Because pain is a multifactorial phenomenon, including sensory, emotional, and cognitive components, there is no one-size-fits-all treatment. Thus, to effectively care for patients and provide palliative care, I work closely with a multidisciplinary team of psychologists (who specialize in cognitive-behavioral therapy), rehabilitation specialists (physical and occupational therapists), and pain medicine physicians. We are fortunate to have all of these services under one roof. However, psychiatrists can create their own network of specialists by cultivating professional relationships with colleagues from these disciplines.
Because of the multiple components of pain (sensory, emotional, cognitive), each patient requires an individualized management plan that can integrate analgesics, rehabilitation therapies, psychological interventions, and a variety of somatic treatments (eg, injections, surgery, complementary and alternative medicine). All older patients, however, should be counseled that:
• Chronic pain is a syndrome with many potential contributors, all of which require treatment for optimal clinical outcome
• Chronic pain can be treated but not cured; improvement is the rule, not the exception
• Improvement in functional ability is often greater than the reduction in pain severity8
It may be helpful to refer patients to a pain clinic for more intensive treatment if pain is the primary complaint, if the pain is not diminishing (or is worsening), or if “serial referrals” to specialists have been unsuccessful. There are different types of pain clinics, including single-modality clinics (eg, a nerve block clinic), syndrome-oriented clinics (eg, for low back pain or headaches), and multidisciplinary clinics that treat a variety of pain syndromes.
There are no established recommendations for when to refer a patient or who should be referred to a pain clinic. In general, though, a referral is usually appropriate between 4 and 6 months after severe symptom onset in patients who also have evidence of related physical or psychosocial deterioration.9 In addition to reduction in pain severity and pain “bothersomeness,” treatment outcome parameters for older adults include the degree to which pain interferes with performance of basic, instrumental, and discretionary activities of daily living. Other relevant outcomes include the effect of pain on the patient’s mobility/activity, energy, appetite, sleep, mood and irritability, interpersonal functioning, attention and concentration, and frequency of as-needed dosing of an analgesic.
Older patients with moderate to advanced dementia
To date there are no disease-modifying or preventive medications for dementia, of which Alzheimer disease is the most common. In addition to memory and other cognitive deficits, the majority of patients with moderate to advanced dementia have a range of neuropsychiatric and behavioral disorders, such as depression, anxiety, disordered sleep, apathy, agitation, and psychosis.
The goal is not cure but a palliative reduction in symptom burden and an enhancement of quality of life. An important function of the psychiatrist is to teach families and caregivers about the most distressing neuropsychiatric symptoms and behaviors that can be expected, such as repetitive behavior, restlessness, incontinence, lack of inhibition, sleep problems, and suspiciousness. Table 2 lists practical recommendations for coping with these behaviors. In addition, it is important to educate patients and their caregivers so that they have reasonable expectations about dis-ease progression and management options and to provide information about services, entitlements, and options (eg, nursing home placement, respite care, hospice, and geriatric case managers).
In working with elderly patients with dementia and their families, patient preferences regarding type and level of care should be ascertained (Table 3). This is especially useful if premorbid preferences for care in late life (when capacity to make decisions is less likely to be challenged) have been documented.
The ability of families to care for loved ones with dementia in the home varies. It is a standard of care to consistently assess caregivers for burnout and depression to ensure that their quality of life is maintained and that proper care can be provided to the patient. Minimizing patients’ neuropsychiatric and behavioral symptoms can prolong the time they can stay in their homes and can maximize the amount of meaningful time they can spend with loved ones.
Hospice is an option for severely demented patients. Key clinical indicators for hospice include:
• Progressive decline in status despite curative treatments
• Frequent hospitalizations
• Recurring or multiple infections
• Increased or uncontrolled pain
• Progressive/profound weakness and fatigue
• Shortness of breath with or without oxygen
• Profound dependency (decrease in activities of daily living)
• Alterations in mental status
• Weight loss