Clinical Geriatrics

Case Presentation
Mr. HD was an 86-year old man with a history of diabetes, hypertension, congestive heart failure, chronic kidney disease, and moderate dementia. He was admitted to the hospital from a subacute rehabilitation facility with three gangrenous toes on his right foot. Work-up at that time revealed a large arterial thrombus in the internal iliac artery extending to the femoral artery. At the time of hospitalization, the patient was delirious with episodes of lethargy and agitation. Mr. HD was evaluated by a vascular surgeon, who recommended an iliofemoral bypass procedure. As part of the preoperative evaluation, his cardiologist obtained a pharmacologic stress test, which revealed significant ischemia and an ejection fraction of 15%. It was deemed at that time that the patient’s cardiac risk was too high, and surgery was not performed. The nurse noted that Mr. HD moaned at times and held his right leg as if it were in pain. The palliative care service was consulted for management of his pain.

Palliative Care in an Aging Population
Palliative care is the interdisciplinary specialty that focuses on improving quality of life for patients with advanced illness and their families. It is offered simultaneously with all other appropriate medical care, and relieves patient and family suffering by providing expert pain and symptom management, as well as sophisticated communication regarding advance care planning, delivery of bad news, establishing goals of care, and decisions to withhold or withdraw medical treatments.^1,2 The aging population, in combination with an increasingly fragmented healthcare system, makes the need for palliative care evident now more than ever. In Part I of this two-part article, the authors address the core palliative care skills of pain and symptom management. In the follow-up article, the authors will address communication skills.

Pain and Other Common Symptoms
Pain and symptom management is an essential proficiency when caring for patients with serious or terminal illnesses. Although being pain-free is a priority for patients living with serious and advanced illness,3 multiple studies in different settings and patient populations demonstrate a high prevalence of pain and other symptoms in the seriously ill.^4-6

Pain in the geriatric patient
Pain is a common problem for older adults; its prevalence in the community is estimated to range between 20% and 45%. Pain in the geriatric patient can lead to depression, decreased socialization, insomnia, gait instability, and loss of functional capacity.⁷

Pain can be classified as nociceptive or neuropathic. Nociceptive pain can be further subdivided into somatic and visceral. Somatic pain results from direct stimulation of pain fibers in the cutaneous and deep tissues, as in arthritis or bone pain from metastatic disease, whereas visceral pain originates in the thoracic and abdominal cavities. Neuropathic pain is derived from direct damage to the central or peripheral nervous system, as exemplified by diabetic neuropathy or spinal stenosis.⁸

Given the prevalence of cognitive impairment in the geriatric population, proper assessment of pain is essential. The frequency of untreated pain in nursing home residents is as high as 25%.^9-11 When assessing a patient for pain, the clinician should ask about the quality, points of radiation, severity, timing, instigating factors, and alleviating features. In addition, the impact of pain on quality of life and functional capacity should be addressed.

A variety of pain scales have been established to help quantify the severity of pain.