Assessing post-op pain can be difficult in patients of all ages, in part because of our own expectations. Variable patient responses can further inhibit our ability to identify pain. When the patient is elderly, the challenge is even greater.

This is because our preconceived notions about the elderly may be solidly entrenched, and age-related cognitive impairment can hinder communication. Here are four strategies to help you better assess - and thus treat - pain in the rapidly growing population of elderly outpatients.

1. Understand the elderly perspective
In general, elderly patients are less likely than their younger counterparts to report pain. They tend to believe that pain is a normal consequence of aging; therefore, they do not view the experience of pain as aberrant. They are also more likely to believe they can work through pain on their own, since they have lived through many experiences. Because of their age, elderly patients also tend to have a heightened concern about their prognosis, causing them to focus on outcomes, rather than pain, during encounters with practitioners. In addition, these patients are less likely than younger patients to question practitioners, and many quietly surmise that their practitioners would make their pain go away if they could. As a result, elderly patients are often stoic and guarded, even when they are feeling significant pain.

2. Try self-reporting first
Practitioners sometimes presume elderly patients are cognitively impaired and, as a result, discount self-reporting altogether. Unless significant cognitive impairment is obvious at the time of evaluation, practitioners should always try a self-report. It's the most reliable indicator of pain, and, with good communication, elderly patients are often capable of reporting pain. To maximize the self-report's success, consider these rules of thumb:

• Assess cognition at the time of evaluation. Cognitive impairment in the elderly is often transient. Elderly patients may have good days and bad days, or they may experience impairment during certain times of day. In addition, the presence of family often enhances elderly patients' mental clarity, and family members can help these patients interpret pain scales.
• Probe for "trigger descriptives." When working with elderly patients, it is important to find words that have meaning for them. Patients often describe pain with words like "achiness" or "soreness," and these trigger descriptives provide a basis for effective communication. I think of this as getting into their reality. For example, one ex-nursery school teacher I treated used the word "boo-boo" to describe her pain.
• Encourage visualization. Some elderly patients may be number-phobic or have degenerating math skills. In all cases, I find it helps patients greatly when they can visualize the pain scale. I introduce a large-print, "mild-moderate-severe" scale first, and then I use a transparency to superimpose the 0-to-10 numeric rating scale (NRS) over it.
• Use consistent language. When explaining the pain scales, practitioners should repeat the explanation several times, using the same words and phrases.

3. Tune in to nonverbal signs
In the absence of self-report, nonverbal cues may be reliable indicators of pain for cognitively impaired, elderly individuals. They can also be useful adjuncts to the NRS for cognitively intact patients. Unfortunately, we tend to overlook behaviors such as agitation and confusion because we may expect them in the elderly. In addition, many facilities rely instead on tools like the Wong-Baker FACES Pain Rating Scale or the FLACC Pain Assessment Tool, even though there are no reliable data to show that these tools work for elderly or cognitively impaired patients. In fact, these tools (which were designed for the very young) may lead practitioners astray by causing us to measure factors other than pain. For example, the elderly patient may point to a frowning face on the FACES scale simply because he dislikes the food, doesn't have enough blankets or is longing for a family visit.

To maximize reliability of nonverbal cues, the practitioner must identify the etiology of patients' behaviors. Doing so requires the practitioner to cut through preconceived notions by using good observational skills, questioning patients and their families, and considering the context.

• Observational skills. Even when patients profess to be pain-free, facial expressions such as grimacing, body language such as fidgeting, vocalizations such as moaning, and behavioral changes such as refusal to move or sudden incontinence can indicate pain. In these cases, the practitioner should question the patient closely. For example, the practitioner may say: "I see you're having difficulty taking a deep breath. Why is that?"
• Family questioning. Don't hesitate to ask the family for help, as family members often know how their loved ones respond to pain. For example, one family helped me understand that a patient of mine was in pain because she was grinding her teeth.
• Context. Finally, when evaluating nonverbal cues, consider patients' behaviors in context. If a nurse just shifted a surgical patient's position, for example, any atypical behavior is likely to suggest discomfort.

4. Treat anticipated pain
Given the challenge of assessing pain in elderly patients, it is important to treat them for anticipated pain. That is, whenever patients undergo a painful procedure, assume pain is present, even if the patients show no obvious signs. A simple rule of thumb is this: If it would hurt me, it would hurt them.

A growing need
With the population of 65-to-74-year-olds projected to grow 74 percent between 1990 and 2020, you can continue to expect to see more elderly patients for outpatient procedures such as cholecystectomies, laminectomies, colonoscopies and even certain cancer procedures. By following these four basic strategies, practitioners can help ensure that their elderly patients' surgical experiences will be as comfortable as possible.