Pain Management in the Older Adult

The week before writing this article, I received an urgent call from a patient’s daughter. I had seen the patient in the past to provide advice on the control of her hypertension. The daughter told me that her mother was in agony with a pounding headache, which the daughter assumed meant that her blood pressure was dangerously elevated. I quickly went to see her, and of course the problem was not related to her blood pressure. In fact, this woman had had a lifelong history of severe headaches, generally self-managed with large doses of acetaminophen with codeine. She had never really received a systematic assessment for her severe pain, and this led me to consider how many older patients have poorly managed pain. Certainly the scientific literature suggests that it is all too common. There are numerous reasons for this. We often assume that with all their medical conditions older adults should be in pain, and there is often a nihilistic attitude towards management. Often the management is focussed exclusively on analgesics, an approach that is too limited for chronic pain conditions. As well, the multiplicity of diseases that some older adults present with makes diagnosis and specific management quite difficult. I am pleased, therefore, that the theme of this issue is on Pain Management in the Older Adult.

The CME article this month is by Dr. Marek Gawel, a neurologist who is also an international authority on headache. His article is entitled “Headaches in the Older Adult.” After my recent experience, it seems rather important for me to complete the CME course! Then, Dr. Deborah Dillon McDonald discusses “Post-Operative Pain Management for the Aging Patient.” In order to understand the intensity of treatment required for a painful condition, the physician must be able to assess the severity of the patient’s pain. This topic is beautifully addressed in the article “Assessing Pain Intensity in Older Adults” by Drs. Sophie Pautex and Gabriel Gold. Finally, Dr. Lucia Gagliese explores the association between physical pain and mood in her review of “Pain and Depression in Aging Individuals.”

As usual, we also have several articles on other topics. In our cardiovascular column, Drs. Rachel L. McIntosh and Tien Y. Wong consider the importance of “Hypertensive Retinopathy as a Risk Marker of Cardiovascular Disease.” As a geriatrician, I believe that poor dental health in demented patients can trigger an inexorable downward spiral as nutrition is impaired. I am pleased that Dr. Michael J. Sigal is addressing this problematic area in his article “Dental Considerations for Persons with Dementia.” For those of us who like to eat (I am one of those!), the importance of healthy teeth and a healthy oral cavity cannot be over emphasized. Drs. Richard J. Payne, Jamil Asaria, and Jeremy L. Freeman review the important topic of “Oral Cavity Cancer in the Older Population.” Finally, our caregiving article by Dr. Rory Fisher addresses a very timely ethical issue, “Euthanasia and Physician-Assisted Suicide: Are They Next?”

Enjoy this issue,
Barry Goldlist