Pain is an unpleasant sensory and emotional experience. 1 Pain is a complex phenomenon derived from sensory stimuli or neurologic injury and modified by individual memory, expectations, and emotions. 2 Pain is usually associated with injury or a pathophysiologic process that causes an uncomfortable experience and is usually described in such terms. Although there are no objective biologic markers of pain, an individual’s description and selfreport usually provides accurate, reliable, and sufficient evidence for the presence and intensity of pain. 3 Persistent pain can be defined as a painful experience that continues for a prolonged period of time that may or may not be associated with a recognizable disease process. The terms persistent and chronic are often used interchangeably in the medical literature. Unfortunately for many elderly persons, chronic pain has become a label associated with negative images and stereotypes often associated with longstanding psychiatric problems, futility in treatment, malingering, or drug-seeking behavior. The term persistent pain may foster a more positive attitude by patients and professionals for the many effective treatments that are available to help alleviate suffering. 4 The clinical manifestations of persistent pain are commonly multifactorial. Because of the complex interplay among these factors across several domains (physiologic, psychologic, and social), discriminating which factors are most important for the purpose of treatment can be very challenging. Further complicating this task is the fact that pain expression and hence the importance of specific factors commonly vary, not only across individuals but also over time in one individual. Elderly persons have been defined by demographers, insurers, and employers as those aged 65 years and over. In healthcare discussions, the elderly persons often described are those who are most frail, with health and disability problems typically encountered in the older population. By age 75 many persons exhibit some frailty and chronic illness. In the population above age 75, morbidity, mortality, and social problems rise rapidly, resulting in substantial strains on the healthcare system and societal safety nets. This group represents the fastest growing segment of the total population. 5 The greatest challenges in geriatric medicine are represented by the oldest, sickest, and most frail patients with multiple medical problems and few social supports. The guideline panel focused its attention on this group as it prepared this update. Persistent pain is common in older people. 6 A Louis Harris telephone survey found that one in five older Americans (18%) are taking analgesic medications regularly (several times a week or more), and 63% of those had taken prescription pain medications for more than 6 months. 7 Older people are more likely to suffer from arthritis, bone and joint disorders, back problems, and other chronic conditions. This survey also found that 45% of patients who take pain medications regularly had seen three or more doctors for pain in the past 5 years, 79% of whom were primary care physicians. Previous studies have suggested that 25% to 50% of community-dwelling older people suffer important pain problems. 6,8,9 Pain is also common among nursing home residents. 10,11 It has been estimated that 45% to 80% of them have substantial pain that is undertreated. Studies of both the community-dwelling and nursing home populations have found that older people commonly have several sources of pain, which is not surprising, as older patients commonly have multiple medical problems. A high prevalence of dementia, sensory impairments, and disability in this population make assessment and management more difficult. The consequences of persistent pain among older people are numerous. Depression, anxiety, decreased socialization, sleep disturbance, impaired ambulation, and increased healthcare utilization and costs have all been found to be associated with the presence of pain in older people. Although less thoroughly described, many other conditions are known to be worsened potentially by the presence of pain, including gait disturbances, slow rehabilitation, and adverse effects from multiple drug prescriptions. 12 Psychosocial factors affect and are affected by pain in older patients. It has been shown that older adults with good coping strategies have significantly lower pain and This guideline was developed and written under the auspices of the American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons and approved by the AGS Board of Directors on April 8, 2002.

The management of persistent pain in older persons.

Introduction The Millennium Development Goals (MDGs) were adopted in 2000 with the aim of reducing the severe gaps between rich and poor populations Most countries have endorsed Goal 4 of the MDGs to "reduce by two thirds [between 1990 and 2015] the mortality rate among children under-five" (1,2) Reliable information on the magnitude, patterns and trends of causes of death of children aged less than 5 years helps decision-makers to assess programmatic needs, prioritize interventions and monitor progress It is also crucial for planning and evaluating effectiveness of health services and interventions Yet, data are very scarce in low-income settings where they are most needed and estimations are necessary for these areas In the 1980s, Snyder and Merson3 generated one of the earliest attempts to estimate the worldwide burden of diarrhoeal diseases, demonstrating the substantial health onus due to diarrhoeal diseases on mortality among children aged less than 5 years In the following decades, subsequent reviews updated these initial estimates using similar methods of assessment (4,5) These initial estimates were based on average values derived from a limited set of studies without taking into account the epidemiological variations across different regions Responding to international demand and to the need for better evidence-based cause-specific mortality, the Child Health Epidemiology Reference Group (CHERG)--an independent group of technical experts jointly coordinated by WHO and the United Nations Children's Fund (UNICEF)--was established in 2001 CHERG has undertaken a systematic, extensive and comprehensive literature review of published information and developed a methodological approach that is transparent and consistent across different diseases and conditions to produce estimates of the major causes of childhood deaths (6-10) This study is an essential part of the overall CHERG efforts Its main objective is to provide estimates of deaths from diarrhoea in 2004 at all levels, mainly for countries with incomplete or non-existing civil registration data Methods Data sources Common sources of data for cause-specific mortality include vital registration systems, sample registration systems, nationally representative household surveys, sentinel Demographic Surveillance Sites (DSS) or epidemiological studies of cause-specific mortality In countries that account for 98% of under-5 deaths worldwide, there is very limited or virtually no functioning vital registration system in place to support attribution of causes of deaths (11-14) A sample registration system, which reports causes of death on a regular basis, is currently available only in China and its coverage and quality for under-5 deaths is challenging (15) Nationally representative household surveys such as Demographic Health Surveys (DHS) and UNICEF's Multiple Indicator Cluster Surveys (MICS) do not usually report on causes of death, and DSS data were not available until very recently (16) Epidemiological studies currently constitute the main source of data available and were therefore used in this review for estimating diarrhoea-specific mortality Search strategy Studies included in the analysis were identified through a systematic search of the scientific literature published since 1980 Medline was searched using the terras: "developing countries", "mortality/death", different spellings of "diarrhoea" and combinations of these terms No restriction was placed on publication language The search identified a total of 804 papers of which 207 were kept for review of abstracts The reference sections of the studies retrieved were reviewed to identify additional papers Studies were then assessed to ensure that they met the main inclusion criteria: (i) direct or derivable diarrhoea-specific proportional mortality data; (ii) a minimum of 25 total deaths; (iii) a maximum of 25% of unknown or undetermined causes of death; (iv) community-based studies with at least 1 year of follow-up; and (v) follow-up time multiple of 12 months to minimize seasonal effects …

Estimating Child Mortality Due to Diarrhoea in Developing countries/Estimation De la Mortalite Infanto-Juvenile Due a la Diarrhee Dans Les Pays En developpement/Mortalidad En la Ninez Por Diarrea En Los Paises En Desarrollo

OBJECTIVE: The major objective of this study is to provide estimates of diarrhoea mortality at country, regional and global level by employing the Child Health Epidemiology Reference Group (CHERG) standard. METHODS: A systematic and comprehensive literature review was undertaken of all studies published since 1980 reporting under-5 diarrhoea mortality. Information was collected on characteristics of each study and its population. A regression model was used to relate these characteristics to proportional mortality from diarrhoea and to predict its distribution in national populations. FINDINGS: Global deaths from diarrhoea of children aged less than 5 years were estimated at 1.87 million (95% confidence interval, CI: 1.56-2.19), approximately 19% of total child deaths. WHO African and South-East Asia Regions combined contain 78% (1.46 million) of all diarrhoea deaths occurring among children in the developing world; 73% of these deaths are concentrated in just 15 developing countries. CONCLUSION: Planning and evaluation of interventions to control diarrhoea deaths and to reduce under-5 mortality is obstructed by the lack of a system that regularly generates cause-of-death information. The methods used here provide country-level estimates that constitute alternative information for planning in settings without adequate data.

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Estimating child mortality due to diarrhoea in developing countries

Many attempts have been made to quantify Africa's malaria burden but none has addressed how urbanization will affect disease transmission and outcome, and therefore mortality and morbidity estimates In 2003, 39% of Africa's 850 million people lived in urban settings; by 2030, 54% of Africans are expected to do so We present the results of a series of entomological, parasitological and behavioural meta-analyses of studies that have investigated the effect of urbanization on malaria in Africa We describe the effect of urbanization on both the impact of malaria transmission and the concomitant improvements in access to preventative and curative measures Using these data, we have recalculated estimates of populations at risk of malaria and the resulting mortality We find there were 1,068,505 malaria deaths in Africa in 2000 - a modest 67% reduction over previous iterations The public-health implications of these findings and revised estimates are discussed

Urbanization, malaria transmission and disease burden in Africa

Treatment seeking for malaria: a review of recent research.

With the increasing numbers of older adults in our population, nurses are reexamining all aspects of nursing care in order to best meet the needs of these individuals. Normal age changes, the impact of decades of environmental challenges, successful adaptations, acute illnesses, trauma and chronic illnesses combine to create a challenge for accurate and effective assessment of elderly patients. The nurse finds her assessment skills challenged with increasing frequency by the elderly patient who is also acutely confused and experiencing discomfort. The purpose of this study was to explore the clinical utility, validity and reliability of four different approaches to nursing assessment of discomfort with this particularly vulnerable group of elders.

The Assessment of Discomfort in Elderly Confused Patients: A Preliminary Study

Routine care of women experiencing normal deliveries in Zambian maternity wards: A pilot study

Children in Lusaka and in a rural area in central Zambia were examined during November 1984 and April 1985 to assess the effect of urbanization on malaria transmission. Of 423 urban children examined in November, 2·4% had scanty parasitaemia, and low titres of malarial antibodies were found in 46%. These proportions increased in April to a parasite rate of 10·3% and malaria antibodies were detected by indirect fluorescent antibody tests (IFAT) in 62%. The presence of malaria antibodies was positively associated with journeys outside the main towns. Examination of paired sera from the 2 periods showed an association between a history of malaria and an increased antibody titre, but failed to show an association between travel outside the main towns and conversion from a negative to a positive IFAT. The spleen rate in children under 15 years old in Lusaka was 3%, indicating hypoendemic malaria. In rural children the parasite rate was 10% and 27% in the 2 seasons, respectively, and over 97% of the children had malaria antibodies. The spleen rate was 20%, indicating mesoendemic malaria. It is concluded that there is only low transmission of malaria in Lusaka so that many people do not develop resistance and are therefore at risk of severe attacks if they do become infected. Possible measures to protect the urban population are discussed.

Malaria in an urban and a rural area of Zambia

The assessment of acute confusion as part of nursing care

In a prospective study of 257 children in Lusaka during their 1st year of life the infant mortality rate was 118/1000 livebirths. Deaths were due to prematurity and respiratory problems during the 1st few months life and diarrhea measles and malnutrition during the later months. The low birthweight rate was 11%. Growth was good during the 1st 6 months but thereafter dropped in weight gain; gain in length faltered after 8 months. By age 1 only 12% attained the average weight-for-age and 8% the average height-for-age. Breastfeeding decreased in frequency very gradually over the 1st year of life with 66% of children still being breastfed more than 6 times/day at 1 year. Meals were usually given only 3 times/day and consisted mainly of maize porridge with vegetables beans or meat when it was affordable. Over 70% of the children were fully immunized. Milestones were generally achieved at expected ages or even earlier. Where there were delays the affected children died within a couple of months. Recommendations are made on the surveillance of infants in urban areas and the provision of a precooked fortified appropriate weaning food obtained at health centers. (authors modified)

Nicholas Ng'andu

Papers

The Assessment of Discomfort in Elderly Confused Patients: A Preliminary Study

Routine care of women experiencing normal deliveries in Zambian maternity wards: A pilot study

Malaria in an urban and a rural area of Zambia

The assessment of acute confusion as part of nursing care

Children in an Urban Township in Zambia A Prospective Study of Children During Their First Year of Life