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Dolore complesso e multidimensionale
Giovanni
Gambassi
J Royal Soc Med, 2007
Vital Reflex
Condannati
ai
dolori
forzati?
• Screening tools (NP da non NP) - Leeds assessment of Neuropathic Symptoms and Signs (LANSS) - Neuropathic Pain Questionnaire (NPQ)
- Douleur Neuropatique en 4 (DN4)
- PainDETECT
- ID pain
- Standardized evaluation of pain (StEP)
• Assessment tools (diversi NP) - McGill Pain questionnaire (MPQ)
- Neuropathic Pain Scale (NPS) - Pain Quality Assessment Scale (PQAS)
- Neuropathic Pain Symptom Inventory (NPSI)
• Quantitative testing
Considerazioni generali
Sotto-diagnosticato
Sotto-valutato
Sotto-trattato
Se trattamento, spesso
inappropriato/inadeguato
DECALOGUE
1. Older adults feel as much pain
Emotional component Sensory
component
Integrative/discriminatory
component
My brain is hurting me
Striatal activation
2. Pain speaks only one language with different idioms and nuances
0
20
40
60
80
100
CZ D DK F FIN I IS NL NO S UK Total
Pre
vale
nce
of
pain
(%)
Gambassi et al.
AdHOC J Gerontol – Med Sci 2008
SHELTER-pilot
3. Pain is persistent in most cases
The terms ‘‘persistent pain’’ and ‘‘chronic pain’’ are often
used interchangeably, but the newer term, ‘‘persistent
pain,’’ is preferred, because it is not associated with the
negative attitudes and stereotypes that clinicians and patients
often associate with the ‘‘chronic pain’’ label.
Authors have used various durations of painful sensation,
including pain longer than 3 months, 6 months, or more. Some
reports make the assumption that patients with certain
diagnoses, such as postherpetic neuralgia, low back pain, or
cancer-related pain, must also experience persistent pain.
4. Pain is there even if not suspected
46%
39%
39%
54%
41%
Nurses interview Care proxy
5. Pain does not come alone
Association Between Pain and Depression
Method: We conducted a cross-sectional study using data from the Aged in Home
Care (AdHOC) database. Pain was defined as any type of pain manifested over the 7 days preceding the assessment. Depression was defined as a score > = 3 on
the Minimum Data Set Depression Rating Scale.
Results: Mean age of 3976 subjects entering the study was 82.3 years, and 2948 (74.1%) were women. Of the total sample, 2380 subjects presented with pain
(59.9%), depression was diagnosed in 181 (11.3%) of the 1596 participants without pain and in 464 (19.5%) of the 2380 participants with pain (p < .001).
After adjusting for potential confounders, pain was significantly associated with depression (odds ratio [OR] 1.76, 95% confidence interval [CI] = 1.43 to 2.17).
Gambassi et al. J Clin Psychiatry 2005;66:982-8
The 3D’s in elderly patients with cancer:
Delirium, depression, dementia
G. Gambassi
Biblioteca Aula Medica, 2010
6. Pain is not a joke
Persistent pain or its inadequate treatment is associated with a number of adverse outcomes in older people,
including functional impairment, slow rehabilitation, mood
changes (depression and anxiety), decreased
socialization, sleep and appetite disturbance, and greater
healthcare use and costs.
7. Pain as part of a geriatric evaluation
International Textbook of Geriatrics, 2010
CGA - technology of geriatrics
G Gambassi et al. 2000, 33(1):45-56
The comprehensive geriatric assessment: when, where, how
The systematic introduction of CGA in clinical research and in daily practice can contribute to: identify cancer patients for whom we could expect the greatest benefit from treatment; assess their physiologic, functional and health-related quality of life; formulate appropriate treatment and management strategies; monitor clinical and functional outcomes; provide a more accurate evaluation of prognostic indicators.
Cancer pain in the elderly:
a call for competent assessment and care
8. Pain is not forgetful
Pain In Cognitively Impaired
• Sample of 325 subjects with mild to moderate dementia
from 10 community skilled nursing facilities
• Mean MMSE score of 12.1 (± 7.9)
• 62% reported pain complaints
• 83% could complete at least one of 4 unidimensional
pain intensity scales.
– No scale had a higher completion rate than 65%
• Self reports are generally no less valid than those of
cognitively intact individuals
Ferrell B et al, JPSM 1996
The facial expression of pain in patients with dementia
The preserved pain typicalness of facial responses to noxious stimulation suggests
that pain is reflected as validly in the facial responses of demented patients as it is
in healthy individuals.
2008
9. Pain is a pain
Residents with Pain Intensity Scale Used
0%
20%
40%
60%
80%
100%
Baseline Remeasurement
% o
f R
esid
ents
Use of pain intensity scales
Gambassi et al.
PRN vs. Regularly Scheduled Medication
0%
0%
20%
40%
60%
80%
100%
Non Pain Med PRN Med ATC Med
Baseline
Remeasurement
% o
f R
esid
ents
Use of analgesic medications
Predictors of inadequate analgesia
Variable No Analgesia
(n=695)
Analgesia
(n=2003)
Odds
Ratio
95% CI
Age (years)
75-84
85+
300239
868546
1.271.58
(1.01-1.58)(1.22-1.97)
Gender
Female 422 1266 0.95 (0.75-1.08)
Race/ethnicity
Minority 60 132 1.35 (0.96-1.89)
No. of medications
6-10
11+
25664
876296
0.900.65
(0.73-1.10)(0.47-0.89)
Compromised function 521 1457 1.12 (0.89-1.40)
Low cognitive performance 208 485 1.24 (1.00-1.54)
Use of restraints 556 1576 1.09 (0.87-1.38)
Bed-ridden 119 447 0.76 (0.59-0.99)
Explicit terminal prognosis 129 463 0.75 (0.59-0.96)
1998;279:1877-82
Gambassi et al.
Pharmacologic treatment
0
5
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30
35
Any WHO
1
WHO
2
WHO
3
65-74
75-84
>85• As age increased a
lower proportion of patients in pain received analgesic drugs.
• Only 1% of patients 85 years received morhine or other strong opioids
• Patients 85 or older were less likely to receive analgesics (OR 0.73, 0.60-0.89)
2001;161:2721-4
Gambassi et al.
OR crudo OR corr.1 95% IC
Residenti con demenza 0,51 0,65 0,63-0,67
Residenti senza demenza - -
0
10
20
30
40
50
60
70
% p
atie
nts
No
analgesia
WHO 1 WHO 2 WHO 3
CPS 0-1 CPS 2-3CPS 4-6
WHO scale adoption and dementia
Gambassi et al.
10. Future pain for older adults
Gambassi, et al
We have recommended consideration of a number of patient, study, site, and
outcome measurement factors that have the potential to affect the assay
sensitivity of RCTs of chronic pain treatments. Space limitations preclude detailed
discussion of several important issues. As we have emphasized in Section 3.1,
perhaps foremost among these is the effect of efforts to increase the assay sensitivity of RCTs on the generalizability of their results to the treatment of
patients in the community. Because the relevance of the results of an analgesic
trial to clinical practice depends on its setting, inclusion and exclusion criteria,
treatment protocol, outcome measures, and other factors [78], it is imperative
that reports of RCTs describe this information as comprehensively as possible, especially providing as much information as possible about the characteristics of
the patients excluded from the trial and the patients included in the data analyses.
Decalogue
1. Older adults feel as much pain
2. Pain speaks only one language
3. Pain is persistent in most case
4. Pain is there even if not suspected
5. Pain does not come alone
6. Pain is not a joke
7. Pain as part of a geriatric evaluation
8. Pain is not forgetful
9. Pain is a pain
10. Future pain for older adults