NEW YORK-In the elderly cancer patient, pain is a significant problem that can have a "major impact" on quality of life, particularly when the problem is not diagnosed or adequately treated, according to Nessa Coyle, PhD, FAAN. "Pain is very much feared when someone has a diagnosis of cancer," said Dr. Coyle, director of the supportivecare program in the pain and palliative care service at Memorial Sloan-Kettering Cancer Center, New York, NY. "Patients are afraid they are going to die, and are afraid of what the dying might be like. Most people have known an individual who died of cancer [with] very poor control of pain." Special Considerations for Elderly With Pain Dr. Coyle described special considerations when assessing pain in elderly cancer patients: "In the elderly, there is a tendency to underreport pain despite substantial functional impairment," she said. "In addition, multiple concurrent medical problems and sources of pain can make assessment more difficult." "As in anyone with a life threatening illness," said Dr. Coyle, "a comprehensive assessment of the elderly person's physical, emotional, social, economic, psychological, and spiritual states is necessary if pain is to beadequately understood and managed. Listening to the patient's 'story' can be very helpful in sorting out the different components of his or her pain. Sometimes an elderly person may not use the word 'pain' for a variety of reasons, but instread will describe inability to sleep at night, sit in a chair, or walk because he or she is so uncomfortable." Data suggest that about 75% of individuals who have cancer will require pain management at some point in their disease, according to Dr. Coyle. If the patient is elderly, however, the pain is more likely to remain unrecognized or untreated. In one study of elderly nursing home residents with cancer, daily pain was prevalent, and 26% of those with daily pain received no analgesics (JAMA 1998;279:1877- 1882). Consequences of unrelieved pain, Dr. Coyle said, include depression, sleep disturbances, impaired ambulation, and an increased burden on caregivers, among other problems. A thorough pain-focused history and physical examination are helpful in identifying the presence and multiple sources of pain in the elderly cancer patient. Pain Assessment Scales For assessment of pain, Dr. Coyle said the patient should be considered the "expert" on both pain severity and adequacy of relief. Standard pain-assessment scales are usually appropriate, even for elderly cancer patients with mild cognitive impairment. For those with severe cognitive impairment, clinicians may use the Hurley Discomfort Scale, an assessment toolthat utilizes behavioral observations such as breathing, facial expression, vocalizations, and restlessness. Because pain is multifaceted, pain management for elderly cancer patients requires a "multimodal" approach that incorporates drug and nondrug therapies. Useful nondrug interventions include massage, heat and cooling, and acupuncture. Assistive or orthotic devices or simply repositioning the patient also may reduce pain. WHO Ladder of Pain Control Selecting the appropriate pain-drug regimen can be a challenge, however, because the elderly have a higher incidence of side effects to medication. One simple approach is to use the principles of the World Health Organization (WHO) Three-Step Analgesic Ladder as a guide to drug selection but to "start low and go slow," said Dr. Coyle. The five essential concepts in the WHO approach to drug therapy for chronic pain, she added, are: "by the mouth; by the clock; by the ladder; for the individual; and with attention to detail." Under these guidelines, milder pain is treated with milder analgesics, such as NSAIDs, which are a cornerstone of WHO ladder Step One. In addition, adjuvant analgesic drugs such as the tricyclic antidepressants or the anticonvulsants are used in Step One of the ladder if there is a neuropathic component to the pain. If pain persistsor increases, an opioid should be added. Frequently opioids such as codeine(Drug information on codeine), hydrocodone(Drug information on hydrocodone), or oxycodone(Drug information on oxycodone), in combination form with an NSAID, are used (Step Two). Pain that persists, or moderate to severe pain at the onset, should be treated with increasingly potent opioids at doses adequate to control the patient's pain. Morphine, methadone(Drug information on methadone), oxycodone, or fentanyl(Drug information on fentanyl) are most commonly used (Step Three). Because the scale is based on severity of pain, Dr. Coyle said, a patient who presents with severe pain should bypass weaker analgesics and go right to Step Three. Frequently a combination of NSAIDs, adjuvantdrugs, and opioid drugs is used for an individual with severe pain when both nociceptive and neuropathic components are present. Some clinicians are hesitant to prescribe opioids in the elderly because of concern about cognitive adverse effects such as sedation or confusion, said Dr. Coyle. Patients may have similarconcerns and be reluctant to take the prescribed drugs. However, if the principle for any analgesic regimen in the elderly- start low and go slow- is adhered to, and the patient and/or family is educated as to what to watch for, especially when an opioid is started or escalated, these effects can be kept to a minimum, quickly recognized if they occur, and managed, she added. The most common and expected adverse effect of the opioids is constipation. If allowed to go untreated, it can cause great distress to the elderly patient. A rule of thumb, said Dr. Coyle, is "the hand that writes the opioid prescription should also write the prescription for a bowel regimen." Although fear of addiction remains a barrier to pain control in the minds of some clinicians and patients, clinical experience suggests that addiction is "extremely unlikely" if the patient has no history of drug abuse, she said. In the elderly population, "there tends to be the feeling that it is much safer to use NSAIDs than the opioid drugs," Dr. Coyle said. However, the adverse effects of the NSAIDs can be quite significant and are not as immediately recognizable as are the adverse side effects of the opioid drugs. The NSAIDs group of drugs, although extremely useful in managing pain in the elderly, require care in their dosing and in monitoring for adverse side effects, she warned.