UNC Greensboro Pain Presentation in the Geriatric Population The Presentation of Pain Case Study I Referral: By family physician Mr B has experienced MI [myocardial infarction] with some residual muscle injury Patient last year underwent coronary bypass at the CC [Cleveland Clinic] Recently has experienced unremitting migraine headaches over the last three years; neurological work-up here at UH [University Hospitals] and CC reveals no significant sequela Noticeably depressed and frustrated about the treatment management of his migraine headaches Please evaluate and recommend Response: Met with Mr B for initial assessment Mr B is a 63-year-old, white male, semi-retired business executive He was founder, president, and now chairman of the board of a well-known multi-national engineering company founded during the late 1960s As a World War II Holocaust survivor, he spent years at Bellfaire School, completed college, and received advanced training at Case Institute of Technology [now Case Western Reserve University] He is married with three adult children and five grandchildren He was very animated discussing his career achievements and intensely proud of his business negotiating skills as revealed by stories he relayed He has been active within the Jewish community, serving as president of his congregation, active with Jewish Federation in leadership positions, and representative to International Mogen David His wife, who defers to her very gregarious, engaging husband, noted he attends morning prayers daily and has become active in more synagogue and Jewish Community Center programs Mr B indicated he took his second MI as a warning to “take more time” for his wife and family Mrs B has diabetes managed by diet and medication at the present time They have completed several trips to Israel, taken numerous spring and fall cruises to destinations around the world His wife noted they have not experienced too many problems with keeping kosher Even though he and his wife have traveled to Europe for pleasure and business, he has not returned to his native country, Austria He spoke about his two sons, their successes, and his grandchildren but appeared to be melancholy as we discussed his family Mr B’s immediate or extended family did not survive the concentration camps He noted his wife had been busy with Red Cross, and on several occasions has had leadership positions in Cleveland Hadassah and Jewish Appeal The oldest son has assumed his father’s role as executive director; second son is the corporation’s chief legal counsel His sons and their wives are active in synagogue activities and both the social and Jewish scene of Cleveland They are members of two country clubs, one in Cleveland and one at their winter residence in Florida The grandchildren are at University School and active with the Jewish Community Center and youth activities at the synagogue With a pained voice he expressed, “I want my children to be a living example; I outlived and outwitted my persecutors My children and their lives are my testimony to my faith.” Continued questioning, but as we proceeded, Mrs B, who had a handkerchief and constantly twisted it during the interview, now blotted her eyes Mr B arose, stated he had a blinding headache, stood straight up and in gruff voice intoned, “Your questioning me is not giving me any relief!” Clinical Impression: Action Plan: Axis I Axis II Axis III Axis IV Axis IV The Study of Pain Case Study II Referral: Could you please see this man for evaluation? Any advice for residents and staff in managing this case would be appreciated Mr T, a 52-year-old, first generation Italian-American, mechanic, married, and the father of several young children, injured his right foot at work seven years ago A lawsuit was instituted at the time and awaits final disposition Since his accident, the patient has undergone progressive amputations of right leg for relief of intractable pain He has been evaluated by psychiatry but they have provided little direction in this case He has been seen by neurology and it has been recommended he undergo a chordotomy in a further attempt to relieve his pain symptoms Mr T expresses fear his pain is due to cancer of the left leg but several oncology work-ups, including CAT scans, fail to verify any underlying tumors He is pressing for more surgery to correct his “problems” and demands more pain medications His demands for analgesics appear to be out of proportion to his distress He has become very angry with staff and believes no one is listening to him Response: Thank you for a most interesting case Let me provide some details, which may help us understand dynamics of this case Mr T had lost his mother at birth, and was raised by his father and maternal grandmother At the age of he had been evicted from his “father’s bed” by his new stepmother, and subsequently relegated to “third place” by his father when a new sibling was born At the age of 7, his right finger was severed when caught in his father’s lawn mower Mr T contacted tuberculosis when he was 13 years old, and was forced to remain in bed for a year During this period, his father and grandmother were more affectionate and spent more time with him When he was 17 he learned a favorite aunt, “who really was the one who raised me,” had cancer of the right leg and was expected to die Contrary to all expectations the aunt survived – after her leg was amputated Mr T’s pain appears to be intertwined in his excessive need for affection to the point where he is willing to offer a body part in return for “love.” Giving up his leg was a symbolic offering that ensured multiple gains: not only love and attention from those around him, acceptance of his present role reversal, and a means for warding off a more fantasized amputation – he expressed fear of losing his sexual ability Having his leg cut off also served to foster his identification with his beloved aunt Identification with his aunt also meant that if he had the “bad” leg removed, he would not die of cancer either His repeated surgeries and demand for more has legitimized the passive-dependent posture that had proved effective earlier as a mode of getting love and attention from his father now from his wife, family, friends, and medical personnel These longings, which have been shaped and intensified by the early death of his mother and the birth of his daughter, are reinforced by the prospect of receiving compensation for his injury Mr T’s exaggerated focus on pain represents his solution to psychological conflict within the domain of a conversion reaction A conversion reaction is contingent upon: symptoms have symbolic significance and serve as the resolution of unconscious conflict, primary physiological structural changes, and not conform to known anatomical/physiological patterns Thank you for this consult, and will discuss in practice rounds Clinical Impression: Axis I Axis II Axis III Axis IV Axis V PAIN INTERVIEW (Italics are suggestions for discussion) 1.) How important is it to be aware of your client’s emotional, mental, physical and spiritual health and well-being pertaining to their level of pain? Discuss holistic assessment process and awareness of the presence of pain and coping skills used to deal with it 2.) What therapeutic intervention(s) will be most effective with the client to find the solution to their “problem” of pain? Discuss possible interventions such as crisis management, cognitive behavioral, strengths based, problem solving, etc 3.) Pain is a part of the aging process, yet how you assist your client with their outlook on how life is changing regarding loss of control, grief and pain management? Discuss the importance of psychoeducation regarding aging 4.) What resource planning services will be the most effective to assist your client? If family lives at a distance how will you communicate with them to ensure your client’s safety and well-being? Discuss linkage and coordination activities and the importance of resource identification 5.) How will you assist your client in speaking with the physician and other medical personnel about their concerns and needs? Discuss the importance of interdisciplinary communication and the role of social work in the medical community 6.) What steps will you take if your client becomes physically addicted to their prescribed pain medication? Discuss substance abuse concerns particularly with prescription medication Recommended Readings and Reference Materials Pain Presentation in Geriatric Population Meldrum, M (2003) A capsule history of pain management Journal of American Medical Association, 290, 2470-2475 This article provides a history of the development of pain management and special efforts to promote research, education, and better treatment of acute and chronic pain Discussion of recent therapeutic innovations including pharmacological agents in response to pain management are presented Many elderly are reluctant to discuss or explore with their primary care providers possible remedies because they may assume no possible relief may be available for their type of pain and its presentation Edwards, R., Doleys, D., Fillinggim, R., & Lowery, D (2001) Ethnic differences in pain tolerance: Clinical implications in a chronic pain population Psychosomatic Medicine, 63, 316-323 In this article authors report on a study which examines how African American and white patients report the experience of pain tolerance and adjustment to chronic pain Outcomes show available research differential responses to pain vary among various ethnic groups This article is helpful to understand presentation and response to presenting pain is reflective of the meaning of pain and different for each individual and ethnic group Landi, F., Onder, G., Cesari, M., Russo, A., Barillaro, C., & Bernabei, R (2005) Pain and its relation to depressive symptoms in frail older people living in the community: An observational study Journal of Pain and Symptom Management, 29, 255-262 The authors present their study, which found frail elderly patients with pain are at higher risk for experiencing depressive symptoms Their findings support the need for better clinical assessment and intervention for both pain management and corresponding depressive symptoms This article is helpful to geriatric professionals, during an evaluation for depression one must be mindful of the etiology and evidence of pain should be equally assessed Cook, A., Niven, C., & Downs, M (1999) Assessing the pain of people with cognitive impairment International Journal of Geriatric Psychiatry, 14, 421-425 This article examines the literature of why elderly with cognitive impairment are often not screened for pain assessment and interventions Provided in the article are possible behavioral assessments which may be utilized for those who cannot use self-reporting tools This article points the clinical practitioner should be aware that acute changes in persons with cognitive impairment such as behavioral changes, increased agitation, anger, wandering, or even withdrawal from individuals and routines may be a symptom of underlying pain which needs appropriate assessment and intervention Koenig, H (2002) An 83-year-old woman with chronic illness and strong religious beliefs Journal of American Medical Association, 2888, 487-493 Author presents a case of an elderly patient with numerous medical problems, who received various medical interventions and continues to experience chronic progressive pain and weakness The role of spiritual beliefs and how religion facilitates coping with chronic pain is explored Even though this article was written for physicians, health care provides must understand their patient’s religious beliefs and how patients may use these values and ideals to maintain and sustain self against declining health and chronic illness MacDonald, J (2000) A deconstructive turn in chronic pain treatment: A redefined role for social work Health and Social Work, 25, 51-57 This article provides the reader with a discussion of how the concept of pain and its management has been defined in the past Discussion of validating the sufferer’s experiences and including them in the assessment of their own pain management strategy is reviewed The author, a chronic pain sufferer and social worker presents a perspective which recognizes and builds upon the social work perspective, that an individual’s existence and experiences can be important in diagnosis and treatment of chronic pain Berlinger, N (2007) Taking “existential” suffering seriously Journal of Pain and Symptom Management, 34, 108-110 The author reviews two cases and discusses, while posing the question of when is a drug-induced palliative sedation for symptom control appropriate Palliative care teams must attend to both clinical needs of dying patient but the author questions how, if at all, the “existential” issues have been supported Readers need to form their own point of view and future social workers should be prepared to discuss this, as it is equally confusing to other health professionals, families, and the general public