Clinical Geriatrics

Educational Objectives
1. To appreciate the barriers to optional pain management at the end of life
2. To understand the importance of assessment and reassessment of pain for patients at the end of life
3. To be knowledgeable of the unique approaches to assessment and management of pain in the elderly
4. To be able to utilize the Three-Step Analgesic Ladder approach of the World Health Organization in the management of pain at the end of life

ACCREDITATION
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1.0 category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. Valid April 1 - June 30, 2005. Estimated time: 1 hour

FULL DISCLOSURE POLICY AFFECTING CME ACTIVITIES
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The presenting faculty reported the following: Dr. Cavalieri has indicated that he has not received financial support for consultation, research or evaluation or has a financial interest relevant to this article. No faculty member has indicated that their presentation will include information on off-label products.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings and adverse effects before administering pharmacologic therapy to patients.

The management of pain at the end of life can be very challenging and rewarding in clinical practice. Pain at the end of life may have several origins, but frequently the pain is due to a cancer diagnosis. Effective pain management at the end of life calls for an interdisciplinary approach, and the physician is central to coordinating and determining effective management strategies. Pain in the older patient, especially at the end of life, is often not treated or recognized effectively. From 20-50% of community-dwelling older persons have important pain problems, and in the nursing home, 70% of residents have pain that is underrecognized and undertreated.1

From 60-90% of patients with advanced malignancies experience significant pain and most die without adequate pain relief.2 The elderly account for most deaths caused by cancer. Cancers of the lung, colon, breast, and prostate are most common in older persons and are frequently associated with significant pain in the advanced stages of disease.3 Several studies have documented that cancer pain is often undertreated.4 Unrelieved pain can have profound consequences for the patient and his or her family. It can lead to depression, loss of sleep, and poor appetite; prevent the dying patient from experiencing enjoyment; and create a sense of hopelessness.