In the first study to look at the prevalence of pain experienced among older people during the last two years of life, researchers at the San Francisco VA Medical Center found that 46% of study participants suffered moderate to severe pain during their final four months of life.
The researchers also found that more 26% of the participants had moderate to severe pain during the last two years of life, and that arthritis was the biggest single predictor of pain, outweighing all eventual causes of death including cancer.
For many patients approaching death, especially those with arthritis, the pain is potentially controllable.
The study appears in the November 2, 2010 issue of the Annals of Internal Medicine.
Between 1992 and 2004, the Health and Retirement Study interviewed a nationally representative sample of community-dwelling older adults every two years about matters concerning their health. Researchers used HRS data to determine the prevalence of pain during the last years of life. The authors analyzed data from interviews conducted with 4,703 men and women age 50 and older who died while enrolled in the study.
The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis. However, the cause of death (e.g., cardiovascular disease or cancer) was not associated with important differences in the amount of pain.
"The impact of arthritis on the experience of pain among older adults has not been recognized to the extent it should be," says lead author Alexander K. Smith, MD, MS, MPH, a palliative medicine physician at SFVAMC and an assistant professor of medicine in the division of geriatrics at the University of California, San Francisco.
Why isn't pain being controlled? There are several reasons, Laurel Herbst, MD, chief medical officer of the San Diego Hospice and The Institute for Palliative Medicine, tells HealthLeaders. "The treatment of pain has begun to evolve in the past several years with better understanding of mechanisms, genetics, and medication interactions. This is, however, always accompanied by social and cultural issues to overlay the perceptions of the need for treatment."
It's not just a clinical issue; it's also cultural, she says. "Think of all the messages we receive about stoicism and the redemptive values of pain: 'no pain, no gain,' 'a little pain never hurt anyone,' etc." Complicating matters is the fact that there are individuals who misuse or abuse opioid medications. In this context, many physicians are not trained to deal well with all the complexities of chronic pain management, she says.
Such issues were one impetus for the development of palliative medicine as a specialty—to treat, teach, research, and develop better protocols, she explains.
"This research tells us that physicians should anticipate pain will increase among their elderly and dying patients, assess their patients for pain frequently and prescribe appropriate pain medications at appropriate levels," says Smith.
He recommends physicians also regularly assess and treat pain in their older patients with chronic diseases who are not obviously nearing death. "In other words," he says, "pain management is not just for hospice patients."