Use Special Skills, Tools to Assess Pain in Children, Elderly

BETHESDA, Md—Children 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 Children’s 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 you have?”

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 Alzheimer’s’ 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

 Patients may need extra time to assimilate to the test setting and may have a limited attention span.

 Any visual cues should be in large print.

 Adequate ambient light is important.

 If patient wears a hearing aid, check that he/she is wearing it and that it is working.

 Patients may require more frequent pain assessments.

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 been described.

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.”