[Pain assessment and pain treatment in the geriatric patient. Part II: pain treatment]. / Schmerzdiagnostik und -therapie in der Geriatrie. Teil II: Schmerztherapie.

A primary goal of pain treatment in geriatric patients consists of maintaining physical and mental function, which is a precondition of activity and participation. In patients with chronic pain, multidisciplinary treatment without excluding invasive procedures is the most effective approach. The medication ladder, suggested by the WHO initially for cancer pain, provides a guideline for pharmacological treatment. Due to age-dependent alterations in the kinetics and dynamics of pharmaceuticals, the titration of the medication follows the rule "start low and go slow." The same principle holds true for the maintenance or augmentation of physical activity in order to escape from the activity-deconditioning cycle. The training should be based on learning theories, include pain management strategies, and incorporate psychological approaches to facilitate the active participation of the patient in the treatment program. In hospitals and nursing homes, nurses play an important role in defining the need for pain treatment and in supervising the patient in the treatment process. Despite all these endeavors, a significant number of patients remains whose pain cannot be controlled sufficiently. Euthanasia on demand of the patient with untreatable pain is not admitted in Germany.

[Pain treatment in geriatric patients]. / Schmerztherapie in der Geriatrie.

A primary goal of pain treatment in geriatric patients is the maintenance of physical and mental functions. This is a precondition for activity and participation. In patients with chronic pain, multidisciplinary treatment, without excluding invasive procedures, is the most effective approach. The medication ladder, initially suggested by the WHO for cancer pain, provides a guideline for pharmacological treatment. Due to age-dependent alterations in the kinetics and dynamics of pharmaceuticals, the titration of the medication follows the rule "start low-go slow". The same principle holds true for the maintenance or augmentation of physical activity in order to escape from the activity-deconditioning cycle. Training should be based on learning theories, include pain management strategies, and incorporate psychological approaches to facilitate the active participation of the patient in the treatment program. In hospitals and nursing homes, nurses play an important role in defining the need for pain treatment and in supervising the patient in the treatment process. Despite these endeavours, a significant number of patients remain whose pain cannot be controlled sufficiently. Euthanasia on demand for a patient with untreatable pain is not admitted in Germany.

[Pain specialist in the assessment process]. / Der Schmerztherapeut bei der Begutachtung.

Pain specialists are often involved in assessing social medical aspects of chronic pain patients. A standardized examination in the assessment process is not published. Data and statements on the assessment process between 1993 and 1997 were recorded from 15 experts by questionnaire. Statements to 568 reports were made. The majority of performance impairments were caused by back pain (35.9%) and headache (19.3%). All examiners integrated a psychological assessment. Although the assessment processes were very different, all examiners fulfilled the minimal criteria of the presented process for assessment of chronic pain patients. Verifying the symptoms as well as capturing some aspects of aggravation proved to be problematic. The present assessment practice is discussed with regard to the unequal procedure. On basis of the received data and the own experience in examination the process of structured assessment of chronic pain patients is presented under medical and psychological aspects. It contains a recommendation of a standardized process with minimal criteria and an optional supplement of the standardized process with problematical patients (e.g.demonstration, aggravation, simulation). Minimal demands on a qualified assessment of chronic pain patients should contain the study of the history, the German Pain-Questionnaire, the analysis of all the painful complaints with weighting their importance, the examination and the basic registration of sensational, emotional, cognitive, behavioral and social aspects of the chronic pain syndrome. An appended glossary of the most usable psychological tests with comments on their validation criteria aims to provide a more standard multimodal assessment of chronic pain patients complaints and functionability.

[A structured pain interview for geriatric patients]. / Ein strukturiertes Schmerzinterview für geriatrische Patienten.

BACKGROUND: In old age, assessment of pain often is hampered by sensory and cognitive deficits that do not allow the patients to fill in standardized questionnaires without help from significant others. Therefore, as an alternative, we developed a structured pain interview, and examined its properties and acceptance in a sample of geriatric patients with pain. METHODS: The interview covers site of pain, intensity of pain, its duration and persistency, pain related disability and, finally, emotional and cognitive variables. In addition, the interviewer addresses significant others to get information about medication, previous treatment, and residence, and administers the Mini-Mental-State-Examination (MMSE). The analysis includes 128 patients of pain centers older than 74 years, of whom 80% are female. RESULTS: Forty percent of the subjects score below the critical MMSE value < or =23 indicative of cognitive impairment. These patients are responsible for 36 out of a total of 39 missing values. A significant increase of missing values is observed in patients with a MMSE score below 10. Cognitive impairment goes along with greater functional and social disability. On the other hand, cognitive impairment is unrelated to localization, intensity, and duration of pain. The memory item of the MMSE can be used as a screening tool for cognitive impairment. Patients, who are unable to recall any of the three objects, comprise 80% of the total of missing values and demonstrate a low MMSE score. CONCLUSION: As long as geriatric patients are able to communicate verbally, they are most likely to profit from the structured pain interview in spite of existing cognitive impairment. A MMSE score <10 indicates that the interpretation of the data obtained may be difficult, especially due to a high frequency of missing values.

[Pain conference. An example of an interdisciplinary cooperation]. / Schmerzkonferenz Beispiel einer interdisziplinären Kooperation.

BACKGROUND: In the interdisciplinary Pain Conference, pain specialists of various disciplines discussed - partly in the presence of the concerned patient - explanations as to the cause of a specific pain. The following example portrays the events of the conference. CASE REPORT: In this case, despite extensive diagnostics, no explanation due to an organ failure could be found for a 74-year-pld man with worsening neurological pain above the knee. The patient's desire the change was so strong that after ineffective outpatient care and different operations, such as hernitomy, fibroma removal and the implantation of an epidural stimulating electrode (SCS), other inpatient pain therapies followed using anasthesiological, balneophysical and psychological techniques, as well as medications. DIAGNOSIS AND THERAPY: The interdisciplinary discussion, including all the various diagnostical findings and the results of the therapeutical efforts, lead to the decision by conference participants to use the new electrophysical and imaging diagnostics. This lead to the discovery of a leiomyosarcoma, which had surrounded the N. obtoratius. After the removal surgery, the pain was gone and the pain medications being used could gradually be dropped.

[Treatment of chronic pain with drug addicts]. / Behandlung von chronischen Schmerzen bei Drogenabhängigen.

BACKGROUND: The therapy of chronic pain of primarily drug addicted patients is a problem which has hitherto remained unresolved within the field of pain therapy. Synergistic effects of the prescribed medicine with additionally taken drugs or medicine which can lead to an unpredictable increase of effect of prescribed opioids are of special significance. When addiction and pain appear simultaneously medical aspects of the syndrome of addiction have to be implemented within the framework of coordinated therapy. In this case regular controls are to be taken; at the same time the treatment of cases of relapse must occur gradually. Not only is the final aim of this therapy abstinence but also a survival as healthy as possible. We don't ask more of the patient as he is able to perform, but we do ask everything which can be expected of him. In a treatment contract both therapist and patient agree on their individual tasks. With exemplary cases both the case history and the course of the therapy of four patients with simultaneous symptoms are illustrated. DISCUSSION: It becomes clear that the cooperative concept of therapy both with regard to pain as to addiction render an individual weighing of risks necessary. If the treatment of chronic pain is to be regarded as a primary goal then addicts can be treated in an institution devoted to the treatment of pain, providing there is a functioning cooperation with colleagues who are experienced in the treatment of addiction.

[Medical prohibition of pain therapy in cancer patients - an incredible case report]. / Arztliches Verbot von Schmerztherapie bei Tumorschmerzpatienten. Ein unglaublicher Fallbericht.

CASE REPORT: Case presentation of a 59-year old female patient, who has been treated for her cancer by a physician of internal medicine with peroxodisulphuric acid. For this therapy to be successful - according to the physician - all drugs especially the analgetics had to be stopped. DISCUSSION: Along with this case presentation the statement by the German Medical Association is shown and legal assessment is discussed.

[Analgesia using oral administration of tilidine naloxone for extracorporeal shockwave lithotripsy. A double blind study]. / Analgesie mit oraler Gabe von Tilidin-Naloxon zur extrakorporalen Stosswellenlithotripsie. Eine Doppelblindstudie.

Reduction in pain perception during ESWL due to a technical modification of the lithotriptor was expected and prompted a reassessment of anaesthesia techniques for ESWL. In this study the need for analgesic treatment had to be investigated. After satisfactory preliminary results in a previous pilot study, the value of the oral combination of the anti-anxiety drug dipotassium clorazepate on the evening before ESWL together with the analgesic tilidine-naloxone before treatment was tested in a randomised double-blind study in 120 patients. In case of intolerable pain during the treatment all patients were free to ask for additional intravenous analgesic medication (fentanyl). During ESWL, 28.3% of the tilidine-N group patients and 6.7% of the placebo group were pain-free, whereas intolerable pain was reported by 30% of the tilidine-N group and 56.7% of the placebo group. Therefore, 70% of the tilidine-N group patients were treated without any additional analgesic or sedative medication. The good experience with this oral anaesthesia approach, the lack of significant side effects and a good acceptance by the patients warrant further recommendation of this technique.

New generator for low pressure lithotripsy with the Dornier HM3: preliminary experience of 2 centers.

The technical innovation of a low pressure generator with a standard ellipsoid installed into the Dornier HM3 lithotriptor leads to a decrease in pressure at the second focus by 30 per cent. The preliminary experience with 273 patients treated at 2 centers is presented. The success rate in terms of stone disintegration was similar compared to the old generator (96 versus 97 per cent). However, the rate of secondary treatments increased from 8 to 15.5 per cent, respectively. Owing to the lower peak pressures at the second focus, an additional 700 impulses per session were necessary. The method of anesthesia was changed to a combination of an anxiolytic and analgesic drug in the majority of the patients. Treatment was judged as free of pain or with easily tolerable pain in 93 and 88 per cent of the patients, respectively.

[Initial experience with preorally administered dipotassium clorazepate and tilidine-naloxone in extracorporeal shockwave lithotripsy]. / Erste Erfahrungen mit der peroralen Gabe von Dikaliumclorazepat und Tilidin-Naloxon zur extrakorporalen Stosswellenlithotripsie.

After 70 treatments with extracorporeal shock wave lithotripsy (ESWL), using a combination of dipotassiumclorazepate p.o. 12 h before treatment and tilidin-naloxon 45 min before ESWL, 56 patients reported to be painfree or only minor, well-tolerable pain. Informed consent was obtained in all patients for this pilot study, leaving the possibility of further pain medication. 7 patients asked for an additional analgesic (fentanyl) and another 7 patients required a sedative (midazolam). No further anesthesiologic procedures were necessary. Nausea was observed in one patient as a possible side-effect of tilidin. To confirm these preliminary results, a prospective randomized study is currently conducted.