Pain Management in the Elderly

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Pain Management in the Elderly

• Advocacy and Compassion

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Pain Defined

• An unpleasant sensory and emotional experience
  associated with actual or potential tissue
  damage -Merskey 1986

• A complex phenomenon derived from sensory
  stimulation or neurologic injury its perception
  is modified by individual memory, emotions, and
  expectations

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Pain Defined

• Pain is whatever the experiencing person says it
  is, existing whenever he says it does.
  McCaffrey 1968

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Prevalence of Pain in Nursing Homes

• 45 to 83 of people gt65 experience pain
• 60 to 70 of nursing home residents have
  significant pain, one third in constant pain
• 32 to-36 of older people in the community have
  pain
• Core Curriculum for Pain Management Nursing, 2002

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Goals of Pain Management

• Improved functionality
• Improved quality of life
• Increased comfort
• Decreased health care costs

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Pain Physiology
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Pain Physiology

• Nociceptive Pain
• Neuropathic Pain
• Peripheral sensitization
• Central sensitization
• Neuroplastic changes

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Types of Pain

• Nociceptive Pain -caused by activity in neural
  pathways in response to potentially
  tissue- damaging stimuli
• e.g. post-op pain, mechanical low back pain,
  exercise injuries, arthritis

• Neuropathic Pain -caused by primary lesion or
  dysfunction in the nervous system
• e.g. postherpetic neuralgia neuropathic back
  pain CRPS, distal poly- neuropathy
• Mixed Type -combination of both

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Peripheral Sensitization

• Increased sensitivity of nociceptors due to
  changes in ion channels--nerves fire at increased
  frequency, from weaker stimuli

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Central Sensitization and Neuroplasticity

• Central processing circuits become overreactive,
  and form spontaneous (ectopic) impulses
• With persistent (gt24 hours) moderate to severe
  pain, changes occur in the structure and function
  of the spinal segment of the nervous system
  result in more intense, widespread pain

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Common Pain Conditionsin Elderly Populations

• Arthritis/Musculoskeletal--especially
  degenerative arthritis and low back pain
• Cancer
• Leg Cramps
• Peripheral Vascular Disease
• Herpes Zoster/Postherpetic Neuralgia
• Headache
• Diabetic Neuropathies

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Consequences of Unrelieved Pain
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Physiologic Consequences of Unrelieved Pain

• Prolonged stress response triggered by unrelieved
  pain has negative effects!
• Cardiac
• Respiratory
• GI
• Musculoskeletal
• Cognitive/behavioral
• Future Pain

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Consequences of Unrelieved PainCardiac

• Hypercoagulability
• Increased heart rate, blood pressure
• Increased cardiac workload
• Increased oxygen demand
• Increased risk of myocardial infarction

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Consequences of Unrelieved Pain Respiratory

• Diminished respiratory function
• Decreased alveolar ventilation
• Pneumonia
• Atelectasis
• Pulmonary embolism
• Hypoxia
• Slowed wound healing

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Consequences of Unrelieved PainGastrointestinal

• Delayed gastric emptying
• Decreased motility
• Ileus
• Anorexia/weight loss

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Consequences of Unrelieved PainMusculoskeletal

• Muscle spasm
• Impaired muscle function
• Decreased mobility
• Decreased ability to ambulate
• Diminished short- and long-term recovery rehab

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Consequences of Unrelieved PainCognitive

• Mental status changes
• Confusion
• Sleep disturbance
• Depression
• Behavior disturbances
• Anxiety
• Anhedonia

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Consequences of Unrelieved PainFuture Pain

• Post-Mastectomy Pain Syndrome
• Phantom Limb pain
• Post-Thoracotomy Pain Syndrome
• Postherpetic Neuralgia
• Trigeminal Neuralgia
• Frozen Shoulder Syndrome
• Reflex Sympathetic Dystrophy/Complex Regional
  Pain Syndrome

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Consequences of Unrelieved PainPersonal

• Inability to perform ADLs/loss of independence
• Impaired relationships with family/friends
• Impaired intimacy/sexual activity
• Social Isolation
• Anger
• Loss of self-esteem

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Pain Assessment
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Pain Assessment

• Location
• Quality
• Severity
• Duration
• History
• Exacerbating/relieving factors
• Efficacy of current treatment

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Pain Assessment

• Impact on mobility
• Impact on sleep
• Impact on appetite
• Imact on mood
• Impact on social life

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Pain AssessmentTools

• Numerical scales
• Visual analog scales
• Verbal Descriptor scales
• Behavioral cues

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Pain AssessmentPain Scales
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Pain AssessmentBehavioral Cues

• Grimacing
• Agitation
• Restlessness
• Moaning/crying
• Guarding
• Appetite and activity changes
• Irritability/swearing

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Pain AssessmentSpecialized Tools

• Functional Pain Scale
• Pain Thermometer
• Discomfort Scale for the Dementia of Alzheimers
  Type
• Face, Legs, Activity, Crying, Consolability
  (FLACC) Scale

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Treatment Strategies

• Barriers to effective pain management
• Controversial issues in pain management
• Medications for pain relief
• Non-medicinal treatment methods
• Interventional pain management

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Barriers to Effective Pain Management

• PCPs Inadequate knowledge re pain and its
  management, fear of side effects, fear of
  regulatory retribution
• Patients Exaggerated fear of addiction, belief
  that pain is normal/inevitable part of aging
• Health Care System dissuades opioid use,
  under-utilization of pain specialists due to
  insufficient knowledge of benefit

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Controversial Issues in Pain Management

• Addiction
• Dependence
• Tolerance
• Pseudo-addiction

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Issues in Pain ManagementAddiction

• Primary, chronic, neurobiologic disease,
  characterized by a persistent pattern of
  dysfunctional opioid use that may
  involve -adverse consequences with opioid
  use -loss of control over opioid
  use -preoccupation with obtaining opioids
  despite adequate analgesia

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Issues in Pain ManagementPseudo-addiction

• A set of behaviors a person exhibits to obtain
  adequate pain relief
• becomes focused on obtaining meds
• clock watching
• may seem to be drug seeking
• may resort to doctor shopping, deception, to
  obtain adequate relief
• Behaviors resolve when pain treated
  effectively

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Issues in Pain ManagementAddiction

• Controlled substances have legitimate clinical
  usefulness and the prescriber should not hesitate
  to consider prescribing them when they are
  indicated for the comfort and well being of the
  patient.
• D.E.A. Physicians Manual

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Issues in Pain ManagementDependence

• A state of adaptation manifested by a specific
  drug class withdrawal syndrome produced by abrupt
  cessation, rapid dose reduction, decreasing blood
  level of the drug, and/or administration of an
  antagonist.
• Purdue Pharma leaflet, Providing Relief,
  Preventing Abuse

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Issues in Pain ManagementTolerance

• A state of adaptation in which exposure to a drug
  induces changes that result in a dimuition of one
  or more of the drugs effects over time.
  Tolerance may develop with opioid side effects
  (e.g. respiratory depression, drowsiness).
  Exceeding tolerance can be fatal.

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Undertreatment of pain is a serious problem in
the United States, including pain among patients
with chronic conditions and those who are
critically ill or near death. Effective pain
management is an integral and important aspect of
quality medical care, and pain should be treated
aggressively. -Joint statement of 21
organizations
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Medications for Pain Management

• World Health Organizations three-step analgesic
  ladder

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WHO Analgesic LadderStep 1 Non-opioids/adjuvant
s

• Mild to moderate pain
• NSAIDS and/or acetaminophen
• Corticosteroids
• Tricyclic antidepressants
• Anticonvulsants
• Topical preparations

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WHO Analgesic LadderStep 2 Opioids Adjuvants

• For moderate to moderately severe pain
• Codeine, hydrocodone, and propoxyphene (often
  combined w/APAP or NSAID)
• Tramadol - binds weakly to opioid receptors,
  inhibits reuptake of norepinephrine, serotonin
  (some studies find comparable to HC for certain
  types of pain)
• Propoxyphene inappropriate for use in older
  adults due to renal elimination, toxicity when
  accumulated (limit to mild, short term use)

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WHO Analgesic LadderStep 3 Opioids adjuvants

• For moderate to severe pain
• Morphine, oxycodone, fentanyl, hydromorphone
• Usually no ceiling effect
• Tolerance develops to side effects
• Side effects more severe in opioid-naïve pts.
• Constipation does not improve-MUST institute a
  bowel regimen!

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WHO Analgesic LadderStep 3 Contraindicated Meds

• Meperidine
• Intermittent use X 48 hours ONLY
• Active metabolite normeperidine can lead to
  confusion, seizures
• Daily dose lt 600 mg
• Methadone
• second-line agent due to long half-life
• risky in older patients (but good for neuropathic
  pain)

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WHO Analgesic LadderStep 3 Dosing
Administration

• Oral route preferred
• Topical opioid patches effective
• ATC doing for acute or progressive malignant pain
• Provide breakthrough dosing when using
  long-acting or patch (5-15 of daily dose)

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Medications for Pain Management

• Confounding factors
• Polypharmacy-- drug interactions
• Impaired hepatic/renal function
• Risk factors (e.g. risk of falls increases if
  drowsiness occurs)

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Non-pharmacologic Treatment Strategies

• TENS/Interferential Stimulators
• Accupuncture
• Distraction--humor, music, pets diminish
  perception of pain
• Behavior modification--hypnosis, biofeedback,
  relaxation
• NOT a ploy to avoid analgesics work
  synergistically

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Interventional Pain Management

• Epidural Steroid Injections
• Radiofrequency Rhizotomy for facet joint pain
• Epidural medications for herpes zoster, cancer
  pain
• Vertebroplasty for compression fracture
• Neurolytic blocks for cancer pain

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Nurse as Primary Pain ManagerChris Pasero, 2003

• Nurses advocate for patients for adequate pain
  relief
• Increased liability/accountability for safe and
  effective pain relief
• Increased education in current body of knowledge
  in Pain Management