Page 450 Acute Pain Management

(using familiar words such as none, slight, moderate, severe and unbearable) could be used
with reasonable success in patients with mild, moderate and severe cognitive impairment
(Pesonen et al, 2009 Level III‐2). That the VDS may be of most use has been confirmed by other
studies (Closs et al, 2004 Level III‐2; Herr et al, 2004 Level III‐2).
Self‐assessment pain scales can be used reliably in most older patients with mild‐to‐moderate
cognitive impairment, and in a significant number of patients with severe impairment,
although a trial of different scales may be warranted (Pautex et al, 2005) and the patients may
need more time to understand and respond to questions regarding pain (Gagliese & Melzack,
1997). Immediate reports of present pain may be reasonably accurate and as valid as those of
cognitively intact patients, but recall of past pain is less likely to be as reliable (Herr et al, 2006).
Other measures of pain
Assessment of pain in non‐communicative patients is more difficult. Behaviours such as
restlessness, frowning, and grimacing or sounds such as grunting or groaning have been used
in attempts to assess pain severity. In cognitively intact adults some of these behaviours have
been shown to correlate reasonably well with patient self‐report of pain (Bell, 1997). However,
they may not always be valid indicators of pain in the non‐verbal adult (Farrell et al, 1996) and
can be difficult to interpret (Herr et al, 2006).
Observations of facial expressions and sounds may be accurate measures of the presence of
pain but not pain intensity in patients with advanced dementia (Herr et al, 2006). More than 20
different observational pain assessment scales have been developed and used in patients with
varying degrees of dementia. Examples include: Faces Pain Scales (Herr et al, 2004); Abbey Pain
Scale (Abbey et al, 2004), Pain Assessment in Advanced Dementia (PAINAD, a simple, reliable
and validated five‐item observational tool) (Warden et al, 2003; Leong et al, 2006), Pain
Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) (Fuchs‐Lacelle
& Hadjistavropoulos, 2004) and Mobilization‐Observation‐Behavior‐Intensity‐Dementia Pain
Scale (MOBID) (Husebo et al, 2007). For a more detailed and critical review of 10 pain‐
assessment tools for use with non‐verbal adults see Herr et al (Herr et al, 2006).
11.2.4 Drugs used in the management of acute pain in older people

In general there is limited evidence about the use of analgesic medications in older patients;
these patients, because of their age, comorbidities, or concurrent medications, are often
specifically excluded from clinical trials. However, these factors will need to be taken into
consideration when a choice of analgesic regimen is made.
CHAPTER 11 the older patient, as with other patients, physical and psychological strategies should also be
While Sections 11.2.4 and 11.2.5 concentrate on the use of analgesic drugs and techniques in
employed.
Non-selective non-steroidal anti-inflammatory drugs, coxibs and
paracetamol
Older patients are more likely to suffer adverse gastric and renal side effects following
administration of nsNSAIDs and may also be more likely to develop cognitive dysfunction
(Pilotto et al, 2003; Peura, 2004; Juhlin et al, 2005). In elderly (age over 65 years) medical
inpatients, use of nsNSAIDs was a significant risk factor for renal function deterioration; other
risk factors were loop diuretics, hypernatraemia and low serum albumin levels (Burkhardt et al,
2005).
Coxibs have a significantly lower incidence of upper gastrointestinal complications and have
no antiplatelet effects, which might be of some advantage in the older patient; the risk of
other adverse effects, including effects on renal function and exacerbation of cardiac failure,

402 Acute Pain Management: Scientific Evidence