KEYWORDS. :
Dear Editor,
This letter has been inspired by publications on diagnosis, management, and treatment efficacy assessment concerning musculoskeletal pain in elderly people with mild cognitive impairment (Citation1–3). The letter is to express our opinion based on our experience and the available literature (Citation1–6).
Every physician is obliged to investigate causes of pain reported by patients. Implemented treatment should promptly eliminate patient's suffering and suppress mechanisms involved in chronification of pain. The physician's reaction is often manifested by excessive pharmacotherapy of pain. In other words, fast pain relief is often achieved by unnecessary use of potent analgesics, exposing patient to their adverse effects.
In older patients with chronic musculoskeletal pain and cognitive impairment, perception of pain is strongly modulated by extrasomatic influences (Citation4, 5). The reason for this is intensive attention concentration on pain sensation. Additional negative external influences [e.g., financial, familial, or professional] could potentiate psychogenic elements of pain. An example could be a switch in family hierarchy level or in people dependent on external aid.
Propagation of extrasomatic symptoms could be reinforced by other deficits related to cognitive impairment resulting from decrease in cortical functions. Very often, the only form of reaction in patients with cognitive impairment is a gesture or grimace repeated in reply to various questions. That is why interpretation of pain behavior could lead to incorrect conclusions because the behavior is largely determined by influences other than pain intensity.
We should always make therapeutic decisions according to pain intensity reported by patient, but we should also bear in mind that it is the physician who is responsible for adverse effects of the treatment. Thus, the most important issue in treatment modality selection for patients with cognitive impairment is searching for those features of the disease syndrome that could be helpful in the objective evaluation of pain intensity. This could be a change in muscle tone, a decrease in range of movement, a change in previous movement pattern, a change in physiological spinal curvatures, tissue odema, and many other signs (Citation6).
Decisions concerning modification of pharmacotherapy are out of favor, but they have to be made to manage chronic pain syndromes more safely, especially in patients with difficulties in describing objectively their disease symptoms.
REFERENCES
- Shega JW, Rudy T, Keefe FJ, Perri LC, Mengin OT, Weiner DK: Validity of pain behaviors with mild to moderate cognitive impairment. J Am Geriatr Soc 56(9): 1631–1639, 2008.
- Tsai PF, Landes RD, Ghormley C, Beck C, Feldman Z, Duncan A: Analgesic intake, cognitive functioning, and disruptive behaviors in elderly people with cognitive impairment. J Am Geriatr Soc 56(3): 574–575, 2008.
- Reynolds KS, Hanson LC, DeVellis RF, Henderson M, Steinhauser KE: Disparities in pain management between cognitively intact and cognitively impaired nursing home residents. J Pain Symptom Manage 35(4): 388–396, 2008.
- Rudy TE, Weiner DK, Lieber SJ, Slaboda J, Boston JR: The impact of chronic low back pain on older adults: A comparative study of patients and controls. Pain 131(3): 293–301, 2007.
- Schuler M, Njoo N, Hestermann M, Oster P, Hauer K: Acute and chronic pain in geriatrics: Clinical characteristics of pain and the influence of cognition. Pain Med 5(3): 253–262, 2004.
- Gasik R, Styczynski T: Specyfic of pharmacotherapy in back pain among the elderly. Pol Merk Lek 21(124): 394–397, 2006.