BETHESDA, MdChildren and elderly people with pain present
special problems in assessing the presence and causes of pain and
other symptoms, as well as determining treatment efficacy, two pain
specialists said at the 1st International Conference on Research in
Palliative Care, held at the NIH.
John Collins, MD, of New Childrens Hospital, Newmead,
Australia, pointed out that normal physiologic parameters that
accompany pain, such as cardiovascular acceleration and autonomic
changes, are not specific for determining the existence of pain in
infants less than 6 months old. Many of the behaviors exhibited by
children in pain can also be caused by a myriad of events not
necessarily related to pain.
Most of the studies done on very young children focus on the
existence of pain, not the severity, he said. Furthermore, few data
are available on the response of young children to specific analgesics.
In neonates, for example, facial expression is a more reliable
indicator of the presence of pain than crying. In children older than
4 years, quantification of pain can be accomplished by using poker
chips as a numerical scale. One chip represents a little bit of
hurt, while four chips is the most hurt you could ever
have. The child is then asked, How many pieces of hurt do
For children age 10 to 18, Dr. Collins reported that he has validated
a modified version of the Memorial Symptom Assessment Scale (MSAS).
The MSAS assesses symptoms in terms of frequency, severity, and
distress, and can be completed in an average of about 11 minutes.
Subscale analyses measure physical, psychological, and global distress.
In Dr. Collins study of the modified MSAS in children, the most
common symptoms reported were lack of energy followed by pain,
drowsiness, nausea, cough, lack of appetite, and psychological
distress. He concludes that the MSAS could be a useful tool for
assessing the range and impact of various symptoms in children who
are enrolled in therapeutic clinical trials.
Improvements in care have led to a greater percentage of chronically
ill elderly people in the population. The population over the age of
60 will increase by 69% by the year 2020. The prevalence of
Alzheimers dementia can range as high as 50% in people
over the age of 90.
Altered mental status can occur in 20% to 30% of medical inpatients,
and in 50% to 90% of nursing home residents, said Wendy Stein, MD,
assistant professor of geriatrics, UCLA, and medical director of the
Jewish Home for the Aging, Reseda, California. Dr. Stein addressed
issues of symptom assessment in the cognitively impaired elderly
population (see table). Delirium, dementia, major depression, visual
or auditory impairments, language barriers, and unresponsiveness make
assessment of symptoms in these patients difficult.
Assessment Strategies in the Cognitively Impaired
Delirium can be caused by drugs, reduced oxygenation, infections,
dehydration, metabolic complications, strokes, or subdural hematomas,
she said. Dementia is a decline in multiple cognitive functions
without a change in consciousness. Dementia in nursing home residents
may range as high as 50%, and more than 50 different etiologies have
Chronic pain in unresponsive, cog-nitively impaired patients may
manifest as major depression or as a change in baseline mental
status, she said. In a study of pain prevalence among cognitively
impaired geriatric nursing home residents, Ferrell et al found that
37% of the residents reported pain that was not mentioned in the
physician or nursing notes.
Often, in this study, different patients had a better ability to
complete a particular type of pain assessment, such as a visual
analog scale, descriptor scale, or pain questionnaire. Thus, Dr.
Stein stressed the importance of tailoring the specific assessment
tool to the individual patient, since no one tool was universally
useful among all study participants.
The study also showed that residents who had cognitive impairment
could provide an accurate assessment of their current pain location
and intensity, but were less able to convey similar information about
a previous point in time. Therefore, Dr. Stein concluded, it is
important to do more frequent pain assessments in cognitively
impaired geriatric patients.
Although pain impacts significantly on function, depression,
and mental status, none of the standardized tools commonly used in
geriatric assessment are sensitive to measuring pain, she said.
They need to be validated in both communicative and
noncommunicative cognitively impaired elderly patients.