Page 282 Guide to Pain Management in Low-Resource Settings

270 Andreas Kopf

• Th ey tend to not insist on certain medical inter- If adequate pain medication is provided for
ventions. elderly patients, why might they still not receive
From the patient’s and doctor’s perspective: suffi cient pain control?
• Pain in old age is “part of life” and “fate.” Communication problems and misconceptions of pain
From society’s perspective: are relevant causes of this situation. A number of par-
• Inadequate resources in the health care system ticularities must be considered in the geriatric patient:
restrict adequate treatment. • Compliance: Geriatric patients will have predict-
From the doctor’s perspective: able practical problems with their pain medica-
• Elderly patients do not feel pain as intensely as tion. Impaired vision and motor skills, combined
younger patients. with xerostomia (dry mouth) and disturbances
• Th ey cope better with pain and therefore need of memory, may make an adequate treatment a
less analgesia. complete failure. It has to be noted that the aver-
age geriatric patient in industrialized countries
What are the opinions and statements has a prescription for seven diff erent drugs, and
of scientifi c medical organizations?
only a minority of patients have been prescribed
A wealth of literature shows that geriatric patients are fewer than fi ve daily drugs, making noncompli-
not provided with adequate pain management. Medi- ance and drug interactions highly likely. Noncom-
cal societies have made the elderly patient a medical pliance rates are estimated to be as high as 20%.
priority. Since pain is frequent, meaningful, underdi- Apart from that, intellectual, cognitive, and sim-
agnosed, and undertreated, and since research on this ple manual impairments may interfere with treat-
topic is scarce, pain in the elderly has to be declared a ment. More than a fi fth of geriatric patients fail
medical priority. Consequently, the IASP in September at the task of opening drug packages and blister
2006 proclaimed “pain in old age” the main target of the packs. Another patient-related compliance factor,
“Global Day of Pain.” compared to younger patients, is reduced “posi-
tive thinking”: only 20% of geriatric patients ex-
Is it true that pain is frequent pect recovery and healing.
in elderly patients?
• Availability of opioids and the risks of prescrip-
A number of studies document that the incidence of tion.
pain is high. In old people’s homes, up to three-quarters • Comorbidity: Comorbidity may impair physical
of interviewed residents reported pain. Half of these had performance, thereby possibly reducing the ef-
daily pain, but less than one-fi fth were taking an anal- fects of rehabilitation eff orts.
gesic medication. Studies show that unrelieved pain is • Pharmacokinetic changes: One of the main
one of the most important predictive factors for physi- physiological changes in geriatric patients is the
cal disability. reduction of cytochrome P450-dependent me-
tabolization. Also, due to reduced hepatic func-
What are the typical pain locations tion, plasma protein levels are generally lower
in elderly patients?
in elderly patients. Both altered mechanisms
Th e number one cause of pain in elderly patients is may cause potential dangerous drug interac-
degenerative spine disease, followed by osteoarthro- tions and unpredictable plasma levels. Th is ef-
sis and osteoarthritis. Other important pain etiolo- fect may be most pronounced for drugs that are
gies include polyneuropathy and postherpetic neural- eliminated through the kidneys, since glomeru-
gia. Cancer pain is also a very relevant pain etiology. lar fi ltration rate is generally reduced, too, and
In highly industrialized countries cancer pain in the for drugs with high plasma protein binding,
elderly is often—at least partially—adequately con- where unpredictable serum levels of free sub-
trolled. But in other countries, management of cancer stance may result.
pain often is not a top priority, although good cancer • Vegetative state: Sympathetic reactions are re-
pain management could be accomplished fairly easy duced, causing misunderstanding and underesti-
with simple treatment algorithms based mainly on an mation of pain, since the elderly patient appears
adequate opioid supply. to be less strained by pain.