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Roberto Bernabei, MD; Giovanni Gambassi, MD; Kate Lapane, PhD; Francesco Landi, MD; Constantine Gatsonis, PhD; Robert Dunlop, MD; Lewis Lipsitz, MD; Knight Steel, MD; Vincent Mor, PhD; for the SAGE Study Group

JAMA. 1998;279:1877-1882.

Context.— Cancer pain can be relieved with pharmacological agents as indicated by the World Health Organization (WHO). All too frequently pain management is reported to be poor.

Objective.— To evaluate the adequacy of pain management in elderly and minority cancer patients admitted to nursing homes.

Design.— Retrospective, cross-sectional study.

Setting.— A total of 1492 Medicare-certified and/or Medicaid-certified nursing homes in 5 states participating in the Health Care Financing Administration's demonstration project, which evaluated the implementation of the Resident Assessment Instrument and its Minimum Data Set.

Study Population.— A group of 13625 cancer patients aged 65 years and older discharged from the hospital to any of the facilities from 1992 to 1995. Data were from the multilinked Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database.

Main Outcome Measures.— Prevalence and predictors of daily pain and of analgesic treatment. Pain assessment was based on patients' report and was completed by a multidisciplinary team of nursing home personnel that observed, over a 7-day period, whether each resident complained or showed evidence of pain daily.

Results.— A total of 4003 patients (24%, 29%, and 38% of those aged 85 years, 75 to 84 years, and 65 to 74 years, respectively) reported daily pain. Age, gender, race, marital status, physical function, depression, and cognitive status were all independently associated with the presence of pain. Of patients with daily pain, 16% received a WHO level 1 drug, 32% a WHO level 2 drug, and only 26% received morphine. Patients aged 85 years and older were less likely to receive either weak opiates or morphine than those aged 65 to 74 years (13% vs 38%, respectively). More than a quarter of patients (26%) in daily pain did not receive any analgesic agent. Patients older than 85 years in daily pain were also more likely to receive no analgesia (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.13-1.73). Other independent predictors of failing to receive any analgesic agent were minority race (OR, 1.63; 95% CI, 1.18-2.26 for African Americans), low cognitive performance (OR, 1.23; 95% CI, 1.05-1.44), and the number of other medications received (OR, 0.65; 95% CI, 0.5-0.84 for 11 or more medications).

Conclusions.— Daily pain is prevalent among nursing home residents with cancer and is often untreated, particularly among older and minority patients.

From the Istituto di Medicina Interna e Geriatria, Università Cattolica del Sacro Cuore, Rome, Italy (Drs Bernabei, Gambassi, and Landi); Center for Gerontology and Health Care Research (Drs Gambassi, Lapane, and Mor), Department of Community Health (Drs Gambassi, Lapane, and Mor), and Center for Statistical Science (Dr Gatsonis), Brown University, Providence, RI; St Christopher's Hospice, London, England (Dr Dunlop); Hebrew Rehabilitation Center for the Aged, Harvard Medical School, Boston, Mass (Dr Lipsitz); and University of Medicine and Dentistry of New Jersey, New Jersey Medical School and Homecare Institute, Hackensack University Medical Center, Hackensack (Dr Steel).

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