Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

Recently, I had an office visit from a lovely 80-year-old woman, born and raised in Providence, R.I., whose past medical history included pulmonary tuberculosis for which she was sent to a sanatorium – 50 years ago.

Her TB had nothing to do with why she had come to see me. By and large, this is a really healthy patient whose only complaint was a 2-month history of right shoulder pain that turned out to be caused by rotator cuff tendonitis. But I lingered with her, and we chatted for awhile. She used to work at Veterans Affairs, processing claims and grievances so she was familiar with medical terminology and was in general a joy to talk with. And I was captivated by the progress in medicine that she represented.

Now, by the time I went to medical school, we were no longer sending patients to sanatoria. The word was as abstract a concept to me as, say, injecting intramuscular gold to treat rheumatic diseases. By the time I was in training, everyone in the developing world got a BCG vaccine, which prevents severe complications from TB but does not prevent infections. As long as I have been a physician, we have understood transmission well, have known about four-drug regimens, and were aware of drug-resistant TB (I am still floored when I read about XDR-TB, with the X being short for "extensively.")

Needless to say I was fascinated by her story.

When she was originally diagnosed more than half a century ago, this woman did not have the usual symptoms that we associate with active pulmonary tuberculosis. She had not had a cough and certainly did not have "wasting." She simply tripped one day and in doing so coughed up some blood. She was found to have disease in both apices and, subsequently, she spent 14 months in a local sanatorium. She remembers being treated with "PAS and streptomycin" (PAS being p-aminosalicylic acid), and "lots of fresh air."

Although tuberculosis is rare in the USA today, it was "so rampant that cautionary visual messages appeared in myriad public places, from offices to restrooms," according to the National Library of Medicine. "Huber the Tuber" was a mascot developed by TB patient and physician Harry Wilmer (1917-2005). In the educational pamphlet, Huber rides respiratory droplets along with his cohort "Nasty von Sputum, Rusty the Bloodyvitch, and Huey the Long Tuber." That final appellation is supposedly a reference to Sen. Huey Long, according to the NLM. (Can we still anthropomorphize bacteria into corrupt government officials?)

The discovery of Mycobacterium tuberculosis by German bacteriologist Dr. Robert Koch in 1882 led to a revolution of isolating patients, which in turn led to a decrease in transmission. In 1905, the American Sanatorium Association was formed – it still exists today as the American Thoracic Society! When the association started, there were 106 sanatoria in the United States, which provided 9,107 beds for patients. At its peak in 1954, there were 108,457 beds worsening (Am. J. Respir. Crit. Care Med. 2004:169;118-6). From a patient’s journal during time spent in a sanatorium in 1944, we know that there were only two rules for sanatorium residents:

1. Absolute and utter rest of mind and body – no bath, no movement except to toilet once a day, no sitting up except propped by pillows and semireclining, no deep breath. Lead the life of a log, in fact. Don’t try, therefore, to sew, knit, or write, except as occasional relief from reading and sleeping.

2. Eat nourishing food and have plenty of fresh air.

Not everyone got antibiotic treatment, unless their chest x-rays showed worsening. Some patients were treated with an induced pneumothorax, according to the women’s journal. Why this would be is not clear to me.

Then, in 1952, isoniazid was developed, and that was the start of the end of the sanatorium.

In our daily lives, we focus on individual patients, but history informs the current practice of medicine. How wonderful that we can now treat many illnesses that were once considered uniformly fatal. How fortunate are we to call this our profession, one that provides an unambiguous good.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Recently, I had an office visit from a lovely 80-year-old woman, born and raised in Providence, R.I., whose past medical history included pulmonary tuberculosis for which she was sent to a sanatorium – 50 years ago.

Her TB had nothing to do with why she had come to see me. By and large, this is a really healthy patient whose only complaint was a 2-month history of right shoulder pain that turned out to be caused by rotator cuff tendonitis. But I lingered with her, and we chatted for awhile. She used to work at Veterans Affairs, processing claims and grievances so she was familiar with medical terminology and was in general a joy to talk with. And I was captivated by the progress in medicine that she represented.

Now, by the time I went to medical school, we were no longer sending patients to sanatoria. The word was as abstract a concept to me as, say, injecting intramuscular gold to treat rheumatic diseases. By the time I was in training, everyone in the developing world got a BCG vaccine, which prevents severe complications from TB but does not prevent infections. As long as I have been a physician, we have understood transmission well, have known about four-drug regimens, and were aware of drug-resistant TB (I am still floored when I read about XDR-TB, with the X being short for "extensively.")

Needless to say I was fascinated by her story.

When she was originally diagnosed more than half a century ago, this woman did not have the usual symptoms that we associate with active pulmonary tuberculosis. She had not had a cough and certainly did not have "wasting." She simply tripped one day and in doing so coughed up some blood. She was found to have disease in both apices and, subsequently, she spent 14 months in a local sanatorium. She remembers being treated with "PAS and streptomycin" (PAS being p-aminosalicylic acid), and "lots of fresh air."

Although tuberculosis is rare in the USA today, it was "so rampant that cautionary visual messages appeared in myriad public places, from offices to restrooms," according to the National Library of Medicine. "Huber the Tuber" was a mascot developed by TB patient and physician Harry Wilmer (1917-2005). In the educational pamphlet, Huber rides respiratory droplets along with his cohort "Nasty von Sputum, Rusty the Bloodyvitch, and Huey the Long Tuber." That final appellation is supposedly a reference to Sen. Huey Long, according to the NLM. (Can we still anthropomorphize bacteria into corrupt government officials?)

The discovery of Mycobacterium tuberculosis by German bacteriologist Dr. Robert Koch in 1882 led to a revolution of isolating patients, which in turn led to a decrease in transmission. In 1905, the American Sanatorium Association was formed – it still exists today as the American Thoracic Society! When the association started, there were 106 sanatoria in the United States, which provided 9,107 beds for patients. At its peak in 1954, there were 108,457 beds worsening (Am. J. Respir. Crit. Care Med. 2004:169;118-6). From a patient’s journal during time spent in a sanatorium in 1944, we know that there were only two rules for sanatorium residents:

1. Absolute and utter rest of mind and body – no bath, no movement except to toilet once a day, no sitting up except propped by pillows and semireclining, no deep breath. Lead the life of a log, in fact. Don’t try, therefore, to sew, knit, or write, except as occasional relief from reading and sleeping.

2. Eat nourishing food and have plenty of fresh air.

Not everyone got antibiotic treatment, unless their chest x-rays showed worsening. Some patients were treated with an induced pneumothorax, according to the women’s journal. Why this would be is not clear to me.

Then, in 1952, isoniazid was developed, and that was the start of the end of the sanatorium.

In our daily lives, we focus on individual patients, but history informs the current practice of medicine. How wonderful that we can now treat many illnesses that were once considered uniformly fatal. How fortunate are we to call this our profession, one that provides an unambiguous good.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Recently, I had an office visit from a lovely 80-year-old woman, born and raised in Providence, R.I., whose past medical history included pulmonary tuberculosis for which she was sent to a sanatorium – 50 years ago.

Her TB had nothing to do with why she had come to see me. By and large, this is a really healthy patient whose only complaint was a 2-month history of right shoulder pain that turned out to be caused by rotator cuff tendonitis. But I lingered with her, and we chatted for awhile. She used to work at Veterans Affairs, processing claims and grievances so she was familiar with medical terminology and was in general a joy to talk with. And I was captivated by the progress in medicine that she represented.

Now, by the time I went to medical school, we were no longer sending patients to sanatoria. The word was as abstract a concept to me as, say, injecting intramuscular gold to treat rheumatic diseases. By the time I was in training, everyone in the developing world got a BCG vaccine, which prevents severe complications from TB but does not prevent infections. As long as I have been a physician, we have understood transmission well, have known about four-drug regimens, and were aware of drug-resistant TB (I am still floored when I read about XDR-TB, with the X being short for "extensively.")

Needless to say I was fascinated by her story.

When she was originally diagnosed more than half a century ago, this woman did not have the usual symptoms that we associate with active pulmonary tuberculosis. She had not had a cough and certainly did not have "wasting." She simply tripped one day and in doing so coughed up some blood. She was found to have disease in both apices and, subsequently, she spent 14 months in a local sanatorium. She remembers being treated with "PAS and streptomycin" (PAS being p-aminosalicylic acid), and "lots of fresh air."

Although tuberculosis is rare in the USA today, it was "so rampant that cautionary visual messages appeared in myriad public places, from offices to restrooms," according to the National Library of Medicine. "Huber the Tuber" was a mascot developed by TB patient and physician Harry Wilmer (1917-2005). In the educational pamphlet, Huber rides respiratory droplets along with his cohort "Nasty von Sputum, Rusty the Bloodyvitch, and Huey the Long Tuber." That final appellation is supposedly a reference to Sen. Huey Long, according to the NLM. (Can we still anthropomorphize bacteria into corrupt government officials?)

The discovery of Mycobacterium tuberculosis by German bacteriologist Dr. Robert Koch in 1882 led to a revolution of isolating patients, which in turn led to a decrease in transmission. In 1905, the American Sanatorium Association was formed – it still exists today as the American Thoracic Society! When the association started, there were 106 sanatoria in the United States, which provided 9,107 beds for patients. At its peak in 1954, there were 108,457 beds worsening (Am. J. Respir. Crit. Care Med. 2004:169;118-6). From a patient’s journal during time spent in a sanatorium in 1944, we know that there were only two rules for sanatorium residents:

1. Absolute and utter rest of mind and body – no bath, no movement except to toilet once a day, no sitting up except propped by pillows and semireclining, no deep breath. Lead the life of a log, in fact. Don’t try, therefore, to sew, knit, or write, except as occasional relief from reading and sleeping.

2. Eat nourishing food and have plenty of fresh air.

Not everyone got antibiotic treatment, unless their chest x-rays showed worsening. Some patients were treated with an induced pneumothorax, according to the women’s journal. Why this would be is not clear to me.

Then, in 1952, isoniazid was developed, and that was the start of the end of the sanatorium.

In our daily lives, we focus on individual patients, but history informs the current practice of medicine. How wonderful that we can now treat many illnesses that were once considered uniformly fatal. How fortunate are we to call this our profession, one that provides an unambiguous good.

Dr. Chan practices rheumatology in Pawtucket, R.I.

In May and June, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius in May and June announced 107 healthcare innovations grants to improve coordination of care and reduce costs. The grants, a provision of the Affordable Care Act (ACA), range from $1 million to $30 million. HHS anticipates that the projects will reduce healthcare spending by $254 million over the next three years and provide "new ideas on how to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid and [the] Children's Health Insurance Program (CHIP)."

Hospitalists played key roles in planning and developing several of the projects. Common themes include coordination and integration of services, promotion of community collaborations, integrating behavioral and physical care, and the use of telemedicine—many of the same approaches utilized by SHM's Project BOOST and other national initiatives for preventing unnecessary readmissions.

In Atlanta, Emory University's Center for Critical Care received a $10.7 million grant to deploy 40 nurse practitioners (NPs) and physician assistants (PAs) trained in critical care to underserved and rural ICUs in Georgia. In many of the targeted hospitals, hospitalists manage patients in the ICU, but this program brings an additional layer of staffing and expertise to the care, allowing patients to stay in their beds rather than having to be transferred, says Daniel Owens, MBA, the center’s director of operations and senior administrator of the division of hospital medicine at Emory.

The project will bring NPs and PAs from participating hospitals to Emory for an intensive, six-month, critical-care residency. "If they don't have these folks, we'll help to identify staff for the jobs," he adds.

At Vanderbilt University Medical Center in Nashville, Tenn., a $2.4 million project to reduce rehospitalizations for a high-risk geriatric patients aims to close the gaps in care transitions between hospital, outpatient, post-acute, and extended-care settings, says Vanderbilt hospitalist Eduard Vasilevskis, MD. The project will employ transition advocates or coordinators in the hospital to improve communication at both ends, with evidence-based protocols to improve discharge planning. Long-term care providers will be offered Web-based training and video conferencing.

"The goal is to break the cycle of rehospitalization," says Dr. Vasilevskis, "but if patients need to come back to the hospital, there will be someone involved in their care who is familiar with the settings where they’ve come from."

Beth Israel Deaconess Medical Center (BIDMC) in Boston received $4.9 million for its Post-Acute Care Transitions program (PACT), which links the hospital to six affiliated primary care practices using a bundle of post-acute care interventions, care-transition specialists, and dedicated clinical pharmacists. Nurses remain in contact with patients by telephone for 30 days post-hospital discharge and coordinate the services of extended-care facilities and visiting nurses. Pharmacists perform in-hospital medication reconciliation and patient education, says hospitalist Lauren Doctoroff, MD, FHM. She and Julius Yang, MD, BIDMC medical director of inpatient quality, helped develop the pilot program, which began in August 2011.

"These care-transitions specialists offer us an added level of patient support and a different level of integration focused on risk assessment of such issues as social supports and problems with medical compliance, which can be used by the inpatient team to come up with the most rational and ideal discharge plan," Dr. Doctoroff says. "One of my colleagues said to me, ‘I feel so much better knowing there is this added level of support for patients after discharge.'"

The HHS grants reflect an important recognition that what happens to patients following discharge partly reflects what happens in the hospital but also depends on collaborations with post-acute providers, Dr. Doctoroff says.

"Hospitalists can't do everything, but they need their eye out of the hospital on post-acute providers in order to deliver the best care," she adds.

In May and June, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius in May and June announced 107 healthcare innovations grants to improve coordination of care and reduce costs. The grants, a provision of the Affordable Care Act (ACA), range from $1 million to $30 million. HHS anticipates that the projects will reduce healthcare spending by $254 million over the next three years and provide "new ideas on how to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid and [the] Children's Health Insurance Program (CHIP)."

Hospitalists played key roles in planning and developing several of the projects. Common themes include coordination and integration of services, promotion of community collaborations, integrating behavioral and physical care, and the use of telemedicine—many of the same approaches utilized by SHM's Project BOOST and other national initiatives for preventing unnecessary readmissions.

In Atlanta, Emory University's Center for Critical Care received a $10.7 million grant to deploy 40 nurse practitioners (NPs) and physician assistants (PAs) trained in critical care to underserved and rural ICUs in Georgia. In many of the targeted hospitals, hospitalists manage patients in the ICU, but this program brings an additional layer of staffing and expertise to the care, allowing patients to stay in their beds rather than having to be transferred, says Daniel Owens, MBA, the center’s director of operations and senior administrator of the division of hospital medicine at Emory.

The project will bring NPs and PAs from participating hospitals to Emory for an intensive, six-month, critical-care residency. "If they don't have these folks, we'll help to identify staff for the jobs," he adds.

At Vanderbilt University Medical Center in Nashville, Tenn., a $2.4 million project to reduce rehospitalizations for a high-risk geriatric patients aims to close the gaps in care transitions between hospital, outpatient, post-acute, and extended-care settings, says Vanderbilt hospitalist Eduard Vasilevskis, MD. The project will employ transition advocates or coordinators in the hospital to improve communication at both ends, with evidence-based protocols to improve discharge planning. Long-term care providers will be offered Web-based training and video conferencing.

"The goal is to break the cycle of rehospitalization," says Dr. Vasilevskis, "but if patients need to come back to the hospital, there will be someone involved in their care who is familiar with the settings where they’ve come from."

Beth Israel Deaconess Medical Center (BIDMC) in Boston received $4.9 million for its Post-Acute Care Transitions program (PACT), which links the hospital to six affiliated primary care practices using a bundle of post-acute care interventions, care-transition specialists, and dedicated clinical pharmacists. Nurses remain in contact with patients by telephone for 30 days post-hospital discharge and coordinate the services of extended-care facilities and visiting nurses. Pharmacists perform in-hospital medication reconciliation and patient education, says hospitalist Lauren Doctoroff, MD, FHM. She and Julius Yang, MD, BIDMC medical director of inpatient quality, helped develop the pilot program, which began in August 2011.

"These care-transitions specialists offer us an added level of patient support and a different level of integration focused on risk assessment of such issues as social supports and problems with medical compliance, which can be used by the inpatient team to come up with the most rational and ideal discharge plan," Dr. Doctoroff says. "One of my colleagues said to me, ‘I feel so much better knowing there is this added level of support for patients after discharge.'"

The HHS grants reflect an important recognition that what happens to patients following discharge partly reflects what happens in the hospital but also depends on collaborations with post-acute providers, Dr. Doctoroff says.

"Hospitalists can't do everything, but they need their eye out of the hospital on post-acute providers in order to deliver the best care," she adds.

In May and June, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius in May and June announced 107 healthcare innovations grants to improve coordination of care and reduce costs. The grants, a provision of the Affordable Care Act (ACA), range from $1 million to $30 million. HHS anticipates that the projects will reduce healthcare spending by $254 million over the next three years and provide "new ideas on how to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid and [the] Children's Health Insurance Program (CHIP)."

Hospitalists played key roles in planning and developing several of the projects. Common themes include coordination and integration of services, promotion of community collaborations, integrating behavioral and physical care, and the use of telemedicine—many of the same approaches utilized by SHM's Project BOOST and other national initiatives for preventing unnecessary readmissions.

In Atlanta, Emory University's Center for Critical Care received a $10.7 million grant to deploy 40 nurse practitioners (NPs) and physician assistants (PAs) trained in critical care to underserved and rural ICUs in Georgia. In many of the targeted hospitals, hospitalists manage patients in the ICU, but this program brings an additional layer of staffing and expertise to the care, allowing patients to stay in their beds rather than having to be transferred, says Daniel Owens, MBA, the center’s director of operations and senior administrator of the division of hospital medicine at Emory.

The project will bring NPs and PAs from participating hospitals to Emory for an intensive, six-month, critical-care residency. "If they don't have these folks, we'll help to identify staff for the jobs," he adds.

At Vanderbilt University Medical Center in Nashville, Tenn., a $2.4 million project to reduce rehospitalizations for a high-risk geriatric patients aims to close the gaps in care transitions between hospital, outpatient, post-acute, and extended-care settings, says Vanderbilt hospitalist Eduard Vasilevskis, MD. The project will employ transition advocates or coordinators in the hospital to improve communication at both ends, with evidence-based protocols to improve discharge planning. Long-term care providers will be offered Web-based training and video conferencing.

"The goal is to break the cycle of rehospitalization," says Dr. Vasilevskis, "but if patients need to come back to the hospital, there will be someone involved in their care who is familiar with the settings where they’ve come from."

Beth Israel Deaconess Medical Center (BIDMC) in Boston received $4.9 million for its Post-Acute Care Transitions program (PACT), which links the hospital to six affiliated primary care practices using a bundle of post-acute care interventions, care-transition specialists, and dedicated clinical pharmacists. Nurses remain in contact with patients by telephone for 30 days post-hospital discharge and coordinate the services of extended-care facilities and visiting nurses. Pharmacists perform in-hospital medication reconciliation and patient education, says hospitalist Lauren Doctoroff, MD, FHM. She and Julius Yang, MD, BIDMC medical director of inpatient quality, helped develop the pilot program, which began in August 2011.

"These care-transitions specialists offer us an added level of patient support and a different level of integration focused on risk assessment of such issues as social supports and problems with medical compliance, which can be used by the inpatient team to come up with the most rational and ideal discharge plan," Dr. Doctoroff says. "One of my colleagues said to me, ‘I feel so much better knowing there is this added level of support for patients after discharge.'"

The HHS grants reflect an important recognition that what happens to patients following discharge partly reflects what happens in the hospital but also depends on collaborations with post-acute providers, Dr. Doctoroff says.

"Hospitalists can't do everything, but they need their eye out of the hospital on post-acute providers in order to deliver the best care," she adds.

Clinical question: Does treatment with drotrecogin alfa (activated) reduce mortality in patients with septic shock?

Background: Recombinant human activated protein C, or drotrecogin alfa (activated) (DrotAA), was approved for the treatment of patients with severe sepsis in 2001 on the basis of the Prospective Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study. Since approval, conflicting reports about its efficacy have surfaced.

Study design: Double-blind, randomized-controlled trial.

Setting: Multicenter, multinational trial.

Synopsis: This trial enrolled 1,697 patients with septic shock to receive either DrotAA or placebo. At 28 days, 223 of 846 patients (26.4%) in the DrotAA group and 202 of 834 (24.2%) in the placebo group had died (relative risk in the DrotAA group, 1.09; 95% confidence interval, 0.92 to 1.28; P=0.31). At 90 days, there was still no significant difference in mortality. Mortality was also unchanged in patients with severe protein C deficiency at baseline. This lack of mortality benefit with either therapy persisted across all predefined subgroups in this study.

The incidence of non-serious bleeding was more common among patients who received DrotAA than among those in the placebo group (8.6% vs. 4.8%, P=0.002), but the incidence of serious bleeding events was similar in both groups. This study was appropriately powered after adjusting the sample size when aggregate mortality was found to be lower than anticipated.

Bottom line: DrotAA does not significantly reduce mortality at 28 or 90 days in patients with septic shock.

Citation: Ranieri VM, Thompson BT, Barie PS, et al. Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med. 2012;366:2055-2064.

Read more of our physician reviews of recent, HM-relevant literature.

Clinical question: Does treatment with drotrecogin alfa (activated) reduce mortality in patients with septic shock?

Background: Recombinant human activated protein C, or drotrecogin alfa (activated) (DrotAA), was approved for the treatment of patients with severe sepsis in 2001 on the basis of the Prospective Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study. Since approval, conflicting reports about its efficacy have surfaced.

Study design: Double-blind, randomized-controlled trial.

Setting: Multicenter, multinational trial.

Synopsis: This trial enrolled 1,697 patients with septic shock to receive either DrotAA or placebo. At 28 days, 223 of 846 patients (26.4%) in the DrotAA group and 202 of 834 (24.2%) in the placebo group had died (relative risk in the DrotAA group, 1.09; 95% confidence interval, 0.92 to 1.28; P=0.31). At 90 days, there was still no significant difference in mortality. Mortality was also unchanged in patients with severe protein C deficiency at baseline. This lack of mortality benefit with either therapy persisted across all predefined subgroups in this study.

The incidence of non-serious bleeding was more common among patients who received DrotAA than among those in the placebo group (8.6% vs. 4.8%, P=0.002), but the incidence of serious bleeding events was similar in both groups. This study was appropriately powered after adjusting the sample size when aggregate mortality was found to be lower than anticipated.

Bottom line: DrotAA does not significantly reduce mortality at 28 or 90 days in patients with septic shock.

Citation: Ranieri VM, Thompson BT, Barie PS, et al. Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med. 2012;366:2055-2064.

Read more of our physician reviews of recent, HM-relevant literature.

Clinical question: Does treatment with drotrecogin alfa (activated) reduce mortality in patients with septic shock?

Background: Recombinant human activated protein C, or drotrecogin alfa (activated) (DrotAA), was approved for the treatment of patients with severe sepsis in 2001 on the basis of the Prospective Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study. Since approval, conflicting reports about its efficacy have surfaced.

Study design: Double-blind, randomized-controlled trial.

Setting: Multicenter, multinational trial.

Synopsis: This trial enrolled 1,697 patients with septic shock to receive either DrotAA or placebo. At 28 days, 223 of 846 patients (26.4%) in the DrotAA group and 202 of 834 (24.2%) in the placebo group had died (relative risk in the DrotAA group, 1.09; 95% confidence interval, 0.92 to 1.28; P=0.31). At 90 days, there was still no significant difference in mortality. Mortality was also unchanged in patients with severe protein C deficiency at baseline. This lack of mortality benefit with either therapy persisted across all predefined subgroups in this study.

The incidence of non-serious bleeding was more common among patients who received DrotAA than among those in the placebo group (8.6% vs. 4.8%, P=0.002), but the incidence of serious bleeding events was similar in both groups. This study was appropriately powered after adjusting the sample size when aggregate mortality was found to be lower than anticipated.

Bottom line: DrotAA does not significantly reduce mortality at 28 or 90 days in patients with septic shock.

Citation: Ranieri VM, Thompson BT, Barie PS, et al. Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med. 2012;366:2055-2064.

Read more of our physician reviews of recent, HM-relevant literature.

For many years, I chaired the office efficiency course at the American Academy of Dermatology’s annual meeting. Each year, I asked how many participants compiled a yearly budget for their practices. In an audience of 400, the largest affirmative response I ever received was three, and some years there were no raised hands at all.

Why do physicians so vigorously resist an exercise that is so basic to every other business and profession on the planet? Typically, I hear one of two reasons: It’s tedious, or my colleagues seem to be doing just fine without one.

But the days of "doing just fine" are coming to an end. As competition for patients increases, expenses continue their upward spiral, and the government continues its steady encroachment on private practice, physicians who plan ahead will have an advantage.

Budgeting need not be tedious; determine what you need to do yourself and what can be delegated. And now, as the year winds down, is an excellent opportunity to map out your finances.

The first step – the basic gathering of numbers that everyone seems to dread – can be delegated. Ask your accountant to compile the practice’s gross income over the last 12 months, in monthly increments.

Break it down by type of service: office visits, hospital visits, surgery, lab fees, and so on, listing both the amounts billed and collected. This is not only for calculations of collection ratios, but to determine your "seasonality" – which I’ll discuss in greater detail next month. Do the same for expenses, and again break them down by category: salaries, rent/mortgage, business and medical supplies, and so on.

In many cases, the mere collection of this raw data will save money. You might discover, for example, that expenditures for business supplies are unexpectedly high. Perhaps a competing vendor can do better, or perhaps you have an overuse or theft problem.

Once the numbers are accumulated, start extrapolating them into next year. If your income rose by, say, 6% this year, can you expect a similar rise next year? Why or why not? To get a fix on a realistic goal, go through each component of your gross income and decide where the increase could come from. Can you raise prices for office visits or cosmetic procedures, renegotiate at least one third-party contract, or add another exam room in order to see more patients?

Perhaps there is an impending change in your area that you can factor in, such as a competitor who is retiring. If that physician is known for a specific service, and it’s not a service you offer, could you start?

You are, I hope, beginning to see that this exercise is well worth the effort. After you have mapped out income, turn to expenses. Perhaps some of the assumptions that you’ve made on income will affect expenses; for example, adding a new procedure may require the purchase of new equipment. If you have a higher census goal, you may need an additional assistant.

If you’re considering adding an associate, you can determine if he or she will bring in enough revenue to cover salary and expenses by completing two versions of next year’s projected budget – one with the associate and one without.

Once you have prepared your budget, follow it. Your accountant or manager can generate monthly spreadsheets comparing actual financials with projections, and the year-to-date, compared with previous years. There are many parameters to explore.

Look for deviations from predictions and possible reasons for them, such as factors you didn’t (or couldn’t) anticipate. Make a note of them; it will help you with next year’s projections.

A budget can be justified in two major ways: You’ll better understand where your practice is going, and the forces at work to change it. And you’ll become aware of unexpected events while there is still time to influence them, rather than making such discoveries well after the fact – or worse, never finding out at all.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

For many years, I chaired the office efficiency course at the American Academy of Dermatology’s annual meeting. Each year, I asked how many participants compiled a yearly budget for their practices. In an audience of 400, the largest affirmative response I ever received was three, and some years there were no raised hands at all.

Why do physicians so vigorously resist an exercise that is so basic to every other business and profession on the planet? Typically, I hear one of two reasons: It’s tedious, or my colleagues seem to be doing just fine without one.

But the days of "doing just fine" are coming to an end. As competition for patients increases, expenses continue their upward spiral, and the government continues its steady encroachment on private practice, physicians who plan ahead will have an advantage.

Budgeting need not be tedious; determine what you need to do yourself and what can be delegated. And now, as the year winds down, is an excellent opportunity to map out your finances.

The first step – the basic gathering of numbers that everyone seems to dread – can be delegated. Ask your accountant to compile the practice’s gross income over the last 12 months, in monthly increments.

Break it down by type of service: office visits, hospital visits, surgery, lab fees, and so on, listing both the amounts billed and collected. This is not only for calculations of collection ratios, but to determine your "seasonality" – which I’ll discuss in greater detail next month. Do the same for expenses, and again break them down by category: salaries, rent/mortgage, business and medical supplies, and so on.

In many cases, the mere collection of this raw data will save money. You might discover, for example, that expenditures for business supplies are unexpectedly high. Perhaps a competing vendor can do better, or perhaps you have an overuse or theft problem.

Once the numbers are accumulated, start extrapolating them into next year. If your income rose by, say, 6% this year, can you expect a similar rise next year? Why or why not? To get a fix on a realistic goal, go through each component of your gross income and decide where the increase could come from. Can you raise prices for office visits or cosmetic procedures, renegotiate at least one third-party contract, or add another exam room in order to see more patients?

Perhaps there is an impending change in your area that you can factor in, such as a competitor who is retiring. If that physician is known for a specific service, and it’s not a service you offer, could you start?

You are, I hope, beginning to see that this exercise is well worth the effort. After you have mapped out income, turn to expenses. Perhaps some of the assumptions that you’ve made on income will affect expenses; for example, adding a new procedure may require the purchase of new equipment. If you have a higher census goal, you may need an additional assistant.

If you’re considering adding an associate, you can determine if he or she will bring in enough revenue to cover salary and expenses by completing two versions of next year’s projected budget – one with the associate and one without.

Once you have prepared your budget, follow it. Your accountant or manager can generate monthly spreadsheets comparing actual financials with projections, and the year-to-date, compared with previous years. There are many parameters to explore.

Look for deviations from predictions and possible reasons for them, such as factors you didn’t (or couldn’t) anticipate. Make a note of them; it will help you with next year’s projections.

A budget can be justified in two major ways: You’ll better understand where your practice is going, and the forces at work to change it. And you’ll become aware of unexpected events while there is still time to influence them, rather than making such discoveries well after the fact – or worse, never finding out at all.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

For many years, I chaired the office efficiency course at the American Academy of Dermatology’s annual meeting. Each year, I asked how many participants compiled a yearly budget for their practices. In an audience of 400, the largest affirmative response I ever received was three, and some years there were no raised hands at all.

Why do physicians so vigorously resist an exercise that is so basic to every other business and profession on the planet? Typically, I hear one of two reasons: It’s tedious, or my colleagues seem to be doing just fine without one.

But the days of "doing just fine" are coming to an end. As competition for patients increases, expenses continue their upward spiral, and the government continues its steady encroachment on private practice, physicians who plan ahead will have an advantage.

Budgeting need not be tedious; determine what you need to do yourself and what can be delegated. And now, as the year winds down, is an excellent opportunity to map out your finances.

The first step – the basic gathering of numbers that everyone seems to dread – can be delegated. Ask your accountant to compile the practice’s gross income over the last 12 months, in monthly increments.

Break it down by type of service: office visits, hospital visits, surgery, lab fees, and so on, listing both the amounts billed and collected. This is not only for calculations of collection ratios, but to determine your "seasonality" – which I’ll discuss in greater detail next month. Do the same for expenses, and again break them down by category: salaries, rent/mortgage, business and medical supplies, and so on.

In many cases, the mere collection of this raw data will save money. You might discover, for example, that expenditures for business supplies are unexpectedly high. Perhaps a competing vendor can do better, or perhaps you have an overuse or theft problem.

Once the numbers are accumulated, start extrapolating them into next year. If your income rose by, say, 6% this year, can you expect a similar rise next year? Why or why not? To get a fix on a realistic goal, go through each component of your gross income and decide where the increase could come from. Can you raise prices for office visits or cosmetic procedures, renegotiate at least one third-party contract, or add another exam room in order to see more patients?

Perhaps there is an impending change in your area that you can factor in, such as a competitor who is retiring. If that physician is known for a specific service, and it’s not a service you offer, could you start?

You are, I hope, beginning to see that this exercise is well worth the effort. After you have mapped out income, turn to expenses. Perhaps some of the assumptions that you’ve made on income will affect expenses; for example, adding a new procedure may require the purchase of new equipment. If you have a higher census goal, you may need an additional assistant.

If you’re considering adding an associate, you can determine if he or she will bring in enough revenue to cover salary and expenses by completing two versions of next year’s projected budget – one with the associate and one without.

Once you have prepared your budget, follow it. Your accountant or manager can generate monthly spreadsheets comparing actual financials with projections, and the year-to-date, compared with previous years. There are many parameters to explore.

Look for deviations from predictions and possible reasons for them, such as factors you didn’t (or couldn’t) anticipate. Make a note of them; it will help you with next year’s projections.

A budget can be justified in two major ways: You’ll better understand where your practice is going, and the forces at work to change it. And you’ll become aware of unexpected events while there is still time to influence them, rather than making such discoveries well after the fact – or worse, never finding out at all.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

Until last month, I had only ever had two positive pregnancy test results in women of child-bearing age taking isotretinoin. Both of the previous reports came in on the same day, one after the other. When I called each patient to give her the results, and asked her to repeat the test, neither was at all perturbed. "If I’m pregnant," laughed one, "it would be another Immaculate Conception."

Both results turned out to be laboratory errors committed by a single technician, who was reported and rebuked. Repeat tests were negative.

Then, last month, I got another positive. Victoria had actually completed her treatment course 6 weeks earlier, and had already obtained a 30-day post-treatment test – which was negative. Then, she had another test done a few weeks later, which was positive.

I called and got her mother, who asked, "Is everything all right?" But Victoria is 19, so I just said I needed her daughter’s cell phone number.

"We had a condom accident," Victoria said when I reached her. We reviewed her case, determining the last day she had actually taken the medication. Her sexual activity had clearly taken place more than 30 days later.

I suggested she contact her gynecologist at once, to be evaluated and to have the pregnancy test repeated, and I faxed a note to that physician with the relevant details. "If pregnancy is confirmed," I told her, "I’m sure you’ll consider many things before you decide what to do. But one thing you don’t have to factor in is your isotretinoin treatment, because it was no longer in your blood when you became pregnant."

A few days later, Victoria came to my office. "I’ve decided to end the pregnancy," she said. "This just isn’t the right time."

I told her I understood. "By the way," I said, "you listed your two methods of contraception as the patch and condoms. So even if the condom failed, it looks like the patch did too."

"No," said Victoria, "I wasn’t on the patch anymore."

"What?!" I exclaimed.

"I ran out a month earlier," she said, "and my regular doctor was out on maternity leave."

"Wasn’t there anyone else in her office who could refill it for you?" I asked.

"I guess so," she said, "but I kept calling and pushing the button for ‘prescription refills,’ and no one ever called back."

I tried my best not to shake my head in disbelief. Victoria is an intelligent young woman. There is no language barrier. We had discussed contraception before she started therapy, and she signed all the right forms. Each month she got a pregnancy test. Each month she went online and answered the contraceptive-related questions before she could get more isotretinoin.

And when she ran out of contraceptive patches, she didn’t get them refilled.

Victoria’s story could have been worse. She might have become pregnant while still taking isotretinoin. She might have been forced to make a decision to terminate a pregnancy she otherwise would have wanted to carry to term.

Victoria’s story speaks for itself. Despite our best efforts, persuasive or bureaucratic, people will sometimes act in ways that they themselves know perfectly well are against their own interests.

The newest iPledge program upgrade includes some changes, some of which are helpful. One novelty, however, is that if "Abstinence" is the first form of contraception, "None" automatically becomes the second – there is a new warning that this is "Not recommended." This means we should not rely on a patient’s self-reported abstinence, but are better off relying on her use of artificial contraception. Perhaps. But perhaps not. Contraception only works if you use it.

Humans have what a psychiatrist I know calls "design flaws." If ever called upon to redesign the species, I’m sure many of us would contribute some good ideas. In the meantime, however, all we can do is try to acknowledge these flaws, and do our best to mitigate their impact.

After all, we have them ourselves.

Dr. Rockoff practices dermatology in Brookline, Mass. 

Until last month, I had only ever had two positive pregnancy test results in women of child-bearing age taking isotretinoin. Both of the previous reports came in on the same day, one after the other. When I called each patient to give her the results, and asked her to repeat the test, neither was at all perturbed. "If I’m pregnant," laughed one, "it would be another Immaculate Conception."

Both results turned out to be laboratory errors committed by a single technician, who was reported and rebuked. Repeat tests were negative.

Then, last month, I got another positive. Victoria had actually completed her treatment course 6 weeks earlier, and had already obtained a 30-day post-treatment test – which was negative. Then, she had another test done a few weeks later, which was positive.

I called and got her mother, who asked, "Is everything all right?" But Victoria is 19, so I just said I needed her daughter’s cell phone number.

"We had a condom accident," Victoria said when I reached her. We reviewed her case, determining the last day she had actually taken the medication. Her sexual activity had clearly taken place more than 30 days later.

I suggested she contact her gynecologist at once, to be evaluated and to have the pregnancy test repeated, and I faxed a note to that physician with the relevant details. "If pregnancy is confirmed," I told her, "I’m sure you’ll consider many things before you decide what to do. But one thing you don’t have to factor in is your isotretinoin treatment, because it was no longer in your blood when you became pregnant."

A few days later, Victoria came to my office. "I’ve decided to end the pregnancy," she said. "This just isn’t the right time."

I told her I understood. "By the way," I said, "you listed your two methods of contraception as the patch and condoms. So even if the condom failed, it looks like the patch did too."

"No," said Victoria, "I wasn’t on the patch anymore."

"What?!" I exclaimed.

"I ran out a month earlier," she said, "and my regular doctor was out on maternity leave."

"Wasn’t there anyone else in her office who could refill it for you?" I asked.

"I guess so," she said, "but I kept calling and pushing the button for ‘prescription refills,’ and no one ever called back."

I tried my best not to shake my head in disbelief. Victoria is an intelligent young woman. There is no language barrier. We had discussed contraception before she started therapy, and she signed all the right forms. Each month she got a pregnancy test. Each month she went online and answered the contraceptive-related questions before she could get more isotretinoin.

And when she ran out of contraceptive patches, she didn’t get them refilled.

Victoria’s story could have been worse. She might have become pregnant while still taking isotretinoin. She might have been forced to make a decision to terminate a pregnancy she otherwise would have wanted to carry to term.

Victoria’s story speaks for itself. Despite our best efforts, persuasive or bureaucratic, people will sometimes act in ways that they themselves know perfectly well are against their own interests.

The newest iPledge program upgrade includes some changes, some of which are helpful. One novelty, however, is that if "Abstinence" is the first form of contraception, "None" automatically becomes the second – there is a new warning that this is "Not recommended." This means we should not rely on a patient’s self-reported abstinence, but are better off relying on her use of artificial contraception. Perhaps. But perhaps not. Contraception only works if you use it.

Humans have what a psychiatrist I know calls "design flaws." If ever called upon to redesign the species, I’m sure many of us would contribute some good ideas. In the meantime, however, all we can do is try to acknowledge these flaws, and do our best to mitigate their impact.

After all, we have them ourselves.

Dr. Rockoff practices dermatology in Brookline, Mass. 

Until last month, I had only ever had two positive pregnancy test results in women of child-bearing age taking isotretinoin. Both of the previous reports came in on the same day, one after the other. When I called each patient to give her the results, and asked her to repeat the test, neither was at all perturbed. "If I’m pregnant," laughed one, "it would be another Immaculate Conception."

Both results turned out to be laboratory errors committed by a single technician, who was reported and rebuked. Repeat tests were negative.

Then, last month, I got another positive. Victoria had actually completed her treatment course 6 weeks earlier, and had already obtained a 30-day post-treatment test – which was negative. Then, she had another test done a few weeks later, which was positive.

I called and got her mother, who asked, "Is everything all right?" But Victoria is 19, so I just said I needed her daughter’s cell phone number.

"We had a condom accident," Victoria said when I reached her. We reviewed her case, determining the last day she had actually taken the medication. Her sexual activity had clearly taken place more than 30 days later.

I suggested she contact her gynecologist at once, to be evaluated and to have the pregnancy test repeated, and I faxed a note to that physician with the relevant details. "If pregnancy is confirmed," I told her, "I’m sure you’ll consider many things before you decide what to do. But one thing you don’t have to factor in is your isotretinoin treatment, because it was no longer in your blood when you became pregnant."

A few days later, Victoria came to my office. "I’ve decided to end the pregnancy," she said. "This just isn’t the right time."

I told her I understood. "By the way," I said, "you listed your two methods of contraception as the patch and condoms. So even if the condom failed, it looks like the patch did too."

"No," said Victoria, "I wasn’t on the patch anymore."

"What?!" I exclaimed.

"I ran out a month earlier," she said, "and my regular doctor was out on maternity leave."

"Wasn’t there anyone else in her office who could refill it for you?" I asked.

"I guess so," she said, "but I kept calling and pushing the button for ‘prescription refills,’ and no one ever called back."

I tried my best not to shake my head in disbelief. Victoria is an intelligent young woman. There is no language barrier. We had discussed contraception before she started therapy, and she signed all the right forms. Each month she got a pregnancy test. Each month she went online and answered the contraceptive-related questions before she could get more isotretinoin.

And when she ran out of contraceptive patches, she didn’t get them refilled.

Victoria’s story could have been worse. She might have become pregnant while still taking isotretinoin. She might have been forced to make a decision to terminate a pregnancy she otherwise would have wanted to carry to term.

Victoria’s story speaks for itself. Despite our best efforts, persuasive or bureaucratic, people will sometimes act in ways that they themselves know perfectly well are against their own interests.

The newest iPledge program upgrade includes some changes, some of which are helpful. One novelty, however, is that if "Abstinence" is the first form of contraception, "None" automatically becomes the second – there is a new warning that this is "Not recommended." This means we should not rely on a patient’s self-reported abstinence, but are better off relying on her use of artificial contraception. Perhaps. But perhaps not. Contraception only works if you use it.

Humans have what a psychiatrist I know calls "design flaws." If ever called upon to redesign the species, I’m sure many of us would contribute some good ideas. In the meantime, however, all we can do is try to acknowledge these flaws, and do our best to mitigate their impact.

After all, we have them ourselves.

Dr. Rockoff practices dermatology in Brookline, Mass. 

Managing chronic pain in an older adult can be a complicated task, with risks for adverse effects, under- or overmedication, and nonadherence. Pain can be alleviated in many cases, however, if you address potential complications and barriers to effective treatment when prescribing analgesic medications.

Pain is a part of daily life for many older adults

As many as 50% of community-dwelling older adults experience a chronic pain disorder, defined as pain on most days for at least 3 consecutive months.¹ Prevalence rates are typically higher (49%-84%) among residents of long-term care facilities.² Untreated chronic pain can lead to health consequences such as depression, decreased ability to socialize, impaired ambulation, impaired sleep, increased falls, malnutrition, and decreased quality of life.^1,3 Among older women, pain is the most common reported cause of impairment in activities of daily living.⁴

Arthritis and arthritis-related diseases (such as back pain) are common causes of chronic pain in older adults.⁵ Other causes include neuropathies, vertebral compression fractures, cancer and cancer treatments, and advanced chronic diseases such as end-stage heart, lung, and kidney disease.^6-10

Substantial literature documents that chronic pain is underdetected and undertreated with advancing age^11,12 and strongly supports efforts to improve pain care in later life. Treatment guidelines recommend a multimodal approach, including evidence-based nonpharmacologic treatments such as cognitive-behavioral therapy, exercise, and physical therapy.¹ At the same time, pharmacotherapies remain the primary treatment used by physicians,¹³ and studies indicate that older people use analgesics frequently:

• When 551 older black and non-Hispanic white adults with osteoarthritis were interviewed, more than 80% of each group reported regular use of prescription and over-the-counter (OTC) analgesic medications.¹⁴
• In a cross-sectional study of 272 community-dwelling older adults with chronic pain from diverse causes, 59% reported routine use of an analgesic medication.¹⁵

The following 6 steps can improve the likelihood of a successful analgesic trial when managing chronic pain in people ages 65 and older. They take into account barriers you are likely to encounter, including polypharmacy, multimorbidity, cognitive and sensory impairment, sociodemographic factors, specific health beliefs about pain and pain treatments, and age-related physiologic changes.

TABLE

Refine your approach to chronic pain in older patients with these 6 steps

Step 1. Conduct a comprehensive pain history

The first step in pain management is to perform a comprehensive pain assessment. Without a proper pain assessment, it will be difficult to effectively treat and monitor response to treatment. Whichever pain scale you decide to use, it is important to use the same pain scale consistently each time a pain assessment takes place.³ The numeric rating scale and verbal descriptor scales (or pain thermometer) are widely used and have been shown to be preferred in the older adult population.^3,16 The numeric rating scale asks a patient to rate his or her pain on a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain imaginable. The verbal descriptor scale is a measure of pain intensity on a vertical scale (typically a thermometer) from “no pain” to “excruciating.”³

Recommendations. In addition to assessing the intensity of the pain using a pain assessment tool, it is important to determine certain characteristics of the pain. What is the location and quality of the pain? Ask patients how the pain limits them. What prior treatments have been tried and failed? What has worked the best? What treatment/coping strategies are they using now? Have they had any intolerable adverse effects from specific treatments? Reliable predictors of treatment response require further definition,¹⁷ but a successful trial of a given analgesic in the past is often a good indicator of what might work again.

Step 2. Review the patient’s problem list

Use of multiple medications. Polypharmacy—with 5 or more being a typical threshold criterion—is common in people ages 65 and older and frequently complicates the pharmacologic management of chronic pain.^16,18 Complications most often occur as a result of drug-drug interactions.

Multiple coexisting chronic conditions. Multimorbidity is common in older adults with chronic pain. Consider co-occurring diabetes, hypertension, and osteoporosis when initiating any trial of a pain medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in treating pain syndromes, but their use can be hazardous in older individuals, particularly those with coexisting hypertension, cardiovascular disease, history of peptic ulcer disease or gastropathy, or impaired renal function. NSAID use has been implicated as a cause of approximately one-quarter of all hospitalizations related to drug adverse effects among adults over age 65.¹

The geriatric syndrome of frailty is defined by deficits in physiologic reserve and decreased resistance to multiple stressors.¹⁹ Risk of fracture is a particular concern of clinicians, older patients, and their caregivers. Opioids are the analgesic medications most often associated with increased fracture risk. In a recent analysis of Medicare claims data, opioid users were found to have a significantly increased fracture risk compared with users of nonselective NSAIDs.²⁰ Mechanisms underlying this association include opioid-associated cognitive dysfunction and worsening gait/balance function.

Recommendations. Obtain a full list of the patient’s medications, including all OTC and complementary preparations. Also consider chronic kidney problems, liver disease, movement disorders, and neurologic problems when selecting a pharmacologic agent. Consider what chronic conditions might be made worse by an analgesic trial or would operate as a contraindication to starting a specific pain medication. Establish which medications or comorbidities might modify your treatment choices.

Step 3. Establish the patient’s treatment goals

We recommend shared decision-making when planning treatment and monitoring outcomes for older adults with chronic pain. Use your patient’s reports of the experience of pain— including pain intensity and how pain affects daily functioning¹ —and identify his or her treatment goals, which might differ from yours. You may be aiming for the best pain relief possible, but your patient might be focused on practical issues such as increased mobility or ability to socialize. By talking openly, you can reach consensus and agree upon realistic treatment goals.

This approach can improve patients’ outcomes and satisfaction with treatment; it also has been shown to improve physician satisfaction when treating patients with chronic pain.²¹ In a recent qualitative study, older individuals varied in how much they wanted to participate in making decisions and being a “source of control” in their pain treatment. ²² Some patients—particularly those ages 80 and older—prefer to have their physicians make treatment decisions for them, whereas others embrace active participation. Regardless of how much older individuals wish to share in treatment decisions, they all value being listened to and understood by their physicians.²¹

Recommendations. The patient’s goals and expectations for treatment may or may not be the same as yours. Before starting a medication trial, address potential unrealistic expectations such as complete relief of pain or a belief that treatment is not likely to help. Come to a mutual decision as to what constitutes the most important outcomes, and you will then be able to monitor and assess treatment success.

Step 4. Identify barriers to initiating and adhering to therapy

Cognitive impairment is a strong risk factor for undertreatment of pain. It can lead to underreporting of pain by patients or difficulty for clinicians in assessing treatment response from those who are unable to communicate pain effectively. A study of nursing home residents found that only 56% of those with cognitive impairment received pain medications, compared with 80% of those with intact cognition.²³ Older patients with cognitive deficits and memory loss also may take analgesic medications inappropriately or forget when/if they took them, increasing the risk of undertreatment or overdosing.

Sensory impairment. Patients with visual deficits may have difficulty reading prescription bottle labels and information sheets. Those with auditory deficits may have trouble hearing, communicating, and understanding treatment instructions during a busy clinical encounter.

Sociodemographic factors. Many older adults live alone and have limited social support to encourage medication adherence.²⁴ Some have significant caregiving responsibilities of their own (such as a spouse in poor health), which can lead to stress and inconsistent use of prescribed medications.²⁵ Some older adults can’t afford the costs of certain pain medications and may take less than the prescribed amount.

Many older adults lack the necessary skills to read and process basic health care information, including understanding pill bottle instructions, information that appears in patient handouts, and clinicians’ instructions about possible adverse effects.^26,27 Low health literacy can lead to problems with medication adherence (taking too much or too little of an analgesic medication) and associated complications.

Health beliefs. Many older adults believe chronic pain is a natural part of aging; in one study, this was true of 61% of approximately 700 primary care patients with osteoarthritis pain.²⁸ Some older adults believe pain only gets worse over time,²⁸ and others believe treatment for pain is not likely to provide any meaningful benefit.^29,30 Beliefs such as these can lead to stoicism or acceptance of the status quo.³¹

Older adults also may endorse beliefs about pain medications that are likely to decrease their willingness to engage in, or adhere to, recommended pharmacologic interventions. Some use pain medicines sparingly because they fear addiction or dependence.^32,33 Caregivers—often a spouse or adult child—also may express fears about the possibility of addiction.³² Finally, some older adults believe that using prescription analgesic medications invariably results in adverse effects;³² those who endorse this belief report minimizing medication use except when the pain is “very bad.”³⁴

Recommendations. Elicit concerns patients may have about using analgesic medications and discuss them openly. Although not all barriers (such as economic issues) are modifiable, most (such as beliefs that pain medications are addictive) can be successfully addressed through patient education.

If other social support, such as a family member or caregiver in the home, could positively affect analgesic engagement/adherence, include these facilitators when discussing treatment decisions and in monitoring for medication effectiveness and adverse effects.

Step 5. Start low and go slow when initiating analgesia

Advancing age is associated with increased sensitivity to the anticholinergic effects of many commonly prescribed and OTC medications, including NSAIDs and opioids.³⁵ Increasing the anticholinergic load can lead to cognitive impairments, including confusion, which can be particularly troublesome for older adults.¹

Changes in pharmacokinetics (what the body does to the drug in terms of altering absorption, distribution, metabolism and excretion) and pharmacodynamics (what the drug does to the body in the form of adverse effects) occur as a function of advancing age. ¹ Body fat increases by 20% to 40% on average, which increases the volume of distribution for fat-soluble medications.¹⁶ Hepatic and renal clearance decrease, leading to an increased half-life and decreased excretion of medications cleared by the liver or kidneys. Age-associated changes in gastrointestinal (GI) absorption and function include slower GI transit times and the possibility of increased opioid-related constipation from dysmotility problems.¹

As a result of these physiologic changes, advancing age is associated with a greater incidence of drug-related adverse effects. Even so, individuals within the older population are highly heterogeneous, and no geriatric-specific dosing guidelines exist for prescribing pain medications to older adults.

Recommendations. We recommend the adage “start low and go slow” when initiating an analgesic trial for an older patient with chronic pain. This does not mean you should “start low and stay low,” which can contribute to undertreatment.³⁶ If treatment goals are not being met and the patient is tolerating the therapy, advancing the dose is reasonable before moving on to another intervention.

Step 6. Assess for effects and outcomes outside the office

Adverse effects are a primary reason older adults discontinue an analgesic trial.³⁷ Make certain the patient (or caregiver, as appropriate) understands what adverse effects might occur, and create a plan to address them if they do.

Recommendations. Because many older people are reluctant to communicate with their physicians outside of an office visit, establish how often and when communication should occur. Telephone calls and/or e-mail are practical tools for patients to communicate questions or concerns to you, and you can enhance treatment outcomes with timely replies. In the near future, mobile health technologies may play a key role in monitoring for adverse effects and communicating positive treatment outcomes.

Managing chronic pain in an older adult can be a complicated task, with risks for adverse effects, under- or overmedication, and nonadherence. Pain can be alleviated in many cases, however, if you address potential complications and barriers to effective treatment when prescribing analgesic medications.

Pain is a part of daily life for many older adults

As many as 50% of community-dwelling older adults experience a chronic pain disorder, defined as pain on most days for at least 3 consecutive months.¹ Prevalence rates are typically higher (49%-84%) among residents of long-term care facilities.² Untreated chronic pain can lead to health consequences such as depression, decreased ability to socialize, impaired ambulation, impaired sleep, increased falls, malnutrition, and decreased quality of life.^1,3 Among older women, pain is the most common reported cause of impairment in activities of daily living.⁴

Arthritis and arthritis-related diseases (such as back pain) are common causes of chronic pain in older adults.⁵ Other causes include neuropathies, vertebral compression fractures, cancer and cancer treatments, and advanced chronic diseases such as end-stage heart, lung, and kidney disease.^6-10

Substantial literature documents that chronic pain is underdetected and undertreated with advancing age^11,12 and strongly supports efforts to improve pain care in later life. Treatment guidelines recommend a multimodal approach, including evidence-based nonpharmacologic treatments such as cognitive-behavioral therapy, exercise, and physical therapy.¹ At the same time, pharmacotherapies remain the primary treatment used by physicians,¹³ and studies indicate that older people use analgesics frequently:

• When 551 older black and non-Hispanic white adults with osteoarthritis were interviewed, more than 80% of each group reported regular use of prescription and over-the-counter (OTC) analgesic medications.¹⁴
• In a cross-sectional study of 272 community-dwelling older adults with chronic pain from diverse causes, 59% reported routine use of an analgesic medication.¹⁵

The following 6 steps can improve the likelihood of a successful analgesic trial when managing chronic pain in people ages 65 and older. They take into account barriers you are likely to encounter, including polypharmacy, multimorbidity, cognitive and sensory impairment, sociodemographic factors, specific health beliefs about pain and pain treatments, and age-related physiologic changes.

TABLE

Refine your approach to chronic pain in older patients with these 6 steps

Step 1. Conduct a comprehensive pain history

The first step in pain management is to perform a comprehensive pain assessment. Without a proper pain assessment, it will be difficult to effectively treat and monitor response to treatment. Whichever pain scale you decide to use, it is important to use the same pain scale consistently each time a pain assessment takes place.³ The numeric rating scale and verbal descriptor scales (or pain thermometer) are widely used and have been shown to be preferred in the older adult population.^3,16 The numeric rating scale asks a patient to rate his or her pain on a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain imaginable. The verbal descriptor scale is a measure of pain intensity on a vertical scale (typically a thermometer) from “no pain” to “excruciating.”³

Recommendations. In addition to assessing the intensity of the pain using a pain assessment tool, it is important to determine certain characteristics of the pain. What is the location and quality of the pain? Ask patients how the pain limits them. What prior treatments have been tried and failed? What has worked the best? What treatment/coping strategies are they using now? Have they had any intolerable adverse effects from specific treatments? Reliable predictors of treatment response require further definition,¹⁷ but a successful trial of a given analgesic in the past is often a good indicator of what might work again.

Step 2. Review the patient’s problem list

Use of multiple medications. Polypharmacy—with 5 or more being a typical threshold criterion—is common in people ages 65 and older and frequently complicates the pharmacologic management of chronic pain.^16,18 Complications most often occur as a result of drug-drug interactions.

Multiple coexisting chronic conditions. Multimorbidity is common in older adults with chronic pain. Consider co-occurring diabetes, hypertension, and osteoporosis when initiating any trial of a pain medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in treating pain syndromes, but their use can be hazardous in older individuals, particularly those with coexisting hypertension, cardiovascular disease, history of peptic ulcer disease or gastropathy, or impaired renal function. NSAID use has been implicated as a cause of approximately one-quarter of all hospitalizations related to drug adverse effects among adults over age 65.¹

The geriatric syndrome of frailty is defined by deficits in physiologic reserve and decreased resistance to multiple stressors.¹⁹ Risk of fracture is a particular concern of clinicians, older patients, and their caregivers. Opioids are the analgesic medications most often associated with increased fracture risk. In a recent analysis of Medicare claims data, opioid users were found to have a significantly increased fracture risk compared with users of nonselective NSAIDs.²⁰ Mechanisms underlying this association include opioid-associated cognitive dysfunction and worsening gait/balance function.

Recommendations. Obtain a full list of the patient’s medications, including all OTC and complementary preparations. Also consider chronic kidney problems, liver disease, movement disorders, and neurologic problems when selecting a pharmacologic agent. Consider what chronic conditions might be made worse by an analgesic trial or would operate as a contraindication to starting a specific pain medication. Establish which medications or comorbidities might modify your treatment choices.

Step 3. Establish the patient’s treatment goals

We recommend shared decision-making when planning treatment and monitoring outcomes for older adults with chronic pain. Use your patient’s reports of the experience of pain— including pain intensity and how pain affects daily functioning¹ —and identify his or her treatment goals, which might differ from yours. You may be aiming for the best pain relief possible, but your patient might be focused on practical issues such as increased mobility or ability to socialize. By talking openly, you can reach consensus and agree upon realistic treatment goals.

This approach can improve patients’ outcomes and satisfaction with treatment; it also has been shown to improve physician satisfaction when treating patients with chronic pain.²¹ In a recent qualitative study, older individuals varied in how much they wanted to participate in making decisions and being a “source of control” in their pain treatment. ²² Some patients—particularly those ages 80 and older—prefer to have their physicians make treatment decisions for them, whereas others embrace active participation. Regardless of how much older individuals wish to share in treatment decisions, they all value being listened to and understood by their physicians.²¹

Recommendations. The patient’s goals and expectations for treatment may or may not be the same as yours. Before starting a medication trial, address potential unrealistic expectations such as complete relief of pain or a belief that treatment is not likely to help. Come to a mutual decision as to what constitutes the most important outcomes, and you will then be able to monitor and assess treatment success.

Step 4. Identify barriers to initiating and adhering to therapy

Cognitive impairment is a strong risk factor for undertreatment of pain. It can lead to underreporting of pain by patients or difficulty for clinicians in assessing treatment response from those who are unable to communicate pain effectively. A study of nursing home residents found that only 56% of those with cognitive impairment received pain medications, compared with 80% of those with intact cognition.²³ Older patients with cognitive deficits and memory loss also may take analgesic medications inappropriately or forget when/if they took them, increasing the risk of undertreatment or overdosing.

Sensory impairment. Patients with visual deficits may have difficulty reading prescription bottle labels and information sheets. Those with auditory deficits may have trouble hearing, communicating, and understanding treatment instructions during a busy clinical encounter.

Sociodemographic factors. Many older adults live alone and have limited social support to encourage medication adherence.²⁴ Some have significant caregiving responsibilities of their own (such as a spouse in poor health), which can lead to stress and inconsistent use of prescribed medications.²⁵ Some older adults can’t afford the costs of certain pain medications and may take less than the prescribed amount.

Many older adults lack the necessary skills to read and process basic health care information, including understanding pill bottle instructions, information that appears in patient handouts, and clinicians’ instructions about possible adverse effects.^26,27 Low health literacy can lead to problems with medication adherence (taking too much or too little of an analgesic medication) and associated complications.

Health beliefs. Many older adults believe chronic pain is a natural part of aging; in one study, this was true of 61% of approximately 700 primary care patients with osteoarthritis pain.²⁸ Some older adults believe pain only gets worse over time,²⁸ and others believe treatment for pain is not likely to provide any meaningful benefit.^29,30 Beliefs such as these can lead to stoicism or acceptance of the status quo.³¹

Older adults also may endorse beliefs about pain medications that are likely to decrease their willingness to engage in, or adhere to, recommended pharmacologic interventions. Some use pain medicines sparingly because they fear addiction or dependence.^32,33 Caregivers—often a spouse or adult child—also may express fears about the possibility of addiction.³² Finally, some older adults believe that using prescription analgesic medications invariably results in adverse effects;³² those who endorse this belief report minimizing medication use except when the pain is “very bad.”³⁴

Recommendations. Elicit concerns patients may have about using analgesic medications and discuss them openly. Although not all barriers (such as economic issues) are modifiable, most (such as beliefs that pain medications are addictive) can be successfully addressed through patient education.

If other social support, such as a family member or caregiver in the home, could positively affect analgesic engagement/adherence, include these facilitators when discussing treatment decisions and in monitoring for medication effectiveness and adverse effects.

Step 5. Start low and go slow when initiating analgesia

Advancing age is associated with increased sensitivity to the anticholinergic effects of many commonly prescribed and OTC medications, including NSAIDs and opioids.³⁵ Increasing the anticholinergic load can lead to cognitive impairments, including confusion, which can be particularly troublesome for older adults.¹

Changes in pharmacokinetics (what the body does to the drug in terms of altering absorption, distribution, metabolism and excretion) and pharmacodynamics (what the drug does to the body in the form of adverse effects) occur as a function of advancing age. ¹ Body fat increases by 20% to 40% on average, which increases the volume of distribution for fat-soluble medications.¹⁶ Hepatic and renal clearance decrease, leading to an increased half-life and decreased excretion of medications cleared by the liver or kidneys. Age-associated changes in gastrointestinal (GI) absorption and function include slower GI transit times and the possibility of increased opioid-related constipation from dysmotility problems.¹

As a result of these physiologic changes, advancing age is associated with a greater incidence of drug-related adverse effects. Even so, individuals within the older population are highly heterogeneous, and no geriatric-specific dosing guidelines exist for prescribing pain medications to older adults.

Recommendations. We recommend the adage “start low and go slow” when initiating an analgesic trial for an older patient with chronic pain. This does not mean you should “start low and stay low,” which can contribute to undertreatment.³⁶ If treatment goals are not being met and the patient is tolerating the therapy, advancing the dose is reasonable before moving on to another intervention.

Step 6. Assess for effects and outcomes outside the office

Adverse effects are a primary reason older adults discontinue an analgesic trial.³⁷ Make certain the patient (or caregiver, as appropriate) understands what adverse effects might occur, and create a plan to address them if they do.

Recommendations. Because many older people are reluctant to communicate with their physicians outside of an office visit, establish how often and when communication should occur. Telephone calls and/or e-mail are practical tools for patients to communicate questions or concerns to you, and you can enhance treatment outcomes with timely replies. In the near future, mobile health technologies may play a key role in monitoring for adverse effects and communicating positive treatment outcomes.

Managing chronic pain in an older adult can be a complicated task, with risks for adverse effects, under- or overmedication, and nonadherence. Pain can be alleviated in many cases, however, if you address potential complications and barriers to effective treatment when prescribing analgesic medications.

Pain is a part of daily life for many older adults

As many as 50% of community-dwelling older adults experience a chronic pain disorder, defined as pain on most days for at least 3 consecutive months.¹ Prevalence rates are typically higher (49%-84%) among residents of long-term care facilities.² Untreated chronic pain can lead to health consequences such as depression, decreased ability to socialize, impaired ambulation, impaired sleep, increased falls, malnutrition, and decreased quality of life.^1,3 Among older women, pain is the most common reported cause of impairment in activities of daily living.⁴

Arthritis and arthritis-related diseases (such as back pain) are common causes of chronic pain in older adults.⁵ Other causes include neuropathies, vertebral compression fractures, cancer and cancer treatments, and advanced chronic diseases such as end-stage heart, lung, and kidney disease.^6-10

Substantial literature documents that chronic pain is underdetected and undertreated with advancing age^11,12 and strongly supports efforts to improve pain care in later life. Treatment guidelines recommend a multimodal approach, including evidence-based nonpharmacologic treatments such as cognitive-behavioral therapy, exercise, and physical therapy.¹ At the same time, pharmacotherapies remain the primary treatment used by physicians,¹³ and studies indicate that older people use analgesics frequently:

• When 551 older black and non-Hispanic white adults with osteoarthritis were interviewed, more than 80% of each group reported regular use of prescription and over-the-counter (OTC) analgesic medications.¹⁴
• In a cross-sectional study of 272 community-dwelling older adults with chronic pain from diverse causes, 59% reported routine use of an analgesic medication.¹⁵

The following 6 steps can improve the likelihood of a successful analgesic trial when managing chronic pain in people ages 65 and older. They take into account barriers you are likely to encounter, including polypharmacy, multimorbidity, cognitive and sensory impairment, sociodemographic factors, specific health beliefs about pain and pain treatments, and age-related physiologic changes.

TABLE

Refine your approach to chronic pain in older patients with these 6 steps

Step 1. Conduct a comprehensive pain history

The first step in pain management is to perform a comprehensive pain assessment. Without a proper pain assessment, it will be difficult to effectively treat and monitor response to treatment. Whichever pain scale you decide to use, it is important to use the same pain scale consistently each time a pain assessment takes place.³ The numeric rating scale and verbal descriptor scales (or pain thermometer) are widely used and have been shown to be preferred in the older adult population.^3,16 The numeric rating scale asks a patient to rate his or her pain on a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain imaginable. The verbal descriptor scale is a measure of pain intensity on a vertical scale (typically a thermometer) from “no pain” to “excruciating.”³

Recommendations. In addition to assessing the intensity of the pain using a pain assessment tool, it is important to determine certain characteristics of the pain. What is the location and quality of the pain? Ask patients how the pain limits them. What prior treatments have been tried and failed? What has worked the best? What treatment/coping strategies are they using now? Have they had any intolerable adverse effects from specific treatments? Reliable predictors of treatment response require further definition,¹⁷ but a successful trial of a given analgesic in the past is often a good indicator of what might work again.

Step 2. Review the patient’s problem list

Use of multiple medications. Polypharmacy—with 5 or more being a typical threshold criterion—is common in people ages 65 and older and frequently complicates the pharmacologic management of chronic pain.^16,18 Complications most often occur as a result of drug-drug interactions.

Multiple coexisting chronic conditions. Multimorbidity is common in older adults with chronic pain. Consider co-occurring diabetes, hypertension, and osteoporosis when initiating any trial of a pain medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in treating pain syndromes, but their use can be hazardous in older individuals, particularly those with coexisting hypertension, cardiovascular disease, history of peptic ulcer disease or gastropathy, or impaired renal function. NSAID use has been implicated as a cause of approximately one-quarter of all hospitalizations related to drug adverse effects among adults over age 65.¹

The geriatric syndrome of frailty is defined by deficits in physiologic reserve and decreased resistance to multiple stressors.¹⁹ Risk of fracture is a particular concern of clinicians, older patients, and their caregivers. Opioids are the analgesic medications most often associated with increased fracture risk. In a recent analysis of Medicare claims data, opioid users were found to have a significantly increased fracture risk compared with users of nonselective NSAIDs.²⁰ Mechanisms underlying this association include opioid-associated cognitive dysfunction and worsening gait/balance function.

Recommendations. Obtain a full list of the patient’s medications, including all OTC and complementary preparations. Also consider chronic kidney problems, liver disease, movement disorders, and neurologic problems when selecting a pharmacologic agent. Consider what chronic conditions might be made worse by an analgesic trial or would operate as a contraindication to starting a specific pain medication. Establish which medications or comorbidities might modify your treatment choices.

Step 3. Establish the patient’s treatment goals

We recommend shared decision-making when planning treatment and monitoring outcomes for older adults with chronic pain. Use your patient’s reports of the experience of pain— including pain intensity and how pain affects daily functioning¹ —and identify his or her treatment goals, which might differ from yours. You may be aiming for the best pain relief possible, but your patient might be focused on practical issues such as increased mobility or ability to socialize. By talking openly, you can reach consensus and agree upon realistic treatment goals.

This approach can improve patients’ outcomes and satisfaction with treatment; it also has been shown to improve physician satisfaction when treating patients with chronic pain.²¹ In a recent qualitative study, older individuals varied in how much they wanted to participate in making decisions and being a “source of control” in their pain treatment. ²² Some patients—particularly those ages 80 and older—prefer to have their physicians make treatment decisions for them, whereas others embrace active participation. Regardless of how much older individuals wish to share in treatment decisions, they all value being listened to and understood by their physicians.²¹

Recommendations. The patient’s goals and expectations for treatment may or may not be the same as yours. Before starting a medication trial, address potential unrealistic expectations such as complete relief of pain or a belief that treatment is not likely to help. Come to a mutual decision as to what constitutes the most important outcomes, and you will then be able to monitor and assess treatment success.

Step 4. Identify barriers to initiating and adhering to therapy

Cognitive impairment is a strong risk factor for undertreatment of pain. It can lead to underreporting of pain by patients or difficulty for clinicians in assessing treatment response from those who are unable to communicate pain effectively. A study of nursing home residents found that only 56% of those with cognitive impairment received pain medications, compared with 80% of those with intact cognition.²³ Older patients with cognitive deficits and memory loss also may take analgesic medications inappropriately or forget when/if they took them, increasing the risk of undertreatment or overdosing.

Sensory impairment. Patients with visual deficits may have difficulty reading prescription bottle labels and information sheets. Those with auditory deficits may have trouble hearing, communicating, and understanding treatment instructions during a busy clinical encounter.

Sociodemographic factors. Many older adults live alone and have limited social support to encourage medication adherence.²⁴ Some have significant caregiving responsibilities of their own (such as a spouse in poor health), which can lead to stress and inconsistent use of prescribed medications.²⁵ Some older adults can’t afford the costs of certain pain medications and may take less than the prescribed amount.

Many older adults lack the necessary skills to read and process basic health care information, including understanding pill bottle instructions, information that appears in patient handouts, and clinicians’ instructions about possible adverse effects.^26,27 Low health literacy can lead to problems with medication adherence (taking too much or too little of an analgesic medication) and associated complications.

Health beliefs. Many older adults believe chronic pain is a natural part of aging; in one study, this was true of 61% of approximately 700 primary care patients with osteoarthritis pain.²⁸ Some older adults believe pain only gets worse over time,²⁸ and others believe treatment for pain is not likely to provide any meaningful benefit.^29,30 Beliefs such as these can lead to stoicism or acceptance of the status quo.³¹

Older adults also may endorse beliefs about pain medications that are likely to decrease their willingness to engage in, or adhere to, recommended pharmacologic interventions. Some use pain medicines sparingly because they fear addiction or dependence.^32,33 Caregivers—often a spouse or adult child—also may express fears about the possibility of addiction.³² Finally, some older adults believe that using prescription analgesic medications invariably results in adverse effects;³² those who endorse this belief report minimizing medication use except when the pain is “very bad.”³⁴

Recommendations. Elicit concerns patients may have about using analgesic medications and discuss them openly. Although not all barriers (such as economic issues) are modifiable, most (such as beliefs that pain medications are addictive) can be successfully addressed through patient education.

If other social support, such as a family member or caregiver in the home, could positively affect analgesic engagement/adherence, include these facilitators when discussing treatment decisions and in monitoring for medication effectiveness and adverse effects.

Step 5. Start low and go slow when initiating analgesia

Advancing age is associated with increased sensitivity to the anticholinergic effects of many commonly prescribed and OTC medications, including NSAIDs and opioids.³⁵ Increasing the anticholinergic load can lead to cognitive impairments, including confusion, which can be particularly troublesome for older adults.¹

Changes in pharmacokinetics (what the body does to the drug in terms of altering absorption, distribution, metabolism and excretion) and pharmacodynamics (what the drug does to the body in the form of adverse effects) occur as a function of advancing age. ¹ Body fat increases by 20% to 40% on average, which increases the volume of distribution for fat-soluble medications.¹⁶ Hepatic and renal clearance decrease, leading to an increased half-life and decreased excretion of medications cleared by the liver or kidneys. Age-associated changes in gastrointestinal (GI) absorption and function include slower GI transit times and the possibility of increased opioid-related constipation from dysmotility problems.¹

As a result of these physiologic changes, advancing age is associated with a greater incidence of drug-related adverse effects. Even so, individuals within the older population are highly heterogeneous, and no geriatric-specific dosing guidelines exist for prescribing pain medications to older adults.

Recommendations. We recommend the adage “start low and go slow” when initiating an analgesic trial for an older patient with chronic pain. This does not mean you should “start low and stay low,” which can contribute to undertreatment.³⁶ If treatment goals are not being met and the patient is tolerating the therapy, advancing the dose is reasonable before moving on to another intervention.

Step 6. Assess for effects and outcomes outside the office

Adverse effects are a primary reason older adults discontinue an analgesic trial.³⁷ Make certain the patient (or caregiver, as appropriate) understands what adverse effects might occur, and create a plan to address them if they do.

Recommendations. Because many older people are reluctant to communicate with their physicians outside of an office visit, establish how often and when communication should occur. Telephone calls and/or e-mail are practical tools for patients to communicate questions or concerns to you, and you can enhance treatment outcomes with timely replies. In the near future, mobile health technologies may play a key role in monitoring for adverse effects and communicating positive treatment outcomes.