Page 283 Guide to Pain Management in Low-Resource Settings

Pain in Old Age and Dementia 271

With regard to the opioid-receptor population and Case report: Mr. Ramiz Shehu
subjective sensitivity to painful stimuli, there is confl ict- (prostate cancer)
ing evidence. Th erefore the conclusion has to be that
pain perception and analgesic interactions are unpre- Mr. Shehu is a 72-year-old farmer from the north-
dictable. ern part of Albania, living in the village of Filipoje. He
was diagnosed with prostate cancer 3 years ago when
Do patients with impaired communication, he presented himself to the local doctor, Dr. Frasheri,
such as those with Alzheimer disease, receive with diffi culties with urination. As disease of the pros-
insuffi cient analgesia?
tate was suspected, blood was drawn and send to the
Unfortunately, a number of studies show that patients district hospital for the prostate-specifi c antigen (PSA)
with Alzheimer disease, and diffi cult or impossible test. Unfortunately, the PSA was highly positive. After
communication, receive insuffi cient analgesia. Th is has careful evaluation of the individual situation, espe-
been shown both for acute situations such as fractures cially regarding the comorbidity with hypertension and
of the neck of the femur and for chronic pain. Th is ob- heart insuffi ciency as well as the patient’s advanced
servation is alarming since there is evidence showing age, Dr. Frasheri concluded that there would not be
that the pain perception of Alzheimer patients is undis- an indication to send Mr. Shehu to the capital Tirana
turbed. for surgery, chemotherapy, or radiotherapy. Now, after
3 years, Mr. Shehu was still in relatively good general
What is likely to be the most important reason
for inadequate pain management? condition, being an important and active member of St.
Bartholomew’s church in his home village. But in the
Much of the problem of inadequate pain management
recent weeks he had developed increasing pain in his
of the geriatric patient is the lack of appropriate assess-
left chest and left hip. He described his pain as “drill-
ment. Especially in patients with dementia, failure to
ing,” increasing with activity, especially when walking
assess pain properly results in insuffi cient analgesia, be-
and taking a deep breath. Visitors from Italy had fi rst
cause less than 3% of these patients will communicate
suspected coronary disease and hip arthritis, since the
that they need analgesics themselves.
high PSA had been forgotten by that time. But the local
How is pain in the geriatric patient doctor drew the correct conclusions.
assessed eff ectively?
1) Th e options in Filipoje
Th e main rule for the geriatric patient is: “ask for pain.”
Local therapy: Use a walking stick, apply a home-made
Th e patient may not ask for analgesia spontaneously. All
elastic bandage around the chest.
reported pain should be taken seriously; it is the patient
Systemic therapy: Th e only pain killers available were di-
who has the pain, and the pain is what the patient tells
clofenac and morphine.
you it is. Conventional instruments may be used for
pain assessment, such as analogue scales or verbal rat- 2) Th e options in the capital, Tirana
ing scales, if the patient is able to communicate prop-
At Mother Th eresa Hospital, a tertiary care center, the
erly. But rating and analogue scales will fail in the non-
options are:
communicating patient. Th erefore, it will be necessary
Local therapy: X-ray or CT for confi rmation
to use more sophisticated techniques. All these tech-
of bone metastasis, eventually local radiation therapy:
niques are based on careful observation and interpre-
fractioned radiation (multiple) for analgesia and bone
tation of the patient’s behavior. Several scoring systems
stabilization, unfractioned radiation (single) for analge-
have been developed for this task. Typical items for ob-
sia only.
servation include facial impression, daily activity, emo-
Systemic therapy: Bisphosphonates (for bone sta-
tional reactions, body position, the chance of consola-
bilization), radionucleotides such as samarium, or ac-
tion, and vegetative reactions. Some scores also include
tivated phosphates (for patients with multiple painful
the subjective impression of the therapist. Recent clini-
bone metastasis where radiation is not an option), alter-
cal research has tried to interpret various therapeutic
nating opioids (for continuing side eff ects of the fi rst or
interventions to fi nd out more about the patient’s pain,
second opioid, because opioid rotation is the therapy of
with trials called “sequential intervention trials.”
choice if sedation and/or nausea persists beyond 1 week),