Pain at the End of Life

Many elderly people experience pain they would call 'moderate' or 'severe' in the last two years of life, with those who have arthritis reporting pain most often.  That's the sobering conclusion of a study published this week in Annals of Internal Medicine.

In this week's podcast I call the study distressing, but Rick points out that it is also the first study of its kind, and it provides some very valuable information.  Study participants were enrolled in the Health and Retirement Study, and were surveyed periodically over years.  Survey data from those who died was included 2 years retrospectively from their date of death.

Data from just over 4700 people was included in the analysis.  The results show that pain increases at the end of life, irrespective of existing conditions like cancer or others we may believe are less painful, such as congestive heart failure.  By far the most pain producing condition though was arthritis, with the majority of those with the condition reporting at least moderate pain at the end of life.

I think this is distressing because we have very effective agents for pain relief, many of which are not sedating or accompanied by a host of unwanted side effects.  Moreover, many are calling pain the "fifth vital sign," after heart rate, blood pressure, body temperature and respiration rate.  That's because how much pain one is experiencing can have an impact on the others as well as a profound psychological component.  Chronic pain is a well known risk factor for depression and even suicide.

Rick points out that many, if not most physicians are ill-equipped or perhaps ill-inclined to manage pain in their patients.  Given that many elderly patients don't metabolize medications well, pain in such a patient population is challenging indeed.  But studies such as this one illustrate the fact that pain is very common and does compromise quality of life for many elderly people.  It is humane to acknowledge and treat it.

Other topics in this week's podcast include screening for depression in adolescents in this issue of Pediatrics, no help from fish oil for slowing the progression of Alzheimer's disease in JAMA, and a lack of survival benefit with implanted defibrillators, also in Annals of Internal Medicine.  Until next week, y'all live well.

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