To the Editor:

Thank you for the article, "Better Pain Management for Elders in the Intensive Care Unit."1 It is very imperative that pain management in all care settings is optimized for older adults' recovery and quality of life, and there is a great need for pain research with older adults in critical care settings. While the article provided some informative recommendations and was well referenced, there are several points that should be clarified.

1. Diallo and Kautz1^(p317) recommended the visual analog scale can be used to assess pain in older adults. The visual analog scale is not recommended in older adults because of its high failure rate in older adults.2,3 Many older adults do not understand how to use this scale, especially when there are no numerical anchors, and are unable to gauge pain intensity using this type of scale. Vision impairments may also limit their ability to accurately mark the location on the scale that represents their pain intensity. This results in inaccurate appraisal of pain intensity, either underestimating or overestimating pain intensity. Two pain scales that are recommended in older adults who can self-report, but not mentioned in the article, are the Faces Pain Scale-Revised and Iowa Pain Thermometer; these have been extensively tested in diverse racial and ethnic populations and shown to be preferred, valid, and reliable in older adults across care settings.4,5

2. Some of the language used in the example statements could be misleading. For example, "When your pain is adequately treated, then you can get up and walk, and then we can transfer you out of the ICU. So, let me ask again, how is your pain?"1^(p318) As was pointed out earlier in the article, many older adults may deny pain or report pain medication is effective when in fact it is not. Similarly, older adults may report pain is better, when it may not, to avoid prolonging ICU stay and expedite transfer to a lower-acuity unit. Therefore, it is important that our statements refrain from unintentional coercion and do not elicit socially desirable responses from patients. In addition, the word "back slide" was used,1^(p317) and this perhaps may be a poor word choice as this may have a negative connotation, particularly from a religious standpoint.

3. The example of a heating pad was given as an alternative/complementary pain management strategy.1^(p317) It would have been important to elaborate on the safety issues of using a heating pad with elders. A warm towel or compress would be a better option. On the same note, some of the other alternative/complementary strategies (eg, acupuncture and biofeedback1^(p318)) provided may not be appropriate for older adults, especially if critically ill. Some critically ill older adults are likely to be considered "frail" and may be unable to handle acupuncture or have the cognitive capacity or energy to engage in biofeedback, particularly so if they have moderate to severe dementia or delirium. It was even stated that in some cases, older adults may have issues "focusing on pain enough to report pain"1^(p317); likewise, they may also have trouble focusing long enough to engage in biofeedback. Some may even find that acupuncture is painful, creating additional pain. There is also low quality of evidence for acupuncture in older adults.6 I think we must be very careful and specific about the pain treatment strategies we recommend for older adults, being cognizant of their physical and mental abilities.

4. I can appreciate the attempt to provide examples of nurse statements and rationales for patients, but many of the examples were focused on "telling" patients what to do, versus including them as "partners" in their care.1^(p318) For example, "I'm going to get you up in 45 minutes; I want you to take some pain medicine now, so you will be able to do that,"1^(p318) or "[horizontal ellipsis]I am giving you these medications to prevent constipation[horizontal ellipsis]."1^(p318) I may be misinterpreting these statements, but it appears the older adult was not given a choice or allowed to have an opinion on if they wanted to take these various types of medication or use other methods to control pain and prevent constipation. I understand that sometimes we may need to help guide them in their decisions, and this can be done effectively.

5. It was reported that nurses may withhold pain medication when an older adult appears very sleepy or lethargic.1^(p318) While many analgesics have sedating properties, it is not OK to withhold pain medication for this reason. Even though a patient seems sleepy or is asleep, it does not necessarily mean he/she is not in pain. A better solution would be to examine all medications and determine which act as sedatives and perhaps decrease the dosage or change the route or type of pain medication to a less-sedating type. It was also stated several times that an antiemetic could be given if the patient reports nausea, but I would caution adding an additional medication (ie, the prescribing cascade). Polypharmacy (ie, the use of multiple medications, some of which are redundant and clinically unnecessary) is a major issue in older adults, and it is important to limit the number of medications given in order to reduce adverse drug events and drug-drug interactions. Remember, most medications have adverse effects, and treating an adverse effect with another medication only produces additional adverse effects; older adults are more sensitive to adverse effects and are at higher risk of adverse effects.

I can appreciate the overall goal of the article and believe it will help providers to assess and treat pain in older adults in critical care settings.

Staja "Star" Booker, MS, RN

Gerontological Nursing/Aging and

Pain in Older Adults

College of Nursing

The University of Iowa

Iowa City

References