European Journal of Pain 8 (2004) 335–344

www.EuropeanJournalPain.com

Pain management in elderly persons who require assistancewith activities of daily living: a comparison of those living

at home with those in special accommodations

Ulf Jakobsson a,*, Ingalill Rahm Hallberg a,b, Albert Westergren a

a Department of Nursing, Faculty of Medicine, Lund University, P.O. Box 157, SE-221 00 Lund, Swedenb The V�ardal Institute, The Swedish Institute for Health Science, Lund University, P.O. Box 187, SE-221 00 Lund, Sweden

Received 7 April 2003; accepted 23 October 2003

Available online 10 December 2003

Abstract

Objectives: To describe and compare the methods of pain management used by elderly individuals with chronic pain and re-

quiring assistance with activities of daily living, depending on whether they live alone, with someone, at home or in special ac-

commodations.

Methods: This study comprised 294 people aged 76–100 years, identified as having chronic pain and requiring assistance with

activities of daily living. Pain and pain management methods were compared using the Multidimensional Pain Inventory, Swedish

version, and the Pain Management Inventory.

Results: Those living in special accommodations reported more pain than those living at home. Those living with someone

reported more pain and interference in daily life than those living alone, despite using more pain-relief methods and having greater

social support. The median number of pain-relieving methods used was 3.0 (75th–25th percentile: 5–2). Some (3.8%) did not use any

method to relieve their pain. The most frequently used methods were prescribed medicine (20%), rest (20%) and distraction (15%).

The methods rated most effective were using cold, exercise, hot bath/shower and consuming alcohol.

Conclusion: Participants had only a small repertoire of pain management methods and these were mostly conventional in nature.

Few non-pharmacological methods were used. The findings suggest the importance of thorough assessment, and the need to fully

discuss pain management options with the elderly.

� 2003 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All

rights reserved.

Keywords: Aged; Pain; Activities of daily living; Pain measurement; MPI-S; PMI; Living conditions; Pain management

1. Background

There is sparse knowledge about the use of different

pain management methods in elderly people in need of

help to manage activities of daily living, and the possible

difference that the contexts, in which they live and receive

care, may make. Problems related to pain and pain

management methods among the frail old are likely to

differ from those among the younger and presumablyhealthier elderly. A positive correlation has been found

between pain and the ability of the elderly to perform

* Corresponding author. Tel.: +46-222-19-24; fax: +46-222-19-35.

E-mail address: ulf.jakobsson@omv.lu.se (U. Jakobsson).

1090-3801/$30 � 2003 European Federation of Chapters of the International

reserved.

doi:10.1016/j.ejpain.2003.10.007

daily activities (Mobily et al., 1994). Those in need ofhelp to manage activities of daily living may therefore be

especially vulnerable to being affected by pain. This can

be due to a lowered ability to use pain management

methods or the ability to communicate their experience

of their pain, which may also lead to loss of control over

the pain. They do, however, often have contact with

healthcare professionals who can help them to outline

strategies to control the pain and the negative effects of it.Both chronic pain and increased age have been found

to be determinants for the use of home care services

(Stoddart et al., 2002). However, not all people in pain

and in need of help for daily living receive home help/

professional care. Those who are dependent on others to

Association for the Study of Pain. Published by Elsevier Ltd. All rights

336 U. Jakobsson et al. / European Journal of Pain 8 (2004) 335–344

manage daily life and living at home may not have thesame access to professional help to handle their pain

and, hence, may more often face a life with chronic pain

and perhaps also to a higher degree than those living in

special accommodations [various kinds of institutions

for older people such as nursing homes, dwellings for

care of older people, and group-dwellings] (The Swedish

Institute, 1999). This may be so because people in spe-

cial accommodations have access to health care profes-sionals day and night. In contrast, studies have shown

that older people living in special accommodations have

often been found to live with untreated pain (Blomqvist

and Hallberg, 1999; Ross and Crook, 1998). One reason

for unsuccessful pain relief could be lack of systematic

assessment, which seems to explain the poor agreement

between assessment of the elderly person�s pain by the

staff and the elderly person�s own experience (Blomqvistand Hallberg, 1999). Another reason may be that the

pain-relief methods used are insufficient for achieving

satisfactory effect. Studies that determine the use and

effectiveness of various pain management methods are

necessary in order to guide health care professionals in

decision making when outlining treatments that can be

helpful for the elderly. Few studies, however, have fo-

cused on pain management methods and their effectsamong elderly people, especially with regard to various

living conditions.

Different methods are used to manage pain, but the

methods preferred by the elderly have not been well

elucidated. The different methods for pain relief are de-

scribed in the literature as pharmacological and non-

pharmacological (American Geriatric Society, 1998;

Closs, 1994). Pharmacological methods can be dividedinto prescribed and non-prescribed or over-the-counter

medication. Commonly used pain management meth-

ods, such as medication, may not always be considered

helpful by the person in pain (Blomqvist and Hallberg,

2002; Novy and Jagmin, 1997). One explanation for this

seems to be that the dose of the drug is lowered by the

elderly as well as by the care provider, as a result of fear

of addiction to the drugs, and hence the effect is loweredtoo (Ferrell, 1995; Novy and Jagmin, 1997). Another

reason may be the interaction between different medi-

cations. Elderly people living in nursing homes have been

found to experience many side-effects associated with the

prescription of multiple analgesic drugs (Ferrell, 1995).

Non-pharmacological methods such as Transcutaneous

Electrical Nerve Stimulation (TENS), massage, rest,

applying heat or cold can be used, either as stand-aloneor as complementary treatment, to increase pain-relief

and/or reduce adverse drug interactions (American Ge-

riatric Society, 1998; Closs, 1994). An interview study of

older adults (n ¼ 30, mean age: 79, SD 8.5) showed that

of 49 different pain-relieving methods, between 0 and 6

(mean 1.6, SD 1.5) methods were used that worked

successfully (Dillon McDonald and Sterling, 1998).

Blomqvist and Hallberg (2002) found that older peoplereceiving professional care, used a median of 5.0 (75th–

25th percentile; 6.0–3.0) methods for pain management.

Different pain-relieving methods were most often used in

combination rather than in isolation (Ross et al., 2001).

An interview study in Australia (n ¼ 71, mean age 75,

range 65–90) showed that elderly people wanted to be

active in the treatment of their pain, to make informed

choices and were willing to try new methods (Lansbury,2000). Strategies to relieve pain that were mostly pre-

ferred were those that the elderly had developed them-

selves and that they felt to be convenient, inexpensive,

easily accessible, and not demanding major behavioural

changes (Lansbury, 2000). The least preferred pain-

relieving strategies were treatments with medication,

exercise and physiotherapy. This highlights the impor-

tance of finding individually adapted pain-relievingmethods that are both as effective as possible while also

fulfilling the demands of the elderly person.

One way to outline and implement individually adap-

ted treatment plans is to study which methods are used

and regarded as helpful. The use of pain-relieving meth-

ods and their effectiveness has not been fully elucidated

among elderly people, especially not non-pharmacologi-

cal methods. The most successful interventions for painare probably the methods chosen by health care profes-

sionals together with the person suffering from it, because

then the person is given good control over the pain

management, and hence the pain. However, those in need

of help to manage activities of daily living may lack this

control and be at high risk of suffering from untreated

pain or not fully treated pain, because of their diminished

ability to manage such methods (Closs, 1994). Little isknown about how different pain management methods

are used among elderly people and how the older person

perceives their effectiveness. Knowledge of the use of pain

management methods under various living conditions

could form the basis for improved pain management in

older people experiencing chronic pain.

2. Aim

The aim of this study was to describe and compare

the use and perceived effectiveness of pain management

methods among elderly people with chronic pain who

require help with activities of daily living under different

living conditions.

3. Method

3.1. Sample

This study comprised 294 people (aged 76–100 years)

in need of help to manage activities of daily living and

reporting pain lasting 3 months or longer. Data were

U. Jakobsson et al. / European Journal of Pain 8 (2004) 335–344 337

collected using firstly a postal questionnaire, and sec-ondly structured personal interviews. The initial ques-

tionnaire study was conducted in southern Sweden with

an age-stratified sample (75–79, n ¼ 2500; 80–84,

n ¼ 2500; 85–89, n ¼ 2000; 90+, n ¼ 1500) of people

aged 75 years and older (Jakobsson et al., 2003), and

had response rates in the age groups of 75–79: 60%; 80–

84: 56%; 85–89: 48%; and 90+: 42%. Non-respondents

(mean age: 85.7, SD 6.1) were older ðp < 0:005Þ andincluded more ðp < 0:005Þ women (69.6%) than those

who did participated (Jakobsson et al., 2003).

All respondents to the initial questionnaire study

were divided into two groups, those in need of help with

activities of daily living and those not. Those in need of

help with activities of daily living ðn ¼ 1305Þ were se-

lected based on the criteria: because of impaired health

status in need of help with activities of daily living atleast once a week, e.g. with personal hygiene, getting

dressed, cooking or preparing meals. Those in need of

help were contacted by phone and asked if they wanted

to participate in an interview study and 532 (41%)

agreed. Prior to the interview another questionnaire was

sent to them, and the respondents were instructed to

complete the questionnaire before the scheduled inter-

view. If the questionnaire was not fully completed, theinterview began with helping the respondents to fill out

the questionnaire. The interview consisted of questions

about pain and activities of daily living (ADL). Those

who reported having pain for the last 3 months were

included in this study ðn ¼ 294Þ. The study was ap-

proved by the Ethics Committee of the Medical Faculty

at Lund (LU 478-99).

3.2. Measurement

The initial questionnaire had questions about demo-

graphic data, pain, and activities of daily life. The initial

question about pain (‘‘have you been troubled by pain

for the last three months?’’) had four response alterna-

tives: ‘‘no, not at all’’, ‘‘yes, a little’’, ‘‘yes, rather much’’

and ‘‘yes, very much’’. Those reporting a ‘‘little pain’’ ormore in the initial questionnaire were asked to respond

to further questions about their pain and need of help in

daily living. The second questionnaire had questions

about activities of daily living, pain and pain manage-

ment methods. Among the 294 respondents, 161 (51%)

responded to further questions about their pain (i.e.

duration, localisation and cause); the rest of the 294

respondents decided not to respond to further questionsbecause of being too tired, too sick or just not wanting

to respond to the questions, for example.

Activities of daily living (ADL) were assessed using

the ADL staircase (Sonn and Hulter-�Asberg, 1991),

which is an extended version of Katz�s index of ADL

(Katz and Akpom, 1976). The ADL staircase summa-

rises the overall performance of 10 functions (bathing,

dressing, going to the toilet, transfer, continence, feed-ing, cleaning, shopping, transportation) and the degree

of dependency is calculated and graded from 1 to 10 or

as O, in a specific hierarchical order (Sonn and Hulter-�Asberg, 1991; Sonn, 1996). One to nine means depen-

dency in one to nine activities, zero means independent

in all functions, and 10 dependency in all respects. O

(‘‘others’’) means being dependent for help in at least

two and at most nine activities and not classifiable in thehierarchical structure (Katz and Akpom, 1976; Sonn

and Hulter-�Asberg, 1991). ADL scores 1–4 correspond

to need of help with Instrumental ADL (IADL) while

5–10 correspond to need of help with IADL and Per-

sonal ADL (PADL). The ADL staircase has been tested

psychometrically among older people in Sweden and

showed good validity (content, construct, and criterion

validity) as well as reliability (inter-observer reliability,internal consistency, test–retest reliability) (Sonn and

Hulter-�Asberg, 1991; Sonn, 1996).

The Multidimensional Pain Inventory – Swedish

version (MPI-S) (Bergstr€om et al., 1998) was used to

measure pain from a multidimensional view. MPI-S was

also used because it is constructed so that the item em-

phasising work could easily be excluded (in the present

study all respondents were retired). The instrument hasbeen developed from the West Haven Yale Multidi-

mensional Pain Inventory (WHYMPI) (Kerns et al.,

1985), which contains 61 items distributed in 12 sub-

scales, divided into three parts (Kerns et al., 1985). Each

item has a seven-point response scale with fixed grading

between 0 and 6, where 0 corresponds to ‘‘no, not at all’’

and 6 to ‘‘yes, very much’’. The Swedish version (MPI-

S) includes 34 of the 61 items and only the first two partsof the WHYMPI. Several items, including one whole

section (Section 3), were removed from the WHYMPI in

the development of MPI-S because of low validity and

reliability (Bergstr€om et al., 1998, 1999). MPI-S was

revised by Bergstr€om et al. (1998, 1999) and was found

to have psychometric validity, reliability and internal

consistency. Section 1, which is used in this study,

contains five different parts: pain severity, interference,life control, affective distress and support (Table 1).

High scores correspond to a high degree of pain inten-

sity, interference in daily life, life control, affective dis-

tress and social support. MPI-S has been used to study

pain in different conditions: chronic musculoskeletal

pain (Bergstr€om et al., 1998, 1999), post-polio syndrome

(Widar and Ahlstr€om, 1999) and stroke (Widar and

Ahlstr€om, 2002). However, these studies includedmostly middle-aged people.

Pain Management Inventory (PMI) is an instrument,

consisting of 17 items, developed to study pain man-

agement methods and their effects (Davis and Atwood,

1996). The respondent is instructed to mark each

method used in the last week. Perceived effect of each

method is measured by a five-point scale: not helpful,

Table 1

Description and comparison between different living conditions regarding demographic data, pain duration, MPI-S scores and number of pain

management methods

Living at home

(n ¼ 229)

Living in special

accommodation

(n ¼ 65)

p value Living alone

(n ¼ 142)

Living together

with someone

(n ¼ 87)

p value

Age, mean (SD) 85.5 (5.2) 87.8 (6.3) 0.005 87.3 (5.4) 82.7 (4.3) <0.001

Men/women % 34.4/65.6 16.9/83.1 0.07 20.1/79.9 55.3/44.7 <0.001

ADL score, md

(75th–25th percentile)

4.0 (5.0–2.0) 6.0 (9.0–4.5) <0.001 3.5 (5.0–2.0) 4.0 (5.0–2.0) 0.2

Pain duration md

(75th–25th percentile)

years

5.0 (15.0–2.0) 7.0 (20.0–3.0) 0.3 4.8 (15.0–2.0) 5.0 (16.3–2.0) 0.6

Degree of pain (%) 0.003 0.02

Little 39.9 28.6 44.3 32.5

Rather much 34.5 31.7 36.4 31.3

Very much 25.6 39.7 19.3 36.2

MPI-Sa

Section 1

Pain severity, mean (SD) 2.63 (1.53) 2.58 (1.77) 0.8 2.63 (1.58) 2.63 (1.56) 0.9

Interference, mean (SD) 2.72 (1.48) 2.86 (1.79) 0.8 2.50 (1.61) 3.23 (1.25) 0.02

Life control, mean (SD) 3.95 (1.40) 3.83 (1.65) 0.9 3.92 (1.45) 3.97 (1.41) 0.8

Affective distress, mean (SD) 1.42 (1.48) 1.52 (1.46) 0.9 1.46 (1.55) 1.39 (1.29) 0.8

Support, mean (SD) 3.83 (2.10) 3.64 (1.92) 0.5 3.29 (2.05) 4.69 (1.79) <0.001

No. of pain management

methods used, md

(75th–25th percentile)

3.0 (5.0–2.0) 4.0 (5.0–2.0) 0.4 3.0 (4.0–2.0) 4.0 (6.0–2.0) 0.05

aMPI-S score range between 0 and 6 (high scores indicate high degree of pain severity, interference, life control, affective distress, support).

338 U. Jakobsson et al. / European Journal of Pain 8 (2004) 335–344

somewhat helpful, generally helpful, very helpful and

extremely helpful. Psychometric testing made in a sam-

ple (n ¼ 82; mean age: 58, SD 14.5) with rheumatoid

arthritis and/or osteoarthritis, showed that the instru-

ment had an acceptable psychometric validity and reli-

ability (Davis and Atwood, 1996). The modified version

of PMI, as used in this study, has also been used in a

previous study of elderly people in pain (Blomqvist andHallberg, 2002). The changes were made in accordance

with the results of a pilot study (studying elderly people)

that aimed to test the instrument. The changes made, in

the modified version, were that the item ‘‘bracing or

splinting the affected part’’ was changed to ‘‘using splint,

brace or stretch bandage to relieve pain’’ (Blomqvist and

Hallberg, 2002). Further, the item ‘‘using bio-feedback’’

was removed, while ‘‘using alcohol to relieve pain’’and ‘‘using any other activities to relieve pain’’ were

added.

3.3. Data analysis

Demographic data, pain, pain management methods

and their effects were analysed for those living in special

accommodations and for those living at home. Thegroup living at home was further divided into those

living alone and those living with someone and com-

parisons were made between those two groups. Tests for

statistical significance were performed using v2 test for

nominal data, Fisher�s exact test for nominal data (2� 2

tables with an expected counts less than 5 in at least one

cell), and Mann–Whitney U test for testing ordinal and

interval data (Altman, 1991). Continuous data are pre-

sented with mean and standard deviation, discrete nu-

merical data and ordered categorical data are presented

with median and the 75th percentile and the 25th per-

centile, and categorical data are presented with percent(Altman, 1991).

Internal consistency was tested using Cronbach�s a(Cronbach, 1951), and a-values for MPI-S Section

1 ranged between 0.63 and 0.89 (pain severity: 0.70;

interference: 0.89; life-control: 0.73; affective distress:

0.63; support: 0.69). Internal consistency for the 10-

grade ADL scale was also calculated using Cronbach�sa and it was supported by acceptable internal consis-tency: a ¼ 0:85. All data were computerised and

analysed using SPSS for Windows 11.0 (Norusis,

1992).

4. Results

Of the 294 participants, 229 (79%) people were livingat home and 65 (21%) people lived in special accom-

modations (Table 1). Among those living at home, 142

(62%) were living alone while 87 (38%) were living with

No. of methods used109876543210

Cou

nt

40

30

20

10

0

Degree of pain

Very much

Rather much

Little

Fig. 1. Description of the number of methods used related to the de-

gree of pain in total sample ðn ¼ 294Þ.

U. Jakobsson et al. / European Journal of Pain 8 (2004) 335–344 339

someone (Table 1). Thirty six per cent of the respon-dents were categorised between 1 and 4 (dependent in

I-ADL) on the ADL staircase and 10% were categorised

as O (not classifiable in the hierarchical structure).

Those in special accommodations had significantly

higher ADL scores than those living at home, indicating

greater need for help to manage daily living (Table 1).

No significant difference in ADL score was found be-

tween those living alone and those living together withsomeone (Table 1). Among those living at home the help

received was mostly from children not living in the

household (42%), public home help service (41%) and

spouses (28%). Further, among those living at home

15% received help from primary nursing care and 3.5%

received help from personnel at ‘‘service units’’ for

elderly people.

The distribution (total sample) of the degree of painwas 38% reporting little pain, 34% reporting rather

much pain, and 29% reporting very much pain. Those

living in special accommodations reported a signifi-

cantly higher degree of pain than those living at home,

and those living together with someone reported a sig-

nificantly higher degree of pain than those living alone

(Table 1). No significant differences were found in the

subscales of MPI-S between those living at home andthose in special accommodations (Table 1). However,

those living alone scored significantly lower on inter-

ference and in support than those living together with

someone (Table 1).

Among the 294 respondents, 161 (51%) responded

to further questions about their pain (i.e. duration,

localisation and cause). Those who did not respond to

these further questions were significantly olderðp < 0:002Þ and had significantly less pain ðp < 0:001Þ,but there was no significant difference in living condi-

tions between responders and non-responders. A

median duration of 5 years (75th–25th percentile: 15.0–

2.0) was reported. Thirty seven per cent reported that

they not had received any diagnosis, or did not know

the reason, for the pain. The reasons reported for

having pain were unspecified musculoskeletal pain(1%), osteoporosis (2%), rheumatoid arthritis (6%),

osteoarthritis (34%), other rheumatic diseases (14%)

such as Sj€ogren�s syndrome, Systemic Lupus Erythe-

matosus (SLE), fibromyalgia and unspecified rheumatic

disease. Other reasons were musculoskeletal diseases/

problems (27%) such as fracture, displaced interverte-

bral disc, joint and muscle inflammation and other

non-specified musculoskeletal problems. Non-muscu-loskeletal diseases/problems (16%) as reasons for the

pain included lowered circulation of the blood (above

all in the legs), herpes zoster and damaged nerves. The

locations of the pain were, in descending order, legs/

feet (33%), back/neck (22%), hip/pelvis (15%), shoul-

ders/arms/hands (14%), joints (6%), the whole body

(4%) and other not specified (6%).

4.1. Pain management

The respondents used a median of 3.0 (75th–25th

percentile: 5.0–2.0) methods for pain relief. Those re-

porting a high degree of pain used more pain-relieving

methods than those with a lower degree of pain, al-

though the differences was not statistically significant

(Fig. 1). The number of methods used did not differ

significantly across ADL score. Six (3.8%) people didnot use any pain-relieving method and 18 (11.4%) used

only one method to relieve their pain (Fig. 1). Those

who did not use any methods were all living at home.

About 56% used between two and four methods (Fig. 1).

No significant difference in the number of methods used

was found between those in special accommodations

and those living at home. However, those living alone

used significantly fewer methods than those living to-gether with someone (Table 1). The methods used most

frequently (in the total sample) were prescribed medicine

(20%), resting (20%) and distraction (15%). The least

used methods were TENS (0.5%), cold (1.4%), alcohol

(1.4%), and support groups (0.5%). No significant dif-

ferences were found between those living in special ac-

commodations and those living at home with regard to

methods used (Tables 2 and 3). Massage was used sig-nificantly more often by those living alone (Table 3).

The pain management method ‘‘other things to relieve

the pain’’ (Tables 2 and 3) was described as stretching,

rebuilding the bed, liniment/salve, acupuncture or mac-

robiotic food.

The helpfulness of each method used, compared be-

tween those living in special accommodations and those

living at home, showed a significantly higher degree ofhelpfulness regarding talking to people who understand

Table 2

Pain management methods and their effects among older people (75+)

Method No. of users

living at home

(n ¼ 229)

No. of users

special

accommodation

(n ¼ 65)

p value Helpfulness

living at home

Helpfulness special

accommodation

p valuec

md (75th–25th

percentile)dmd (75th–25th

percentile)d

Prescribed medicine 89 (39%) 20 (31%) 0.4a 3.0 (4.0–2.0) 2.5 (3.0–2.0) 0.07

Non-prescribed medicine 52 (23%) 6 (9%) 0.1a 3.0 (4.0–2.0) 2.0 (3.3–1.0) 0.3

TENS 2 (1%) 0 (0%) 0.7b 2.5 (4.0–1.0) – –

Relaxation 17 (7%) 2 (3%) 0.4b 2.0 (3.5–2.0) 1.0 (1.0–1.0) 0.1

Heat 34 (15%) 6 (9%) 0.8a 2.0 (3.0–2.0) 3.0 (4.0–2.0) 0.4

Cold 4 (2%) 1 (2%) 0.6b 2.5 (3.8–2.0) 4.0 (4.0–4.0) 0.4

Exercise 41 (18%) 9 (14%) 0.7a 2.0 (3.0–2.0) 3.0 (3.3–1.8) 0.3

Massage 19 (8%) 7 (11%) 0.1b 2.0 (4.0–2.0) 2.0 (3.0–1.5) 0.5

Hot bath/shower 28 (12%) 4 (6%) 0.6a 2.0 (4.0–2.0) 2.0 (3.0–1.0) 0.4

Rest 86 (38%) 21 (32%) 0.2a 3.0 (3.0-2.0) 2.0 (3.0–2.0) 0.4

Lowered physical and

mental effort

13 (6%) 2 (3%) 0.6b 2.0 (3.0–2.0) 2.0 (2.0–2.0) 0.8

Bracing/stretch bandage 20 (9%) 4 (6%) 0.6b 2.0 (4.0–2.0) 2.0 (5.0–2.0) 0.8

Talking to people who

understand

45 (20%) 12 (18%) 0.3a 2.0 (2.3–1.0) 3.0 (3.3–2.0) 0.03

Use of alcohol 6 (3%) 1 (2%) 0.7b 2.0 (2.3–1.8) 4.0 (4.0–4.0) 0.3

Distracting methods 64 (28%) 16 (25%) 0.2a 2.0 (3.0–2.0) 2.0 (3.0–2.0) 0.8

Support groups 1 (0.5%) 0 (0%) 0.8b 2.0 (2.0–2.0) – –

Other things relieving

the pain

21 (9%) 3 (5%) 0.5b 2.5 (3.0–2.0) 3.0 (4.0–2.0) 0.7

Comparison between those living at home and those in special accommodation.a v2 test.b Fisher�s exact test.cMann–Whitney U test.dHelpfulness scale: 1, not helpful; 2, somewhat helpful; 3, mostly helpful; 4, very helpful; 5, extremely helpful.

Table 3

Pain management methods and their effects among those living at home

Method No. of users living

alone (n ¼ 142)

No. of users living

with someone

(n ¼ 87)

p value Helpfulness of

the method.

Living alone

Helpfulness of the

method. Living

with someone

p valuec

md (75th–25th

percentile)dmd (75th–25th

percentile)d

Prescribed medicine 72 (51%) 38 (44%) 0.6a 3.0 (4.0–2.0) 3.0 (4.0–3.0) 0.02

Non-prescribed medicine 40 (28%) 18 (21%) 0.8a 2.5 (4.0–2.0) 2.5 (3.3–2.0) 1.0

TENS 0 (0%) 2 (2%) 0.1b – 2.5 (4.0–1.0) –

Relaxation 10 (7%) 10 (11%) 0.08a 2.0 (2.0–2.0) 2.0 (3.0–2.0) 0.5

Heat 27 (19%) 13 (15%) 0.9a 2.5 (4.0–2.0) 3.0 (3.0–2.0) 0.9

Cold 3 (2%) 2 (2%) 0.5b 2.0 (4.0–2.0) 2.5 (3.0–2.0) 0.4

Exercise 30 (21%) 21 (24%) 0.1a 4.0 (4.0–2.0) 2.0 (3.0–2.0) 0.6

Massage 22 (15%) 4 (5%) 0.04a 2.0 (3.0–2.0) 2.0 (2.0–1.3) 0.1

Hot bath/shower 19 (13%) 14 (16%) 0.3a 3.0 (3.8–2.0) 4.0 (4.0–2.0) 0.1

Rest 66 (46%) 42 (48%) 0.06a 2.0 (4.0–1.8) 3.0 (4.0–2.0) 0.01

Lowered physical and

mental effort

7 (5%) 8 (9%) 0.09a 1.0 (2.0–1.0) 2.0 (3.0–2.0) 0.3

Bracing/stretch bandage 15 (11%) 10 (11%) 0.5a 2.0 (3.0–2.0) 2.0 (4.0–2.0) 1.0

Talking to people who

understand

36 (25%) 21 (24%) 0.5a 2.0 (2.3–1.8) 2.0 (2.8–1.0) 0.2

Use of alcohol 5 (4%) 2 (2%) 0.8a 2.0 (2.0–2.0) 2.5 (3.0–2.0) 0.6

Distracting methods 50 (35%) 31 (36%) 0.2a 2.0 (4.0–2.0) 2.0 (3.0–2.0) 0.1

Support groups 1 (0.5%) 0 (0%) 0.7b 2.0 (3.0–2.0) – –

Other things relieving the pain 16 (11%) 9 (10%) 0.8a 2.0 (3.0–1.5) 3.0 (4.0–3.0) 0.009

Comparison between those living alone with those living together with someone.a v2 test.b Fisher�s exact test.cMann–Whitney U test.dHelpfulness scale: 1, not helpful; 2, somewhat helpful; 3, mostly helpful; 4, very helpful; 5, extremely helpful.

340 U. Jakobsson et al. / European Journal of Pain 8 (2004) 335–344

U. Jakobsson et al. / European Journal of Pain 8 (2004) 335–344 341

among those living in special accommodations (Table2). The most effective methods for people living at home

were prescribed medicine (median 3.0), non-prescribed

medicine (median 3.0) and resting (median 3.0) (Table

2). The most effective methods among those living in

special accommodations were using cold (median 4.0),

consuming alcohol (median 4.0), heat (median 3.0), ex-

ercise (median 3.0), talking to people who understand

(median 3.0), and using ‘‘other things to relieve thepain’’ (median 3.0) (Table 2).

Those living together with someone rated prescribed

medicine, resting and ‘‘other things to relieve the pain’’

as significantly more helpful than those living alone did

(Table 3). The method perceived as most effective

among people living alone was exercise (median 4.0),

while those living with someone rated hot bath/shower

as the most effective (median 4.0) (Table 3).

5. Discussion

Those living in special accommodations reported

significantly more pain and were more dependent (ADL

score) than those living at home. Those living together

with someone reported significantly more pain, moreinterference of the pain but also more support in daily

life than those living alone. The respondents used a

median of 3.0 (75th–25th percentile: 5–2) pain-relieving

methods. The number of methods used did not differ

significantly across ADL score, and 3.8% did not use

any methods at all to relieve their pain. Prescribed

medicine, resting and distracting methods were the most

frequently used methods, while TENS and supportgroups were the least used. No significant difference in

the number of pain management methods used was

found between those living at home and those living in

special accommodations, whilst those living together

with someone used significantly more pain-relieving

methods than those living alone. Those living alone used

massage significantly more often than those living to-

gether with someone. Those in special accommodationsconsidered talking to people significantly more helpful

than those living at home, while those living together

with someone rated prescribed medicine, resting and

‘‘other things to relieve the pain’’ as significantly more

effective than those living alone.

The limitations of this study can be evaluated in

terms of threats to external validity (Kazdin, 1998)

which above all was related to the drop-out rate. Thedrop-outs were significantly older and therefore most

likely the most frail. The reasons given (6%) for not

responding were that they were too tired, suffered from

various diseases and/or impairments (e.g. visual im-

pairment, lowered motor function) that made it difficult

to respond indicating that the frailest old may have been

lost. Thus, the results from this study may not be gen-

eralised to the oldest and the frailest old. The structuredinterviews were, however, conducted to help the re-

spondents with the questions and, hence, include as

many as possible of the most frail. Interpretation of the

results needs to consider that the high drop-out, espe-

cially of the most frail may mean a more positive view of

the daily life situation than if the ‘‘drop-outs’’ were

participating.

Another limitation may stem from the fact that theMPI-S instrument has been sparsely used among elderly

people and therefore problems may arise when using the

instrument in this kind of population. Widar and Ah-

lstr€om (1999, 2002) had some representation of elderly

people aged 75 years and above, but no study besides the

present study has been found to use the MPI-S in a

sample with only elderly people. The MPI-S instrument

may be seen valid and reliable for use among elderlypeople when only section one is used (reducing total

number of questions to 22) and items are excluded that

emphasise, for this sample, irrelevant issues such as

work. Having few questions is known to increase the

chance of reducing the internal as well as external drop-

out. However, more psychometric tests would be pref-

erable, to further evaluate the instrument for use in an

elderly population.The findings from this study indicated that pain in

older people is common, especially among those in need

of help for daily living. A common misconseption is that

the intensity and prevalence of pain decrease in higher

ages, but there is no firm evidence for this (Klinger and

Spaulding, 1998). When the MPI-S scores from this

study are compared with other studies, several differ-

ences can be noticed (Bergstr€om et al., 1998, 1999; Wi-dar and Ahlstr€om, 2002). The comparison with findings

from this study showed lower scores in pain severity and

affective distress, while the life-control scores were higher

compared to a younger sample (Bergstr€om et al., 1998,

1999; Widar and Ahlstr€om, 2002). However, the sample

from this study is not a clinical sample and therefore

lower pain severity scores cannot be taken as an indi-

cation that elderly people suffer less from pain thanyounger people. The findings also showed a high degree

of life-control and this may indicate good adaptation to

a life with chronic pain among older people. Another

interpretation could be that elderly people might be

more reluctant to report pain, and regard it as an un-

avoidable part of ageing (Gagliese and Melzack, 1997).

The reason for the higher life-control scores could be

that elderly people have a different view of life and lifeevents than younger people, although this has not been

fully elucidated (Birren, 1996). Thus, elderly people may

adapt to chronic pain better or underreport pain. In any

case the findings show that many older people experi-

ence pain and that pain therefore should be addressed

systematically in healthcare to improve the overall life

and functional ability of elderly persons. More efficient

342 U. Jakobsson et al. / European Journal of Pain 8 (2004) 335–344

treatments combining pharmacological and non-phar-macological methods are needed.

Old people in special accommodations are at higher

risk of suffering from more intense pain than those living

at home. People in special accommodations reported

significantly more pain compared to those living at

home, whilst no differences in MPI-S scores and in the

number of methods used to manage pain were found

between those living at home and those in special ac-commodations (Table 1). The high degree of pain (about

40% reported very much pain) in people living in special

accommodations corresponds to the findings of previous

studies (Blomqvist and Hallberg, 1999; Ross and Crook,

1998). This is noteworthy since these people in fact have

professionals available on a 24-h basis. This high degree

of pain could be the result of under-treatment of the

pain (maybe not adequately assessed and/or treated)(Blomqvist and Hallberg, 1999; Ross and Crook, 1998).

Healthcare professionals in general assess pain on the

basis on the patient�s subjective reports, but also judge

the reports against the patients� personality, past medi-

cal history and their own perceived notion of pain

(Wallace, 1994). They may also share the same attitude

as elderly people that pain is unavoidable in old age.

Thus, there could be several explanations to misinter-pretation and also a lack of or inefficient assistance

leading to under-recognition and under-treatment of

pain. A study by Blomqvist and Hallberg (2001) showed

that elderly people (in special accommodations) some-

times became reluctant to talk about their pain because

they felt that the nurses lacked empathy or interest in

their pain and/or always were in a hurry. A systematic

assessment of pain and its causes is needed to effectivelytreat elderly people�s pain and outline individually

adapted pain management methods. This seems espe-

cially important for those living in special accommo-

dations.

An interesting finding was that pain seemed to in-

terfere more with daily life among those living with

someone than among those living alone. Those living

with someone reported significantly more pain and in-terference in daily life caused by the pain (MPI-S), and

they used significantly more pain-relief methods al-

though they reported significantly more social support

(MPI-S) than those living alone (Table 1). In most cases

social network and social support is found to buffer

negative effects from pain (Roy, 2001). Rowe and Kahn

(1999) reported, however, in a review that high levels of

support do not necessarily mean that the pain decreases.Unneeded or unwanted support may cause more harm

than good, and that in turn can reduce the elderly per-

son�s independence and self-esteem (Rowe and Kahn,

1999). Also Roy (2001) stated that overly solicitous so-

cial support might actually also reinforce pain. It is

sometimes difficult to fulfil the other person�s/partner�sexpectations and this may lead to ‘‘negative social sup-

port’’. Furthermore, negative spouse behaviour has beenfound to be associated with pain (Waltz et al., 1998).

Similar results were reported by Cano et al. (2000)

(n ¼ 165; mean age: 48.6, SD 13.6) who showed that

frequent negative spouse behaviour, i.e. negative re-

sponses to pain, were associated with increased pain

severity and decreased marital satisfaction. Those living

with someone (in this study) reported more pain and

interference, despite significantly more social support,than those living alone and one explanation may be that

of negative social support. However, because of the

cross-sectional design no causal relationships could be

established. There are no previous studies (that we have

found) that investigate elderly people in pain, in need of

help for daily living and living at home. From a clinical

perspective gerontological care needs to identify those in

pain, living at home together with someone, to provideinformation about various methods/strategies to relieve

pain. It is, however, important to also consider signifi-

cant others, and take possible ‘‘negative social support’’

into consideration in the care for elderly people.

Older people seem to use few pain management

methods in various combinations to relieve their pain

(Fig. 1). Reasons for this might be that elderly people

have little knowledge about different pain-relievingmethods and that nurses do not use, introduce or inform

patients about options that are less common. One single

method is often not effective enough to give full or at

least acceptable pain relief, and a combination of

methods is most likely required to relieve pain (Ross

et al., 2001). The result of this study showed no relation

between pain severity and the number of methods used.

However, achieving relief or reduction of pain is highlyindividualised and there is most likely no relationship

between the number of methods used and success in

achieving pain relief. Previous studies have shown that

elderly people (median age: 85 years; 75th–25th per-

centile: 89–80) receiving professional care were using a

median of 5 methods (Blomqvist and Hallberg, 2002).

An explanation for the higher number of methods used

in that study compared to this study could be that therespondent in the study of Blomqvist and Hallberg

(2002) received help in various ways such as information

and assistance to use the methods from professional

healthcare providers, while the respondents in this study

also included people living at home with no staff mon-

itoring them. There is reason to believe that the elderly

benefit more from small amounts of many treatments

(also including pharmacological strategies) in variouscombinations, than intensive treatment with a single

method (Gagliese and Melzack, 1997). Therefore, the

non-pharmacological methods, such as resting, talking

to people, or distraction, may be an effective comple-

ment to pharmacological interventions in pain treatment

among elderly (Ferrell, 1995). These methods may be

best used in combination rather than alone. A major

U. Jakobsson et al. / European Journal of Pain 8 (2004) 335–344 343

benefit is that these methods do not result in unwantedside-effects and may also be easier to handle for the

person in pain and hence may result in increased

autonomy.

Pain management among elderly people in need of

help for daily living was mostly based on well-known

pain-relieving methods such as prescribed medication,

rest and distraction (Tables 2 and 3). These findings

correspond to those of previous studies (Blomqvist andHallberg, 2002; Davis and Atwood, 1996; Hopman-

Rock et al., 1998; Lansbury, 2000). The reason that el-

derly people more often used the methods presented

above, although they were not always rated as most

helpful, could be that these methods are easy to access

and to handle by both health care professionals and the

person him/herself. A study by Lansbury (2000) showed

that the elderly preferred methods that were felt to beconvenient, inexpensive, easily accessible, and not de-

manding major behavioural changes. However, infor-

mation about available methods may not have been

available, especially to those living alone. One step to

improve the care of people in pain could be that

healthcare professionals to provide better information

about available methods to relieve pain and, hence,

enable elderly people to make informed choices amongeasily accessible, convenient methods. Information,

however, should not only be given to the ‘‘patient’’, but

also to the next-of-kin (e.g. spouse) who is involved in

the care.

6. Conclusion

Elderly people seem to experience less impact from

pain on daily life than younger people do, and this could

be due to an adaptation process and/or better life-

control. This study showed that those living in special

accommodations reported significantly more pain than

those living at home. It also showed that those living at

home and together with someone had significantly more

pain than those living alone, despite using more pain-relieving methods and having more social support. This

may indicate that methods used by those living together

may not always be efficient. On the one hand, the most

optimal effect is probably not achieved by using only

one method, and the result of this study showed that

elderly persons used on average three methods to relieve

the pain. There was no significant relationship between

the pain severity and the number of methods used. Onthe other hand, using more methods does not necessarily

mean decreased pain. Structured routines for pain as-

sessment, treatment and information are a prerequisite

for creating high-quality nursing. Informing the elderly

person about available methods is especially important

so that the methods could then be chosen together with

the elderly person. Further, non-pharmacological

methods as well as pharmacological methods should beused in combination to increase the pain-relieving effect.

Acknowledgements

The authors thank all the respondents for partici-

pating in the study. We are also most grateful to Mag-dalena Andersson, Gunilla Borglin, Anna Ekwall, Ylva

Hellstr€om, Ann-Christine Janl€ov, Karin Stenzelius and

Bibbi Thom�e for assistance with the data collection, to

Per Nyberg for the statistical advice and to Alan Crozier

for his revision of the English. This study was supported

by grants from the Swedish Rheumatism Association,

the V�ardal Foundation and the Department of Nursing,

Faculty of Medicine, Lund University.

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