: Pharmacists are very accessible to patients and are crucial members of medication management teams. They have the necessary medication expertise to review medication regimens and provide patient education. Towards addressing chronic pain medication management of older populations, pharmacists can contribute in several ways, such as being aware of relevant guidelines and completing further training, contributing to policy and guideline development, participating in multidisciplinary panels, working groups and pain management teams, collaborating on research projects, and educating the community. With regards to opioid medication management, pharmacists are in an ideal position to: monitor prescription dispensing and potential misuse, provide education about overuse, and, if appropriate, provide access to naloxone. In order to fulfil these roles and responsibilities, allied healthcare professionals should be educated and informed, and opportunities for continuing professional education should be available and utilised. Pharmacists should have the necessary knowledge and skills to optimise chronic pain management, and to both deliver and inform policies and guidelines on pharmacological management of chronic pain in older people.

The clinical frailty scale predicts functional decline and mortality when used by junior medical staff: a prospective cohort study.

BACKGROUND: Increasing frailty is associated with risk of mortality and functional decline in hospitalized older adults, but there is no consensus on the best screening method for use by non-geriatricians. The objective of this study is to determine whether the clinical frailty scale (CFS) can be used to identify patient baseline frailty status in the acute general medical setting when used by junior medical staff using information obtained on routine clinical assessment. METHODS: This was a prospective cohort study in an acute general medical unit. All patients aged 65 and over admitted to a general medical unit during August and September 2013 were eligible for the study. CFS score at baseline was documented by a member of the treating medical team. Demographic information and outcomes were obtained from medical records. The primary outcomes were functional decline and death within three months. RESULTS: Frailty was assessed in 95 % of 179 eligible patients. 45 % of patients experienced functional decline and 11 % died within three months. 40 % of patients were classified as vulnerable/mildly frail, and 41 % were moderately to severely frail. When patients in residential care were excluded, increasing frailty was associated with functional decline (p = 0.011). Increasing frailty was associated with increasing mortality within three months (p = 0.012). CONCLUSIONS: A high proportion of eligible patients had the frailty measure completed, demonstrating the acceptability of the CFS to clinicians. Despite lack of training for medical staff, increasing frailty was correlated with functional decline and mortality supporting the validity of the CFS as a frailty screening tool for clinicians.

The science and art of pain management in older persons: case study and discussion.

INTRODUCTION: Evidence-based medicine has been adopted as a means of achieving optimal medical care and to reduce variations in clinical practice. Randomised controlled trials are considered the highest level of scientific evidence. Older individuals are either excluded or underrepresented in these studies, and those who are included are often atypical of patients seen in clinical practice. OBJECTIVE: To examine the approach to clinical decision making in frail older persons when there is little or no scientific evidence to guide management. METHODS: A case study is presented of refractory post herpetic neuralgia in a frail older person. Management plans were developed combining the scientific evidence from the pain literature with the practice known as Comprehensive Geriatric Assessment. The rationale and evidence for clinical decision making is explored. RESULTS: Standard therapies for post herpetic neuralgia had been ineffective or limited by side effects in this patient. By a process of trial and error a combination of treatments was found that improved pain and mood but adversely affected cognition. Adjustment in treatments over time resulted in improved pain, mood, and cognition. CONCLUSIONS: The art of medicine is not the antithesis of the scientific approach. The art of medicine involves balancing the scientific evidence with the circumstances and the preferences of the patient. Combining the practices of Pain Medicine and Comprehensive Geriatric Assessment may result in a better outcome. When treating older people, clinicians not only need to take into consideration the severity of pain, but also the impact of pain and its treatment on cognition, mood and functional status.

Ageing Holocaust survivors in Australia.

In recent years, a phenomenon of "late effects of the Holocaust" has emerged, with impacts on the psychological and physical health of ageing Holocaust survivors. As Holocaust survivors age, they may experience heightened anxiety around normal processes of ageing, worsened post-traumatic stress disorder with cognitive decline, and fear of the medical system. Holocaust survivors are at increased risk of osteoporosis, cardiometabolic disease due to hypothalamic-pituitary-adrenal axis dysfunction, cancer, and sequelae of Nazi medical experiments. From existing medical literature on this topic, practical principles of management are derived to create a framework for sensitive medical management of Holocaust survivors in Australia. The issues discussed are also relevant to the wider geriatric refugee or prisoner-of-war experience.

The aged care pain chart: an innovative approach to assessing, managing and documenting pain in older people.

This article presents the development and initial testing of a comprehensive pain chart for the assessment, management and documentation of pain in older people in subacute and residential aged care. The pain chart was developed from existing assessment scales and pain indicators, and is targeting needs of older people in residential care and geriatric hospital settings with high prevalence of cognitive impairments. The chart is based on self-report of pain but allows for observation of pain-related behaviours for those unable to report pain. The chart consists of one evaluative and one documentation dimension, and was evaluated by a group of clinicians in geriatric hospital care (n = 15) and residential aged care (n = 6). The chart was found to be content valid, informative and easy to use, facilitating clinical assessments and monitoring, and assisting visual readings of patients' temporal pain trends.

An interdisciplinary expert consensus statement on assessment of pain in older persons.

This paper represents an expert-based consensus statement on pain assessment among older adults. It is intended to provide recommendations that will be useful for both researchers and clinicians. Contributors were identified based on literature prominence and with the aim of achieving a broad representation of disciplines. Recommendations are provided regarding the physical examination and the assessment of pain using self-report and observational methods (suitable for seniors with dementia). In addition, recommendations are provided regarding the assessment of the physical and emotional functioning of older adults experiencing pain. The literature underlying the consensus recommendations is reviewed. Multiple revisions led to final reviews of 2 complete drafts before consensus was reached.

The impact of dementia on the pain experience.

Advancing age is associated with an increased risk of illness. Investigating the influence of ageing on the experience of pain must take account of this association, as well as the impact of past experience of life. Dementia, which is almost exclusively restricted to older people, is an illness where the effects of past experience and future life anticipation are severely curtailed. The influence of dementia on the experience of pain has received little attention and many questions remain unanswered. This review draws upon this literature to describe current knowledge of the area. Suggestions for further research are made.