Pain in Older Persons ®
NEWSLETTER of the IASP Special Interest Group on Pain in Older Persons July 2008 Interim Committee David Lussier (Canada) – Interim chair, Benny Katz (Australia) – Interim vicechair, Andrew Cook (United States) Herta Flor (Germany) Lucia Gagliese (Canada) Stephen Gibson (Australia) Keela Herr (United States) Gisele Pickering (France) Debra Weiner (United States) Timely topics in pain research and treatment have been selected for publication, but the information provided and opinions ex pressed in this newsletter have not involved any verification by the International Asso ciation for the Study of Pain (IASP ® ) or the SIG on Pain in Older Persons of the find ings, conclusions, and opinions stated in this publication. Thus, opinions expressed in this publication are solely those of its author(s) and do not necessarily reflect those of IASP or the SIG on Pain in Older Persons, or of the Officers or Councilors of IASP, or of the Officers of the SIG on Pain in Older Persons. No responsibility is assumed by IASP or this SIG for any injury, and/or damage to persons or property resulting, whether as a matter of product liability, negligence or otherwise, from any use or reliance on any methods, products, instruction, or ideas contained in this publication. Because of the rapid ad vances in the medical sciences, the publisher recommends independent verification of any diagnoses and drug dosages referenced in this publication.
Editorial The 12 th World Congress on Pain is approaching. This will represent an im portant step for our SIG, since we will not be considered “in formation” any more, and will be an official SIG of the IASP. Consequent to this, we have to elect an executive committee and to adopt bylaws. We have received nomina tions for the executive committee and will soon be able, via a special commu nication, to give you more information on this topic. As for the bylaws, you will find the ones we propose in this issue of the Newsletter. I would appreci ate you reviewing them and forwarding me any comments you may have, es pecially if you will not be present in Glasgow, so we can make the appropriate changes before we discuss them in Glasgow. Speaking of Glasgow, we will hold our first business meeting, on Wednes day August 20 from 16:3017:30, in the Alsh room at the Scottish Exhibi tion and Convention Center, Glasgow. I urge all SIG members who will attend the Congress to be present for this business meeting, where we will re view our accomplishments of the last 3 years and, most importantly, plan for the future of our SIG. This newsletter contains an article by Bruce Barber on the role of music ther apy in pain management, and two articles by members of the SIG describing their local efforts in regard to improving pain management in older people. There is an article on the multidisciplinary pain clinic in Montreal, and Lepa Jovanovic describes a number of initiatives underway in Belgrade, Serbia. Thomas Hadjistavropoulos answers some questions regarding his new book, "Pain Management for Older Adults A selfhelp guide." The next edition of our SIG newsletter will be entirely devoted to the World Pain Congress in Glasgow. All members attending Glasgow are invited to con tribute an article on any aspect of the congress that you feel is important. Arti cles may be short, about 200 words, or long up to 1500 words. You may wish to comment on a particular session, or the congress as a whole. Please forward you contribution to Benny Katz at [email protected]
. We are happy to assist members who do not have English as their first language.
David Lussier, MD, FRCP(c) SIG Corresponding Address: David Lussier, MD, FRCP Montreal General Hospital, Room D17173 1650 Cedar Avenue Montreal QC H3G 1A4 Canada Fax: 5149348286
Table of Contents: Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Proposed SIG on Pain in Older Persons Bylaws. . . . . . . . . . . . . ..2 Music in the Treatment of Pain . . . . . . . . . . . . . . ……………... 4 Interdisciplinary Geriatric Pain Clinic at McGill . . . . . . . . . . . . . 6 About the SIG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . 6
SIG on Pain in Older Persons Newsletter – July 2008
Proposed BYLAWS SIG on Pain in Older Persons Introduction
The objectives of the SIG on Pain in Older Persons are : 1. To increase awareness and promote education about pain in older persons.
2.5. Quorum. Fifteen members of the SIG shall constitute a quorum at a business meeting.
2. To provide an international and interdisciplinary forum for people interested in clinical and research questions on pain in older persons.
Article 3. Officers and Executive Commitee
3. To develop/endorse best practice guidelines for as sessment and management of pain in older persons. 4. To promote discussion and research on pain in older persons, including: senescence of pain percep tion, multidimensional assessment of pain and its con sequences, pharmacological and nonpharmacological management of pain, and uniqueness of the pain ex perience in patients with cognitive impairment. 5. To facilitate the development of international collabora tive research efforts on pain in older persons. Article 1. Membership. 1.1. Membership. Active membership shall be open only to all members of the International Association for the Study of Pain® (IASP®). 1.2. Annual Dues. Dues are usually paid at the time of paying IASP dues in accordance with IASP guidelines. An IASP member may also join a SIG by paying SIG dues at any other time. (see ‘Article 5 Finances’ below) 1.3. Termination of membership. Membership in the SIG of a member can be terminated by a written request to the Chair of the SIG, or by the failure of the member to pay dues for 90 days past the date the IASP dues payments are expected. Article 2. Meetings. 2.1. Business Meeting. The SIG will hold a business meeting every second year in conjunction with the IASP World Congress on Pain. Ex traordinary meetings occurring in other years will be at the discretion of the Executive Committee, or at the request of 25 or more members of the SIG. 2.2. Scientific Meetings. The scientific meetings will be held when deemed appropri ate by the executive committee, as a Satellite Symposium to the IASP World Congress, at a regional IASP chapter meeting, or at any other national or international meeting where pain is a topic in the scientific program. Such meet ings will not conflict with the IASP World Congress. 2.4. Notice of meetings. Notice of business or other meetings will be provided to the membership at least one month prior to the date of the
3.1. Officers. The SIG Officers shall be the Chair/SecretaryTreasurer and the ViceChair. 3.2. Terms of Office. The term of all Officers and members of the Executive Committee shall be four years. However, for the first Execu tive Committee, the term of half of the members will be two years. Terms will end at the close of the business meeting. Officers and members of the Executive Committee may be reelected after a lapse of four years. 3.3. Election of Officers and members of the Executive Committee. Officers and members of the Executive Committee will be nominated following a Call for Nominations issued at least three months before the end of the term. If there is only one nomination for a position, the nominate will be elected by acclamation. If several persons nominate for the same po sition, they shall be announced to all SIG members and be elected by a simple majority vote by the membership by means of a ballot. All Officers and members of the Execu tive Committee must be members of the SIG and therefore members of the IASP. 3.4. Removal of Officers. Any Officer who fails to attend two consecutive business meetings, or fails to pay dues, shall no longer be an Officer of the SIG. 3.5. Resignations. Resignations of Officers will be officially accepted by the Chair when submitted in writing. 3.6. Vacancies. Vacancies in the Executive committee, with the exception of the Chair (see below), shall be filled from the general mem bership of the SIG. Written nominations by at least two SIG members are required to place members into consideration for filling a vacancy of the Executive Committee. In the event of multiple nominations for consideration, the choice will be made by the remaining members of the Executive Committee. 3.7. Executive Committee. The Executive Committee shall be composed of the SIG Officers (Chair/SecretaryTreasurer and Vice Chair/Communications representative) and the Chairs of the Committees. It may propose dues and will function as the governing body of the SIG. It shall also be charged to
SIG on Pain in Older Persons Newsletter – July 2008 assess the financial status of the SIG to ensure financial integrity and security within the SIG. The Committee shall also oversee the handling of the treasury by the Secretary Treasurer. 3.8. Chair/SecretaryTreasurer The Chair shall be responsible for announcing annual meet ings, conducting meetings in an orderly fashion, submitting an annual report to the IASP Secretariat and carrying out any other duties that serve to foster the objective of the SIG. The Chair will also act a SecretaryTreasurer and, in this role, shall maintain the treasury, provide minutes of meetings, maintain the Bylaws and correspond as appro priate with the membership, in collaboration with the Com munications representative. 3.9 ViceChair/Communications representative The duties of the ViceChair are to assist the Chair in the performance of his/her duties and to assume the position of the Chair in the event of a vacancy or resignation. In addi tion, he/she will also be responsible for Communications with the membership, in collaboration with the Chair, and will be editor of the quarterly newsletter and of the website. If deemed appropriate, he/she might form a committee of members of the SIG to assist him/her with these tasks. 3.10. Chairs of Committees Chairs of Committees will be members of the Executive Committee, and will be elected as described above (see Article 3.3 above). They will be responsible of establishing the committees, will report to the Chair and to the member ship at business meetings or when deemed appropriate, via the newsletter. Article 4. Committees. 4.1. Composition. All committees shall be established by the Chair of the Committee, to provide a working core of members of the SIG. All members of the Committee are voting members. 4.2. Appointment in Committees. All members to committees will be appointed by the Chair of the Committee. The term of the Committee members is four years. Committee members may be reappointed. 4.3. Standing Committees. The SIG shall have the following standing committees : Committee on Scientific Meetings and Symposia Committee on Scientific Matters Committee on Clinical Matters Committee on Education 4.4. Committee on Scientific Meetings and Symposia The charge of this Committee shall be to organize Scientific Meetings and Symposia and to gain emphasis for the SIG in the programs of established pain meetings internation ally, as outlined above (see Article 2.2). Members shall include the SIG Chair and ViceChair, and other members appointed by the Chair of the Committee. The Committee might choose to have one or several SIG members to act as a Local Arrangements Committee. 4.5.
Committee on Scientific Matters
Page 3 Members of this Committee shall be appointed by the Chair of the Committee. The charge of this Committee shall be to coordinate efforts and projects on scientific matters related to pain in older persons, with the objective of promoting discussion and research on pain in older persons and facili tating the development of international collaborative re search efforts on pain in older persons 4.6. Committee on Clinical Matters Members of this Committee shall be appointed by the Chair of the Committee. The charge of this Committee shall be to coordinate efforts and projects on clinical matters related to pain in older persons, including, in collaboration with the Committee on Education, the development/endorsement of best practice guidelines for assessment and management of pain in older persons. 4.7. Committee on Education Members of this Committee shall be appointed by the Chair of the Committee. The charge of this Committee shall be to increase awareness and promote education about pain in older persons, which might include the develop ment/endorsement/dissemination of best practice guide lines, in collaboration with the Committee on Clinical Mat ters. 4.8. Committee on Meetings and Symposia. The charge of this Committee shall be to arrange the scien tific meetings of the SIG and to gain emphasis for the SIG in the programs of established pain meetings internationally Article 5. Finances. 5.1 SIG Activities. The SIG is responsible for financial support of all its activi ties, including meetings. Annual membership dues payment to the SIG shall be included in the members’ IASP annual dues payment to the IASP; these funds will be held by IASP in a restricted account for the exclusive use of the SIG. The SIG will not collect membership dues independ ently and may not collect such dues on behalf of the IASP. 5.2 Financial Responsibility All debts and liabilities incurred by or on behalf of the SIG are the sole responsibility of the SIG, and are not the re sponsibility of IASP. Any contractual or other arrangements with third parties shall contain a statement to that effect. Article 6. Amendments. Amendments to the Bylaws must initially be proposed and be approved by the Executive Committee. Thereafter, they will be announced to all SIG members, be submitted to a vote at the subsequent business meeting at which a quo rum has been obtained and approved by a simple majority of those members present. Article 7. Relationship between the SIG and IASP; Pub lications, etc. The SIG is established under the auspices of IASP and must comply with IASP's bylaws. The SIG members are also members of IASP. Subject to these requirements, the SIG functions independently of IASP and is financially re sponsible for its own activities and for any obligations or liabilities incurred by it or on its behalf. Neither the SIG nor any SIG member may enter into any contract, agreement or
SIG on Pain in Older Persons Newsletter – July 2008 other arrangement binding on IASP, nor may they purport to speak on behalf of IASP. The SIG shall ensure that any books, articles, and other publications published by, through or on behalf of the SIG contain a prominent disclaimer substantially in the following terms: "Timely topics in pain research and treatment have been selected for publication, but the infor mation provided and opinions expressed in this (Title of Newsletter, Book, Article, etc.) have not involved any verification by the International As sociation for the Study of Pain (IASP ® ) or the SIG on Pain in Older Persons of the findings, conclu sions, and opinions stated in this publication. Thus, opinions expressed in this publication are
Page 4 solely those of its author(s) and do not necessar ily reflect those of IASP ® or the SIG on Pain in Older Persons, or of the Officers or Councilors of IASP ® or of the Officers of the SIG on Pain in Older Persons. No responsibility is assumed by IASP ® or the SIG on Pain in Older Persons for any injury and/or damage to persons or property resulting, whether as a matter of product liability, negligence or otherwise, from any use of or reli ance on any methods, products, instruction, or ideas contained in this publication. Because of the rapid advances in the medical sciences, the pub lisher recommends that there should be inde pendent verification of any diagnoses and drug dosages referenced in this publication."
Music in the Treatment of Pain Bruce Barber PhD, National Ageing Research Institute Parkville, Australia The treatment of pain in older people is beset by a number of factors that contribute ongoing concerns about efficacy and safety. Comorbid illness, geriatric syndromes that con found diagnosis and treatment, physiological changes that modulate pharmacokinetic and pharmacodynamic proc esses and the limited evidence available to guide the pre scription of analgesic and adjuvant drugs in the elderly are factors that lead to the undertreatment of pain (especially in those with cognitive impairment) or to the increased inci dence of adverse drug events in those over 60 years of age. The use of complementary and alternative therapies for the treatment of pain is not uncommon. The range of available therapies is diverse and includes among others physical, psychological, cognitive, spiritual, vitamin supplement and herbal approaches that are unsupported by levels of evi dence that meet the current criteria applied in medical prac tice. The study of complementary and alternative therapies has gained increasing attention in the past two decades and a comprehensive introduction to the therapies, their reported efficacy and the current evident for their use is available on the National Centre for Complementary and Alternate Medicines web site www.nccam.nih.gov. Anecdotal evidence, observational statements and personal testimonials appear to provide an adequate basis for large numbers of people to spend large amounts of money on devices (such as copper bracelets for arthritic pain), topical creams and ointments containing botanical derivatives, ho meopathic and naturopathic treatments and many others. It has to be said that private testimonials as to the efficacy of many of these treatments can be highly persuasive and, given the value medical practice and medical research, of necessity, places on selfreport (ie the gold standard), it is not possible simply to discount them all as the work of na ïve people who are held in thrall by charismatic charlatans. The therapeutic use of music is less controversial than many complementary or alternative therapies. This may be
because it at least seems relatively harmless when viewed in light of the complexities of modern health care systems and procedures. Many would hold the view that, at worst, music might be annoying or aggravating. Our understand ing of music is typically based on our experience of it in our sociocultural context and, although it can become an intri cate and profound mnemonic of our individual autobiogra phies, it may seem counterintuitive to conceive of it as hav ing a role in the treatment of pain. Nonetheless, a recent review was far from dismissive (Cepeda et al, 2006). This review included 51RCTs reported over the period 1986 – 2004. The studies examined the effects of music during diagnostic or therapeutic procedures, on postoperative pain, on chronic noncancer pain, on cancer pain, on labor pain and on experimental pain. The aim of the review was to evaluate the effects of music on acute, chronic or cancer pain intensity, levels of relief and analgesic requirements. The authors summarised the results with the unsurprising observation that music should not be considered as a first line treatment for pain relief, a conclusion with which even the most ardent music therapy advocate is likely to agree. However, they found that music reduced pain, increased the numbers of patients reporting at least 50% pain relief and reduced the need for morphinelike analgesics. In four of the reviewed studies, subjects who received mu sic had a 70% greater chance of achieving at least 50% pain relief and an NNT of 5. Postsurgery, at 2 hours those exposed to music required 18.4% less morphine and at 24 hours, 15.4% less morphine than those not exposed to mu sic. While these were statistically significant differences, the opioidsparing effect of music was less than that produced by paracetamol (acetaminophen) or NSAIDS. Opioid re quirements during painful procedures were lower in those who received a music intervention but the differences were not statistically significant. While these effects are modest, the authors made the observation that other treatments that yield similar levels of reduction in pain intensity such as
SIG on Pain in Older Persons Newsletter – July 2008 neurolytic celiac block, are used clinically. No significant musicrelated reduction in drug sideeffects was observed. The reviewers concluded that the evidence is such that mu sic and other nonpharmacologic therapies deserve further evaluation. As is the case with pharmacological treatments, there is very little research into the effects of music on pain in the elderly. This is surprising for two reasons. Firstly, the fac tors that discourage drug trials on the elderly (for example, frailty, comorbidities, polypharmacy and the increased po tential for drugdrug interactions, cognitive impairment) do not involve the same level of risk with music. Secondly, it is arguable that there is a greater need for benign yet poten tially effective complementary treatments in this ‘at risk’ population. One RCT that did examine the effects of music on chronic osteoarthritic pain in the elderly yielded positive results (McCaffery and Freeman, 2003). This study of 66 community dwelling people (~75 years of age) with chronic osteoarthritis pain acquired data using the Short Form McGill Pain Questionnaire to evaluate the effect of 20 minutes daily spent listening to ‘relaxing’ music (three works by W.A. Mozart) compared to sitting quietly for 20 minutes daily. The questionnaires were completed prior to and after the 20 minutes of music or sitting quietly on days 1, 7 and 14 of the intervention period. Results showed that listening to music significantly reduced pain at each test interval and that pain relief significantly increased over the 14 day listening period. The control group showed no sig nificant changes in pain report. The participants had no role in selecting the music which was selected by the primary investigator on the basis of the argument that music at a tempo of 60 – 80 beats per minute is considered to be relaxing. This criterion for the selection of music does not account for the basic principle held by trained music therapists that familiar, preferred and self selected music has a greater potential effect. The mechanisms by which music may modulate the experi ence of pain are not known. A recent experimental study (Roy et al, 2008) examined the possibility that the effect is mediated by the valence of the emotions induced by music. Pleasant and unpleasant music (composers of the latter may take exception) was identified and matched for high level arousal effects as determined according to a ‘relaxing stimulating’ dimension. Participants received painful thermal stimuli (45.5, 47 and 48.5 degrees) while listening to pleas ant music, unpleasant music and during silence. After each trial they indicated whether the stimulus was painful and then rated it for both intensity and unpleasantness. They also rated the valence (pleasantunpleasant), arousal (re laxingstimulating) of the music and the moods induced by the music. In summary, pleasant music was found to significantly re duce pain compared to both unpleasant music and silence. Furthermore, the greater the musical valence the greater the reduction in pain report.
Page 5 These studies identify positive analgesic effects of music in clinical, community and experimental settings and they en courage further research. While it is not argued that music, in itself, may serve as a single effective treatment for the kinds of pain commonly experienced by older people, there appears to be increasing evidence that music may be a useful, cheap and effective adjunct to pharmacotherapies and other complementary therapies such as exercise, re laxation and CBT. Of course music is not a simple unidimensional phenome non. Prescribing a drug can be undertaken with a high de gree of confidence that the drug is invariant in its content and somewhat consistent in its metabolism and its effect. The same cannot be said of music, characterised as it is by an immense diversity born of a broad spectrum of environ mental, cultural, subcultural and individual imperatives. Musical preferences are such that the exact impact of any given piece of music cannot be predicted with confidence. Generalisations such as ‘pleasantunpleasant’, ‘relaxing stimulating’, ‘happysad’ are quite well established charac terisations and they serve as a useful starting point for in vestigations. But if we aim to improve the treatment efficacy of music we need a much better understanding of the cog nitive, neuropsychological and neurophysiological proc esses subserving its apparent pain modulating effects. Such information may contribute to the development of mu sic interventions that more precisely target painful condi tions associated with a range of differing aetiologies and may also guide music applications that assist in addressing some of the psychological and functional sequelae to chronic pain. Music employed as an adjunct to enhance primary modali ties of pain relief in the elderly may be of particular value where other wellsupported complementary approaches cannot be implemented. Among culturally and linguistically diverse populations, for example, cognitive behavioural therapy is dependent upon the availability of shared lan guage expertise. Where language differences are a barrier to CBT, a music intervention using culturally specific music may serve as an effective alternative. Similarly, where physical disability prohibits the use of exercise regimes in pain treatment, even the current limited level of evidence of pain relieving potential of music suggests that it may have a useful role. Given that music is so profoundly integrated with the sense of self and cultural identity it is possible that it is a readily available complement in the treatment of pain. Further re search is warranted. References Cepeda MS, Carr DB, Lau J, Alvarez H. Music for pain relief. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No: CD004843. DOI: 10.1002/14651868.CD004843.pub2. McCaffery, R, Freeman, E. Effect of music on chronic osteoarthritis pain in older people. Journal of Advanced Nursing 2003. 44; (5): 517 – 524. Roy, M, Peretz, I, Rainville, P. Emotional valence contributes to music induced analgesia. Pain 134 (2008) 140 –147
SIG on Pain in Older Persons Newsletter – July 2008
The Interdisciplinary Geriatric Pain Clinic of the McGill University Health Center David Lussier, MD, FRCP(c) Medical director Geriatric Pain Clinic, MUHC McGill University, Montreal, Canada A multidisciplinary approach is the preferred method of de livering health care to patients with persistent pain that is accompanied by functional disability and adverse psycho social consequences. A multidisciplinary approach to pain assessment and management is the best approach to per sistent pain. Despite the growth in the number of older people in our population and a higher prevalence of persis tent pain with advancing age, older patients are often un derrepresented in pain management clinics. Older patients attending pain treatment centers are offered less treatment and fewer treatment options than younger counterparts, particularly behavioral and nonpharmacological therapies. The underrepresentation may be due to reluctance by phy sicians to refer older adults to pain management clinics, to the difficulties older individuals have traveling to clinics, or to restrictive admission criteria. Because of the frequent occurrence of comorbidities, polypharmacy, cognitive and functional impairment, management of persistent pain in older persons represents a specific challenge. The best way to overcome this challenge is to count on a team with expertise in both pain and geriatric medicine. As has been reviewed by Benny Katz in a previous newsletter, there are currently a few such clinics worldwide. Although they share several characteristics, these clinics each have their own specificities. In this issue of the newsletter, we wish to describe the In terdisciplinary Geriatric Pain Clinic that has been in place at the McGill University Health Center (MUHC) in Montreal, Canada, since 2004, and share some of the outcomes of our assessments. The clinic is currently staffed by a geriat rician with training in pain management, a geriatric nurse, a physical therapist and a psychologist. It is the result of a close collaboration between the MUHC Division of Geriatric Medicine and the McGill Pain Centre. One of the specifici ties of our clinic is that, although it is closely linked with the Pain Centre, it is held in the Geriatric Clinic space, with its staff. Thanks to the combined expertise in geriatrics and pain management, it allows us to provide a comprehensive geriatric assessment to the patients, including assessment and management of geriatric syndromes other than pain, and to refer them to appropriate community resources when appropriate (for which the nurse coordinator, who also acts as the Geriatric Clinic nurse coordinator and therefore knows these resources very well, is extremely useful). The clinic runs three halfdays a week, with two halfdays devoted to new patients and one halfday to followups. New patients are assessed by the physician, nurse and physical therapist. A meeting is held at the end of the clinic to discuss the management of the patients. If deemed ap propriate, the patients are referred to the psychologist for assessment, cognitivebehavioral therapy and other psy chological approaches to pain management. If an interven tion or an assessment by another specialist (anaesthesiolo gist, rheumatologist, physiatrist, dentist) is indicated, they are referred to the Pain Centre. The referrals come from
several sources, including community family physicians, geriatricians and other specialists of the MUHC, as well as from other institutions. So far, since there have been very limited advertisement of our service (due to limited capac ity), most of the patients are referred by their treating physi cian to the Pain Centre, where they are triaged and referred to our service if older than 75 years old or older than 60 years old with significant comorbidities. The results of the first 150 initial assessments conducted at the Clinic will be presented as a poster at the World Con gress in Glasgow in August. When we compiled the initial assessments of the first 100 patients, we noted very inter esting findings. The average age of the patients was 81 years old (6095 years old) and 70% were female. 39% lived alone, and 38% were receiving home care services. The mean MiniMental Status Exam (MMSE) Score was 25 (range, 1030) and 26% had an MMSE lower than 24, sug gestive of dementia. The average number of medications taken was 11 (range, 024). Almost all of them (93%) had chronic pain lasting more than 3 months; while most of them had pain lasting 15 years (42%), several of them had been suffering from pain for 510 years (17%) or even more than 10 years (20%). Not surprisingly, most pain was mus culoskeletal in origin, with the most frequent diagnoses be ing osteoarthritis and spinal stenosis with lumbar radiculo pathy. The mean “worst” and “on average” intensity of pain in the past week were 8.6 and 6.2, respectively. 75% of patients were treated an analgesic; despite the frequent reporting of moderate or severe pain, only 46% were taking an opioid analgesic (28% shortacting, 29% longacting). Following this initial assessment, nonpharmacological in terventions were suggested to 73% of patients, and phar macological to 79%. 26% of patients were referred to an other resource, including home care and rehabilitation ser vices. But the most interesting finding is that, in addition to managing the pain, our team diagnosed and managed an other geriatric syndrome in 28% of the patients, including 11 patients who were diagnosed with dementia. From this limited case series, we see that, although most of these patients were initially referred by their treating physi cian to a “general” pain clinic who later redirected them to our Geriatric Pain Clinic, they often have a “geriatric profile” and several signs of frailty, including very old age, cognitive and functional impairments and polypharmacy. Several interventions would not have been done in a “general” pain clinic. Furthermore, this only takes into account the initial assess ments of these patients. Surely, several more specific inter ventions are done during the followup of these patients, who unfortunately too often present progressive functional and cognitive deterioration over the years. This therefore strongly supports the development of Interdisciplinary Pain Clinics especially devoted to older patients. _____________________________________
SIG on Pain in Older Persons Newsletter – July 2008
Correspondence: Improving Pain Management for Older People. Lepa Jovanovic, Institute for Gerontology, Belgrade, Serbia Continuing on the theme of previous newsletters discussing individual contributions to pain management for older peo ple, I would like to report on some of the activities that have been undertaken over the past year in Belgrade, Serbia. The month of October 2007 was devoted to the theme of Care of the Elderly. The Institute of Gerontology, with the support of the Municipal Secretariat of Health, published a Geriatric Manual for Primary Care Facilities. I contributed two chapters; Chronic Pain in the Elderly and Basic and Clinical Pharmacotherapy in the Elderly. Between February and May 2008, I was involved in another health promotion project for older people funded by the Mu nicipal Secretariat of Health. I coordinated a project ad dressing measures of improvements in primary and secon dary healthcare in people over 65, looking at quality of health and of life in old age. One aim of the project was to promote the classification of chronic pain taxonomy of IASP. Our aim is to now translate this into the Serbian lan guage. An electronic pain medical history was developed as part of this project. A chronic pain management unit for older people was es tablished within the Mental Health Department. All patients are assessed for psychiatric disorders, social conditions, activities of dailay living and IADL (Functional Status Index) and pain. This is followed by a detailed assessment of the specific pain problem resulting in the formulation of a treatment program.
New Publications: 1. Pain Management for Older Adults A selfhelp guide. Edited by: Thomas Hadjistavropoulos and Heather D. Hadjistavropoulos
This book is designed to help older adults better un derstand their chronic pain problems. Available on www.iasppain.org/olderadultsIASP members for US$25.95 (Nonmembers:US$29.95)
Page 7 Thomas Hadjistavropoulos answers some questions about this new book: Q. What niche does this book fill? A: Although there are many selfhelp books that have been designed for people to deal with pain and its consequences (e.g., depression, disability), the selfhelp literature has not paid much attention to pain management issues among older persons. The type of pain management information that is suitable for younger persons is not always generaliz able to the older adult. For example, agerelated physio logical changes result in the need for different medication dosages. Moreover, increased frailty that often accompa nies aging requires adaptations in recommended physical activity programs. In addition, pain management programs for younger persons often focus on returntowork and em ployment issues that are not applicable to retired persons. In our book, we present the pain management information (e.g., whether it is educational information about medication management or coping techniques) within the context of the older adult. Our book brings together many clinical experts from disciplines as diverse as clinical psychology, geriatric medicine, family medicine, nursing, physical therapy exer cise physiology, dietetics and pharmacy, with vast com bined expertise in the physical, medical and psychosocial management of chronic pain. Q. What is the target audience is it written solely for the person in pain or is it relevant to a broader audience? A. Although this book was written primarily for older adults who live independently and suffer from persistent pain, it would also be useful for several other target audiences. For example, we have included a chapter with information for caregivers of older adults with dementia. This chapter pro viders caregivers with suggestions about how to monitor pain in a loved one (i.e., information that they could then communicate to a health care provider) as well as how to help loved ones who suffer from dementia cope with pain more effectively. The information presented in the book would also be useful for health professionals who work in pain management with older persons as it contains useful forms and therapeutic exercises that can be used in prac tice. Q. Tell us about the writing style and content of the book? A. The book has eleven chapters each written by people with special expertise in the topic covered. The full list of chapters is as follows: a) Pain among Seniors b) Pain and Psychology c) Taking Control: Effective Pain Management d) Pain and Emotion e) Social Support, Loneliness, and Pain f) The Role of Exercise in Seniors’ Lives g) Living in More Comfort: Maximizing Function and Energy h) Sleep Hygiene and Nutrition i) Effective Communication with Your Doctor j) The Role of Medications k) Information for Caregivers of Older Adults Who Have Dementia We have also included information about pain management
SIG on Pain in Older Persons Newsletter – July 2008 resources in several countries of the world. The material in the book is presented in a language that lay people can relate to and understand. As much as possible, we avoid scientific jargon. Where appropriate, and always using lay language, the book makes reference to scientific evidence that supports the effectiveness of approaches discussed in the book. We include vignettes to illustrate some of the problems and potential solutions that we discuss in the book, and encourage readers to move slowly as they prac tice the coping skills discussed in the book. Photographs are used to illustrate gentle physical exercises and ergo nomic principles. We also provide recording forms to help people monitor their practice, progress, and successes over time. Q. In what way would this book be useful to profes sionals who are members of our SIG? A. The book not only describes coping strategies for man aging pain but also provides useful educational information about topics such as medication, nutrition and sleep hy giene. Health professionals often provide such information to their patients, but time constraints limit the amount of information they can provide during sessions. Having such information available in written form can help patients un derstand the information, while saving time in the clinic. In addition, the book contains a variety of coping techniques and information that health professionals could recommend to their patients.
2. The assessment of pain in older people. Developed by the British Geriatrics Society, the British Pain Society and the Clinical Standards Department of the Royal College of Physicians. Published November 2007 This concise guideline is aimed at providing health care professionals and caregivers guidance with the identifica tion and interpretation of pain in older patients, particularly nonverbal signs in patients unable to report pain due to dementia, stroke and other conditions. It may be downloaded at: http://www.rcplondon.ac.uk/pubs/contents/ff4dbcd6ffb7 41adb2b861315fd75c6f.pdf
SIG business meeting Wednesday August 20 from 16:3017:30, Alsh room at the Scottish Exhibition and Convention Center, th Glasgow, UK during the 12 World Congress on Pain MARK YOUR CALENDARS TO ATTEND!
The Newsletter: Members are encouraged to con tribute to this newsletter. Please consider submitting an article on your research, a case study, conference report, literature review, etc. For details, please con tact Benny Katz at [email protected]
SIG Information SIG on Pain in Older Persons statistics: The SIG currently has 227 members representing 29 disciplines in 42 different countries. Treasurer’s report: As of June 30, 2008, the SIG account balance was US$9,538. The Pain in Older Persons SIG objectives are: · to increase awareness and promote education about pain in older persons · to provide an international and interdisciplinary forum for people interested in clinical and research questions on pain in older persons · to develop/endorse bestpractice guidelines for assessment and management of pain in older persons · to promote discussion and research on pain in older persons, including: senescence of pain perception multidimensional assessment of pain and its consequences pharmacological and nonpharmacological management of pain uniqueness of the pain experience in patients with cognitive impairment to facilitate the development of international collaborative research efforts on pain in older persons SIG Membership Membership in SIGs is open to any members of IASP. Members wishing to join the SIG should indicate their preference on the annual IASP membership renewal form with the $20.00 SIG dues. This can be done online at: www.iasppain.org under Membership, or contact the IASP main office directly at: [email protected]