In 1992, the Agency for Health Care Policy and Research (AHCPR) published its guideline for acute pain management after surgical or medical procedures and trauma. The research-based guideline's four major goals are to

* reduce the incidence and severity of patients' postoperative or posttraumatic pain;

* educate patients about the need to communicate unrelieved pain so they can receive prompt evaluation and effective treatment;

* enhance patient comfort and satisfaction; and

* contribute to fewer postoperative complications and, for some patients, shorter stays after surgical procedures.(1)

The guideline was developed because of the widespread inability of caregivers to effectively manage acute pain. Despite the guideline and education efforts, inappropriate acute pain treatment continues.(2) One patient population that may be at greater risk for improper pain assessment and management is the elderly.

Many older adult patients undergo surgical procedures. In the past, patients older than 65 years of age were considered too elderly to undergo surgery. Today, patients older than 85 years of age are the fastest growing surgical population.(3) Although older adult patients compose a significant percentage of our surgical patient population, postoperative pain management for this population has received little attention.(4) According to early 1990s data, more than 4,000 documents are published annually about pain, but fewer than 1% focus on older adult patients' pain.(5) Researchers reviewed eight geriatric nursing textbooks and discovered only 18 of 5,000 pages discussed pain.(6) With the lack of published information about geriatric pain, it is not surprising that misinformation is common among caregivers of older adult patients. Lack of research data also causes most patients' pain to be managed by trial and error.

PAIN ASSESSMENT IN THE OLDER ADULT PATIENT

Accurate pain assessment in every patient is a primary step before appropriate management can be accomplished. Assessing older adult patients may be more challenging than other patient populations. Challenges result from professional caregiver factors and patient factors.

Professional caregiver factors. The perception that older adult patients have less pain sensitivity than younger patients influences some caregivers. This belief is influenced somewhat because of silent myocardial infarctions and emergent "painless" intraabdominal surgical procedures that frequently occur in older adult patients.(7) Research has not proven that these episodes are age-related. No empirical evidence conclusively supports that an age-related difference in pain perception exists.(8) Research studies about geriatric pain exist, but the conflicting results make it difficult to establish a relationship between aging and the sensory pain component.(9) Anecdotal documentation shows that older adult patients may perceive pain at a slower rate but indicates they feel pain differently, not less intensely.(10) Some researchers suggest there is a change in the pain quality, not the intensity, in older adult patients.(11)

Some caregivers refrain from providing adequate postoperative analgesia to older adult patients because they fear possible medication interactions and adverse effects.(12) Those are valid fears, but careful attention to each patient's current medication regime and prehospitalization medication regime can provide the caregiver with data to make an informed decision. Analgesia addiction concerns caregivers who fear that liberal analgesia administration will cause...