無口語或認知障礙老人之疼痛評估

Assessment of Pain in the Nonverbal or Cognitively Impaired Elderly

有50％的老人會經歷疼痛，在護理之家的比例更高達70到80％。輕中度失智老人雖能自我陳述疼痛，但可信度可能不高。重度失智症患者可能喪失語言能力，因此其疼痛常被低估，甚至缺乏適當的治療。老人的譫妄症可能由疼痛所致，也可能和疼痛有共同的成因，和疼痛也常有共同的行為表現，因此在鑑別診斷相當困難。加護病房病人因意識喪失、插管、氣切等因素無法表達疼痛。針對老人之疼痛評估，可遵循階梯式的五個步驟：自我陳述、尋找潛在疼痛的原因、觀察病人行為並使用行為評估量表、參考親近者描述的疼痛或行為改變、嘗試給予止痛藥物。疼痛會造成某些特定行為，但這些行為的出現並不能代表一定有疼痛存在。美國老年醫學會將認知功能障礙的老人之疼痛行為分成六大項：臉部表情、言語或發聲、身體動作、人際互動的改變、日常活動型態改變、心智狀態改變。行為評估工具需注意適用的 對象，以及臨床的可行性。當有造成疼痛的病理性或醫源性因素存在時，或是充份滿足病人的基本需求仍出現疼痛行為時，就需考慮給予止痛。止痛藥在老年人使用要注意起始劑量的調整，不建議使用精神用藥做為疼痛行為的第一線治療。

Pain occurs in approximately half of elderly persons and 70-80% in nursing home residents. Although older adults with mild to moderate dementia can self-report pain, the results may not be reliable. The elderly with severe dementia may lose their verbal abilities; therefore, their pain is frequently underestimated, and hence, undertxeated. Delirium in the elderly may be caused by pain, has common contributing factors with pain, overlaps with pain in terms of behaviors, thereby making the differentiation between delirium and pain more difficult. Critically ill patients in intensive care units have difficulty in reporting their pain due to unconsciousness, intubation, tracheostomy, etc. A Hierarchy of Pain Assessment Techniques has been recommended to provide a structure in assessing pain for the elderly, and incorporates the following steps: 1. obtain self-report, 2. search for potential causes of pain, 3. observe patient behaviors, 4. proxy reporting of pain and behavior/activity change, and 5. attempt an analgesic trial. Pain causes some behaviors, but these behaviors do not guarantee the existence of pain. The American Geriatrics Society identified six categories of pain behavioral indicators observed in older adults with cognitive impairment: facial expressions, verbalization/vocalizations, body movements, changes in interpersonal interactions, changes in activity patterns or routines, and mental status changes. Appropriate behavior assessment tools should be chosen for specific populations and clinical feasibility should be considered. The use of analgesics is indicated when some pathological or iatrogenic causes of pain exist, or pain behaviors persist after fulfillment of basic needs. The initial dose of analgesics in the elderly should be adjusted. Psychotropic drugs are not suggested as the first line therapy for pain behaviors.