The science and art of pain management in older persons: case study and discussion.

INTRODUCTION: Evidence-based medicine has been adopted as a means of achieving optimal medical care and to reduce variations in clinical practice. Randomised controlled trials are considered the highest level of scientific evidence. Older individuals are either excluded or underrepresented in these studies, and those who are included are often atypical of patients seen in clinical practice.

OBJECTIVE: To examine the approach to clinical decision making in frail older persons when there is little or no scientific evidence to guide management.

METHODS: A case study is presented of refractory post herpetic neuralgia in a frail older person. Management plans were developed combining the scientific evidence from the pain literature with the practice known as Comprehensive Geriatric Assessment. The rationale and evidence for clinical decision making is explored.

RESULTS: Standard therapies for post herpetic neuralgia had been ineffective or limited by side effects in this patient. By a process of trial and error a combination of treatments was found that improved pain and mood but adversely affected cognition. Adjustment in treatments over time resulted in improved pain, mood, and cognition.

CONCLUSIONS: The art of medicine is not the antithesis of the scientific approach. The art of medicine involves balancing the scientific evidence with the circumstances and the preferences of the patient. Combining the practices of Pain Medicine and Comprehensive Geriatric Assessment may result in a better outcome. When treating older people, clinicians not only need to take into consideration the severity of pain, but also the impact of pain and its treatment on cognition, mood and functional status.