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Beyond that initial (and subsequent) evaluation with a good pain assessment tool, the management direction will be predicated on a good clinical history of the pain and a competent physical examination. For seniors, both are likely to take more time than for younger patients, if only because seniors are unlikely to follow Ocham's razor; that is, multiple problems may contribute to even a single complaint.

The history must involve basic elements that include location, timing, ameliorating and exacerbating factors, context, duration, quality, severity, and any associated signs or symptoms. It should also be noted that some people would deny "pain" but admit to "discomfort," an "ache," or some similar terminology for pain (17).

Location should involve not only the area of the body, but also whether the pain is superficial or deep. The pain may also be localized to bone, joint, muscle, or the like. Location here does not refer to pain that may accompany change in physical or geographic location, such as accompa nying rapid transitions to high altitudes, rapid changes in depths when diving, or visits to certain relatives or ceremonial dinners, all of which might be more properly categorized as "modifying factors." (In the case of certain relatives and ceremonial dinners, some might argue that they would be better categorized as the cause of pain.)

Timing includes whether the pain is continuous or intermittent. If intermittent, when does it occur (e.g., on awakening)? If continuous, are there times when it is worse? Regardless of whether continuous or intermittent, modifying factors need to be determined. Recognizing that pain frequently occurs immediately after physical therapy sessions may be an indication for preemptive analgesia, modification of the therapy regimen, or both.

Whether the pain occurs in certain settings and the overall context of the pain (e.g., postoperatively or as part of a chronic or persistent scenario) is also important information. Determining whether it interferes with specific activities or functions also should be documented. Does the pain limit social activity, appetite, sleep, intimacy, or other factors that have an impact on quality of life?

The duration refers to the acute or chronic nature of the pain. Pain that has been present for months or years may have different etiologies as well as different associated symptoms. In addition, the approach to chronic or persistent pain may be different from acute or transient pain situations.

Associated signs and symptoms may refer directly not only to the pain etiology, but also to comorbid findings (e.g., depressive symptoms). Changes in function also may accompany pain. Thus, an assessment of function using an appropriately standardized instrument for the senior being evaluated is warranted (18,19).

The quality of the pain (i.e., burning, dull, throbbing, shocklike, tearing, and other such descriptors) must be ascertained as well. Indication of severity must accompany the rest of the history. Usually, this is when a score on a specified pain scale will be documented. Other subjective terms may appear here as well.

It is important also to recognize and document observations about secondary gain, anxiety, prior experiences, mental focus, and other psychological factors that may have an impact on pain status. Spiritual issues and social support should also be recognized as important factors that should be identified in the history (20). Chapter 4 deals specifically with spirituality, which is infrequently described and often has a tremendous impact on pain management.

A good social history will include information on an older patient's social support structure. This will provide valuable information with regard to ability to attend therapy sessions, which may require transportation; accessibility to pharmacies; and financial capabilities, which bear on prescription coverage and other such factors associated with medication and treatment options. It makes little sense to develop a treatment plan without knowing whether the patient can feasibly comply. Provided that the patient is agreeable, it also may be useful to involve other family members, who may be sources of such support and who can help provide such information.

A good medication history, especially what has been tried and proven problematic or ineffective, can be very helpful when ultimately developing a treatment plan, as will information on patient concerns. For example, a patient who fears addiction or does not believe that notification of pain will produce relief may be reluctant to comply with recommendations (21).

Advance directives, including the designation of the health care agent to render decisions should the patient not be able to do so, are a necessary part of the history. These should ideally be obtained early during a routine visit setting. Remember that these decisions, for many patients, will require the input of other people in whom the patient places confidence. Thus, although the discussion should be initiated, it may be only temporarily resolved until a later visit after more input can be obtained.

Many older patients see several physicians because of multiple comorbid conditions; therefore, it is important to identify any other clinicians involved in the patient's care. It is also useful to determine which clinicians are responsible for which therapies. Such information will facilitate communication among clinicians during efforts to modify regimens and when working on the task of medicinal debridement (i.e., reducing the number and frequency of medications) for patients with polypharmacy issues.

The physical examination for the older population requires additional diligence as well. Seniors may present with symptoms different from their younger counterparts. For example, visceral pain may be less intense in the seniors, and even serious infectious causes of pain may have minimal or absent leukocytosis (22). Even presentations of pain, such as for head ache, which is common and usually benign in young patients, may be due to more serious causes for older patients. For example, the headache in an older adult is more likely to be associated with etiologies like temporal arteritis, cervical osteoarthritis, depression, congestive heart failure, subdural hematoma, or electrolyte disturbances (23).

The physical examination, of course, should include the site of reported pain, common areas for pain referral, and common sites of pain in older patients (24). In addition to an evaluation for tenderness, other aspects of the examination should look for clues pointing to the major underlying diagnostic basis. Thus, erythema, neurological abnormalities, and functional decline are all clinical findings that may help ascertain a root cause of pain and have an impact on quality of life. It should be mentioned that whether or not function is measured by a performance-based tool, the instrument selected should have the same type of standardization and responsiveness testing described for pain scales above (19). In addition, the examination should also encompass physical changes that might be induced by the pain itself. For example, favoring a painful knee may induce malalignment of the spine, exacerbation of osteoarthritis in the opposite knee, and similar changes resulting from adjustments made consciously or unconsciously in response to the painful joint. The abnormal elements of the physical examination should be clearly documented at baseline and followed serially as treatment progresses.

For the patient who has been treated with opioids for pain, the physical examination should also be performed with the astute clinician mindful of the potential for drug withdrawal. In older adults, addiction is rarely an issue. A far greater problem is having patients decrease medications or even completely discontinue medications for pain without discussing such changes with the physician. As pain improves, patients will decide that the opioid, which they had been fearful of starting in the first place because of concerns about addiction or because of reading an unrelated story about abuse potential, is no longer needed. Subsequently, agitation, tremulousness, and, often, more pain develop among other signs and symptoms associated with opioid withdrawal.

In addition to those elements of the physical examination directed toward discovering the direct etiology of pain and the changes associated with such pain, the examination of seniors must include elements that will affect communication and compliance with intervention strategies. Therefore, an examination of hearing and vision are crucial. For seniors, aging is associated with loss in high-frequency tones as well as difficulty in sound discrimination. This, combined with other causes of hearing loss, may make comprehension of instructions for pain control difficult. Presbyopia, the age-related difficulty in focusing on close objects, and other causes of visual impairment may make reading prescriptions and small print impossible. Distinguishing among the expressions on the Faces Pain Scale also may not be reasonable.

An assessment of cognitive function is also needed. Such assessments should include an evaluation of executive function. Appropriate tests for baseline evaluation will be important, and the inclusion of acceptable measures to monitor changes in such functioning will also be required. It should be noted that other sensory deficits may increase the risk for mental status changes (25-27). As part of the cognitive assessment, screening and evaluation for depression are particularly important because depression is not only common, but also pain is very difficult to treat adequately if depression is not also adequately treated (28).

In summary, the assessment of pain in older adults is absolutely vital for successful resolution of pain. The assessment should involve formal assessment instruments, preferably standardized in populations similar to the individual who is being assessed. A good history and physical examination by an astute clinician must also be part of pain assessment. Although the frustration of the physician quoted at the beginning of this chapter is understandable, it should be recognized that pain scales do differ. Nonetheless, there remains great room for research to improve the understanding of appropriate use of those scales currently in existence and to develop new scales for populations not adequately served by currently available assessment modalities.

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