Robert D. Helme, PhD, FRACP, FFPMANZCA, Barbara Walker Centre for Pain Management, St. Vincent’s Hospital, Melbourne, Australia.

Narcotics are commonly required for the treatment of severe pain due to malignancy at all ages. In recent years, it has been recognized that they may also benefit older people with nociceptor pain that is unresponsive to other management strategies. In this circumstance, narcotic treatment should be undertaken in the full knowledge of relevant laws and potential for side effects in patients who are fully informed and involved in their treatment program. The choice of narcotic depends on the preference and experience of the clinician. It must be recognized that both benefits and side effects of narcotics occur at lower doses in older people than in younger cohorts.
Key words: aging, pain, narcotics, comorbidity, side effects.

Conan Kornetsky, PhD, Professor of Psychiatry and Pharmacology, Boston University School of Medicine, Boston, MA, USA.

There is a common belief, supported by considerable experimental reports, that the aged have higher pain thresholds than the young and are more responsive to the analgesic actions of opiate drugs. To a considerable degree this belief shapes pain treatment in aged adults. This article reviews the evidence for this belief and discusses why there is often a disparity between the reported alleviation of pain in older adults and the widely held belief that these individuals receive inadequate pain management. Among the issues discussed is the amount of control the patient really has in patient-controlled analgesia.

Key words: pain, aged, analgesia, pain measurement, morphine.

Madhuri Reddy, MD, MSc, FRCPC, Assistant Professor, University of Toronto, Sunnybrook and Women's College Hospital, Toronto, ON.

Chronic wound pain adversely affects quality of life and causes functional impairment in the older adult. As the population ages and the prevalence of chronic illness increases, an explosion in the number of chronic wounds is expected in both long-term care and community care. Chronic wounds have a myriad of causes and complications, and care can be complex. The most common types of chronic wounds include venous stasis ulcers, diabetic ulcers and pressure ulcers. There is a paucity of clinical trials of chronic wound pain management in the older patient. In the absence of an adequate evidence base, we present a comprehensive clinical approach to chronic wound pain management.
Key words: chronic wounds, pain, venous stasis, diabetes, pressure.

Jane Oshinowo, RNEC, Primary health care Nurse Practitioner,
York Community Services, Toronto, ON.

Introduction
Pain is more than the perception of a nociceptive stimulus in the peripheral or central nervous system. It is "what the person says it is."¹ Ferrell1 developed a conceptual model that identifies four dimensions of pain and their impact on a person's quality of life (Figure 1). This model can be used to enhance the caregiver's understanding of the patient's experience of pain. Pain can be acute, chronic or chronic malignant in nature. In the elderly, illness tends to be chronic and the pain is often related to a degenerative condition. However, the elderly do experience acute pain. Whether acute or chronic, pain is more difficult to assess in the cognitively impaired elder. Despite our recognition of the global impact of pain on the individual, and the morbidity and mortality associated with inadequately managed pain, 25-50% of community dwelling elders are living in pain.²

Chronic pain management today is multidimensional. Analgesics tend to be the mainstay of therapy. However, non-pharmacological therapies are currently under investigation and in practice as complementary or alternative therapies to medications. This field is very large and continues to expand. For the purposes of this article, only the more commonly used and better-researched therapies will be discussed.

Keith B.J. Franklin, PhD
Professor, Department of Psychology, McGill University, Montreal, QC.

Frances V. Abbott, PhD
Professor, Department of Psychiatry, McGill University, Montreal, QC.

Chronic pain afflicts a majority of persons over the age of 60 and a large proportion of those afflicted receives little or no treatment. Many of the long-term conditions that limit activity involve pain, although recognition of pain in primary care settings is complicated by the fact that stoicism tends to increase with age, and older people tend to focus on acute pain and under-report chronic complaints.¹ Activity limitation, as a health indicator, has improved over the past twenty years for non-institutionalized Canadians in the 45-64 and 65-74 age groups (from 19 to 16% and 33 to 22%, respectively). In contrast, the prevalence of activity limitation in those over 75 has remained stable at around 35%. The most significant painful conditions that limit activity, arthritis and rheumatism, have remained stable over the past 20 years with an incidence of about 50% for women and just over 30% for men aged 65 and over.²

In light of the prevalence of pain in the elderly, it is surprising how little is known about the influence of age on the neurology and pharmacology of pain.

Bill McCarberg, MD
Director of Pain Services, Board of Directors, American Pain Society
Department of Family Medicine, Kaiser Permanente Medical Center, San Diego, CA, USA.

As humans age, they invariably become more susceptible to disease, which can impair function and enjoyment of life and pose significant challenges to the health care system. Osteoarthritis, the most common joint disease, affects over 18% of adults in Ontario.¹ Pain has also been associated with a three- to seven-fold increased prevalence of inability to perform daily tasks in the non-institutionalized elderly in Canada.²

More than half of elderly persons in the US are estimated to experience pain daily,³ and recent initiatives in the US have focused attention on the need to treat pain. The Joint Commission on Accreditation of Healthcare Organizations recently introduced new pain management standards to require better pain medicine in hospitals and other institutions as part of their accreditation process.

Non-pharmacologic Therapy
Although medications are commonly required to manage pain and maintain function in elderly patients, non-pharmacologic therapy remains a cornerstone of treatment. It should be started prior to the initiation of pharmacologic therapy, when possible, and be maintained throughout the pain management process.

Ailsa KR Cook, BSc
Research Fellow, Centre for Social Research on Dementia,
Department of Applied Social Science, University of Stirling, Stirling, UK.

Pain Assessment in Patients with Dementia
Pain is an important consideration when caring for patients with dementia. Being in pain leads to cognitive (e.g. poor concentration) and behavioural (e.g. apathy) symptoms, which if left untreated, exacerbate the effects of the existing cognitive impairment.^1,2 Pain is also associated with increased depression amongst people with dementia, as well as increases in other behavioural disorders, such as calling out and aggression.^3,4,5,6

Despite its significant negative impact, research has shown that many older people with dementia experience untreated pain.^7,8,9,10 A survey of 13,625 older cancer patients living in nursing homes revealed that 26% of those with daily pain received no analgesics, and a disproportionate number of this group were cognitively impaired.⁷ Similarly, a review of analgesic use in nursing homes found that residents with dementia were prescribed and administered fewer analgesics than were their cognitively intact counterparts.⁸

If pain management in this population is to improve, it is essential that health care professionals pay more attention to the assessment of pain in patients with dementia.

Angela Mailis, MD, MSc, FRCPC(PhysMed)
Medical Director, Comprehensive Pain Program,
Toronto Western Hospital, Toronto, ON.

The Comprehensive Pain Program (CPP) was founded in 1982 at the Toronto Western Hospital, a University of Toronto affiliated teaching hospital, as a product of the combined efforts of the chiefs of Physical Medicine, Neurosurgery and Psychiatry. Prior to its inception, the three departments offered a limited number of guaranteed beds for investigations of chronic pain patients. At that time, the program operated along the same lines as the Johns Hopkins pain program, which had been created a few years earlier. From the start, the CPP functioned as a multidisciplinary pain program involving Physical Medicine, Anesthesia, Psychiatry, Psychology, Neurosurgery and Allied Health (Occupational and Physical Therapy, Nursing, Social Services). Since 1990, the CPP has received funding from the Alternative Payment Program of the Ontario Ministry of Health (outside the traditional fee-for-service model), enabling it to provide unique clinical services, as well as to educate medical and allied health professionals and conduct extensive clinical research. Currently, the CPP is part of the Neuroscience group at the Toronto Western Hospital, together with programs like Epilepsy, Neurodegenerative, Neuromuscular and Neurovascular Diseases, Neuro-oncology, Neuro-opthalmology, Neuro-psychiatry, and the Spinal program.

Donna Spevakow, RN, MSN
Lisa Hamilton, RN,MSc

Chronic Non-Cancer Pain (CNP) is a clinically complex and common phenomenon in the older adult. Data suggest that CNP is undertreated in older adults who are likely to suffer from arthritis, back problems and joint disorders. Left untreated, CNP in the older adult can lead to depression, sleep disturbances and decreased socialization.

Recently, the problem of untreated CNP was investigated at the Toronto Rehabilitation Institute, a tertiary rehabilitation centre and a teaching hospital of the University of Toronto. A survey to determine pain prevalence and severity was conducted in a patient population consisting of complex continuing care, geriatric, acquired brain injury and stroke rehabilitation. One hundred and ten patients were able to verbally respond to the survey questions, and results showed that 47% of the patient population experienced CNP and 39% of those with pain rated it as severe. At that time, no structures were in place within the organization for the assessment and management of CNP.

This evidence led to the creation of a clinical interprofessional CNP task force which had the goals of establishing a patient-centred, interprofessional approach to CNP rehabilitation using "best practice" evidence, preventing unnecessary suffering and improving outcomes in rehabilitation.

Clinical practice guidelines included information on cultural consideration in pain assessment and management, an initial pain assessment form, and a pain flow sheet to evaluate effectiveness of interventions. Pain assessment scales were made available in 14 languages. Three categories of therapeutic approaches were identified within the guidelines: pharmacological, physical and psychoeducational. These guidelines were then developed into policies.

In order to achieve consistent use in the clinical practice setting, all clinical staff needed to be knowledgeable about the guidelines and policies. To this end, the CNP task force developed an innovative teaching tool--a colourful poster that serves as a quick reference guide for both physicians and patients.

In addition, an educational program was developed for front-line staff. Staff attended a one half-day workshop where, using a case study, they reviewed the pain assessment forms. A second half-day workshop on specific physical modalities was offered to the Registered Nurses who had attended the previous workshop, and to physiotherapists. A full-day workshop was offered by an expert in guided imagery.

Patient and family education is also a crucial component in management of CNP. Recognizing this need, the task force developed an educational booklet entitled "Chronic Pain and You," available in four languages: Chinese, Portuguese, Italian and English.

Other outcomes of the initiative are that links have been established with the Comprehensive Pain Program at Toronto Western Hospital, University of Toronto Centre for the Study of Pain, and that a medical pain specialist is now available on-site for consultation.

We hope that this issue of Geriatrics & Aging will update our readers on the management of pain in the elderly. We have a series of excellent articles including an overview of the biology of pain, a summary of pain management and assessment in the elderly, the principles of palliative care and the management of pain in patients with dementia. We also have a summary of the Toronto Western Hospital's Chronic Pain Program. Topics for our regular columns include 'Syncope in the elderly' (Cardiology column) and chronic lymphocytic leukemia (Cancer column). Enjoy!

Donna Spevakow is a CNS at Toronto Rehabilitation Institute and Lisa Hamilton is a CNS at York Central Hospital. They were Co-Chairs of this Initiative. Toronto Rehab received the Health Care Papers National Best Practice Award at the Ontario Hospital Association Convention, November 2000 for this interprofessional Non-Cancer Pain initiative.

Lucia Gagliese, PhD
Assistant Professor, School of Kinesiology and Health Science, York University,
Staff Scientist, Department of Anaesthesia, University Health Network, and
Assistant Professor, Department of Anaesthesia, University of Toronto.

Brenda Kraetschmer, RN, BScN
Clinical Research Coordinator,
Department of Anaesthesia, Mount Sinai Hospital and
University Health Network, Toronto, ON.

As the population ages, health care workers will increasingly be called upon to provide effective pain assessment and management to elderly patients. Fortunately, information regarding age-related patterns of pain, disability and psychological distress has become more readily available over the past decade. However, this area of study remains in its infancy and further research is urgently needed. In this article, we present a brief overview of some of the most recent data about the epidemiology, assessment and management of chronic pain in elderly people.

Epidemiological Studies
There is no clear-cut pattern of age differences in the prevalence of pain. Results vary depending on the population and type of pain studied.¹ Epidemiological studies conducted in community settings have found that the prevalence of many pain complaints, including headache, migraine and low back pain, peaks in middle-age and decreases thereafter.