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INTRODUCTION — Palliative care is an interdisciplinary medical specialty that focuses on preventing and relieving suffering and on supporting the best possible quality of life for patients and their families facing serious illness. The primary tenets of palliative care are symptom management; establishing goals of care that are in keeping with the patient’s values and preferences; consistent and sustained communication between the patient and all those involved in his or her care; psychosocial, spiritual, and practical support both to patients and their family caregivers; and coordination across sites of care. Palliative care aims to relieve suffering in all stages of disease and is not limited to end of life care. Within an integrated model of medical care, palliative care is provided at the same time as curative or life-prolonging treatments. (See "Benefits, services, and models of subspecialty palliative care".)
While palliative care was once considered to be synonymous with end of life care (which was often delivered in a hospice setting), it is now recognized that palliative care can be appropriately offered to patients at any time along the trajectory of any type of life-threatening illness, even concurrent with restorative, life-prolonging therapies.
Most serious, chronic illness in the United States, Europe, and other developed countries occurs in those aged 65 years and older. These older individuals often live with and die from chronic illnesses that are preceded by long periods of physical decline and functional impairment. Thus, providing medical care for the elderly often involves medically and ethically complex decision-making, requiring consideration of patients' multiple comorbid conditions, their quality of life, and their wishes regarding treatments.
Establishing the goals of care is of the utmost importance when treating older adults with life-limiting illnesses. Depending upon the circumstances, this may be done directly with the patient or may require a surrogate decision-maker.
Issues in symptom assessment and management that are primarily applicable to the older adult will be reviewed here. General aspects of palliative care relating to decision-making that are relevant to the geriatric population (eg, decision-making capacity, advance directives) and issues relevant to assessment and management of symptoms in palliative care patients are discussed separately:
SYMPTOM ASSESSMENT — One of the major foci of palliative care is the relief of physical suffering through the identification and treatment of symptoms. The spectrum of symptoms in the elderly differs somewhat from that seen in younger persons. As examples, dementia, delirium, urinary incontinence, and a high propensity for falls are more common in older individuals . Despite these differences in the elderly, elimination of physical pain remains the most common patient need . (See "Overview of comprehensive patient assessment in palliative care" and "Approach to symptom assessment in palliative care" and "Comprehensive geriatric assessment".)
In older patients with chronic illnesses, the prevalence of symptoms is high and they are often not recognized. The frequency of symptoms in this population was illustrated by a study of community-dwelling elders age 60 or older with advanced chronic obstructive pulmonary disease (COPD), heart failure (HF), or cancer . Overall, 86 percent reported at least one symptom that was rated as moderate or severe and 69 percent had at least two such symptoms. The most commonly reported symptoms included limited activity (61 percent), fatigue (47 percent), and physical discomfort (38 percent).
There are a number of validated instruments for this that can provide valuable information regarding the presence and intensity of a wide variety of symptoms. These include the Edmonton Symptom Assessment Scale (ESAS, (figure 1)), the Memorial Symptom Assessment Scale (MSAS, (figure 2)), or the Rotterdam Symptom Checklist, among others [4-6]. (See "Comprehensive geriatric assessment for patients with cancer".)
Some instruments, such as the MSAS and the Rotterdam Symptom Checklist, may be difficult to administer to older adults because of their length. The ESAS may be particularly useful, because it is shorter than some of the other symptom assessment tools . The original ESAS (figure 1) included 10 domains and this has been supplemented with five additional areas aimed at capturing symptoms commonly present in older adults with advanced chronic disease . The 15 domains are summarized in a table (table 1).
Elderly patients often have significant cognitive, motor, visual, or auditory impairments that must be considered when evaluating the presence and intensity of symptoms, and the assessment method should be modified accordingly [8,9]. As an example, some older adults may find a three-word descriptor scale (mild, moderate, severe) or a graphic pictorial scale easier to use than a 0 to 10 visual analog scale [10,11].
Despite such difficulties, an assessment can usually be completed in the elderly, as was illustrated in a study in which over 80 percent of individuals were able to complete an assessment using one or another of these approaches . The same assessment scale should be used serially, so that the clinician can assess symptom control over time, set reasonable goals, and foster patient trust .
Cognitive impairment due to either dementia or delirium can make both the assessment and management of symptoms more difficult. It is common for clinicians to be concerned that patients with impaired cognition may have a tendency to underreport pain. However, a study of 750 nursing home residents found that their self-reports were as valid as those from elderly without cognitive impairment .
When elderly patients with mild or moderate dementia report pain, they often cannot recall symptoms from earlier times and may not be able to integrate pain symptoms over time. As a consequence, more frequent assessment is often required to adequately identify and assess the severity of pain in these individuals. Close attention should be paid to mood disturbances, functional decline, and changes in behavior that may be a reflection of increasing or new pain . In order to identify patients with cognitive impairment who might benefit from more frequent pain assessment, simple screening tests for delirium and dementia can be utilized. (See "Diagnosis of delirium and confusional states", section on 'Evaluation' and "Evaluation of cognitive impairment and dementia", section on 'Cognitive testing'.)
In patients with severe cognitive impairment who are nonverbal, pain and other symptoms often are difficult to identify and may present as agitation, increased confusion, or decreased mobility . In this situation, the clinician should attempt to assess pain and other symptoms by direct observation and through information from caregivers (algorithm 1 and table 1 and table 2) . Evidence of pain-related behaviors may become evident during ambulation, transfers, and personal care.
SYMPTOM MANAGEMENT — The management of symptoms in older individuals follows the same principles as in younger patients. However, the approach may require modification because of comorbidities or physiologic changes associated with aging. In general, the choice of the proper analgesic medication should be carefully considered based upon the source and intensity of the pain, the patient's previous responses and reactions to analgesic medications, and baseline organ function. (See "Drug prescribing for older adults".)
Differences in symptom management in elderly versus younger patients have been best studied for persistent chronic pain of both somatic and neuropathic origin.
Chronic somatic pain — Persistent pain commonly affects older people and can be malignant or nonmalignant in origin. Chronic somatic pain in older adults is most frequently associated with musculoskeletal disorders, such as degenerative spine conditions and arthritis [15,16]. In addition to a high incidence of chronic, nonmalignant pain, as many as 80 percent of older individuals diagnosed with cancer experience pain during the course of their illness , and pain as a consequence of cancer treatment is increasingly recognized . The distress of cancer pain creates an obligation for clinicians to provide effective pain management, particularly near the end of life. Unrecognized or undertreated pain in the geriatric population can lead to a number of adverse outcomes, including mood change (depression and anxiety), decreased socialization, sleep and appetite disturbance, gait instability, loss of functional capacity, and greater health care use and cost .
Approach to treatment — The use of analgesic medications is the most common strategy in the management of pain in older adults. However, physiologic changes (eg, decreased renal or hepatic function and altered body fat distribution) may result in higher serum drug levels in elderly patients given the same dose of a medication as younger individuals . Furthermore, older patients may be more susceptible to adverse events. As a result, lower initial doses are generally recommended. Ultimately, the choice to utilize opioid therapy in an older adult with persistent nonmalignant pain should be based on a balanced review of the potential benefits and risks for an individual patient. We agree with the recommendations for initial doses of oral analgesic medicines for the elderly from the American Geriatrics Society panel on the pharmacologic management of persistent pain in older adults, and these are outlined elsewhere (table 3) .
For patients with cancer, opioid therapy is the first-line approach for moderate or severe chronic pain. Despite this, they are underprescribed to older adults with malignant pain [20,21]. As an example, in a cross-sectional cohort study linking patients 65 and older diagnosed with cancer in Ontario who completed a pain assessment as part of systematic symptom screening with a database of opioid prescriptions, one-third of those who described pain as severe did not receive an opioid prescription between the 30 days prior to assessment of pain to seven days afterward . (See "Assessment of cancer pain" and "Cancer pain management: General principles and risk management for patients receiving opioids".)
For patients with nonmalignant pain, the use of opioids remains controversial. Recommendations from the American Geriatrics Society support the use of opioids for older adults who continue to report moderate to severe pain despite non-opioid therapy, including those who experience pain-related functional impairment. However, opioid use in this population may place these patients at an increased risk for complications. This was shown in a large comparative safety study of 12,840 Medicare beneficiaries (mean age = 80 years) with osteoarthritis or rheumatoid arthritis, which found that opioid use was associated with an elevated relative risk of cardiovascular events, fractures, safety events requiring hospitalization, and all-cause mortality when compared with nonselective nonsteroidal anti-inflammatory drug use . (See "Overview of the treatment of chronic pain".)
For patients with baseline renal insufficiency who are candidates for an opioid, fentanyl is safer than morphine, which has a toxic metabolite that is renally cleared and can, if it accumulates, cause seizures. Care should be taken to ensure that initial doses are low and that dosing intervals are appropriately increased over what would be considered standard for patients with normal organ function. (See "Cancer pain management with opioids: Optimizing analgesia", section on 'Use in renal failure'.)
All patients are at risk of developing the common side effects of opioids (eg, nausea, constipation, pruritus, sedation, mental cloudiness). In older patients, fecal impaction and urinary retention are more common and a particular concern . Therefore, close attention to the regularity of bowel movements and bladder emptying is recommended, especially in patients who are nonverbal. (See "Cancer pain management with opioids: Prevention and management of side effects".)
Delirium is a common complication in the elderly [24,25]. Although opioids are often cited as culprits in the development of delirium in older adults, carefully controlled studies have demonstrated that proper pain management actually decreases the incidence of delirium in cognitively intact patients . This finding can be explained by the fact that uncontrolled pain itself is a risk factor for the development of delirium. (See "Diagnosis of delirium and confusional states" and "Delirium and acute confusional states: Prevention, treatment, and prognosis".)
While there are no specific studies on dosing adjustments for opioids in the geriatric population, a prudent approach is to start with a low dose, monitor closely, and titrate the dose upward as required. A reasonable approach is to begin with 30 to 50 percent of the recommended starting dose for younger adults. The recommendations for initial doses of opioids and other analgesics by an American Geriatric Society Panel on pharmacologic management of persistent pain are outlined in the table (table 3). (See "Cancer pain management with opioids: Optimizing analgesia".)
Specific issues related to risk assessment and management and driving while patients are receiving therapy with opioids are addressed elsewhere. (See "Cancer pain management: General principles and risk management for patients receiving opioids", section on 'Risk assessment and management for patients receiving opioids' and "Cancer pain management: General principles and risk management for patients receiving opioids", section on 'Driving safety'.)
Neuropathic pain — Neuropathic pain syndromes are common in older adults. Etiologies can include a spectrum of disorders (eg, diabetic neuropathy, post-herpetic neuralgia, spinal stenosis). General aspects of the management of neuropathic pain in cancer patients are discussed separately. (See "Cancer pain management: Adjuvant analgesics (coanalgesics)", section on 'Drugs used for neuropathic pain'.)
Approach to treatment — In addition to opioids, a number of pharmacologic agents termed adjuvant analgesics or coanalgesics may be useful in the treatment of neuropathic pain and have special considerations in the geriatric population.
●Gabapentin is widely used in the treatment of neuropathic pain, but common side effects include drowsiness and dizziness, which can be particularly problematic in the geriatric population. If gabapentin is used in older adults, treatment should be initiated with a dose of 100 mg at night (table 3) . Patients should be questioned specifically about these side effects before any increases in the dose . Although gabapentin can be titrated up to a maximum of 3600 mg/24 hours, the maximum tolerated dose in older adults is likely closer to 1200 mg/24 hours due to age-related decline in creatinine clearance . Likewise, pregabalin is also becoming used more commonly for the treatment of neuropathic pain. There are no specific dosing adjustments recommended for the geriatric population. While a starting dose of 75 mg twice daily is the general recommendation, a starting dose of 25 to 50 mg twice daily is recommended in debilitated patients . Additional caution and dose adjustment should be used in those with renal impairment. To avoid precipitating pain or seizures with both gabapentin and pregabalin, or a withdrawal syndrome of headache, insomnia, nausea, and diarrhea in the case of pregabalin, these medications should be withdrawn gradually over at least one week [27,28].
●While both tricyclic antidepressants (TCAs) and carbamazepine have been shown to be effective in neuropathic pain, their side effects and potential for drug-drug interactions limit their utility in older adults . Other medications that have been evaluated for the treatment of neuropathic pain include the selective serotonin reuptake inhibitors (SSRIs) and mixed reuptake inhibitors (eg, paroxetine, citalopram, duloxetine, venlafaxine). These agents may be particularly useful in elderly patients because of their favorable side effect profiles. Recommended initial doses for persistent pain are outlined in the table (table 3) . (See "Angle-closure glaucoma", section on 'Risk factors'.)
●Transdermal lidocaine can be useful in the elderly to treat both neuropathic and localized, nociceptive pain because of its low incidence of side effects. Proper usage of transdermal lidocaine is critical, and careful instructions should be provided. Transdermal lidocaine should be applied for 12 hours and removed for 12 hours each day, and patients can cut the patches in half in order to utilize them on different parts of the body (eg, the right and the left knee) . (See "Cancer pain management: Adjuvant analgesics (coanalgesics)", section on 'Topical therapies'.)
Patients who are also using other transdermal preparations (eg, fentanyl, clonidine, nitroglycerin) should be carefully instructed regarding the differences between these medications and their appropriate use. While transdermal lidocaine patches can be cut with scissors, the others cannot. Confusion is a particular concern when a patient is using transdermal preparations of both lidocaine and fentanyl for pain management.
Depression — Major depression is a treatable condition, even in terminally ill patients. The more favorable side effect profile of newer antidepressants has facilitated their use in the elderly and medically ill. Because treatment with these agents is relatively benign and well tolerated, clinicians should have a low threshold for initiating therapy. The treatment of depression in palliative care is discussed separately. (See "Assessment and management of depression in palliative care", section on 'Treatment'.)
Other symptoms — While other symptoms including delirium, dyspnea, fatigue, nausea, constipation, and anorexia are all common in older adults, there is a paucity of evidence focusing specifically on their evaluation and management in older adults. More general guidelines can be found separately. (See "Overview of managing common non-pain symptoms in palliative care".)
●Palliative care utilizes an interdisciplinary team to focus on preventing and relieving suffering, regardless of the disease, stage, or need for other therapies. Although the goals of palliative care in the elderly are the same as those in younger individuals, older persons often live with and die from chronic illnesses that are preceded by long periods of physical decline and functional impairment.
●Palliative care in the geriatric population requires an accurate identification of all symptoms, and the comprehensive geriatric assessment may be particularly useful for this purpose. Elderly patients often have significant impairments that make such as assessment difficult. Simplified instruments, such as the Edmonton Symptom Assessment Scale, may circumvent these difficulties and are particularly useful. (See 'Symptom assessment' above.)
●The management of symptoms in the older patient follows the same principles as that in younger persons. However, differences in side effect profiles and the metabolic handling of medications in the elderly need to be considered. These factors may influence the choice and dose of medications in the geriatric population. (See 'Symptom management' above.)
ACKNOWLEDGMENT — We are saddened by the death of J Andrew Billings, MD, who passed away in September 2015. UpToDate wishes to acknowledge Dr. Billings' many contributions to palliative care, in particular, his work as our Editor-in-Chief and Section Editor for Non Pain Symptoms: Assessment and Management.
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