Trigeminal Neuralgia
Trigeminal neuralgia is characterized by severe, unilateral facial pain described as lancinating, electric shocklike jolts in one or more distributions of the trigeminal nerve. The maxillary and mandibular divisions are most commonly affected. The causes vary by age. In the elderly, compression of the trigeminal root by an artery or vein or both is the cause about 80% of the time. Intracranial tumors and demyelinating disease have also been implicated. The characteristic jabs of pain last from 2 to 120 seconds and are often precipitated by activities such as brushing, chewing, or talking. The paroxysms of pain are separated by pain-free intervals. Because there are no cranial nerve deficits, the diagnosis of tumor may be delayed. Careful clinical evaluation and magnetic resonance imaging (MRI) are recommended for all patients presenting with trigeminal neuralgia.65
17 II ASSESSMENT OF PAIN AND ITS TREAT MENT
Table 4^1.Selected Instruments for Pain Assessment in Older Adults
Domain Instrument Instrument Characteristics
Psychometrics Established
by Setting Comments
Pain intensity Numerical rating scale (NRS)
Available in a variety of scale ranges including 05, 010, 020, and 0100. Acute care Subacute care Pain clinic Long-term care (LTC) Assisted living Community dwelling
Preferred by many older adults
Verbal version may be difficult for elders with cognitive impairment
Vertical orientation of scale easier to use for elders
Verbal descriptor scale (VDS)
Available in a variety of scale types including 5-Point Verbal Rating Scale
Pain Thermometer77
Present Pain Inventory (PPI)78 Graphic Rating Scale79
Acute care Subacute care Pain clinic LTC Assisted living Community dwelling
Most preferred by older adults Requires abstract thought
Thermometer adaptation may assist with tool understanding80
Pictorial Pain Scales Facial pain scales tested in older adults: Faces Pain Scale (FPS)81
Wong-Baker FACES Scale82
Acute care Subacute care Pain clinic LTC Assisted living Community dwelling
Preferred by many older adults
Validated in white, African American, and Spanish Does not require language
Requires abstract thinking
Multidimensional pain assessment
Short-Form McGill Pain Questionnaire (SF-MPQ)61
15 Pain quality words rated on a Likert scale, plus a visual analog scale (VAS) of pain intensity, plus a PPI
Community dwelling Pain clinic
Acute care
Measures sensory and affective dimensions Not recommended for illiterate or cognitively
impaired Brief Pain Inventory
(BPI)60
11-Item instrument that gathers information on pain severity and level of pain interference on seven key aspects of function
Multiple settings including cancer, chronic pain conditions, postoperative pain, and older adults
Measures intensity and pain interference Does not measure quality or affective dimensions
of pain
Available in over 30 languages Pain Disability Index
(PDI)83
Seven items using 11-point scale to measure perceived pain interference with the performance of seven areas of daily function
Community dwelling Chronic pain
Measures pain-related disability Short and easy to use
Needs further study for utility in outcomes measures Geriatric Pain Measure
(GPM)84
24-item questionnaire measuring five clusters of components: Pain Intensity, Disengagement, Pain with Ambulation, Pain with Strenuous Activities, and Pain with Other Activities
Ambulatory geriatric clinic Measures intensity, interference, disengagement, and pain with activity
Limited evaluation data Multidimensional Pain
Inventory (MPI)85
61 Items, made up of 13 subscales across three sections
Multiple settings Pain clinic
Measures pain intensity, interference, significant other support, general activity
Cross-culturally validated
Identifies adaptation styles and response to treatment Lengthy to complete, approximately 20 min Limited psychometric study in the elderly Functional Pain Scale
(FPS)86
05 Scored tool that combines pain severity and function and rates ability to tolerate activity
Community dwelling Measures intensity and function
Limited by indicators that measure interference based on ability to watch TV, read, and use a telephone
18 Chapter 4 A S S E S S M E N T O F P A IN IN O L D E R A D U LT S
Functional status Functional Status Index (FSI)87
Two self-administered subscales: pain and difficulty; difficulty subscale focuses attention on task performance rather than amount of pain experienced while performing the task
Acute care Primary care
Measures basic activities of daily living (ADLs) and instrumental ADLs
Takes approximately 8 min to administer Physical Activity Scale88 Measures levels of physical activity in past week in
areas of leisure, occupation, and household activities
Community dwelling Measures basic, instrumental, and advanced ADLs 8 min to complete
Site-specific disability
Oswestry Disability Scale89
10 Items measuring level of pain and interference with physical activities, sleep, self-care, sex life, social life, and travel
Primary care Evaluates low back pain
Measures basic, instrumental, and advanced ADL’s 5 min to complete
Rowland Morris Disability Index77
24-Item instrument derived from the Sickness Impact Profile in which the phrase ‘‘because of my back’’ was added to each statement, making it disease specific
Includes, but not specific to, older adults
Evaluates low back pain
Measures basic and instrumental ADLs 5 min to complete
Western Ontario And McMaster Universities Osteoarthritis Index (WOMAC)90
24-Item instrument assesses pain, disability, and joint stiffness
Includes, but not specific to, older adults
Evaluates hip and knee pain 8 min to complete
Neck Pain and Disability Index91
20-Item instrument designed to measure intensity of pain and interference with vocational, recreational, social, and self-care activities as well as emotions
Includes, but not specific to, older adults
Evaluates neck pain 5 min to complete Cognitive processes; pain specific Cognitive Errors Questionnaire92
48 Vignettes assessing four depression-related cognitive disorders: catastrophizing,
overgeneralization, personalization, and selective abstraction; half of the vignettes use chronic pain as the stimulus for the situation
Adults with rheumatoid arthritis, including, but not specific to, older adults
Inventory of Negative Thoughts in Response to Pain93
21 5-Point items made up of three subscales: negative self-statements, negative social cognitions, and self-blame
Includes, but not specific to, older adults
Pain Attitudes Questionnaire94
27 Items load on four factors representing stoicism (superiority, reticence) and cautiousness (self- doubt, reluctance)
Community dwelling Age-related increase in degree of reticence to pain, self-doubt, and reluctance to label a sensation as painful was found
Pain Catastrophizing Scale95
13 Items made up of three subscales describing catastrophizing thinking: helplessness, rumination, and magnification
Not known
Arthritis Helplessness Index96
5 Items tapping perceived (un)controllability of arthritis symptoms
Includes, but not specific to, older adults
Helplessness correlated with greater age, lesser education, lower self-esteem, lower internal health locus of control, higher anxiety and depression, and impairment in performing ADLs
Arthritis Self-efficacy Scale97
20 Items measuring self-efficacy in three domains: pain, function, and other symptoms
Primary care Community dwelling
Health outcomes and self-efficacy scores improved when patients participated in the Arthritis Self- Management Course
Affective processes
Pain Anxiety Symptoms Scale98
Multidisciplinary pain clinic
Continued 19 II AS S E S S M E N T O F P A IN A N D IT S T R E A T M E N T
Table 4^1.Selected Instruments for Pain Assessment in Older Adultsçcont’d
Domain Instrument Instrument Characteristics
Psychometrics Established
by Setting Comments
62 Items made up of four subscales: fear of pain, cognitive anxiety, somatic anxiety, escape and avoidance
Includes, but not specific to, older adults
May be useful in the continued study of fear of pain and its contribution to the development and maintenance of pain behaviors
Beck Anxiety Inventory38 21 Items answered on a 4-point scale Tampa Scale of
Kinesiophobia99
17 Items addressing fears about pain and re(injury)
Not known For older chronic pain patients, a stronger mediating role for pain-related fear was supported100
Items may represent catastrophic thinking rather than fear of movement101
Survey of Activities and Fear of Falling in the Elderly102
11 Items, subscales include activity, restriction, fear of falling, and activity level
May be able to differentiate fear of falling that leads to activity restriction from fear of falling that accompanies activity
Geriatric Depression Scale (GDS)32
30 Yes/no items; omits somatic and other depressive symptoms possibly confounded with aging
Community dwelling LTC facility
Short form available
Performed better than the CESD in residential settings for elders
Center for
Epidemiological Studies Depression Scale (CESD)33
20 4-Point items Community dwelling
LTC facility
Performed better than the GDS in community dwelling elders
Coping skills Coping Strategies Questionnaire103
42 Items assess seven strategies (making coping self-statements, ignoring pain sensations, reinterpreting pain sensations, praying/hoping, catastrophizing, diverting attention, and
increasing activities), but various factor structures have emerged
Widely used in older adults, especially those with osteoarthritis
Chronic Pain Coping Inventory104
65 Items assess behavioral coping strategies in 11 domains
Short form available
Has been used, but not validated in older adults Vanderbilt Pain
Management Inventory42
Separate active (11 items) and passive (7 items) subscales
Coping with Chronic Illness105,106
54 Items made up of six subscales: cognitive restructuring, emotional expression, wish- fulfilling fantasy, self-blame, information seeking, and threat minimizing
Includes, but not specific to, older adults
Not pain specific
Ways of Coping Scale (Revised)107
66 Items made up of numerous subscales and two higher-order factors: problem-focused and emotion-focused coping. Revised
Not pain specific
Adapted from Hadjistavropoulos T, Herr K, Turk DC, et al. An interdisciplinary expert consensus statement on assessment of pain in older persons. Clin J Pain 2007;23(1 suppl):S1S43; Gibson SJ, Weiner DK. Pain in Older Persons. Seattle: IASP Press, 2005; and Herr KA, Garand L. Assessment and measurement of pain in older adults. Clin Geriatr Med 2001;17:457478, vi.
20 Chapter 4 A S S E S S M E N T O F P A IN IN O L D E R A D U LT S
Postherpetic Neuralgia
Postherpetic neuralgia (PHN) is a frequent complication after an outbreak of herpes zoster in the elderly. Sensory findings include allodynia or hyperalgesia in the associated dermatomal region, the thoracic being more common than the facial. Patients with allodyn- ia complain of the wind or a piece of clothing causing pain. Hyperalgesic patients describe provocation of pain by a relatively mild stimulus, such as bumping up against a piece of furniture. Tingling, severe itching, burning, or steady throbbing pain have also been described. Pain associated with PHN can interfere with ADLs and quality of life, and therefore, identification and interven- tion are crucial.65
Poststroke Pain
Poststroke pain, an underrecognized consequence after stroke, occurs in 33% to 40% of patients who have had a stroke. The pain may present as shoulder pain in the paretic limb or present as central poststroke pain (CPSP). CPSP is characterized as pain that is severe and persistent with accompanying sensory abnormalities.66,67
Metastatic Bone Pain
Bone pain that is worse at night, when lying down, or not associated with acute injury should raise suspicion of metastatic disease. Also, pains that gradually but rapidly increase in intensity or with weight bearing or activity are suspicious. Frequent sites of metastatic pain include the hip, vertebrae, femur, ribs, and skull. Examination includes palpation of the affected site.
Temporal Arteritis
Greater than 95% of the cases of temporal arteritis occur in patients over 50 years old. Presentation includes complaints of new-onset headache, malaise, scalp tenderness, and jaw claudication. Physical examination reveals an indurated temporal artery that is tender with a diminished or absent pulse. Because irreversible blindness is a consequence if untreated, timely assessment and treatment are essential.68Generally, patients are started on glucocorticoids while awaiting temporal artery biopsy.