Barriers to assessment

Making complete pain assessments can be complicated in any population, but there are particular difficulties with the older patient, including barriers and misconceptions on the part of the public and healthcare profession.

Clinicians, nurses, and psychologists with an interest in pain surveyed the ethical issues relating to pain man agement, finding that the undertreatment of pain in the elderly and pain management at the end of life were both major dilemmas.36 Underlying these were a range of themes, including concern about barriers inhibiting care, conflicts with others, inappropriate pain management, and regulatory issues.

Specific barriers in the postoperative assessment of pain in the elderly include issues related to patients and/ or healthcare workers.37 Recent work identifies similar issues (see Table 45.1). Language can also be a barrier, as an older patient may not describe a sensation as painful, but may describe it as an ache or unpleasant sensation. Other research suggests that older patients are reluctant to label some sensations as painful38 and there are limited investigations of language in the postoperative setting.39 Multiple barriers remain despite developments over recent years, including outdated attitudes, poor assessment, and inadequate use of medications.40

Surveys of nursing homes suggest a lack of written policies and absence of standardized assessments, low rates of staff education, and low rates of access to pain specialists.41 Surveys assessing nursing responses to two scenarios of pain in elderly patients highlights that a patient's self-report alone was not enough for staff to report pain, with the more experienced nurses being least likely to believe self-reports of pain. Under half the nurses involved indicated they would alter the analgesic dose in response to the scenarios.42 When staff and patient reports of pain have been compared, a UK study found reasonable concordance between staff and patients when interviews of patients and staff were compared to reviews of medical records. Differences in reporting were greater in the severely cognitively impaired patients, and patients reported more back and wound pain, while staff reported cardiac and stroke pain. Staff reported they could tell if a patient was in pain, but less than one-third asked patients about pain. In this study there was little difference between qualified and unqualified staff assessments.43 As has been shown in other groups, the assessment of pain in the elderly by different health professionals may yield different results. The degree of agreement of assessment between nurses and physicians was 32 percent in medicine and 44 percent on the geriatric wards.44 The prevalence of pain in a group assessed by proxy was 65 percent on the medical wards and 20 percent on the geriatric wards. Clearly, barriers remain with regard to providing consistent pain assessment across settings and across modalities of assessment.

There are several areas of poor understanding with regard to pain management in this population that persist at all levels (professional and public alike). Education is the link if these barriers are to be addressed before there is the opportunity to improve the delivery of interventions aimed at managing the patient's pain. Recent guidelines on pain assessment in the elderly provide practical skills for use in hospital and domestic settings.45 [V]

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