Quality Indicators for Pain Management in Vulnerable Elders

Persistent pain has many different meanings for different patients and physicians. For this article, persistent pain is defined as pain of a duration or intensity that adversely affects the function or well-being of the patient, attributable to any etiology. This is a modification of the definition of chronic pain of the American Society of Anesthesiologists Task Force on Pain Management, which did not include cancer pain. The American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons defined persistent pain as a painful experience that continues for a prolonged period of time that may or may not be associated with a recognizable disease process. Although pharmacological treatment with analgesics is the most common form of pain treatment in older people, the use of alternative medications and nonpharmacological interventions should also be considered, especially when success with the former is less than satisfactory or the burden of potential adverse effects outweighs the benefits. Although patients should expect relief of symptoms, complete relief for the older patient with persistent pain is often an unrealistic expectation, and treatment decisions require continued weighing of risks and benefits in open discussion between patients and physicians. Pain occurs frequently with disease and is quite prevalent in older people. A number of population-based studies have suggested that pain-related problems are present in 25% to 50% of community-dwelling elderly people. For example, a random survey of 500 households in Ontario, Canada, identified twice as many painful conditions in persons aged 60 and older as in their younger counterparts. Available data from nursing home studies are even more compelling. As many as 70% to 85% of long-term care residents may have at least one pain-associated problem. The consequences and costs of pain in elderly people are significant. Its association with depression, social isolation, sleep disturbance, gait impairment, and the increased use of health services and attendant costs is well documented. Although there is little disagreement that painful conditions should be treated, there is far less consensus on specific treatments for specific conditions. For this reason, these quality indicators (QIs) focus on general assessment and management approaches for which there is strong evidence or a consensus of expert opinion. Whereas some of the indicators are most relevant to ambulatory care settings, others are more easily operationalized in inpatient or long-term care settings. METHODS: A total of 200 articles were considered in this review: 55 identified through a Web search, 14 through reference mining, 106 through the Assessing Care of Vulnerable Elders (ACOVE)-3 literature searches, and 25 through references in the ACOVE-1 monograph. RESULTS: Of the 11 potential QIs, the expert panel process judged eight to be valid. Three indicators were rejected. The literature summaries that support each of the indicators judged to be valid in the expert panel process are described.