Principles of perioperative pain management in older adults.

The consequences of poor planning for pain management during surgery of geriatric patients not only affect the immediate well-being of the patient but also have terrible socioeconomic implications. Delays in rehabilitation, increases in hospital lengths of stay, and increased comorbidity can be expected if interventions for pain management are either inadequate or excessive without appropriate monitoring. During surgery, seniors are likely to suffer from acute and chronic pain that must be addressed aggressively in the postoperative period to ensure a rapid functional recovery. New pain scales have been developed with seniors in mind, and greater testing of older scales in elderly populations have helped to identify measures of pain more suited to frail seniors. This article is designed to help clinicians to strategically implement optimal pain management principles and techniques and, thus, help to fulfill the obligation to relieve pain and suffering in patients in the perioperative period, which will ensure the greatest chance of recovery to optimal independence for patients.

Pain management in older adults: prevention and treatment.

The release of guidelines in 1998 by the American Geriatrics Society on "The Management of Chronic Pain in Older Persons" was a breakthrough in helping to manage pain in this population. Already advances have fostered a need to update recommendations. This article focuses on the treatment strategies available for seniors that are likely to help to fulfill the obligation to relieve pain and suffering in patients. A review was done of the literature using Medline and other search techniques. New pain scales have been developed with seniors in mind and greater testing of older scales in elderly populations have helped to identify measures of pain more suited to frail seniors. Advances in cyclooxygenase inhibition selectivity, alternative medicine, and progress in the identification of nonopioid pain receptors and the development of products to target them are just a few of changes that have altered the way clinicians think about treating pain. The use of hospice in end-of-life palliative care is a valuable resource for clinicians managing pain at that phase in care as well. Tools are available to prevent and treat pain successfully in seniors. Educating clinicians about available assessment tools, techniques and interventions may be the biggest challenge to comforting the older adult in pain.

The Functional Pain Scale: reliability, validity, and responsiveness in an elderly population.

OBJECTIVES: Because of difficulty experienced in assessing pain in frail older patients and the lack of pain assessment tools with standardization in the elderly, the Functional Pain Scale (FPS), an instrument incorporating both subjective and objective components to assess pain, was developed and evaluated. DESIGN, SETTING, PARTICIPANTS, AND MEASURES: One hundred subjects more than 65 years old participated in the validity, reliability, and responsiveness (the clinical sensitivity of the instrument to change) testing of the Functional Pain Scale. Subjects were recruited from a geriatrics inpatient setting, a geriatrics outpatient setting, and a local hospice (residing in their homes). Ninety-four of the subjects completed all phases of testing. Reliability was tested using a test-retest format and a correlation matrix. Criterion-related validity was established as compared with the Visual Analog Scale (VAS), the Present Pain Intensity (PPI), the McGill Short Form Questionnaire (MPQ-SF), and the Numeric Pain Scale (NPS) instruments. Responsiveness for the FPS, the VAS, the PPI, the MPQ-SF, and the NPS instruments was determined using five previously described techniques: effect size, standardized response means, relative efficiency, direct comparison of t test scores, and direct comparison of P values. A cumulative index was developed to rank each scale. Cumulative responsiveness index scores were based on individual scale performance for each separate responsiveness test. The lowest score in the cumulative responsiveness index indicated the most responsive scale. RESULTS: Interrater reliability for instruments tested exceeded 0.95 for all instruments tested. Validity testing showed high correlations as well (r = 0.62, r = 0.85, r = 0.80, r = 0.90 for the VAS, the PPI, the MPQ-SF, and the NPS respectively). Responsiveness evaluated overall by the responsiveness index was best for the Functional Pain Scale (7) followed by the Visual Analog Scale (12), the Present Pain Intensity (13), the McGill Pain Questionnaire-Short Form (19), and the Numerical Pain Questionnaire (24). CONCLUSIONS: The Functional Pain Scale was determined to be reliable, valid, and responsive. The responsiveness of the Functional Pain Scale was superior to the other instruments tested. The Functional Pain Scale is an acceptable instrument for assessing pain in older adults and may reflect changes in pain better than other instruments tested. Further testing in other populations is warranted.

Developing a physicians' palliative care pain hotline in Maryland.

Physicians have had relatively little formal training in pain management and palliative care. For this reason, a telephone consultation service was offered, the physicians' palliative care pain hotline, that would allow physicians to call a toll-free number and, within 15 minutes, speak to a board-certified physician in hospice and palliative medicine. To our knowledge, this is the first program of its kind. This article describes the process involved in creating such a pain hotline and reports on some data collected on its use in the first 10 months. This report should help others who have an interest in establishing a similar program.

Geriatric pain. Factors that limit pain relief and increase complications.

Persons age 65 and older are more likely than younger adults to experience chronic pain but less likely to obtain pain relief. Achieving adequate pain management for the older patient is complicated by comorbid diseases, increased risk of adverse drug reactions, and physician factors such as inadequate training in pain medicine and a reluctance to prescribe opioid medications. Nociception appears not to change with age or with the development of dementia, although a person's perception of pain and willingness to report it may change. Control of depression and anxiety greatly facilitates pain management. As a patient's number of medications increases, so does the risk of adverse reactions; therefore, care is required when adding any new medication to the drug regimen.

The Frail Elderly Functional Assessment questionnaire: its responsiveness and validity in alternative settings.

OBJECTIVE: To test the Frail Elderly Functional Assessment (FEFA) questionnaire for responsiveness (sensitivity to change) to low-level functional tasks in a frail elderly cohort and to evaluate its validity over the telephone or when administered to a caregiver proxy. SUBJECTS: Fifty-eight elderly patients from three urban inpatient rehabilitation settings and an outpatient geriatrics center. METHODS: A prospective, clinical, comparative trial. The FEFA questionnaire was administered serially. For validity, subjects were observed performing the tasks on the questionnaire within 24 hours of each interview. For responsiveness, repeat measures were performed within a 1- to 2-week period. Validity and sensitivity to change (responsiveness) of the questionnaire were determined by correlating patient responses to direct observations by rehabilitation staff. Responsiveness was also determined based on the Guyatt technique that divides clinically significant change by the normal variance, sigma/(2x [mean squared error])1/2, as well as by measures of effect size, standardized response means, and relative efficiency tests for responsiveness. To evaluate FEFA validity in alternative settings, kappa statistic and regression analyses were used based on the previously validated interviewer-administered format. RESULTS: Responsiveness was excellent with effect size (.35), standardized response means (.48), and relative efficiency (2.67) tests as well as Guyatt (1.26). There was 83% agreement when compared with FEFA task performance. Regression between change in FEFA score versus performance testing was significant (r2 = .33; p = .01). ANOVA was significant at a p = .03 for FEFA scores at first measure in rehabilitation compared to second. Correlation for caregiver proxy administration was .92 (p< or =.0001) and for telephone administration was .99 (p<.0001). CONCLUSIONS: The FEFA questionnaire, previously demonstrated to be reliable and valid, is sensitive to functional change (responsive) in frail elderly people. It is also valid when administered by phone or to a caregiver proxy.

The impact of a geriatrics evaluation and management unit compared to standard care in a community teaching hospital.

A prospective, controlled trial was initiated to determine whether an acute inpatient geriatrics unit located in a community-based teaching hospital provides better care for frail elderly patients at less cost than conventional medical-surgical units.

Vitamin D vs broad spectrum phototherapy in the treatment of seasonal affective disorder.

Seasonal Affective Disorder (SAD) is prevalent when vitamin D stores are typically low. Broad-spectrum light therapy includes wavelengths between 280-320 nm which allow the skin to produce vitamin D. This study was designed to test the hypothesis that vitamin D deficiency might play a role in SAD. A prospective, randomized controlled trial was conducted in a group of 15 subjects with SAD. Eight subjects received 100,000 I.U. of vitamin D and seven subjects received phototherapy. At the onset of treatment and after 1 month of therapy subjects were administered the Hamilton Depression scale, the SIGH-SAD, and the SAD-8 depression scale. All subjects also had serum levels of 25-hydroxyvitamin D (25-OH D) measured before and 1 week after intervention therapy. All subjects receiving vitamin D improved in all outcome measures. The phototherapy group showed no significant change in depression scale measures. Vitamin D status improved in both groups (74% vitamin D group, p < 0.005 and 36% phototherapy group, p < 0.01). Improvement in 25-OH D was significantly associated with improvement in depression scale scores (r2=0.26; p=0.05). Vitamin D may be an important treatment for SAD. Further studies will be necessary to confirm these findings.

Advance directives in internal medicine outpatient residents' clinics.

This study assessed the frequency of obtaining advance directives from patients of internal medicine residents in two Baltimore teaching programs. A survey was conducted of the medical records of 130 patients in the medical clinics from these programs. Independent variables included age, sex, and race. Dependent variables included documentation of terminal illnesses, resuscitation or code status, and discussion regarding resuscitation status. Only 25 of 130 patients (19%) had a resuscitation status recorded, 24 were documented as full resuscitation and 1 as do not resuscitate. Of subjects older than 65 years, 23% had a resuscitation status. Although 4 of 37 subjects older than 65 years had a terminal illness, none had advance directives.

Concerns with chronic analgesic therapy in elderly patients.

Of the community-dwelling elderly population, 25-50% can be expected to suffer pain. The elderly population often receives inadequate pain relief due to (1) ignorance of recommended guidelines for pain control and (2) concern among physicians about prescribing appropriate analgesics for elderly patients, who often have other ailments that directly or indirectly affect pain and its management. Management of chronic pain in older patients differs from that in younger patients because of age-related changes in metabolism and an increased likelihood of multiple medication use. Understanding age-related physiologic changes and other principles of pain management in the elderly patient will allow clinicians to reduce suffering successfully. By considering these factors and by choosing analgesics based on receptor activity, mode of action, and adverse-effect profile, better pain control can be achieved. This article reviews the nociceptive and psychologic factors that contribute to pain. Pharmacologic interventions and pitfalls in pain management for the elderly patient also are reviewed.

Vitamin D deficiency in homebound elderly persons.

OBJECTIVE: To assess the vitamin D status in homebound, community-dwelling elderly persons; sunlight-deprived elderly nursing home residents; and healthy, ambulatory elderly persons. DESIGN: A cohort analytic study. PARTICIPANTS: Of 244 subjects at least 65 years old, 116 subjects (85 women and 31 men) had been confined indoors for at least 6 months, either in private dwellings in the community (the Hopkins Elder Housecall Program) or in a teaching nursing home (The Johns Hopkins Geriatrics Center). The 128 control subjects, a healthy ambulatory group, came from the Baltimore Longitudinal Study on Aging. All subjects were free of diseases or medications that might interfere with their vitamin D status. MAIN OUTCOME MEASURES: Serum levels of 25-hydroxyvitamin D (25-OHD) and 1,25-dihydroxyvitamin D (1,25-[OH]2D) were measured in all subjects. In a subgroup of 80 subjects, serum levels of intact parathyroid hormone (PTH), ionized calcium, and osteocalcin and intake of vitamin D (through 3-day food records) were assessed. A randomly selected cohort of sunlight-deprived subjects also had serum levels of vitamin D binding protein measured. RESULTS: In sunlight-deprived subjects overall, the mean 25-OHD level was 30 nmol/L (12 ng/mL) (range, < 10 to 77 nmol/L [< 4 to 31 ng/mL]) and the mean 1,25-(OH)2D level was 52 pmol/L (20 pg/mL) (range, 18 to 122 pmol/L [7 to 47 pg/mL]). In the sunlight-deprived subjects, 54% of community dwellers and 38% of nursing home residents had serum levels of 25-OHD below 25 nmol/L (10 ng/mL) (normal range, 25 to 137 nmol/L [10 to 55 ng/mL]). A significant inverse relationship existed between 25-OHD (ie, Log [25-OHD]) and PTH when they were analyzed together (r = -0.42; R2 = 0.18; P < .001) and for each cohort separately. All other parameters measured, except ionized calcium, differed significantly from the Baltimore Longitudinal Study Group means. The mean (SD) daily intakes of vitamin D (121 [132] IU) and calcium (583 [322] mg) were below the recommended dietary allowance only in the community-dwelling homebound population. The mean vitamin D binding protein level in the sunlight-deprived subgroup was in the normal range. CONCLUSIONS: Despite a relatively high degree of vitamin supplementation in the United States, homebound elderly persons are likely to suffer from vitamin D deficiency.

Use of a bisphosphonate (etidronate) to improve metastatic bone pain in three hospice patients.

OBJECTIVE: This report investigates the association among the bisphosphonate etidronate and relief of metastatic bone pain. Maintaining cognitive function while providing adequate relief from metastatic bone pain can be particularly difficult in elderly patients. DESIGN: Case Series. SETTING: Rural community dwellings (Carroll County, Maryland) and an urban nursing home (Baltimore, MD). PATIENTS: One patient residing in a skilled nursing facility and two patients from a home hospice program (Carroll Hospice). INTERVENTIONS: Administration of 400 mg of etidronate in cases of refractory metastatic bone pain. MAIN OUTCOME MEASURES: Reduction in analgesic dosing, improvement in cognitive function, and subjective pain improvement. RESULTS: Three cases are presented in which the use of the bisphosphonate etidronate allowed for a reduction in opiate use with improvement in pain control and preservation of cognitive function. CONCLUSION: Etidronate and perhaps bisphosphonates, in general, should be considered in the management of refractory metastatic bone pain, particularly in the hospice population.

Functional improvement with vitamin D replenishment in a cohort of frail, vitamin D-deficient older people.

OBJECTIVE: To evaluate functional improvement in a population of frail, homebound older persons with low vitamin D status as vitamin D stores improve. DESIGN: Randomized, controlled intervention study. SETTING: Subjects' homes and a nursing facility in Baltimore, Maryland. PARTICIPANTS: The first 32 subjects (community-dwelling, homebound older subjects from the Johns Hopkins Elder Housecall Program and nursing home residents from the Johns Hopkins Geriatrics Center) entered in a longitudinal study of vitamin D replacement. MEASUREMENTS: Baseline 25-hydroxyvitamin D levels were measured and repeated at least 1 month after therapy with either placebo or vitamin D (ergocalciferol). Subjects were also administered the Frail Elderly Functional Assessment (FEFA) questionnaire, an instrument demonstrated to be reliable, valid, and sensitive to small increments of functional change in this population. MAIN RESULTS: All subjects started with 25-hydroxyvitamin D levels less than 15 ng/mL. Those subjects whose levels improved by at least 3 ng/mL (> assay coefficient of variation) also demonstrated improvement in FEFA score. Regression analysis between change in FEFA score compared with change in 25-hydroxyvitamin D was significant (r = .4; P = .02). CONCLUSIONS: In this cohort of homebound older people, improvement in vitamin D status was associated with functional improvement as measured by the FEFA questionnaire.

Vitamin D deficiency in older people.

Because of changes that occur with aging, older people with any other risk factors for vitamin D deficiency are likely to have inadequate stores of this vitamin. The consequences of vitamin D deficiency are likely to be losses in bone, strength, and function and the development of pain. Many questions remain regarding screening, prevention, and treatment of vitamin D deficiency. Supplementation may be unnecessary in most healthy, ambulatory seniors. Excessive supplementation in this group may lead to vitamin D toxicity. There does seem to be a role for supplementation in homebound older people who will not get adequate vitamin D from sunlight exposure. This population is at particular risk of developing vitamin D deficiency. Issues such as inadequate diet, physiologic changes with aging, polypharmacy, and diseases that interfere with vitamin D metabolism contribute to this risk. In such circumstances, a recommendation of 800 IU per day is reasonable. An alternative to daily dosing is a single oral dose of 100,000 IU of vitamin D (ergocalciferol or cholecalciferol) every 3 to 6 months. A simple maneuver is for geriatricians, who see many chronically ill patients with low vitamin D stores (who are likely to be seen in the office every 3 to 6 months), to administer vitamin D during the office visits. These dosing schedules have not been associated with toxicity and can be considered safe in homebound (sunlight-deprived) older adults.(ABSTRACT TRUNCATED AT 250 WORDS)

Reliability and validity of the Frail Elderly Functional Assessment questionnaire.

Measuring functional activity for elderly at very low functional levels remains a challenge because many functional instruments have not been standardized in a frail elderly population. The Frail Elderly Functional Assessment questionnaire (FEFA) is a 19-item, interviewer-administered questionnaire designed to assess function in frail elderly at a very low activity level. The purpose of this study was to determine the reliability and validity of this instrument in a frail elderly population. Two groups of subjects over 65 yr old were selected to test the reliability and validity of this questionnaire. Test-retest reliability was determined by correlating the responses of 29 homebound (including nursing home-bound) subjects who answered the questionnaire on two occasions 2 wk apart. To assess the validity of the FEFA, the questionnaire was administered to 23 frail, homebound (including nursing home-bound) elderly subjects who had a Mini-Mental State Examination score of > or = 18. Validity was determined by correlating patient responses to direct observations by the investigators of tasks addressed in the questionnaire. Correlation was also determined against the Katz's Activity of Daily Living index, Lawton's Instrumental Activity of Daily Living index, and the Barthel index. The reliability coefficient was 0.82. Correlation between the FEFA questionnaire and direct observation of questionnaire task performance was 0.90. Construct validity against the Katz's Activity of Daily Living, Lawton's Instrumental Activity of Daily Living, and the Barthel index showed correlations of 0.86, 0.67 and 0.91, respectively. Initial data indicate that the FEFA is a valid and reliable instrument that may be useful in assessing function in frail elderly people.