June 22, 1998 PROVIDENCE, R.I. -- A new five-state study shows that daily pain among elderly nursing home residents with cancer is widespread and often untreated, especially among older and minority patients.
The study appears in the June 17 issue of the Journal of the American Medical Association. Its findings indicate that many frail and older cancer patients receive inadequate medical treatment and that dramatic room exists for improving how pain is managed in these individuals.
"We're not pointing fingers, but we know that nursing homes and many clinical settings do not do a good job in this area, and here's more proof," said Giovanni Gambassi, M.D., visiting professor in the Center for Gerontology and Health Care Research at Brown University and one of the study's authors.
"At some point, nursing home staff and in-house doctors may give up on patients who they know are going to die," he said. "The results of our study are particularly alarming since there are ways to treat patients to greatly relieve their conditions. There is no acceptable excuse for not treating pain appropriately in terminally ill patients."
Gambassi and colleagues examined data collected on 13,625 cancer patients aged 65 and older discharged from hospitals to 1,492 nursing homes from 1992 to 1995. In total, 4,003 patients reported daily pain. Of those, 16 percent received a simple analgesic such as aspirin or acetaminophen. Thirty-two percent were given codeine or other weak opioids, and 26 percent received morphine.
However, 26 percent of patients with daily pain received no analgesics, not even an aspirin or acetaminophen tablet. Patients older than 85 years in daily pain were about 50 percent less likely to receive any analgesic than those aged 65 to 74 years. Only 13 percent of patients aged 85 years and older received codeine or other weak opiates or morphine, compared to 38 percent of those aged 65 to 74 years.
African Americans were fifty percent less likely than whites to receive any analgesics. Although not statistically significant, a similar trend in the data was noted for Hispanics, Asians and American Indians.
Failure to prevent or to treat pain effectively is unacceptable and should be considered a first-line indicator of poor quality of medical care, Gambassi said. The researchers call for solutions that address barriers to pain management including the unwillingness of many nursing homes to stock opiates, inadequate staff to provide and monitor the frequent use of analgesics and the insufficient knowledge and failure of many physicians to use basic pain medications aggressively.
The study cites several patient-based reasons for why cancer pain is also probably greatly underestimated. Older patients may be less likely than younger ones to complain about pain. Some individuals may view pain as a natural consequence of aging and may be reluctant to report pain. The presence of multiple medical problems, increased likelihood of cognitive and sensory damage, and the presence of depression may all contribute to an under-reporting of pain.
For minority patients, the authors suggest that language barriers account for some of the differences. Cultural and language backgrounds affect ratings of how pain interferes with physical function, mood and sleep. There is evidence that Hispanics are more reluctant to report pain and, like African Americans, less willing to complete advanced directives.
Only recently have medical schools offered training on the care of terminally ill elderly, Gambassi said. There still is a need to educate individual clinicians and patients to influence their behaviors, he said. "We must tear down the cultural, social and intellectual barriers to do a better job of attending to those who are terminally ill."
The study represents a one-time snapshot of cancer pain management. The information comes from the Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database, established and maintained by Brown University. The data was collected as part of the Health Care Financing Administration's Multistate Nursing Home Case-mix and Quality Demonstration Project.
Nursing home staff in all Medicare and Medicaid facilities in Kansas, Maine, Mississippi, New York and South Dakota evaluated patients using a resident assessment instrument, which includes a 350-item minimum data set. In addition, nursing staff recorded up to 18 different medications received by each resident in the prior seven days.
Other Brown researchers and SAGE investigators are exploring the existence of racial biases in treatment received by patients in the study.
The SAGE group originates from a collaborative effort between faculty at Brown and at Catholic University in Rome. The collaboration emerged as part of an international consortium of long-term care researchers, called interRAI, which is devoted to the creation and use of common assessment tools.
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