Although the ability to improve pain management has occurred, specific issues of the elderly, including their unique psychosocial characteristics, have been neglected (Portenoy, 1987). When speaking of such characteristics, Shahady (1990) maintains that 50% of patients have beliefs that need to be dispelled so that the real problems and diagnoses can be made. However, before such beliefs can be dispelled, they must be detected by the health professional during assessment. Also, just as nurses are influenced by their beliefs when doing a pain assessment (Dalton, 1989), it seems logical that patients are influenced by their beliefs when responding to a pain assessment.
This article will describe possible beliefs of the elderly patient that, if not incorporated into the pain assessment, can block pain management because they can interfere with the patient's willingness to acknowledge pain and provide complete and accurate information about the pain experience. Such blocks can result in an inadequate assessment and the multiple effects of poor pain management (Figure).
Does the patient's self-concept block pain management? Hickey contends that a patient's fear of potential loss of control in decision making about health may be a greater factor than previously thought in explaining why patients are reluctant to share information about their health (Hickey, 1988). Does the patient believe pain should be endured because of a perception about self? If patients were socialized in a culture that stressed stoicism, they may rarely complain of pain, as it would be considered a sign of weakness. Copp's study (1990) of the pain experience of 148 patients indicated that 11% viewed suffering as a challenge with positive effects; 10% perceived pain as weakness on their part; and 13% perceived pain as punishment for some wrong deed.
What are the patient's beliefs about aging? A patient's view of aging will affect how health status, including pain, is perceived; what information will be told others; and what health activities will be taken (Hickey, 1988; Rosseau, 1987). If the patient has internalized the ageist view that pain is a normal component of aging and, as such, should be expected and tolerated, pain may be underreported or not reported at all.
Is the patient striving to play the "good patient" role? If so, a passive role may be assumed, including a reluctance to complain about pain because of the fear of being labeled a "bad patient." Hickey (1988) believes that elderly patients are prone to assuming a passive role either because of inexperience with the patient role or because of intimidation felt by the knowledge and authority attributed to the professional. Enck (1991) contends that a major impediment to good pain control is family-patient dynamics regarding ownership of pain; the family may believe they are the authority on whether the patient's pain is controlled. Passive patients may permit family involvement; if they are not passive, there may be a struggle as each strives for control. Nurses can rninknize potential problems by being aware of their possibility and by remembering that pain is whatever the patient says it is.
Does the patient believe the staff is "too busy" to hear complaints, including complaints of pain? Some patients may be willing to talk to the staff about pain, but refrain from doing so because they believe they are taking too much of the professional's time. Shahady (1990) maintains that 50% of his patients enable the correct diagnosis to be made when they are given the opportunity to discuss concerns. Do patients believe the staff is interested in them? If patients perceive the nurse is abrupt, in a hurry, or does not believe what is being said, they may compensate by underreporting the pain experience. This can accentuate feelings of hopelessness, helplessness, anxiety, and pain.
What is the patient's trust and respect level for the health professional? Elderly patients may believe that older doctors and nurses have greater knowledge and can be trusted more than those who "look young enough to still be in school." Also, elderly patients may believe that nurses who wear more traditional uniforms can be trusted and respected more than those in contemporary dress. The elderly also may lack respect for those they perceive as condescending. This includes being too personal: referring to the elderly by their first name, rather than as Mr. or Mrs., or touching and hugging them without permission.
Distrust and disrespect also can emerge if the nurse seeks information that the patient considers inappropriate or if information is asked of a relative rather than of the patient. In such situations, patients may not share information that they consider sensitive, personal, and private (Copp, 1990). Similarly, patients may not reveal information or complain about pain if they believe that their own pain remedy is more efficacious than that offered by the nurse or that it will be ridiculed by the nurse. At the other extreme, patients may have such a high trust level for the nurse that they believe the nurse knows about the pain without having to be told.
Does the patient believe that telling the nurse about the pain may lead to further tests and expenses, which can put a strain on personal and monetary resources (Portenoy, 1988)? Is the patient denying pain because of the fear of an invasion by unwanted others or equipment? Copp's (1990) study of patients' pain experiences indicated they have fears related to the unknown and to procedures and equipment, including intubation and spinal taps.
Is the patient attempting to deny or not acknowledge pain because of the belief that using drugs now will render them ineffective if or when the pain becomes worse? The wife of a patient admitted she did not give her husband the prescribed drug dosage because she wanted to save it for when the pain became worse. Finally, does the patient believe the acknowledgement of pain will result in the use of drugs, which may be a signal that death is on the way? Patients with this belief may be reluctant to acknowledge pain or may attempt to deny its presence because they believe if they can hold off the pain, they can hold off the certainty of death (Duffy, 1988).
Consequences of Treatment
Does the patient believe that the drugs or their side effects will produce changes that will make daily living more difficult or drastically change their behavior or personality? Elderly patients may afraid to take drugs because of having experienced or heard from friends of the consequences of taking a drug.
CONSEQUENCES OF TAKING DRUGS
Is the patient reluctant to take medication because of the belief it will lead to addiction? The term "opiophobia" has been coined to characterize the unwillingness of both patients and professionals to use opioids because of fears related to this belief. Opiophobia has been reinforced by the national "just say no to drugs" campaign, which ". . . has increased societal awareness that opioids are hazardous materials and are used only by the weak and vulnerable" (Blum, 1990).
THE MULTIPLE EFFECTS OF POOR PAIN MANAGEMENT IN THE ELDERLY
Xerostomia (Dry Mouth)
Xerostomia is common in the elderly and can occur for various reasons, including the use of drugs for pain management. In fact. White et al reported a highly significant association between the use of morphine and dryness of the mouth in 199 patients. When they controlled for concurrent treatment, patients receiving morphine sulfite were approximately four times more likely to have a dry mouth of any severity than patients taking weak opioids, nonopioids, or no analgesics.
Dry mouth can impair the quality of life because of problems related to mucosal soreness, taste impairment, difficulty with eating dry foods, speech and swallowing, and the impediment of using oral routes for drug administration. Denture wearers may have additional problems, such as denture sores, denture retention, and the tongue sticking to the palate (White, 1989). These problems can result in compromised nutrition and even cachexia (McDonald, 1991).
If a drug causes sedation, disorientation, and confusion, the risk for injury from falls can occur (Hussar, 1988). In addition, orthostatic hypotension, a risk factor for falls, can result from the hypotensive effects of prescribing a tricyclic antidepressant or neuroleptic drug for pain in a patient who is taking an antihypertensive or antianginal drug (Portenoy, 1988). The potential for falls was reflected in a study of 74 institutionalized elderly. Perlin et al reported that at the time of falls, 60 (81%) patients were taking central nervous system drugs and 58 (78%) patients were taking nonsteroidal anti-inflammatory drugs (Perlin, 1990).
The etiologies of constipation are numerous and include decreased ambulation, nutritional deficiencies, decreased fluid intake, diverticular disease, irritable bowel syndrome, neurologic diseases, laxatives, and drugs (Murray, 1991). For example, the opioid drugs act at multiple sites throughout the gastrointestinal tract and spinal cord to cause not only a decrease in peristalsis, but also a decrease in intestinal, gastric, biliary, and pancreatic secretions.
In addition, tolerance develops very slowly to the smooth muscle effects of opioids, so that constipation persists when these drugs are used for chronic pain (Ventafridda, 1987). Because of their daily concern about constipation, nurses need to determine if constipation may deter elderly patients from taking certain drugs for pain management.
Estimating the extent of drugrelated sexual dysfunction is difficult because such side effects often go unrecognized or are attributed to other causes, such as depression (Galbraith, 1991). In addition, elderly patients may be reluctant to discuss their concern. Rather, they will not acknowledge the presence of pain or be noncompliant with therapy. Galbraith states that knowledge of the mechanisms whereby drugs produce sexual side effects is limited and, in some cases, there is no known or even postulated mechanism, yet the association remains empirical (Galbraith, 1991). (For information and multiple lists of drugs reported to cause sexual side effects, the reader is referred to the Galbraith article.)
Drugs with anticholinergic activity and antidepressants may cause erectile problems and vaginal dryness (Douglas, 1988). Naproxen can cause impotence and ejaculatory abnormalities, whereas methadone will cause these problems plus decreased libido (Galbraith, 1991). In view of the reluctance of patients to initiate discussion, and because such side effects are often reversible following a drug substitution or dosage reduction, the nurse should inquire about the sexual concerns so action can be taken to minimize them.
Many elderly patients are concerned about age-related memory loss, confusion, and disorientation, and may be fearful of any regimen that could contribute to the emergence of such problems. Also, the elderly can experience nightmares, anxiety, agitation, euphoria, dysphoria, paranoia, hallucinations, and depression at moderate drug dosage levels because of an enhanced sensitivity to drugs.
One example is meperidine, in which the accumulation of the metabolite normeperidine can cause central nervous system excitation. Similar care should be taken with methadone. It has a long half-life (15 to 30 hours), so chronic dosing can lead to drug accumulation and to sedation. Hussar (1988) cautions against using drugs with anticholinergic activity because they have been found to be associated with memory and self-care impairment and blurring of vision, which can be especially troublesome for those elderly who have had to give up many activities other than reading for enjoyment. It should be recognized that sedation and confusion may occur when a drug regimen is first begun and at the time of significant dosage increases. Also, because of an additive effect, caution must be exercised in the use of other central nervous system depressants, such as alcohol, barbiturates, and benzodiazepines, in combination with opioids (Ventafridda, 1987).
IMPLICATIONS FOR NURSES
Optimal management of pain in elderly patients is based on a complete assessment of pain, including beliefs that may affect the patient's perception and willingness to share information vital to the assessment. Such assessment may take several patient-nurse visits because there is a tendency among patients to reveal more information about health problems with succeeding visits, even if the patient is seen by a different person at each visit. It is believed that such behavior reflects a sense of rapport and a trust level that enables patients to reveal true concerns (Hickey, 1988; Shahady, 1990).
Nurses can help patients minimize the passive role belief by discussing benefits of being an active participant in health care and methods for integrating patient coping strategies into the plan of care. Such involvement also gives the patient a sense of control over the pain (Scott, 1987). Nurses can help patients minimize the belief that "the staff is too busy" by informing the patient that some patients are reluctant to express problems because the staff seems to be always busy. Discussion can then focus on how the patient and staff must work together if the goal of providing quality care is to be accomplished.
If the patient perceives that pain should be endured for some reason, the nurse may need to educate the patient about the effects of pain and allay the belief that pain is punishment for a past behavior. If the patient is fearful of taking drugs because of failure to understand the difference between addiction (psychological dependence), physical dependence, and tolerance, the nurse can explain the difference and that a "craving for a drug" is not a problem when pain is controlled. If the patient is fearful of drugs because of the side effects, the nurse should explain the benefits of drugs, the consequences of unmanaged pain, and that interventions can nunimize side effects while emphasizing that the patient and nurse must work together. Patient education should be directed toward each fear.
Nurses can contribute to the ability to improve pain management in the elderly by assessing patients' beliefs about themselves and the aging process; their role as patients; the health-care professional; and the consequence of acknowledging pain and of accepting various pain management modalities.
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