Wednesday, November 3, 2010

Cartography of EOL Pain

Alex Smith and Eric Widera of GeriPal fame, et al., have just published an article in Annals of Internal Medicine, The Epidemiology of Pain During the Last 2 Years of Life. The L.A. Times article is here. Little is known for certain about the contours of this landscape; so, let's explore.

This was an observational study gleaned from the Health and Retirement Study, a nationally representative survey of community-living adults. The subjects were deceased who, either the subject or proxy, had been interviewed once within the last 24 months of life. The subjects were divided into 24 consecutive cohorts on the basis of the number of months between the interview and death. The prevalence and time-course of clinically significant pain (experienced often and as moderate-to-severe) were described and analyzed with respect to demographic, socioeconomic and clinical factors. These data were modeled and adjusted for the different factors.

Clinically significant pain (CSP) was common (ranging from 26-28%) and varied little among the monthly cohorts until the last four months of life, with a sudden increase in slope leading to a final-month prevalence of 46%.

There were no significant differences, in the overall prevalence, or the prevalence in the last 4 months of life, in CSP among the terminal-diagnosis categories of cancer, heart disease, frailty, sudden death or other. There were significant differences in the overall prevalence, or in the prevalence in the last 4 months of life in CSP observed for age (decreasing with each decade older than 65), sex (more for female), race or ethnicity (less for Blacks and Other), net worth (more for less than or equal to median), proxy status (more for proxies), and arthritis (the greatest difference observed among all these variables, ranging from 13-14% without arthritis and 38-40% with arthritis, and then in the last month, 26% without arthritis and 60% with arthritis). The authors noted limitations such as there’s no information in the HRS database about cause, location or treatment of pain, and the possibility of participants attributing any and all musculoskeletal pain, perhaps including even bony mets, as arthritis.

Here Be Dragons, No More

And I was all poised to confront malignant pain as the implacable worm marauding this land. What an important and overlooked chunk of pertinent information this all is. I think it’s always interesting to see things that have been taught or what we have learned in our own practice, based on anecdote and conjecture become recalibrated by large, prospective studies. I have felt like arthritis is this incidental given, dwarfed by the likes of angina, dyspnea, acute fracture, and malignant pain, etc.; a kind of tell-me-something-I-don’t-already-know entity. It’s surprising to see this common, benign condition produce such a large overall, and then burgeoning burden of pain at end-of-life. I think I come away from this with a better appreciation for the impact of the enduring, mundane complaint as well as for the basics, the fundamentals of practice. The authors also point out that pain in the elderly is likely to be multifaceted and so is optimally treated with a multifaceted approach. Even in the setting of dominant, life-limiting diagnoses, we must bear in mind, the burden of chronic, underlying, benign conditions like arthritis.

To quote T.S. Eliot,
We shall not cease from exploration

And the end of all our exploring

Will be to arrive where we started

And know the place for the first time.

Smith AK, Cenzer IS, Knight SJ, Puntillo KA, Widera E, Williams BA, Boscardin WJ, & Covinsky KE (2010). The epidemiology of pain during the last 2 years of life. Annals of internal medicine, 153 (9), 563-9 PMID: 21041575

Pallimed | Blogger Template adapted from Mash2 by Bloggermint