Eric Widera, MD, Division of Geriatrics, University of California at San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
Alex Smith, MD, Division of Geriatrics, University of California at San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.

This article highlights the complex challenges seen when managing pain in patients with moderate or advanced dementia. Recent evidence demonstrates that pain is often poorly recognized and treated in patients with cognitive impairment. The progressive decline in cognitive function often leads to difficulties in expressing and recalling painful experiences. Making pain assessments routine and combining patient reports, caregiver reports, and direct observation may help alleviate this poor recognition of pain. Once pain is confirmed, a comprehensive history and physical examination are central in determining the underlying cause of pain and in choosing the best modality to treat the pain.
Key words: dementia, cognitive impairment, pain, opioids, assessment.

R.N. Martinez-Gallino, MD, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC.
L.K. Burke, BScN, BHSc, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC.
R.G. McCormack, MD, FRCSC, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC.

Frozen shoulder, or adhesive capsulitis, is a frustrating condition for both patients and physicians. The protracted course of frozen shoulder in combination with the pain and limited range of motion significantly impacts patients’ quality of life. Controversy over the best course of treatment for this chronic condition has proved to be a major challenge for physicians. The goal of this article is to present an organized review of the assessment and management of a frozen shoulder. The emphasis is placed on treatment options. Special considerations for the older adult are highlighted.
Key words: frozen shoulder, adhesive capsulitis, diabetes, glenohumeral joint, pain.

Linda M. Rapson, MD, CAFCI, Rapson Pain and Acupuncture Clinic, Toronto; Consultant, Acupuncture Program, Toronto Rehabilitation Institute Lyndhurst Centre, Toronto, ON.
Robert Banner, MD, CCFP, FRCP(C), Dip AAPM/CAPM, Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON.

Acupuncture, an ancient form of medicine that originated in China several thousand years ago, has been used by Canadian physicians since the 1970s. Research on the neurophysiology of acupuncture analgesia supports the theory that it is mediated primarily via the selective release in the central nervous system of neuropeptides. Evidence of its anti-inflammatory effects is emerging. Meta-analyses of randomized controlled trials provide evidence for acupuncture’s effectiveness in treating back pain, neck pain, and osteoarthritis. Applications of electroacupuncture using transcutaneous electrical nerve stimulation can provide good pain relief via home treatment and make management of cancer pain using acupuncture knowledge realistic.
Key words: acupuncture, pain, TENS, endorphin, anti-inflammation.

In A Sceptic’s Medical Dictionary (London:BMJ Books, 1997), Michael O’Donnell describes clinical experience as, “Making the same mistakes with increasing confidence over an impressive number of years” and evidence-based medicine as, “Perpetuating other people’s mistakes instead of your own.” Like most good humour, there is a large amount of truth in these definitions. Our theme in this issue is pain relief in older adults. Among the articles, we look at traditional methods of pain relief. It is good to remind ourselves that long experience with these modalities is not a guarantee that they are more effective than placebo. On the other hand, absence of proof of effectiveness does not mean the same as proof of absence. Many traditional remedies are clearly worthy of proper study. However, when patients tell me that natural products by definition must be safe, I feel compelled to remind them that arsenic, strychnine, digoxin, and many others, are very dangerous natural products.

Our theme this month, as I mentioned, is on pain relief. Probably the two commonest sources of pain that patients complain of to their family doctor are joint pain and abdominal pain. One of these is covered in our CME article for this edition, namely “Chronic Abdominal Pain: A Real Pain in the Gut” by Dr. Grant Chen. We have an article on “Traditional Chinese Medicine for Chronic Pain: The Oldest Medicine for Older Adults” by Mary Wu as well as a more specific article on “Acupuncture for Pain Management’ by Dr. Linda Rapson and Dr. Robert Banner. Our Musculoskeletal column for this month is also related to our focus: “Managing Rotator Cuff Injury: Can Acupuncture Add Increments to the Current Protocol? Inference from a Case Study” by Dr. Sanjeev Rastogi, Dr. Rajeev Rastogi and Dr. Ranjana Rastogi.

As usual we also have a variety of articles on other topics. Our Men’s Health article is “Bone Densitometry among Older Men: Indications and Interpretation” by Dr. John Schousboe. Our CVD column is on “Revascularization for Peripheral Arterial Disease among Older Adults: Referral, Management, and Prognosis” by Dr. Marc Schermerhorn and Dr. Kristina Giles. The article on Drug Safety, “Benzodiazepine Use among Older Adults: A Problem for Family Medicine?” is by Dr. Steve Illiffe, and we also have an article on a very common medical problem, “Aspiration Pneumonia among Older Adults” by Dr. R.A. Harrison and Dr. T.J. Marrie. Finally, our Dementia column is written by two well known clinical experts (and colleagues of mine) Dr. David Tang-Wai and Dr. Naida L. Graham. Their article is entitled “Assessment of Language Function in Dementia.”

Enjoy this issue.
Barry Goldlist

Evelyn Hutt, MD, Associate Professor of Medicine, University of Colorado at Denver and Health Sciences Center; Director, Colorado Research in Care Coordination, VA Eastern Colorado HCS, Denver, CO, USA.
Martha D. Buffum, DNSc, APRN, BC, CS, Associate Chief Nurse for Research, VA Medical Center, San Francisco; Associate Clinical Professor, School of Nursing, University of California, San Francisco, CA, USA.
Regina Fink, RN, PhD, FAAN, Research Nurse Scientist, University of Colorado Hospital, Aurora, CO, USA.
Katherine R. Jones, RN, PhD, FAAN, Sarah Cole Hirsh Professor and Associate Dean for Evidence-Based Practice, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA.
Ginette A. Pepper, PhD, RN, FAAN, Professor and Helen Lowe Bamberger Colby Endowed Chair in Gerontological Nursing Associate Dean for Research and PhD Program, University of Utah College of Nursing, Salt Lake City, UT, USA.

Pain is common among long-term care residents and is often undertreated. A high prevalence of dementia, sensory impairment, and disability, as well as structural issues such as staffing patterns and turnover in long-term care facilities make assessment and management of pain challenging. An overview of the evidence regarding the assessment and treatment of pain in individual residents, and recommendations for improving the overall quality of pain management in the long-term care setting, is presented.
Key words: pain, dementia, long-term care, pain assessment, pain management.

Sophie Pautex, MD, Pain and Palliative Care Consultation, Department of Rehabilitation and Geriatrics, University Hospital Geneva, Collonge-Bellerive, Switzerland.
Gabriel Gold, MD, Department of Rehabilitation and Geriatrics, University Hospital Geneva, Switzerland.

Persistent pain is common in older adults, and its consequences are often severe. Self-assessment scales have been validated in older populations and remain the gold standard for the evaluation of pain intensity in this age group. Most patients with dementia demonstrate appropriate use of self-assessment scales. Observational scales correlate moderately with self-assessment and tend to underestimate pain intensity; thus, their use should be reserved for patients who have demonstrated their inability to use self-assessment tools reliably.
Key words: pain, dementia, self-assessment, pain scale, cognitive impairment.

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

Hershl Berman, MD, FRCPC, Department of Internal Medicine, Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, ON.
Shawna Silver, BASc, PEng, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON.

Pain in the older adult can present unique challenges. Cognitive impairment and polypharmacy can make assessment and treatment difficult. An interdisciplinary team that includes family caregivers is essential. A rational approach to the ambulatory older patient with nociceptive pain would be to begin with regularly dosed acetaminophen, then add an NSAID if appropriate. The next step would be to add a low-dose opioid. If the patient uses a sufficient quantity of the opiate, dosing should be spread out throughout the day. Once a stable dose is reached, one can use a sustained-release formulation. Nonopioids should be continued throughout the titration process.
Key words: pain, analgesia, opioids, older adult, pain assessment.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Hsiupei Chen, MD, Carolina Pain Consultants and Critical Health Systems, Raleigh, North Carolina, USA.
Randall P. Brewer, MD, The Spine Institute, Willis Knighton Health System, Shreveport, Louisiana, USA.

Neuropathic pain (NP) results from injury or dysfunction in the processing of sensory information in the nervous system. It occurs in a wide array of disease processes and may involve complex management strategies. A comprehensive approach utilizing proven pharmacologic and nonpharmacologic therapies can be used to return function and improve quality of life that has been lost because of pain. In the older population, age-related physiologic and pharmacodynamic alterations, coexisting diseases, and the prevalence of polypharmacy must be considered when selecting therapies for neuropathic pain.
Key words: neuropathic pain, older adults, neuropathy, pain, analgesics.

Aileen Burford-Mason, PhD, President, Holistic Health Research Foundation of Canada, Toronto, ON.
Trish Dryden RMT, MEd, Coordinator of Massage Therapy Research and Development, School of Applied Arts and Health Sciences, Centennial College, Scarborough, ON.
Merrijoy Kelner, PhD, Professor Emerita, Institute for Life Course and Aging, University of Toronto, Toronto, ON.
Paul Richard Saunders, PhD, ND, DHANP, Professor of Materia Medica, Canadian College of Naturopathic Medicine, North York, ON.
Mark Ware, MD, MRCP(UK), MSc, Assistant Professor, Departments of Anesthesia and Family Medicine, McGill University, Montreal, QC.

Complementary and Alternative Medicine (CAM) is defined as a group of diverse medical and health care practices, products, and systems that are not presently considered part of conventional medicine but are increasingly being used. For older patients already receiving multiple drugs, such practices are attractive as nonpharmacological approaches to pain management. This review highlights several CAM therapies, including acupuncture treatment, massage therapy, and several natural health products supported by recent research.
Key words: pain, acupuncture, massage, Devil’s claw, glucosamine.