Handbook of Pain Relief in Older Adults—An Evidence‐Based Approach

Abstract

There is logic in dealing with pain in older adults. They are after all the group most likely to have chronic pain. The excellent Grampian study [1] showed that two in three older people reported chronic pain of at least 3 months' duration, and in a Danish survey one in three reported 6 month chronic pain [2]. This book does talk about analgesics, invasive pain treatments and, briefly, other measures. None of these chapters, however, is particularly good. The drug sections are reasonably comprehensive lists from an American standpoint, but with little critical thought. The NSAID and COXIB adverse effects section, for instance, makes little mention of the heart failure and renal problems which often make these drugs unsuitable for long-term use in older patients. Similarly, with opioids there is little in the way of principles to guide prescribing. Specifically the problems we see in older patients with long-acting formulations, oral or patch, are not reflected here. The title of the book has the fashionable tag line ‘an evidence-based approach’. I saw little to justify that tag. What is written is opinion-based, backed up with a reference. Often the reference is not to the primary source but to a second-generation opinion. Opinion citing opinion does not justify the tag of an evidence-based approach. Ironically, where the book gets interesting is the politics of pain, and how this impinges on the elderly. I say ironically because this is American polemic for an American context, but it shows how a political system can be manipulated to cope with a neglected medical issue. Legislation around the sound bite of ‘pain as the fourth medical sign’ and the acknowledgement of under treatment of pain as a medical sin has meant that the measurement of pain and its treatment have moved up the agenda, even into nursing homes. A whole chapter is devoted to the way in which medicine can use politics, focused primarily on Maryland, and another one to internet resources on pain. Not surprisingly, these are entirely American. The message for the UK reader is salutary. Pain management here was streets ahead 10 years ago, but the small specialist units are easy targets in the current NHS economies. This is not a useful book outside America, but it left me reflecting how we are moving backwards institutionally compared with other countries, despite our equivalent expertise, and how quickly this is happening.