Assessing pain in geriatric patients – a considerable challenge

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Assessing the experience of pain in an elderly patient poses a considerable challenge to doctors and nurses.

Geriatric patients often present with complex and multiple health problems and are already on several medications. Common aches and pains may be co-mingled with a more acute level of pain whose origin needs to be identified. Even more challenging is the patient who is cognitively impaired and can’t articulate his or her pain.

As Canada’s population ages – and with Statistics Canada predicting that the number of seniors suffering from Alzheimer’s and other forms of dementia will triple over the next 30 years – there is a pressing need to provide health-care providers with more effective tools for assessing pain in geriatric clients.

Baycrest Centre for Geriatric Care is spearheading the efforts aimed at creating improved standards of practice in pain management. It has hired Rochelle Caratao as the Al Hertz Clinical Nurse Specialist in Pain Management. The position was created as a result of a generous gift from the Al Hertz Family Foundation. While major gifts to endow research chairs are common, this donation is considered unprecedented in Canada because it supports the delivery of care by endowing a clinical staff position.

Prior to joining Baycrest in January, Caratao spent eight years at Sunnybrook and Women’s College Health Sciences Centre, helping to assess and alleviate pain in acute and palliative care patients. At Baycrest, she will develop guidelines to assist nurses in assessing pain in the elderly, including those with cognitive impairment who can’t articulate their discomfort, and determine the most appropriate pain management strategies.

“Baycrest is an excellent environment for this work because it has a high number of cognitively impaired clients and there is an opportunity to follow them for a longer period of time than in an acute care hospital,” says Caratao.

She says nurses need to be alert to different behavioural changes in a client with dementia that may indicate the expression of pain. For example, she remembers the case of a cognitively impaired man who suddenly developed a repetitive behaviour of rocking in his wheelchair, making loud vocal sounds, and trying to get out of his wheelchair. The care team, which included the doctor, nursing staff and occupational therapist, decided to replace the wheelchair with a more comfortable one, monitor his skin for pressure sores/ulcers, and administer a routine dose of mild analgesic (acetaminophen/Tylenol). It worked and the client settled down.

“Clearly he was experiencing discomfort but could not articulate it,” says Caratao.

The guidelines she is working on will be quite comprehensive in scope, incorporating the many compounding factors that need to be considered when assessing pain. These include:

  • Multiple health problems.
  • Common aches and pains versus sudden acute pain.
  • Ability to identify pain if individual is cognitively impaired or disoriented.
  • Cultural differences – some cultures will tolerate and accept pain with a stoic expression that may lead nurses and other health-care professionals to underestimate the level of pain. It’s important that staff be educated on the different cultural expressions of pain and be comfortable exploring or discussing cultural differences.
  • Family wishes – the family or spouse may disagree with the health-care team on the treatment protocol to manage pain in their loved one. The family may demand more pain medication or perhaps less (out of fear that their loved one may become addicted). It’s important to explore and discuss what is important to the patient and family.
  • The patient, if they are able to communicate, may desire to be alert and lucid rather than drowsy in their final days in order to spend quality time with family.
  • Patient history with medications – legitimate pain versus drug-seeking to feed an addiction.
  • Alternative and adjunct approaches to manage or alleviate pain.

Caratao can’t emphasize enough the importance of three-way communication between the health-care team, the patient and his/her family. “Pain management is a partnership between all three, with the patient’s comfort and well-being at the centre of every discussion,” she says.

Caratao’s work will examine chronic, acute and malignant pain management. She hopes the knowledge gained from her work and development of practice will benefit not only Baycrest but other health-care facilities that care for older individuals.