More Research Needed to Guide Palliative Care for Older Adults, Says Recipient of AGS' Outstanding Scientific Achievement for Clinical Investigation Award

Many older adults who need palliative care to ease pain and other symptoms still suffer without it, and both Medicare coverage and the knowledge base for palliative care for the aging are too limited, according R. Sean Morrison, MD, the recipient of the American Geriatrics Society's 2008 Outstanding Scientific Achievement for Clinical Investigation Award. Palliative care for older patients was the subject of AGS' 2008 Outstanding Scientific Achievement Award Lecture, which Dr. Morrison delivered during the Society's Annual Scientific Meeting this May.

"We're poorly treating pain in older patients," said Dr. Morrison, the director of the National Palliative Care Research Center, vice-chair for research at the Brookdale Department of Geriatrics and Adult Development, director of research at the Hertzberg Palliative Care Institute, and Hermann Merkin Professor of Palliative Care at the Mount Sinai School of Medicine in New York City.

Research suggests that the prevalence of significant pain in community-dwelling older people may be as high as 25% to 65%, according to Dr. Morrison. And as many as 80% of nursing home residents experience significant pain.

Because Medicare only covers hospice care for the last six months of life, however, many older adults suffering pain and other symptoms go untreated. Palliative care should not be restricted to the end of life, rather, it should be provided regardless of prognosis and simultaneously with other necessary treatment, including life-sustaining treatment, Dr. Morrison argued.

Among other things, providing palliative care regardless of prognosis improves outcomes and saves money, he noted. A recent abstract, presented at the European Association of Palliative Care, examining the cost implications of providing palliative care regardless of prognosis at eight U.S. hospitals found that such care resulted in an average savings of $1,500 per admission.

"Palliative care demonstrates that lower cost and higher quality do indeed go hand in hand and is beneficial for all patients with serious and life threatening illness, " Dr. Morrison reported, estimating that, for the average 300-bed hospital, providing such care when needed would result in savings of $1.3 million annually.

Palliative care is becoming more widely available. Between 2000 and 2006, for example, the number of U.S. hospitals offering palliative care services rose from 600 to 1,300. But investment in palliative care research still lags.

"We need more research in palliative care," Dr. Morrison said, emphatically. "If someone has high blood pressure, we have more than 50 medications to choose among. If a patient has pain, we have fewer than 10."

When it comes to easing the pain and suffering of older adults, the knowledge gap is particularly problematic. "There's a lack of solid evidence to guide care regarding pain and symptoms in older patients," Dr. Morrison explained.

Palliative care research and clinical guidelines have focused primarily on younger adults, particularly those with cancer. But palliative care that is appropriate for younger people may not be for older adults, due to the differing nature and duration of chronic illness in late life, he noted. Older patients, who often have multiple health problems, may have a variety of different types and etiologies of pain. Further complicating matters, there are few validated pain and symptom assessment tools for older patients, and assessment is even more difficult among those with cognitive deficits. In addition, recommendations for age-adjusted dosing are lacking for most analgesics and many of these can cause side effects, such as delirium and renal failure, that are particularly problematic for or amplified in older people.

To address this, further public and private investment in research is imperative, Dr. Morrison added. Research concerning the prevalence of pain and other symptoms among, and the effects of palliative treatment on outcomes in, elderly patients is crucial. So are new palliative care research methodologies designed to take into account differences between younger and older adults. To advance this research agenda, additional geriatricians trained as palliative care investigators are needed as well.

Palliative care and geriatrics are two overlapping specialties, Dr. Morrison argued. "We as two specialties can do a better job of integrating care for older patients," he concluded. "Palliative care is an integral part of geriatric medicine."