Book Review

Pain in Older Persons

N Engl J Med 2006; 355:966-967August 31, 2006

Article

Pain in Older Persons
(Progress in Pain Research and Management. Vol. 35.) Edited by Stephen J. Gibson and Debra K. Weiner. 432 pp. Seattle, IASP Press, 2005. $81. ISBN: 0-931092-59-0

Although few would now agree with the notion that children, medically speaking, are little more than small adults, the proposition that older adults are just older is still accepted. That this thinking continues to dominate clinical practice is supported by reviews of how “physiologically complex” pediatric and geriatric surgery is performed in Iowa. Most pediatric surgery has been performed at just three centers, but geriatric surgery has been performed throughout the state. Pain in Older Persons, a follow-up to and updating of Pain in the Elderly (Seattle: IASP Press, 1996), does a very good job of discussing whether pain in older patients is really different or just more of the same. It is an excellent tool for the novice and a fine review for the experienced practitioner in the field of pain management.

The book begins with the mission statement of the publisher, the International Association for the Study of Pain, which is “devoted to understanding the mechanisms of pain and improving the care of patients with pain . . . and [publishing] timely, high-quality, attractive, low-cost publications relevant to the problem of pain.” This multiauthored book consists of five parts that encompass 19 chapters. Parts I and II make the case that pain, particularly pain in older adults, is more prevalent than it has been thought to be. The chapters in these sections discuss how patients' reports of pain change in an aging population — there are fewer reports of mechanical pain (in the low back, shoulder, and arm) and more of pain from degenerative causes (in the hip, knee, and foot). Aging is also associated with atypical patterns of pain or with less severe pain than that seen in younger patients in the later stages of acute diseases, making diagnosis difficult.

Part III discusses pain assessment in elderly patients. In addition to the medical history and physical examination, a helpful variety of tools is provided for use in assessing pain in the older patient who has normal mental functioning or in the older patient with dementia. The connection between chronic pain and the assessment (self-reported and measured) of functional status is emphasized repeatedly. Depression, not considered a normal part of aging, may play an important role in chronic pain and impaired physical functioning. This section of the book reinforces the concept that mental health is an essential component of the evaluation and treatment of persistent pain.

Part IV deals with the treatment of persistent pain. The discussion of oral analgesic agents is particularly on point and contains reasonable and clinically appropriate recommendations. However, some mention of addiction, in contrast to pseudoaddiction, which occurs in patients of all ages who are treated with opioids, would have been beneficial.

In part V, the chapter on peripheral neuropathies and postherpetic neuralgia is authoritative and informative and includes evidence-based recommendations for therapeutic options. The chapter on postoperative pain management makes a convincing case for the importance of improving analgesia after surgery in older patients. The authors correctly point out the physical, mental, humanitarian, and economic effects that aggressive pain management would have in older surgical patients. The discussion of the control of cancer pain and of end-of-life issues is truncated, but since these topics can fill whole books all by themselves, brevity in this book is understandable. As is pointed out, reliance on the World Health Organization's three-step “ladder” for the relief of cancer pain — or all types of pain, for that matter — has grown increasingly problematic as therapeutic options have narrowed in some areas (i.e., use of nonsteroidal antiinflammatory drugs and “weak” opioids) and expanded in others (i.e., interventional options).

Although Pain in Older Persons is a multiauthored book, there is little duplication of material; the cross-referencing of topics is done well. The information is timely and, where possible, recommendations are evidence-based. The publisher, editors, and authors should also be applauded for the much-needed change in the title from “elderly” to “older.”

Brian K. Bevacqua, M.D.
University of Wisconsin School of Medicine and Public Health, Madison, WI 53705