Pain in the Elderly

Prof. Chit SoeDr. Cho Mar LwinWard 1&2 , YGH

18-10-2013

Myanmar Society for the Study of PainTraining of Trainers on Development of Pain

Management in Myanmar

Pain

An unpleasant sensory & emotional experience derived from sensory stimuli, modified by individual memory, expectations and emotions

Pain Management in elderly patients, Journal of pharmacy Practice, 20:49-63, 20072

Pain is common for older people

1 in 5 elderly have pain

• 3 in 5 adults > 65 with pain said it had lasted for one year or

more.

• Women report severely painful joints more often than men

(10 percent versus 7 percent)

18.10.13 Pain-Elderly 3

CDC′s National Center for Health Statistics 2006,

Common Causes of PainIn Elderly Persons

• Osteoarthritis

– back, knee, hip

• Night-time leg cramps

• Claudication

• Neuropathies

– idiopathic, traumatic, diabetic,

herpetic

• Cancer

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Pain in the ElderlySources of pain in the nursing home

Condition causing pain Frequency (%)

Low back pain 40

Arthritis 37

Previous fractures 14

Neuropathies 11

Leg cramps 9

Claudication 8

Headache 6

Generalized pain 3

Neoplasm: 3

18.10.13 Pain-Elderly 5

Stein et al, Clinics in Geriatric Medicine: 1996

Magnitude of the problem

• 71% take prescription analgesics

– 63% for more than 6 months

• 72% take OTC analgesics

– Median duration more than 5 years

• 26% report side-effects

– 10% were hospitalized

– 41% take medications for side-effects

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Pain is undertreated

• 18-24% of bereaved family members believe pain was undertreated

– Less if in hospice (18%)

– More if in home health (43%) or nursing home (32%)

• 41% of cancer patients undertreated

– Primary risk factor age > 70

7Hanson JAGS 45: 1339, Teno JAMA 291: 88, Cleeland NEJM 390: 592

Pain in the Elderly

Consequences of untreated pain:

• Depression

• Suffering

• Sleep disturbance

• Behavioral disturbance

• Anorexia, weight loss

• Deconditioning, increased falls

18.10.13 Pain-Elderly 8

27.2.04 9 Pain

Considered as vital sign

• After a crisis, controlling vital signs include

– Blood pressure

– Heart rate

– Respiratory rate

– Temperature

– Pain !! (5th Vital sign)

Barriers – Patient / Family Attitudes

• Pain is normal when you are old

• Value stoicism, “being strong”

• Fear of addiction

• Problems communicating pain

– Unable to talk

– Confusion/ dementia

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Barriers – provider attitudes

• Pain is normal when you are old

• Older patients feel less pain

• Legal risks of using opioids

• Failure to recognize chronic persistent pain

• Older patients can’t tolerate pain medications

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Acute Behaviours

• An elderly with acute pain may be

– Crying

– Guarding

– Grimacing and moaning

– High BP, pulse

– Restless or extremely still

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Chronic Behaviours

• An elderly with chronic pain

– May not express pain by telling you

– Express pain with depressed mood, withdrawal

– Have no abnormal vital signs

– Come to expect and endure pain

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Assess

• 67 -83% of elderly with dementia are able to use at least one scale

• Words are easier than numbers

• Ask in the present – “Are you in pain now?

• Ask in several ways – “Discomfort”

• Give time to respond

• Changes in behavior – Just not herself – passive, withdrawn, agitated, restless, not eating

14Ferrell BA JPSM 10: 591, Herr KA Clin J Pain 14: 29, Krulewitch H JAGS 48: 1607

Assessment overview1. Complete history and physical examination, focus on pain issues

2. Review of location of pain, intensity, exacerbating and/or

alleviating factors, and impact on mood and sleep

3. Screen for cognitive impairment (eg MMSE)

4. Screen for depression

5. Review of the patient’s ADLs (bathing, dressing, toileting,

transfers, feeding, and continence) and instrumental ADLs (use

of phone, travel, shopping, food preparation, housework,

laundry, taking medicine, handling finances)

6. Assessment of gait and balance

7. Screen for sensory depression to examine basic visual and

auditory function 15

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The most reliable

indicator of the

existence pain and

its intensity is the

patient’s

description.

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Total Pain

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Pain Treatment

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Physiological Changes and

Altered Pharmacology

Cognitive Impairment

and Compliance

Perception of Pain

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Challenges in the Management ofPain in the Elderly

Geriatric Pharmacology

• Absorption – no change

• Distribution – larger VD for lipophilic (benzos, trazodone) ; smaller VD hydrophilic (eg. Morphine)

• Metabolism – decreased hepatic blood flow

• Clearance – decreased RBF and Cr Cl; slower clearance

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Before medication

• Test baseline mental status

• Know baseline renal function

• Know concurrent chronic illnesses

– Hepatic function

– Hydration status

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Renal Disease

• AVOID NSAIDs

• Reduce tramadol doses

• Hydromorphone, methadone, oxycodone, fentanyl somewhat better tolerated

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Analgesic Drugs• Acetaminophen• NSAID's

– Non-selective COX inhibitors– Selective COX-2 inhibitors

• Opioids• Others

– Antidepressants– Anticonvulsants– Substance P inhibitors– NMDA inhibitors– Others

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WHO 3-step Ladder

1 mild

2 moderate

3 severe

Morphine

Hydromorphone

Methadone

Fentanyl

Oxycodone

± Adjuvants

Codeine

Oxycodone

± Adjuvants

Acetaminophen

NSAIDs

± Adjuvants Adjuvant Therapy: Anticonvulsants, Antidepressants, Corticosteroids, Dermal analgesics, Muscle relaxants, Stimulants

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Opioids and delirium

• Cohort study of n=541 hip fracture patients; 16% delirious

– Dementia greatest risk factor for delirium

– <10 mg morphine per day increased risk of delirium

• Opioids cause delirium; however so dose untreated pain

26Morrison RS J Geron 58A: 76

Musculoskeletal Pain

• Osteoporosis, fracture

– Several studies show pain reduction with calcitonin

– Vit D deficiency causes diffuse pain; replacement improves this symptom

• Osteoarthritis

– Scheduled acetaminophen; tramadol; short courses of steroids or NSIDS; injections; low potency opioids

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Non – medication TreatmentsUse for every elder in pain• Soft lighting, decreased noise, or added distractions• Massage• Warm or cold packs• Repositioning• Exercise• Emotional and spiritual support• Meditation• Music• Hypnosis

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Treatment Pearls

• Non-medication treatments

• Scheduled med if – Pain is daily

– Patient is cognitively impaired

• Opioids – longer interval (+/- lower dose)

• Combine low doses of different classes of medication

• Bowel medications

• Know hepatic, renal function, mental status

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Communication tipsPatient and Caregiver Education• Discuss pain care plan with patient, family• Diagnosis, prognosis, natural history of underlying disease• Communication and assessment of pain• Explanation of drug strategies• Management of potential side-effects• Explanation of non-drug strategies

Health care workers• Communicate pain care plan to other involved health care

providers – nurses, physiotherapists etc.• Ask pharmacists for help

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Reasons Patients May Not Report Pain

• Fear of diagnostic tests

• Fear of medications

• Fear meaning of pain

• Cultural cues misread by patient and/or providers

• Communications and misinterpretations

• Cannot adequate describe “pain” or discomfort

• Perceive physicians, nurses, health providers too busy

• Complaining may effect quality of care

• Believe nothing can or will be done

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27.2.04 32 Pain

AIMS of Management are to:

• Educate the patient

• Control pain

• Optimize function

• Beneficially modify the disease process

• Look at the social environment and create best support

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