Explore this issueApril 2014
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SAN DIEGO—Pain and depression are important to assess and treat in patients with rheumatic diseases. Painful joints may signal underlying disease activity. Pain and depression may impair a patient’s quality of life and physical function, and prompt treatment adjustments. Patients are often at higher risk for poor disease outcomes if their symptoms are not treated properly.
At the 2013 ACR/ARHP Annual Meeting, two experts offered suggestions to clinicians on treating rheumatic diseases in the elderly with dementia or cognitive impairment, and in patients with severe psychiatric disorders. (Editor’s note: This session, ARHP: Rheumatic Disease and Pain Management in Special Needs Populations, was recorded and is available via ACR SessionSelect at www.rheumatology.org.)
Difficulty in Reporting Pain
Pain is common among patients older than 70; dementia and cognitive impairment are also prevalent in this population, creating barriers in patients’ abilities to express or report pain, said Devyani Misra, MD, a rheumatologist at Boston University School of Medicine. Dementia causes impairment in thinking, remembering and reasoning, and dementia patients may also have behavioral problems, Dr. Misra added.
“Pain is probably under-reported and under-recognized in this group, and because it is under-reported and under-recognized, it is undertreated,” said Dr. Misra. Significantly fewer elderly hospital patients with dementia or cognitive impairment receive opioids for their pain, she added. Undertreatment of pain leads to physical problems (e.g., impaired sleep, limited function), and psychosocial problems (e.g., depression).
Dr. Misra said that elders with dementia or cognitive impairment have difficulty with their memory or recall of pain.
Standard approaches to pain assessment include the McGill Pain Questionnaire, the Visual Analog Scale and the Wong-Baker FACES Pain Rating Scale, which uses images of facial expressions of pain to rate intensity. However, self-reporting pain scales are problematic to use in this patient population because of their cognitive impairment. Observational scales may be more useful, according to Dr. Misra.
Two scales have shown favorable results in measuring pain among these patients. Doloplus-2 is a 10-item observational pain scale measuring such factors as somatic complaints, protection of sore areas and mobility. The Pain Assessment Checklist for Seniors with Limited Ability to Communicate comes in both a 24- or 60-item checklist form, and also measures various observations, such as facial expressions of pain and changes in personality or mood. Although these tools are helpful, more accurate measurement tools are greatly needed, Dr. Misra said.
Pharmacologic interventions for managing pain in the elderly population include acetaminophen for mild-to-moderate pain, and opioids for moderate-to-severe pain or when there is evidence of diminished quality of life, Dr. Misra said. Constipation and sedation are potential adverse effects of sustained use of opioids. Corticosteroid injections or topical analgesics may be useful for localized pain. Anticonvulsants and antidepressants are other options, but anticholinergics are not recommended for elderly patients with dementia or cognitive impairment, she noted.