WebMD Medical News
Laura J. Martin, MD
Nov. 1, 2010 -- One quarter of all elderly people experience pain during the last two years of their life, and the percentage of people with pain increases to about 50% in the last four months of life.
Arthritis was the No.1 predictor of pain, according to the study, which appears in the Annals of Internal Medicine.
"Clinicians should anticipate an increase in pain, especially as death nears," conclude study authors, who were led by Alexander K. Smith, MD, a palliative medicine physician at the San Francisco VA Medical Center.
Of 4,703 participants in the Health and Retirement Study with an average age of 75, 26% reported pain during the last two years of their lives, and the proportion of people who experienced pain reached 46% in the four months before they died.
Fully 60% of people with arthritis reported pain in the last month of their life, compared with 26% of participants without arthritis.
The number of people with end-of-life pain could increase with the aging of the population. If arthritis prevalence rates remain stable, more than 41 million people will develop arthritis by 2030; according to statistics from the Arthritis Foundation.
In the new study, a terminal diagnosis such as cancer or heart disease did not show any difference in reported pain levels.
"Pain is a problem," says Carmen Green, MD, a professor of anesthesiology at the University of Michigan in Ann Arbor. "This study really tells us that we aren’t doing as great as we could be at treating end-of-life pain."
And this is unfortunate. "We do have ways to alleviate pain and suffering for most people," she says.
"If you have pain, let somebody know," she says. "Many people may believe that pain is a sign that their disease is getting worse or that addressing the pain may distract their doctor from treating their underlying diseases, and they want to live as long as they can," she says.
These are myths, Green says. "If you are afraid to talk to your doctor about your pain, you need to talk to a family member who will advocate for you."
Treating pain -- particularly arthritis pain -- in the elderly is easier said than done, says David Pisetsky, MD, chief of rheumatology at Duke University Medical Center in Durham, N.C.
For example, the use of some pain medications may be limited in the elderly because of their side effects. Narcotics can affect balance, and certain nonsteroidal anti-inflammatory drugs may increase heart or gastrointestinal risks.
"It is always reasonable to reduce pain, but it does get more difficult in this patient population," he says.
"It’s not easy [and] we need to do more."
Doing more starts with taking a better assessment of pain. "Just saying 'I have pain' doesn’t give us tangible information," he says. Pisetsky asks patients to rate their pain on an ascending scale of 0-10, and asks if the pain interferes with a person's life or if there are things they can no longer do because of the pain.
"How intense your pain is and how much it bothers you are both important," he says.
M.C. Reid, MD, PhD, a geriatrician at Weill Cornell Medical College on New York City, agrees with Pisetsky and Green in an editorial accompanying the new study.
"Physicians who care for older adults with chronic illness ... must learn how to manage pain effectively," he writes.
"Clinicians should ask patients not only whether they hurt but also about the preferences for treatment approaches."
SOURCES:Smith, A. Annals of Internal Medicine, 2010; vol 153: pp 563-569.Reid, M. Annals of Internal Medicine, 2010; vol 153: pp 612-613.David Pisetsky, MD, chief, rheumatology, Duke University Medical Center, Durham, N.CCarmen Green, MD, professor, anesthesiology, University of Michigan, Ann Arbor, Mich. Arthritis Foundation: "Arthritis Prevalence."
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