Like many older adults, Miriam S. has several painful medical conditions. Osteoarthritis in her hips and knees and several compression fractures in her back can at times be horribly painful. Miriam's doctor has prescribed pain medication that she can take when necessary. Unfortunately, Miriam also has developed dementia, and she is now sometimes unable to tell her caregiver daughter when and where she hurts.

On the other hand, Mike W. will never complain of pain even though he is fully capable of doing so. Instead, he becomes grumpy, aggressive, and generally impossible to live with. His son and daughter-in-law, with whom he lives, are learning to observe his behaviors rather than ask him whether he is hurting.

Assessing pain is one of the more challenging jobs a caregiver will have to tackle when caring for an older adult who cannot or will not communicate. Unrelieved pain is more than just uncomfortable. It has been associated with heightened anxiety, depression, increased risk of falls and slower recovery from surgery, altered immune function, malnutrition, reduced independence and changes in cognition. Reducing the amount of pain your elder is experiencing will not only improve his comfort, but will make it possible for both his body and his mind to perform more efficiently.

Older adults often develop several conditions that can cause chronic pain. While hip, knee and low back pain are most familiar, heart disease, chronic lung disease, as well as diabetes-related neuropathy, cancer and skin ulcers are also common causes of chronic pain.

While it would appear obvious that a good assessment of someone's pain is important, how does a caregiver manage it when communication is impaired?

The most important thing to remember is that if something can be expected to be painful, it probably is. So, ask. Your elder might not respond to your question about "pain." If that's the case, try changing your vocabulary and ask about "hurting," or "aching."

If you can't get a reliable response, then you must use your powers of observation. Because you know your senior well, you will be most attuned to changes that might not be readily apparent to an outsider.

Do you see physical changes?

Most people cannot consciously control visible signs of acute pain. Unless your elder has a physical condition that might produce the following symptoms, pain should be on your radar if you observe that your elder has become unusually flushed or pale and clammy, or his breathing and heart rate have increased.

Do you see changes in behavior?

When you observe a change in your elder's normal behavior, keep the possibility of pain uppermost in your mind. Do you see grimacing, rigid or tense posture, rocking back and forth or fidgeting, loss of appetite, changes in sleep patterns, becoming withdrawn, acting irritable, angry or depressed, pacing or restlessness, not wanting to be touched in a particular place or manner? Are her movements restricted, or is she having more difficulty than usual getting in and out of a chair? Is his tolerance for frustration much shorter than usual?

If these are not normal behaviors for your partricular loved one, all of the behaviors listed above can be pain indicators.

Do you see changes in verbal activity?

Is your elder panting, sighing, or moaning? Is he verbally abusive? While he may not be willing or able to tell you about increased pain, these are all signs that pain may have increased.

If you see signs that your elder is experiencing pain, what should you do?

If your senior's physician has already prescribed a medication for pain, give it as prescribed. If you see an improvement in the behavior you observed, then you can make a note that this behavior probably indicates pain if and when you see it again.

Confused individuals, or those with communication problems may not be able to ask for pain medication when they begin to feel pain. Talk with your elder's health care professional as soon as you can about giving prescribed "as needed" pain medication according to a regular schedule, rather than waiting until you see symptoms of pain. It is often easier to control debilitating pain if medication is not permitted to completely "wear off" between doses.

If the symptoms of pain that you are seeing are new, and your elder's physician has not been treating for pain, then it is important to make an appointment as soon as possible. Pain should always be addressed immediately.

If you are speaking for your older loved one, her physician will undoubtedly want to know the following:

• How intense does the pain appear to be (mild, moderate, extreme)?
• Where is the pain?
• Is the pain stronger or weaker at particular times of the day?
• Does any activity or behavior appear to cause the pain or make it worse?
• How often does the pain occur?
• What, if anything, improves the pain?
• How is the pain affecting your elder's sleep? Nutrition? Behavior and mood?

Most doctors will treat their patients' pain with medications. As a caregiver, what else can you do to help your elder who appears to be in pain?

Every individual will respond to non-medical pain interventions uniquely. You may find that a dim room and soothing music might alleviate some of the anxiety and restlessness than can accompany pain.

For those who can bear to be touched, a soothing massage might be appreciated. Others will respond better to a warm hot water bottle or a blanket that has been warmed in the dryer. Some people appreciate light aroma therapy such as lavendar. Others will find odors unbearable.

For those with severe joint pain, don't forget to consider such things as an electric lift chair to assist with standing up, and a raised commode in the bathroom. Extra padding for the seat of a wheelchair can make a big difference to someone who sits in a wheelchair for long periods. Such simple things as built-up utensils and every-day tools designed to reduce joint stress can make daily activities enjoyable again.

Several websites offer a wide selection of products that may help to alleviate pain or make pain easier to manage. The Wright Stuff , the Senior Corner Store, and Active Forever all offer good selections of products that can make living with painful conditions easier.

For more information about chronic pain I have found that the following websites are informative and helpful:

American Chronic Pain Association        Pain.com          Web MD