Ali R. Rahimi,MD,FACP,AGSF

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Pain Managementin the Geriatric Population

• Ali R. Rahimi,MD,FACP,AGSF
• Professor of Medicine
• Mercer University School of Medicine
• Clinical Professor
• University of Georgia School of Pharmacy

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Pain

• Webster
• a usu. localized physical suffering associated
  with a bodily disorder also a basic bodily
  sensation induced by a noxious stimulus, received
  by naked nerve endings, characterized by physical
  discomfort (as pricking, throbbing, or aching),
  and typically leading to evasive action
• b acute mental or emotional distress or
  suffering
• Urandictionary.com
• What happens when you reach into the blender to
  dislodge a stuck icecube without unplugging it
  first.

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Pain elderly

• Pain is what many people say they fear most
  about dying.
• Pain is undertreated at the end of life
• Older patients are likely to have a increased
  pain threshold but to be less toleant to severe
  pain.

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PAIN IS MC REASON FOR INDIVIDUALS TO SEEK MEDICAL
CARE
Abdominal Pain
Back pain
Head pain
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Definitions

• Addiction Psychological dependence on a drug.
• Physical Dependence Development of physical
  withdrawal reaction upon discontinuation or
  antagonism of a drug
• Tolerance Need to increase amount of drug to
  obtain the same effect
• Pseudoaddiction Behavior suggestive of addiction
  occurring as a result of undertreated pain

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Pain can be assoc w/

• Psychologic and physical disability
• a source of individual suffering
• Familial distress

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Pain in nursing home patients

• 30 reported daily pain
• 26 of these patients received no analgesia
• Only 26 of them received strong opioids
• What predicted inadequate pain management?
• 1 Advanced age gt85 years old
• 2 Poor cognitive function
• 3 Minority status
• Bernabei (1998), N 13,625 cancer patients

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Obstacles of geriatric pain management

• Accessibility to treatment
• SEs
• Comorbidities
• Ex- NSAID use in pt w/ HTN or heart disease
• Ex- Acetominophen use in Liver dz pt
• Interactions with the current meds
• Pts with cognitive impairments
• The assumption that pain is normal party of aging
• Practitioners bias (pain seeker..)
• fear of legal repercussions

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Its a risk factor!
Myofacial deconditioning
Decreased activity bc of pain
Gait distrubances
INJURIES from falls
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Types of pain

• Nociceptive pain- Nerves responding appropriately
  to a painful stimulus
• Neuropathic pain- results from NS dysfunction,
  and may originate centrally or
  peripherally
• Somatic pain- originates in the skin, bones,
  myo, and connective tissue, and usually is
  located specifically.
• Visceral pain- originated in internal body
  structures and organs, and is located more
  genearlly.

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Neuropathic pain

• Origin
• Nerve damage
• Palliates/potentiates
• Set off by unusual stimuli, light touch, wind on
  skin, shaving (trigeminal neuralgia)
• Quality
• Electric, burning, tingling, pins needles,
  shooting (system isnt working right)
• Radiation
• Nerve-related pattern

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Nociceptive Pain
Easier to treat than Neuropathic!!

• Origin
• Tissue damage
• Palliates/potentiates
• Worse with stress, pressure
• Responds better to opioids, NSAIDs
• Quality
• Sharp, dull, stabbing, pressure, ache, throbbing
• Radiation
• Occasionally radiates (less well-defined), but
  not along an obvious nerve distribution

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• Differentiating between somatic, visceral, and
  neuropathic pain is ESSENTIAL to proper tailoring
  of pain treatments

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Specific Goals

• 1- determining the presence and cause of pain
• 2- identifying exacerbaing comorbidities
• 3- reviewing beliefs, attitudes and expectations
  regarding pain
• Overall to decrease pain and increase function
  and quality of life!

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Common pain syndromes in elderly
MUSCULOSKELETAL CONDITIONS OA Degenerative disk
dz Osteoporosis Fxs Gout
RHEUMATOLOGIC CONDITIONS RA Polymyalgia
rheumatics Fibromyalgia
NEUROPATHIC CONDITIONS Biabetic
neuropathy Postherpatic neuralgia Trigeminal
neuralgia Central poststroke pain Radicular pain
secondary to degenerative disc dz
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Aging takes a toll

• In the PNS
• Loss of myelinated and unmyelinated fibers
• Axonal atrophy common
• Nerve conduction and endoneural blood flow are
  reduced w/ age
• Less nerve regeneration observed
• progressive loss of serotonergic and
  noradrenergic neurons in the superficial lamina
  of the spinal dorsal horn, and bc serotonin and
  norepineph have important roles in the descending
  inhibitory control pathways, such a loss may
  upset the natural endogenous pain-suppressing
  mechanisms.
• Therefore, pain treatment of the elderly
  obviously differs from that of young patients!

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Models of the prevalence of pain

• 1- Pain increases with age and then decreases at
  older ages (ie, 70 and beond). They suppose that
  this pain typically has a mechanical etiologic
  component and possibly is assoc with the
  occupational envioroment
• 2- pain increases with age. This has a
  mechanical etilogic component but also an assoc
  with increasing prevalence of degenerative dz,
  particulary at older ages.
• 3- age-independent pain that (obviously) lacks a
  mechanical etiologic component. (ie- risk
  factors that are constant throughout the life
  course)
• 4- A decrease in pain prevalence at older ages.
  It is not clear whether the trajectory is caused
  by age-related changes in pain and pain
  perception, or by changes in pain reportin.

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Effect of age on human (via clinical observation)

• Clinical observation examples
• increased incidence of silent MI in elderly
  patients
• atypical presntation of an inflamed appendix,
  (absence of RLQ pain)
• Study example (pg 208)
• Yunis compared elderly and young patients with
  fibromyalgia. They found that chronic head
  aches, anxiety, tension, mental stress and poor
  sleep were all less common in the elderly
  patients w this condition.

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Lonliness and pain

• The comorbidity of pain and psychological
  distress is WELL DOCUMENTED-
• The feeling of lonliness is the single most
  important predictor of psychologic state of
  distress in older persons.
• A study by Eisenberger supported the hypothesis
  that Pain distress and social distress share
  neurocognitive substrates
• Study on page 193

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Sleep and pain

• Multiple studies have demonstrated the
  comorbidity of pain and sleeplessness
• Pain is among the best predictors of sleep
  disturbances among older adults
• Thus, it appears that improved pain leads to
  improved sleep, and impoved sleep leads to
  improved pain!
• Study pg 193

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HOW TO QUANTIFY THE PAIN?
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Details!

• Onset
• Duration
• Freq
• Intensity
• Locaiton
• Contributing factors

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Troubleshooting pain assessment

• Demented/Confused patient
• Have to look for

Agitation, agressiveness, etc.
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Pain control vs quality of life

• OVERALL GOAL
• to abolish pain with minimal adverse effects.
• Ex- Patient with COPD and pain
• Cant treat their pain too vigorously bc we will
  exacerbate the COPD symptoms

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Treating the pain
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Pharmacologic approaches

• Opiods
• Anti-inflammatory agents (asa, NSAIDS,
  cyclooxygenase COX-2 inhinitors, steroids)
• Acetaminophen
• Tramadol
• Myo relaxants
• Tricyclic antidepressants
• SRIs
• Antielileptic drugs (AEDs)

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Non-pharmocologic approaches

• Behavioral therapy
• Spiritual counseling
• Physical therapy
• Psychotherapy
• Splinting
• Surgical correction
• Cold packs
• Meditation

• Support groups
• Radiation therapy
• Acupuncture
• Hypnosis
• Cultural healing rituals
• Heat packs
• Prayer
• Community resources

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How to choose an analgesic?
Severe pain Opioids
Moderate to severe Use in combo with opioids
Mild to Moderate painAcetominophen Aspirin NSAID
S
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Drug Classes
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Salicylates
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Salicylates

• Analgesic, antipyretic, anti-inflammatory and
  anti-rheumatic activity.
• MOA
• Inhibits prostaglandin synthesis producing
  analgesic.
• antiplatelet effect by inhibiting the production
  of thromboxane
• Much higher levels needed for anti-inflammatory
  effect than for anti-platelet, anti-pyretic and
  analgesic effects.
• Metab Gut plasma (ASA) liver
  (salicylate) CYP450
• Excrition renal
• Can cause GI irritation and bleeding.
• Use w caution in ppl with hx of gastric or peptic
  ulcercs.

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Acetominophen

• analgesic and antipyretic agent
• MOA
• Inhibits central prostaglandin synthesis with
  minimal inhibition of peripheral prostaglandin
  synthesis
• Antipyretic effect by direct action on the
  hypothalamic heat-regulating center
• Benefits
• Absorbed rapidly
• No gastric mucosa effects
• No effect on platelet aggregation
• Metab by liver
• Excretion urine (metabolites can accumulate w
  renal impairment)
• Hepatotoxic

Can take 500-1000mg orally q 6hr Older pts and
Pts with liver dz do not exceed 2g/day
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NSAIDS

• Antipyretic, analgesic and anti-inflammatory
• properties
• MOA
• Reduce central and peripheral prostaglandin
  synthesis but they do not inhibit the effects of
  the prostaglandins already present, resulting in
  analgesia, followed by relatively delayed
  anti-inflammatory effects.
• Metab liver
• Excretion urine
• Adverse effects
• n/v, bleeding
• Hepato and nephrotoxicity

1.5 times higher risk of GI bleeding (more so in
the elderly) Concurrent use of PPI for prevention
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NSAID 18 available in the US

• All NSAIDS have similar mechanism of action BUT
  differ in
• Potencies
• Time to onset
• Duration
• Response among patients
• Common uses
• After surgeries
• Painful chronic conditions (ex- OA)
• Benefit more notable when used in combo w an
  opiod.
• Opiod SEs like sedation, n/v decreased when used
  w NSAID

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COX 2 NSAIDS

• Purpose in pharmacology unclear
• Only available celecoxib
• Cox2 and NSAIDS are CI in pts with cardiac
  disease!
• estimated to be responsible for up to 20 percent
  of hospital admissions for congestive heart
  failure.
• BY INCREASING SYSTEMIC VASCULAR RESISTANCE and
  REDUCING RENAL PERFUSION

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OPIOID

• a chemical that works by binding to opioid
  receptors, which are found principally in CNS and
  the GI.
• Hence, the GI Ses
• Effects
• decreased perception of pain
• decreased reaction to pain
• increased pain tolerance

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Opioids

• Cornerstone of the analgesic regimen for mod-sev
  pain
• MC ones
• Morphine
• Oxycodone
• Hydromorphone
• Transdermal fentanyl

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3 Main Opioid receptors

• Mu, delta and kappa receptors.
• Mu agonists produce analgesia
• affect numerous body systems
• influence mood reward behavior
• Delta agonists produce analgesia
• not a lot on market
• Kappa agonists produce analgesia
• may cause less resp depression and miosis
• psych effects, can produce dysphoria
• Opioids LACK the adverse renal, and hematologic
  effects of NSAIDs

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• MU-receptor agonists are MC used
• although drugs may interact with more than one
  type of receptor.
• Ex- the mu receptor antagonist and kappa receptor
  agonist drugs were deigned to cause less
  respiratory depression.

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Opioids pharmacokinetics

• Pharmacokinetic properties of an opioid can
  dictate the circumstance which they are
  appropriate in
• Ex- Lipid-soluble drug such as fentanyl, which
  diffuse rapidly acros the BBB, are preferable if
  analgesia is required immediately before a short,
  painful procedure.
• Elimination half life very short
• So, steady state reached in a day or less!
• Thus, you can adjust the dose daily knowing we
  are seeing its effect.

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Adverse effects

• Respiratory depression
• sedation
• N/V
• Constipation
• Urinary retention
• Itching

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1. Respiratory depression

• Caused by directly acting on respiratory center
• Naloxone is specifically used to counteract
  life-threatening depression of the central
  nervous system and respiratory system
• Therapeutic doses of morphine can affect
• Resp rate, minute volume tidal exchange
• Although, tolerance to this effect is usually
  achieved with repeated doses of opioids.
• Avoid/Monitor in pts with
• Imparied resp function
• Sleep apnea
• Or bronchial asthma

Not common if begin with low dose and titrate
upward!!
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2. Nausea and vomiting

• MC SE
• Likely due to changing blood serum levels , not
  problem _at_ steady state
• The freq of nausea and vomiting is higher in
  ambulaory patients (vestibular component?)
• Antiemetics (metoclopramide or droperidol) can be
  used along with the opioid.

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3. Constipation

• Acts on receoptors of GI tract and spinal cord
• to produce decrease in peristalsis and intestinal
  secretions
• Tolerance to this effect is not common-
• Result- prescribe prophylactic laxatives
• use stood softener AND a stimulant laxative.

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4. Urinary retention

• causes increased smooth muscle tone
• increases sphincter tone

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5. Itching

• Mechanism not fully known
• Hypot related to the release of histamine from
  mast cells.
• If itching is with rash- consider allergy.
• Can use an antihistamine to treat this

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Opioids Morphine

• Morphine standard of opioids
• BUT if pt doesnt respond well, they may switch to
  an equianalgesic dosage of
• Hydroporphone
• Oxycodone
• Fentanyl
• Oxymorphone
• Or methadone
• If pt has diminished renal function, they may
  benefit from
• Oxycodone or hydromorphone (bc these dont have
  clinically significant active metaolites)

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Opioid Combos

• Full opioid agonists
• Morphine
• Hydrocodone
• Codeine
• Dextropropoxyphene

Typically combined with acetaminophen or an NSAID
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Acetaminophen con Codeine

• Advantages
• Low regulatory control
• Inexpensive
• Widely available
• Disadvantages
• 10 cannot convert codeine to morphine
• Many drugs interfere with conversion

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Acetaminophen with Oxycodone, Hydrocodone

• Oxycodone combination contains 325 mg
  acetaminophen
• Hydrocodone combination contains 500 mg
  acetaminophen
• No clear advantage between the two

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Three mureceptor agonist to avoid whenever
possible!! ..

1. Meperidine
2. Propoxyphene
3. codeine

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1.Meperidine (DEMEROL)

• Low potency relative to morphine
• A short duration of action so have to dose it
  more frequently
• And a toxic metabolite (normeperidine)
• Ex- meperidine 75mg 5-7.5 mg of morphine
• can cause irritability and seizures

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2. Propoxyphene (DARVOCET)

• treat mild to mod pain
• Toxicities assoc with its primary metabolite
  norpropoxyphene
• can cause cardiotoxicity and pulmonary edema
• Half life 6-12 hourMetabolite half life 30-36
  hours
• Pts with Dec Renal function or pts getting repeat
  doses higher risk
• Puts geriatric pts at higher risks of falls (d/t
  CNS effects)
• study found that propoxy users have twofold
  higher risk for hip frature compared with
  nonusers of analgesics
• ALSO, it has no clinical advantage over nonopioid
  analgesics such as acetominaphen

PG 289
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3. Codeine

• Must be converted to morphine by means of the
  cytochrome P-450 pathway to provide analgesia.
• Lots of Caucasians are poor metabolizers of this
  isoenzyme -thus cant make the conversion!
• So, they do not get any of the codeines benefit
  but still suffer the Side effects.

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Principles of opioid use

• No ceiling effect
• Dose to pain relief without side effects
• Give orally when possible
• Sub-cutaneous administration is basically
  equivalent to intravenous (and preferable)
• Treat constipation prophylactically
• Full opioid agonists are best choice for severe
  pain..

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Where to start?
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Treating Chronic pain

• Basal pain medicine plus a different therapy for
  spikes
• Predictable spikes - Short-acting agent prior to
  event
• Unpredictable spikes - Short-acting agent readily
  available (prn)

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Treating Neuropathic Pain

• Opioids and NSAIDS less effective

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Classes of Agents

• Tricyclic for dysesthetic pain
• Anticonvulsants for shooting pain
• Steroids to decrease peri-tumor edema

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Tricyclic for dysesthetic pain

• Dysesthesia is pain not experienced by a normal
  nervous system.
• Eg- neuropathic burning from chemotherapy
• Considered "Dante-esque" pain.
• Amitriptyline
• Nortriptyline
• Desipramine

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Anticonvulsants for shooting pain

• Gabapentin
• Pregabalin

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Steroids to decrease compression

• Nerve infiltration by tumor or spinal cord
  compresion
• Corticosteroids
• Deamethasone
• Prednisone
• Usu used for pts near end of
• Life bc of detrimental SE of
• Long term steroid use.

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Opioid analgesics available in US

• Mu agonists
• Alfentanil
• Codeine
• Hydrocodone
• Ydromorphone
• Fentanyl
• Levorphanol
• Meperidine
• Methadone
• Morphine
• Opium
• Oxycodone
• Oxymorphone
• Remifentanil
• Sufentanil
• Tramadol

• Kappa agonist/mu antagonist
• Butorphanol
• Nalbuphine
• Pentazocine
• Mu antagonists
• Nalmefene
• Naloxone
• Naltrexone
• Mu partial agonist/kappa antagonist
• Buprenorphine

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When to refer

• Pain not respsoning to opoiods at typical doses
• Neuropathic pain not responding to first line
  treatments
• Comples methadone management issues
• Intolerable side effects from oral opioids
• Severe pain from bone mets
• For a surgical or anesthesia-based procedure,
  intrathecal pump, nerve block, or rhizotomy

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When to admit

• For severe exacerbation of pain that is not
  responsive to previous stable oral opioid
  around-the-clock plus breakthrough doses.
• Pateints whose pain is so severe that they
  cannont be cased for at home
• Uncontrollable side effects from opioids,
  including nausea, vomiting, and altered mental
  status

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Good to know..

• Older individuals tend to be more sensitive to
  benzodiazepines and opiods.
• Pain from bone mets more susceptible to NSAID
  pain relief than opioids
• The 1998 guidelines recommended earlier use of
  narcotics than is typical for treatment of
  younger patients because of the significant
  toxicities assoc with NSAIDS.

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Trigeminal neuralgia

• Characterized by severe, unilateral facial pain
  described as lancinating electrics shock-like
  jolts in one or more distributions of the
  trigeminal nerve.
• Maxillary and Mandibular divisions MC
• Careful clinical evaluation and MRI is recommended

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Postherpetic neuralgia

• Follows outbreak of Herpes zoster
• Sensory findings
• Allodynia (wind against skin hurts, sheet on area
  hurts etc) hyperalgesia

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Post stroke pain

• An underrecognized consequence following storke
• May present as shoulder pain in the paretic limb
  or present as central poststroke pain.
• Characterized as pain that is severe and
  persistnet w accompanying sensory abmomalities
• Ex- the guy from Oceanside.

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Metastatic bone pain

• Bone pain that is worse at night, when laying
  down or not assoc with acute injury
• Pain that gradually but rapidly increase in
  intensity or with weight-bearking or activity.
• Freq sites
• Hips, vertebrae, femur, ribs, and skull

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Temporal Arteritis

• More than 95 of TA are ppl gt50
• Presentation
• New onset headache, malaise, scalp tenderness and
  jaw claudication
• PE indurated temporal arterly that is tender
  with a diminihed or abent pulse
• Irreversible bliness is consequence of untreted..
  So timely assesment and tx is

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Pain perception in rats

• When nociception is tested in mice using an
  electrical current, it seems that there are age
  related changes in nociception .
• The graphic representaion of electical thresholds
  needed to induce a vocal reponse was of a U-shap
  pattern. (high pain tolerance in young and old-
  lower in the middle aged)

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Effect of age on human experimental pain

• 50 studies total
• 21 concluded an increase in pain threshold with
  advancing age
• 3 reporeted a decrease
• 17 noted no change
• However,
• Temporal vs Spatial summation
• It was fround that temopral summation to a heat
  pain stimulus, for example, is more pronounced in
  the elderly as compared with younger subjects.
  Whereas spatial summation is not significantly
  influenced by age.