2 points to start

  • The prevalence of pain increases with age.
  • This is an emergency in geriatrics because it causes anorexia, malnutrition, insomnia, depression, loss of autonomy syndrome shift (significant risk of suicide in the elderly) patient, and affects the ‘entourage.

DEFINITIONS
There are three levels in pain:
1) Definition of pain: There are many. The most satisfactory is that of the International Association for the Study of Pain proposed in 1979: “Pain is a sensory and emotional experience unpleasant linked to tissue damage existing or potential or described in terms of such damage. The pain has four components: sensory, emotional, cognitive and behavioral.
2) Definition of suffering: The reactions caused by pain correspond to the notion of suffering. An association of phenomena in both physical, moral and psychological involving all the mechanisms emotional, intellectual and instinctive. The pain varies greatly from one individual to another, it depends on the context or the meaning of pain. Thus the pain of post-operative scarring is less painful than those that accompany recurrence of cancer.
3) The total pain: Cecily Saunders has described as “total pain” multiple components of chronic pain: physical, psychological, spiritual and social. Chronic pain is in itself a disease for some. The prediction of continuity leads to anxiety, depression and insomnia which, in turn, exacerbate the physical components of pain.


ASSESSMENT OF PAIN
- Above all, he should know the history of the disease history of the patient, his history, his psyche previous
- Differentiate between acute and chronic pain.
- Define the characteristics of pain type, intensity, location, radiation, conditions of occurrence, changes (as gesture, position, drug, visit, occupation …), seniority …
- The patient is the expert to assess his pain.

Two fundamental notions:
- It assesses the patient’s pain (wherever possible). In case of difficulty or impossibility, the evaluation will be conducted by caregivers. In all cases, it will strive to be multidisciplinary.
- The patient is always right when he assesses his pain (even if its evaluation does not correspond to that caregivers would, more or less).
The questioning of the family is also essential.
The score is still threefold: patient (+++), by caregivers, by family, with pooling then.

Ladders:
They do not represent an end in itself but is a good communication tool.
They are of several types:
a) one-dimensional: the best known is the VAS (visual analogue scale) simple and quick to implement, but not always usable because requires a capacity for abstraction and understanding.
b) multi-dimensional: the “Mac Gill pain questionnaire and the questionnaire of the pain of St. Anthony (QDSA). Long, requires good verbalization, does not analyze the behavior.
c) Behavioral: based on studying the behavior of the patient, they are basically three
1 – EGR level (scale Gustave Roussy), which is actually a pain scale in children.
2 – scale Doloplus Bernard Wary, which we believe is the best and most suited to geriatrics, although it is not without its critics. It allows the study of somatic sensation of psychomotor and psycho social impact of pain.
3 – grille pain assessment USP Val d’Azergue.
The peculiarities of the pain assessment in the elderly are twofold:
- Related to the interrogation which is often contrary, interspersed with numerous complaints,
- Linked to clinical findings for the collection of verbal events (audible) and nonverbal (visible) particularly useful in elderly non-communicating. (He should know that none of these scales are perfect and they are all criticism).

Difficulties:
- Assessment should be tripartite: patient, caregivers, family.
- The collection of the pain assessment made by the patient must necessarily be multidisciplinary is to say, including the assessment of the nursing assistant, nurse and physician because the function of the evaluator is very important that they say to that? assessing?
- Should be assessed and reassessed regularly (before and after medication, a visit, occupation …). But at the height of the pain, the patient does not always bear to be “questioned “.
- Assess the various pain (not pain), which may perhaps require more treatment (not treatment).
- Assess pain equivalent to “confront” two subjectivities: that of the patient and that of evalueur. It should be as neutral as possible in its assessment.
- The pain threshold varies over time.
- The assessment can be made difficult in a patient is talkative, more or less hypochondria cal, or rather in a patient whose answers are no or unreliable because:
- A disorder of attention
- A state of confusion, depression,
- Impairment of memory,
- Impairment of sensory or language,
- Disorders of neuro-psychological
- A reduction in pain of cultural,
- Masking of a complaint in an acute complaints attendant chronic fluctuating (hence the importance of clinical examination, even more fundamental in the elderly),
- The multiplicity of pathological damage with therefore the multiplicity of different pains, sometimes in kind or of different origin.
- Note the written assessment, with precision (and not: “It hurts, it was worse or less bad”, which is unusable by the doctor)
- Do not deprive yourself of the therapeutic analgesic test if there is reluctance on the reality of pain: it can “bring big” for the patient.

What words about what evils? Rationale: The patient is always right when he speaks of his grief, and it is important to him that we believe wrongly, we believe his pain, and we have taken into account, even if some patients tend to minimize or otherwise maximize their pain. It should then understand why this attitude. (It is important that caregivers, but also the family, can compare what the patient was able to express verbally or not (the body attitudes, implied …). In fact it does not express the same emotions the same sensations, spouse, physician, and caregiver assistance for example. “consequences” are not the same, any “interests” either. A non-pooling of different messages sent to these “receptors” poses a substantial risk of loss of quality and intensity of them. Expressing his grief at doctor could lead a new hospital, new treatments (eg chemotherapy, often feared or experienced bad), new tests (themselves sometimes painful), a dialogue can resume with his retinue of some difficult words to hear, decisions, thoughts and “brainstorming.” defenses erected with great difficulty may be eroding. Both prospects that the patient is often feared. Therefore we can understand the restraint of the patient. That will do or say the doctor if I understood my pain? (Expressing pain nurse (e) or carer ( e) not all the same resonance. The caregiver has no decision-making (decision sometimes seen as “punishment” by the patient because of its possible consequences). From this point of view, trusting becomes when easier, less “dangerous” (even if his words were relayed to the doctor). On the other hand, this caregiver is often female, with the patient, implicitly, the risk of confusion more or less conscious with role of mother. We then guess the risk and danger, both for the caregiver and the patient. Expressing his sorrow to the family or loved ones brings its own problems: generate pain, the anguish, the insomnia, anger, leakage, miscommunication, trial …

Perception of pain in the elderly: It is identical to that of younger adults, at least from a physiological and neuro anatomy. This expression is altered, not perception. Beware pitfalls of confusion, depression, withdrawal, of silence, the change of character, which may represent as many atypical manifestations of pain. The same applies to the cries of demented or psychotic when we no longer distinguish good cries “normal” for cries of pain. The advancing age, shortcomings and sources of pain are increasing, whether acute or chronic. The elderly ultimately trivialize her pain. He is fatalistic, as if age and pain were bound together. Therefore, he complains less. But it is likely that the future generation of older people complain more than the present for less accustomed to suffer.

The need to always seek the etiology, even and especially among the demented. Clinical examination by a physician is essential and must be as complete as possible even if it requires more time and patience in the elderly. It must strive to determine the etiology and understanding the mechanism (or) pain (s) in order to build a therapeutic strategy adapted and therefore more effective. No treatment “push button” automatic. It is necessary to take stock of different diseases and different treatments.

OTHER NON-DRUG TREATMENT OF PAIN
The quality of the relationship with the elderly and taking into account the psychological dimension of pain are fundamental, otherwise we run the risk include the risk of treatment failure, side effects and poor adherence. It is essential to establish a genuine political support for pain and depression often associated if it is sustained (risk of suffering depression vicious circle).
Preserve maximum autonomy and quality of life must remain a priority.
1) Versant psychological recall the essential support that the family may have about their patients, caregivers and close family.
- In theory, psychotherapeutic support, relaxation, relaxation therapy, hypnosis, spa therapy, music therapy, social therapy.
- In geriatric practice, everything depends on the participation or not, and the state of sensory neuro psycho patient.
2) Physical therapy: it has an important role relational (physical therapy, rehabilitation, electrical stimulation of trans-dermal-TENS-).
3) Surgical treatment: visceral, orthopedic or neurological.
4) Radiotherapy

THE MEANING OF PAIN FOR THE SICK-SICK OF LISTENING
Preamble:
- The patient does not wait or do not always ask “zero pain” what is its application? him pain bearable enough for him quite often.
- Why some patients do not tell, or hide their pain?
- Does it calm all the pain? is there no pain “positive” just as there are positive stress and negative stress? Question of intensity?
- It is necessary to explain the patient’s pain (causes, mechanisms, treatments …) what the pacify.

Meaning: here’s a few:
- Atonement (what?), Punishment (what have I done to be so bad? What has he done to “deserve” it?) => Sometimes guilt.
- Redemption, spiritual magnification (the Church does not think more!) => Acceptance easier.
- Have badly = living being, thus controlling a little (or have the fantasy) and sometimes “fear of not having evil” because feel pain = life.
- Obligatory passage, necessity, inevitability => let go sometimes, depression.
- Test (according to the perception of the family): “He has no courage, he indulges it always complains” => risk of trial by the family so poor tolerance by the patient.
- The only means of communication between the patient and the team or family => encouraged to review the sound quality and care of the patient (pain-mothering, pain-reducing, pain, addiction, pain, depression).
- A defensive wall of psychic economy: the physical pain is much less painful than the emotional pain that it replaces, she avoids thinking about something else, to ask the real questions, slipping into psychosis or neurosis.
- Worsening of the causal condition, especially if pain is increasing => anguish.
- Pretext for blackmail: “If I am cured, I accept the pain, otherwise I accept evil.”

Listening to patients: always necessary, it becomes absolutely necessary to hear and try to understand what the patient we means through words or … his silence, through his experience of pain (beware the trap of interpretation, selective listening, the “get to the place”).

EXPERIENCED THE PAIN OF THE FAMILIES AND CAREGIVERS
Caregivers (recall the need to train on the pain):
- For physicians to learn to evaluate and treat
- For nurses and aides, to learn to evaluate, report it to the doctor, and manage at the bedside,
- For all caregivers to learn to manage his feelings about the pain of another (which does not mean becoming insensitive), and to understand its etiology, mechanisms, the handling of drugs. (Not taking into account, and / or persistent pain despite treatment may well lead induces psychological distress among caregivers, particularly among nurses and aides. (Are often encountered: guilt, responsibility , impotence, anxiety, malaise, projection, rebellion, anger, flight, the sensation of pain itself, frustration, exhaustion (burnout), conflicts in the team, feel not deserve the criticism sometimes leveled by the family may then take shape, at least in the imagination, the temptation of euthanasia: “I can not stand to see him suffer.” (The importance of early requirements is now well highlighted, so you do not leave physical pain settled, and its corollary, the psychic pain. (The utility, and even the need to meet certain physical pain, coming to replace mental pain even more devastating and more intolérables.C is sometimes what the patient when he denies or minimizes his pain.
The family: It is necessary to explain the pathological situation of the family in all its compartments, and the diagnosis and therapy in order to lighten it. Anxious tension will be considerably relieved. The pain of a loved one or friend can cause: anxiety, aggression, anger towards caregivers, revolt, no communication, powerlessness, leaking, even stop the visits, requests for euthanasia.

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