Excerpt from the “ALGOPLUS scale” film © 2016
PAIN IN THE ELDERLY: A VERY FREQUENT SYMPTOM!
The high occurrence of pain among elderly subjects has now been proved by many surveys, in Europe and in North America. Whether it is acute or chronic (osteoarthritic, cutaneous, neuropathic etc.) or even purely palliative (cancerology, terminal phases of dementia or terminal organ failure), its prevalence will range from 40 to 85% depending on the situation. The proportion of elderly people receiving the correct pain relief is 50% at best. That percentage drops to 20% in the case of elderly people with dementia and presenting with non-cancer pain.
Faced with that lack of interest, there is a real need for serious assessment of the symptom for medical, ethical and legal reasons, given that the dangers of a simple estimation of pain are well-known, particularly the frequent risk of underestimation.
We may well know how to treat pain, but we still need to recognise it first…
ASSESSING PAIN IN THE ELDERLY REQUIRES MORE THAN A SIMPLE SELF-ASSESSMENT!
Self-assessment tools are widely available these days, but there are many limitations to their usefulness among the elderly:
– Overestimation of abstraction abilities:
Elderly people have difficulty understanding this concept of assessment (self-assessment of pain experienced). “How does a scale or a cursor relate to my pain? ” With a numerical scale, an elderly person sometimes has no conception of the relationship between a score and the intensity of their pain. With vocabulary-based scales (particularly the St Antoine Pain Questionnaire), sociocultural and cognitive profiles interfere a great deal.
– Memory disorders:
These clearly cause problems when using a relative verbal rating scale (RVRS), because they involve comparing two sensations assessed at different times.
– Sub-optimal assessment conditions (noisy environment, explanations of the tool not suited to the subject’s cognitive abilities or given too quickly, glasses and hearing aids not worn).
– Lack of sensitivity:
There is often an underestimation of the intensity of pain either because of a fear of being a nuisance, or because of preconceptions (from patients and caregivers alike).
– Lack of specificity:
An elderly person tends to evaluate the functional consequences of their pain (difficulty, handicap) rather than the intensity of the pain. They may also use the tool to localise the pain. Conversely, there is a risk of overestimation in the event of anxiety, hypochondria or hysteria.
Deficits in understanding, involvement and communication (sensory problems, concentration problems, coma, aphasia, dementia, behavioural problems etc.) make these self-assessment tools difficult for caregivers to use, given that the simple verbal rating scale seems the most suitable for geriatrics.
Indeed, the 2009 study by Pesonen et al. shows that all patients with an MMSE score >24 are capable of self-assessment using a simple verbal rating scale. 64 to 85% can still achieve it with an MMSE score <17.
In elderly people, the recommendations (Herr 2011) advise combining self- and hetero-assessment for elderly people to avoid the failure to recognise pain.