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Pain Management in Frail, Community-Living Elderly Patients
Francesco Landi, MD, PhD;
Graziano Onder, MD;
Matteo Cesari, MD;
Giovanni Gambassi, MD;
Knight Steel, MD;
Andrea Russo, MD;
Fabrizia Lattanzio, MD, PhD;
Roberto Bernabei, MD;
for the SILVERNET-HC Study Group
Arch Intern Med. 2001;161:2721-2724.
ABSTRACT
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Background Pain is a common problem among older people living in different community
settings. As indicated by the World Health Organization (WHO), pain can be
relieved using pharmacologic agents. However, pain continues to be addressed
inadequately.
Objectives To describe the prevalence of pain in frail elderly people living in
the community and to evaluate the adequacy of pain management.
Methods We analyzed data from a large collaborative observational study group,
the Italian Silver Network Home Care project, that collected data on patients
admitted to home health care programs. Twelve home health care agencies participated
in the project evaluating the implementation of the Minimum Data Set for Home
Care instrument. We enrolled 3046 patients, 65 years and older, in the present
study. The main outcome measures were the prevalence of daily pain and analgesic
treatment.
Results A total of 1341 individuals (39%, 49%, and 41% of those aged 65-74,
75-84, and  85 years, respectively) reported daily pain. Of patients with
daily pain, 25% received a WHO level 1 drug; 6%, a WHO level 2 drug; and 3%,
a WHO level 3 drug (eg, morphine sulfate). Patients 85 years or older were
less likely to receive analgesics compared with the younger patients (univariate
odds ratio, 0.73; 95% confidence interval [CI], 0.60-0.89). Another independent
predictor of failing to receive any analgesic was low cognitive performance
(adjusted odds ratio, 0.80; 95% CI, 0.69-0.93).
Conclusions Daily pain is prevalent among frail elderly patients living in the community
and is often untreated, particularly among older and demented patients.
INTRODUCTION
PAIN IS A COMMON problem among older people, with studies reporting
a prevalence ranging from 45% to 80%, depending on age, the population studied,
and the site of residence.1-3
Despite the widespread dissemination of the 3-level ladder of the World Health
Organization (WHO)4 and the demonstration that
pain can be alleviated in more than 90% of cases,5-6
pain continues to be inadequately addressed.7-8
Even patients with cancer, in whom pain might be most readily recognized,
frequently receive poor treatment for pain.9
Furthermore, the needs of persons in some settings appear to be addressed
especially inadequately, even when medical staff recognize that the patients
are in pain. A recent study among residents of nursing homes with cancer found
that one quarter of the patients did not receive any analgesic despite daily
pain, and those older than 85 years were even less likely to receive analgesics.10
Although no physiological basis exists for a decrease in the sensation
or intensity of pain with increasing age, pain is believed to be less prevalent
among the elderly. Thus, pain is historically underreported and undertreated
in this group.
The aims of the present study were to ascertain the prevalence of pain
in a frail, older population living in the community and to determine how
their pain was addressed.
SUBJECTS AND METHODS
ASSESSMENT OF PAIN AND ANALGESIA
We conducted this study using the database of the Silver Network Home
Care project (SILVERNET-HC), a national home health care program based in
Italy.11 The database is population based,
longitudinal, and multilinked and consists of data collected using the Minimum
Data Set for Home Care (MDS-HC) instrument12
from more than 3000 patients in more than 12 home health care agencies in
Italy, and data on all medications used by each patient at the time of the
MDS-HC assessment. Drugs were coded using the Anatomical Therapeutic and Chemical
codes.
The MDS-HC contains more than 350 data elements, including sociodemographic
variables, numerous clinical items about physical and cognitive status, and
all clinical diagnoses. The MDS-HC also includes information about an extensive
array of signs, symptoms, syndromes, and treatments being provided.13 A variety of different, multi-item summary scales
are embedded in the MDS-HC that measure, eg, physical function (activities
of daily living and instrumental activities of daily living)14
and cognitive status (Cognitive Performance Scale).14
The MDS-HC items have been found to have excellent interrater and test-retest
reliability when completed by nurses performing usual assessment duties (average
weighted  = 0.8).14-15
The study population consisted of all patients admitted to home health
care programs in 12 home health care agencies from January 1, 1997, through
December 31, 1999, who participated in the SILVERNET-HC project (n = 3312).
Patients younger than 65 years (n = 130) and those who were admitted to the
home health care programs before the implementation of MDS-HC (n = 136) were
excluded. As a result, the final analysis sample included 3046 patients.
A multidisciplinary team of professionals (general practitioner, nurses,
and a geriatrician) evaluated signs and symptoms of pain. Daily pain was defined
as any type of physical pain or discomfort in any part of the body that was
manifest daily during the 7 days preceding the assessment.13
The assessors were instructed to ask simple and direct questions about whether
the patients experienced pain. Because some patients had limited verbal communication,
the assessors were also instructed to observe such persons for indications
of pain, including moaning, crying, wincing, frowning, other facial expressions,
or posturing, such as guarding or protecting an area of the body. Independent,
dual assessments of pain items in a diverse sample of patients in nursing
homes during the testing and revision of the MDS-HC showed an average weighted
exceeding 0.7,15 and similar values
were obtained when the MDS-HC was studied for reliability.12
We collected data about use of analgesics, directly from general practitioners.
Analgesics were classified into 3 different groups according to the WHO 3-step
ladder,4 including nonopioids (level 1; eg,
salicylates and nonsteroidal anti-inflammatory drugs), weak opioids (level
2; eg, codeine phosphate, pentazocine hydrochloride, and buprenorphine hydrochloride),
and strong opioids (level 3; eg, morphine sulfate, hydromorphone hydrochloride,
fentanyl citrate, and methadone hydrochloride).
STATISTICAL ANALYSIS
Data were analyzed first to obtain descriptive statistics. Continuous
variables are presented as means ± SD. We evaluated age trends of sociodemographic
variables and indicators of disease severity using the Fisher exact test.
Differences between continuous variables were assessed by means of analysis
of variance comparisons for normally distributed variables; otherwise, we
adopted the Kruskal-Wallis test. We chose the P<.05
level for statistical significance.
To identify predictors of analgesic use, we selected a sample of patients
with daily pain and constructed a multiple logistic regression model, with
use of analgesics as the dependent variable of interest. Potential predictors
included age, sex, functional and cognitive status, and comorbidity. These
were adjusted for confounding by a number of possible contraindications to
pharmaceutical treatment. The instrumental activities of daily living score
was excluded from the multivariate analysis to limit the confounding effect
of collinearity with the activities of daily living score. We have not considered
socioeconomic factors because the Italian National Health Plan provides universal
coverage, including drugs. In fact, the health budget is funded by general
tax income and a special tax. From the final model, we derived odds ratios
(ORs) and corresponding 95% confidence intervals (CIs).
Statistical analyses were performed using commercially available software
(SPSS; SPSS Inc, Chicago, Ill).
RESULTS
The principal characteristics of the study population are shown in Table 1. Patients were white and predominately
female (59%), with a mean age of 78.3 ± 8.9 years. More than 67% of
the individuals were 75 years or older. Overall, patients had a moderate-to-severe
impairment in basic and instrumental activities of daily living; similarly,
cognitive function was compromised in many patients (>35% showed a Cognitive
Performance Scale score of >2, indicating moderate to severe cognitive impairment).
An explicit terminal prognosis was indicated in 5% of patients. Daily pain
was recorded in 40% of patients aged 65 to 74 years, 49% in those aged 75
to 84 years, and 41% in those 85 years and older.
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Table 1. Descriptive Analysis of Baseline Sociodemographic, Functional,
and Clinical Variables by Age*
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Of the 1341 individuals who reported having daily pain, 27% received
analgesics. Level 1 analgesics were used by 25% of patients in pain. Levels
2 and 3 opiates were administered to only 6% and 3% of patients in pain, respectively. Figure 1 shows the relationship between age
and analgesic use. As age increased, a lower proportion of patients in pain
received analgesic drugs (33%, 26%, and 21% of patients aged 65-74, 75-84,
and 85 years, respectively; P<.001 for age
trend). This trend was evident for the 3 different classes of analgesics.
The use of morphine or other strong opiates was relatively uncommon in all
age groups. In particular, only 1% of patients 75 years and older received
this class of drugs compared with 5% of patient aged 65 to 74 years (P<.001).
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Pharmacologic treatment of the 1341 patients with daily pain according
to the 3-level ladder of the World Health Organization. Level 1 includes nonnarcotic
analgesics; level 2, weak opiates; and level 3, morphine and potent opiates.
The 3 levels are described in detail in the "Assessment of Pain and Analgesia"
subsection of the "Subjects and Methods" section. Patients are grouped by
age.
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Table 2 shows predictors
of analgesic use among persons with daily pain. Patients 85 years or older
were less likely to receive analgesics, compared with the younger patients
(OR, 0.73; 95% CI, 0.60-0.89). This association remained significant in a
multivariable model adjusting for several variables, including sex, functional
and cognitive status, indicators of disease severity (eg, explicit terminal
prognosis and comorbidity), and possible contraindications to analgesic use
(eg, gait problems, constipation, hallucinations, vomiting, problems swallowing,
dizziness, and chronic obstructive pulmonary disease). Furthermore, patients
with cognitive impairment were less likely to receive analgesics. In the adjusted
model, patients with dementia appeared to have a 20% decreased probability
of being treated relative to patients with normal cognitive performance (OR,
0.80; 95% CI, 0.69-0.93).
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Table 2. Predictors of Receiving Analgesia Among Patients With Daily
Pain*
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COMMENT
The results of the present study show that more than 40% of elderly
patients living in the community experienced daily pain. Only one quarter
of these individuals received analgesics of any kind. Patients 85 years or
older were even less likely to receive analgesics than the younger elderly
population. Individuals with cognitive impairment were also at greater risk
for receiving no analgesics than were the nonimpaired population. Elderly
subjects and patients with cognitive impairment may receive inadequate analgesia
in part due to an underestimation and underreporting of pain. However, the
observation that older and demented persons were at greater risk for undertreatment
is especially concerning, since it has been documented in previous studies.10, 16-17
Many explanations have been offered to explain poor assessment of pain
and inadequate treatment in this age group. Some authors have suggested that
older patients have less knowledge about pain management and a disproportionate
fear of addiction.18 A recent study among patients
with cancer in nursing homes found that as many as 37% had unrelieved pain.
One quarter of patients did not receive any analgesics, despite daily pain;
and patients older than 85 years and nonwhite patients were even less likely
to receive analgesics.4 Age per se seems to
be a predictor of poor pain management. Cleeland et al9
reported that even outpatients 70 years or older with cancer were less likely
to receive analgesic treatment when compared with younger populations. Although
cultural differences might be invoked to explain some of our results, other
factors certainly contributed to such striking findings. Thus, some special
characteristics of home health care patients, payment mechanisms, state regulation,
and restriction on prescription of opioids likely are factors in so large
a sample of frail elderly patients receiving inadequate care.
Inadequate attention to pain control is unethical, clinically unacceptable,
and wasteful in terms of cost.19 Phillips19 has reported that appropriate pain management results
in quicker clinical recovery, shorter hospital stays, fewer readmissions,
and improved quality of life. As indicated by the WHO,4
almost all patients with daily pain can be adequately treated by means of
simple oral regimens that usually do not produce adverse effects.5-6,20 To begin to address
this problem in the United States, the Joint Commission on Accreditation of
Healthcare Organizations21 has issued pain
management guidelines. They emphasize the importance of a collaborative and
interdisciplinary team in pain management and the need to perform a reliable
assessment and reassessment of each patient's pain with subsequent planning
of an individualized pain control program. Such a program would include the
use of pharmacologic and nonpharmacologic strategies. Finally, experts agree
that a need exists to educate individual clinicians and even patients to influence
their behavior with respect to pain.22
We recognize some limitations of our study. Although the MDS-HC is a
standardized, comprehensive assessment instrument, the recording of pain is
not a specific focus. Pain was assessed by the home health care general staff
(including the general practitioner), and this process might have been complicated,
especially for patients with difficulty communicating. Furthermore, we did
not attempt to identify the site of pain or make an attribution as to its
specific cause.
CONCLUSIONS
Our data suggest that in the community, analgesics are infrequently
prescribed to elderly patients. To identify patients in pain, the MDS-HC assessment
tool can be used by home health care staff and general practitioners. After
a specific intervention is instituted, a second assessment should be performed,
thereby allowing observations to be made on the efficacy of the treatment
plan. Furthermore, research is needed to explore the potential use of MDS-HC
data to target diagnostic evaluation and to monitor the appropriateness of
therapies for daily pain in community setting. A failure to make all reasonable
efforts to treat pain successfully should be considered one of the most important
indicators of poor quality of health care.
AUTHOR INFORMATION
Accepted for publication April 18, 2001.
This study was supported by a grant from the Progetto Finalizzato Invecchiamento
of the National Research Council, Rome, Italy, and from Pfizer Italiana SpA,
Rome.
The SILVERNET-HC Study Group includes the following: Roberto Bernabei,
MD, Pierugo U. Carbonin, MD, and Maria P. Ruffilli, MD (Steering Committee);
Francesco Landi, MD, PhD, and Fabrizia Lattanzio, MD (Coordination); and Giavanni
Gambassi, MD, Andrea Russo, MD, Matteo Cesari, MD, Luca Manigrasso, MD, Francesco
Pagano, MD, Maria G. Di Niro, MD, Graziano Onder, MD, and Antonio Sgadari,
MD (Writing Panel).
Corresponding author and reprints: Francesco Landi, MD, PhD, Istituto
di Medicina Interna e Geriatria, Centro Medicina dell'Invecchiamento (C.E.M.I.),
Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168
Rome, Italy (e-mail: francesco_landi{at}rm.unicatt.it).
From the Istituto di Medicina Interna e Geriatria, Università
Cattolica del Sacro Cuore (Drs Landi, Onder, Cesari, Gambassi, Russo, and
Bernabei), and Pfizer Italiana SpA (Dr Lattanzio), Rome, Italy; and the New
Jersey Medical School and Homecare Institute, Hackensack University, Hackensack,
NJ (Dr Steel). A complete list of participants in the Silver Network Home
Care (SILVERNET-HC) Study Group was published previously (Aging Clin Exp Res. 1999;11:272 and Anziani Oggi. 2000;3-4:152).
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