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Five-minute Practitioner: April 2008

Only got five minutes? Then just read these key points on: pain in older patients, depression in later life and doctors' mental health

Only got five minutes? Then just read these key points on: pain in older patients, depression in later life and doctors' mental health

Pain in older patients

Around 50 to 80% of older people living in the community experience some form of pain, often because of chronic, degenerative conditions. Despite this, the awareness and management of pain in older people remains inadequate.

Pain assessment in older patients can be challenging. There is a high prevalence of cognitive impairment, with associated decline in verbal communication skills, and false assumptions that pain is an inevitable consequence of growing old and that people with cognitive impairment have a higher pain threshold. A high level of stoicism among older people often means that they suffer in silence.

Pain in patients with mild to moderate cognitive impairment can be assessed using simple questions and screening tools. GPs should note the presence of pain behaviour during activity such as walking or transfers.

Patients with severe dementia may have altered affective responses to pain causing them to communicate pain in ways that are challenging to carers and less easily understood. Subtle changes in behaviour patterns should raise the suspicion of pain and lead to a systematic evaluation of possible causes.

There is strong evidence that regular participation in physical activities reduces pain and enhances the functional capacity of older patients with persistent pain.

Stepwise treatment progression is recommended. This should progress from non-opioid analgesics such as paracetamol, to anti-inflammatory drugs, to neurotransmitter-modulating and membrane-stabilising drugs and opioids, while balancing the medical risks and benefits.

Depression in later life

Depression is the most common mental illness in older people and the second most common underlying cause for all GP consultations for people over 70 years of age. Depression is more common in women (10.4%) than men (6.5%).

In older people, depression is frequently characterised by excessive concerns about physical infirmity. In those aged over 55 years, depression is associated with a fourfold increase in mortality. Treating depressive symptoms not only alleviates the suffering intrinsic to the disorder, but also reduces mortality from cardiovascular and cerebrovascular illness.

Late-onset depression and early-onset recurrent depression in older age differ in terms of clinical features, aetiology, neuroanatomical substrates and prognosis. Late-onset depression is associated with somatic symptoms. It is therefore more likely to be caused by intervening (vascular) illness affecting the brain in old age, while early-onset recurrent depression may result in part from genetic predisposition.

GPs successfully treat most patients with depression. The Geriatric Depression Scale is simple and reliable and questions are answered by the patient as ‘yes' or ‘no'.

Doctors' mental health

Compared with the general population, doctors are significantly more likely to suffer from one or more of drug misuse, alcohol misuse and depression. GPs are particularly vulnerable; compared with consultant physicians, and are more than three times as likely to commit suicide.

Doctors have the highest incidence of work-related mental ill health of any profession, with a rate more than 15 times the overall average.

Most GPs have no access to occupational health services, and even if they are available, many occupational health staff have little training in mental health.

The recently published report by the Department of Health Mental health and ill health in doctors recommends that doctors treating other doctors should have appropriate expertise and seniority, local agreements should be in place to provide out-of-area specialist care and occupational health services should be improved and expanded.

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