Proper Pain Assessmentand Treatment Are Criticalfor Elderly Cancer Patients

December 1, 2003

This special supplement to Oncology News International presents 17 reports fromthe first annual Geriatric Oncology Consortium (GOC) multidisciplinary conference,‘‘Advancing Cancer Care in the Elderly.’’ Reports focus on issues in geriatric oncology,in particular team-based patient assessment and care delivery,adherence to medication, accrual to clinical trials, appropriate dosingthrough supportive therapy, radiation therapy, cognition problems, pain management,reassessment of outcomes, and caregiving issues.

NEW YORK-In the elderlycancer patient, pain is a significantproblem that can have a "major impact"on quality of life, particularlywhen the problem is not diagnosed oradequately treated, according to NessaCoyle, PhD, FAAN."Pain is very much feared whensomeone has a diagnosis of cancer,"said Dr. Coyle, director of the supportivecare program in the pain andpalliative care service at MemorialSloan-Kettering Cancer Center, NewYork, NY. "Patients are afraid they aregoing to die, and are afraid of what thedying might be like. Most people haveknown an individual who died of cancer[with] very poor control of pain."Special Considerations forElderly With PainDr. Coyle described special considerationswhen assessing pain in elderlycancer patients: "In the elderly,there is a tendency to underreport paindespite substantial functional impairment,"she said. "In addition, multipleconcurrent medical problems andsources of pain can make assessmentmore difficult.""As in anyone with a life threateningillness," said Dr. Coyle, "a comprehensiveassessment of the elderlyperson's physical, emotional, social,economic, psychological, and spiritualstates is necessary if pain is to beadequately understood and managed.Listening to the patient's 'story' can bevery helpful in sorting out the differentcomponents of his or her pain.Sometimes an elderly person may notuse the word 'pain' for a variety ofreasons, but instread will describe inabilityto sleep at night, sit in a chair, orwalk because he or she is so uncomfortable."Data suggest that about 75% ofindividuals who have cancer will requirepain management at some pointin their disease, according to Dr. Coyle.If the patient is elderly, however,the pain is more likely to remain unrecognizedor untreated. In one studyof elderly nursing home residents withcancer, daily pain was prevalent, and26% of those with daily pain receivedno analgesics (JAMA 1998;279:1877-1882).Consequences of unrelieved pain,Dr. Coyle said, include depression,sleep disturbances, impaired ambulation,and an increased burden oncaregivers, among other problems. Athorough pain-focused history andphysical examination are helpful inidentifying the presence and multiplesources of pain in the elderly cancerpatient.Pain Assessment ScalesFor assessment of pain, Dr. Coylesaid the patient should be consideredthe "expert" on both pain severity andadequacy of relief. Standard pain-assessmentscales are usually appropriate,even for elderly cancer patientswith mild cognitive impairment. Forthose with severe cognitive impairment,clinicians may use the HurleyDiscomfort Scale, an assessment toolthat utilizes behavioral observationssuch as breathing, facial expression,vocalizations, and restlessness.Because pain is multifaceted, painmanagement for elderly cancer patientsrequires a "multimodal" approachthat incorporates drug andnondrug therapies. Useful nondruginterventions include massage, heatand cooling, and acupuncture. Assistiveor orthotic devices or simply repositioningthe patient also may reducepain.WHO Ladder of Pain ControlSelecting the appropriate pain-drugregimen can be a challenge, however,because the elderly have a higher incidenceof side effects to medication.One simple approach is to use theprinciples of the World Health Organization(WHO) Three-Step AnalgesicLadder as a guide to drug selectionbut to "start low and go slow," said Dr.Coyle. The five essential concepts inthe WHO approach to drug therapyfor chronic pain, she added, are: "bythe mouth; by the clock; by the ladder;for the individual; and with attentionto detail."Under these guidelines, milder painis treated with milder analgesics, suchas NSAIDs, which are a cornerstone ofWHO ladder Step One. In addition,adjuvant analgesic drugs such as thetricyclic antidepressants or the anticonvulsantsare used in Step One ofthe ladder if there is a neuropathiccomponent to the pain. If pain persistsor increases, an opioid should be added.Frequently opioids such as codeine,hydrocodone, or oxycodone, in combinationform with an NSAID, areused (Step Two). Pain that persists, ormoderate to severe pain at the onset,should be treated with increasinglypotent opioids at doses adequate tocontrol the patient's pain.Morphine, methadone, oxycodone,or fentanyl are most commonly used(Step Three). Because the scale is basedon severity of pain, Dr. Coyle said, apatient who presents with severe painshould bypass weaker analgesics andgo right to Step Three. Frequently acombination of NSAIDs, adjuvantdrugs, and opioid drugs is used for anindividual with severe pain when bothnociceptive and neuropathic componentsare present.Some clinicians are hesitant to prescribeopioids in the elderly because ofconcern about cognitive adverse effectssuch as sedation or confusion,said Dr. Coyle. Patients may have similarconcerns and be reluctant to takethe prescribed drugs. However, if theprinciple for any analgesic regimen inthe elderly- start low and go slow- isadhered to, and the patient and/orfamily is educated as to what to watchfor, especially when an opioid is startedor escalated, these effects can bekept to a minimum, quickly recognizedif they occur, and managed, sheadded.The most common and expectedadverse effect of the opioids is constipation.If allowed to go untreated, itcan cause great distress to the elderlypatient. A rule of thumb, said Dr.Coyle, is "the hand that writes theopioid prescription should also writethe prescription for a bowel regimen."Although fear of addiction remains abarrier to pain control in the minds ofsome clinicians and patients, clinicalexperience suggests that addiction is"extremely unlikely" if the patient hasno history of drug abuse, she said.In the elderly population, "theretends to be the feeling that it is muchsafer to use NSAIDs than the opioiddrugs," Dr. Coyle said. However, theadverse effects of the NSAIDs can bequite significant and are not as immediatelyrecognizable as are the adverseside effects of the opioid drugs. TheNSAIDs group of drugs, although extremelyuseful in managing pain in theelderly, require care in their dosingand in monitoring for adverse sideeffects, she warned.