Palliative care, as defined in the Arkansas Cancer Plan, is care that does not alter the course of a disease, but improves the quality of life. An unfortunate aspect of cancer is that chronic pain is a part of life for more than 75 percent of those with advanced stages of the disease. These figures remain unchanged for decades despite numerous medical breakthroughs and are significantly skewed towards the elderly.
According to Dr. William B. Ershler’s in “Cancer: a disease of the elderly” published article in J of Support Oncol. 2003 Nov-Dec; 1(4 Suppl 2):5-10, cancer is a major public health problem that disproportionally affects older rather than younger persons. Consequently, treatment for these elders should be tailored taking into account age related physical changes that affect the biology of cancer. This often, but not always, leads to palliative care.
Last year, Jane E. Brody of the New York Times (3/16/2009) chronicled the experience of “Elliot,” an 83-year-old active man diagnosed with an aggressive case of prostate cancer. For Elliot, cancer was just another ailment in a list that already included “a mild case of high blood pressure, Type 2 diabetes, depression and angina—all of which were being treated with medication.” His physician, did not offer palliative care as an option, and recommended instead a daily nine week hormonal and radiation treatment. Three months after treatment, a zero score on his P.S.A. test suggested the malignancy had been eradicated. As Brody reported, “…the outcome for Elliot is a direct assault on the oft-given advice that most cancers affecting people his age be left to take their course. The theory is that either the treatment will kill them or destroy their quality of life, or some other health problem will kill them before the cancer does.” Brody notes 60 percent of cancers occur in individuals 65+ and research to help doctors determine between aggressive treatment and palliative care in their patients is scant. A common theme does develop however, and that is the management of cancer pain.
According to Dr. Lodovico Balducci in “Management of Cancer Pain in Geriatric Patients,” J Support Oncol 2003;1:175–191, due to the aging of the population, cancer in older people and the management of its pain are frequent problems and present unique challenges. Clinicians treating elders need to recognize atypical manifestations of pain; utilize of individualized forms of pain assessment; and select treatment tailored to the individual case. Recognizing these unique challenges, the American Geriatric Society (AGS) annually convenes a panel of experts to discuss the management of pain in the elderly and publishes its recommendations in a yearly supplement to the Society’s journal. The principles stated by Dr Balducci are in substancial agreement with those in the latest AGS supplement. They include the following:
- Pain in elders is common and undertreated due to a number of barriers, including atypical manifestations of pain in the elderly and the inability and unwillingness of older persons to verbalize pain complaints. It behooves the practitioner in charge of the older person to elicit an appropriate pain history, to recognize atypical pain, and to provide adequate pain relief.
- Effective treatment of pain in the older person is compelling, because pain may compromise general health, the management of existing conditions and even shorten the life span.
- Pain assessment in older patients may have to be more comprehensive than in younger ones and to include conditions that may affect the perception of pain, such as depression, disability, and comorbidities. Simultaneous management of these conditions may enhance the effectiveness of pain management. Other conditions, such as functional dependence, may be followed to monitor the effectiveness of pain treatment.
- Self-report of pain by older individuals is reliable, even in the presence of moderate dementia. Vertical visual scales, such as pain thermometers, and numerical or verbal descriptor scales are the most suitable for older individuals with cognitive impairment and/or a low educational level. Observation of pain behavior is useful and reliable in assessing pain in individuals unable to verbalize their complaints.
- Nonpharmacological treatment may be helpful in selected individuals.
- In cases of pain associated with specific movements, the administration of analgesics should occur at those movements.
- In the absence of risk of gastrointestinal bleeding, COX-1 inhibitors are more cost-effective than COX-2 inhibitors, as long as indomethacin, piroxicam, mefenamic acid, and ketorolac are avoided. Of the COX-2 inhibitors, rofecoxib has a lesser risk of drug interactions.
- Older individuals may have an increased sensitivity to opioids, due to decreased hepatic and renal function, as well as a reduced number of opioid receptors because of brain atrophy. . In general, initiation of opioids should be at lower doses and longer dose intervals than used in younger patients. As with younger patients, dose escalations should be linked to individual pain relief.
— Arkansas Cancer Coaltion Staff