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

PAIN DEPRESSION

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

10

15

20

25

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

giovanni.gambassi@rm.unicatt.it

giovanni_gambassi@brown.edu