"Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

International Association for the Study of Pain

International Association for the Study of Pain

"The Relief of Pain Should Be a Human Right"

2004-2005 Global Year Against Pain

Acute Pain Management Best practice is considered to be a multimodal approach – a combination of two or more analgesic modalities with differing analgesic mechanisms –enhancing analgesia and reducing side-effects (Myles and Power, 2007).

Acute Pain Management in the Elderly

Pain relief is important for humanitarian reasons.

It also:

Enables acute nursing care

Improves patients' wellbeing,

Reduces the risk of delirium, and

Facilitates rehabilitation – mobility independence.

Acute Pain Management in the Elderly

Pain is common in people over 65.

Daily pain affects around 25–50% of the population in the community and 80% in long-term care facilities (American Geriatrics Society Panel on Persistent Pain in Older Persons, 2002).

Layzell, M. (2009) Exploring pain management in older people with hip fracture. Nursing Times; 105: 2, 20–23.

Reasons for under- treatment of pain in the Elderly

Issues around pain assessment and patient reports of pain, including problems related to cognitive impairment and communication. Of those in care, 50% are cognitively impaired (Epps, 2001), greatly increasing the difficulty of pain assessment.

Reluctance to prescribe opioids and to take pain medications: co-morbid diseases and concurrent medications, diminished functional status and physiological reserve, and age-related changes in pharmacodynamics and pharmacokinetics.

Altered pain responses

Layzell, M. (2009) Exploring pain management in older people with hip fracture. Nursing Times; 105: 2, 20–23.

Reasons for under- treatment of pain in the Elderly

A key issue with older patients who can self-report pain is their reluctance to complain or report increased levels of pain.

Reasons include:

Belief that pain is a normal part of the ageing process;

They do not want to be seen as a nuisance; and

Pain may delay their discharge from hospital

In addition, psychological and cultural factors, such as fear, anxiety, depression, implications of the traumatic event, loss of independence, feelings of isolation, quality of social support available and family, will all affect pain reporting and ultimately assessment and management.

Layzell, M. (2009) Exploring pain management in older people with hip fracture. Nursing Times; 105: 2, 20–23.

Acute Pain Management in the Elderly

The ageing process is characterized by structural and functional changes affecting all organ systems and results in reduced homeostatic capacity.

Although the function of a particular system may be maintained during resting conditions, the reduction of functional reserve is responsible for an increased vulnerability to stress.

Pharmacokinetics in the Elderly

Changes in body composition cause an increase in the volume of distribution of lipid soluble drugs

Changes in hepatic function alter clearance of lipid soluble drugs

Changes in renal function alter clearance of water soluble drugs.

These lead to an unpredicatable prolongation of plasma elimination half-life.

Studies have shown significant reductions in the clearance of many drugs metabolized by phase-1 pathways in the liver. The main factor is age-related changes in liver size and hepatic blood flow. The activity of drug metabolising enzymes is usually preserved

Pharmacokinetics in the Elderly

Pharmacokinetics in the Elderly

Pharmacokinetics in the Elderly

Pharmacodynamics in the Elderly

Significant changes also occur which, in general, tend to increase sensitivity to drugs.

Acute Pain Management in the Elderly

The reduced functional reserve itself also leads to an increase in sensitivity by impairing homeostatic compensatory mechanisms.

Management goals of patients with Hip Fractures

Mortality rates in elderly patients in the year after low-impact hip fractures:

25% for women and

37% for men.

Morbidity and poor functional recovery is significant:

25% of women and

50% of men are unable to return home within a year.

Acute Pain Management in Hip Fracture Patients

"The common belief that pain following hip fracture surgery is inevitable, or is self-limited and not worth treating, is false,"

Dr. Abou-Setta, Annals of Internal Medicine. 2011

NICE Guidelines

NICE Guidelines

Assess the patient's pain: Immediately upon presentation at hospital Within 30 minutes of administering initial analgesia Hourly until settled on the ward Regularly as part of routine nursing observations throughout admission.

Empiric Analgesic Trial (N=1)

If in doubt, analgesic trial may be diagnostic

Treat behavioral symptoms with pain medication

Studies needed to guide approaches

http://www.americangeriatrics.org/files/documents/annual_meeting/2010/handouts/friday/assessing/HERR_AGS_Guidelines_Assessment.pdf

http://www.americangeriatrics.org/files/documents/annual_meeting/2010/handouts/friday/assessing/HERR_AGS_Guidelines_Assessment.pdf

NICE Guidelines

Analgesia Offer immediate analgesia to patients with suspected hip fracture, including people with cognitive impairment. Ensure analgesia is sufficient to allow movements necessary for investigations and for nursing care and rehabilitation.

NICE Guidelines

This group of patients is most commonly elderly and frail and pain is one of the main physiological and psychological stresses they face.

Trade off between clinical benefits and harm

The risks of pain relief are the side effects of the individual agents used to achieve it.

NICE Guidelines

Ensure analgesia is sufficient to allow movements necessary for investigations (as indicated by the ability to tolerate passive external rotation of the leg), and for nursing care and rehabilitation.

NICE Guidelines

Non-steroidal anti-inflammatory drugs are usually avoided or used with caution because of their side effects. These include upper gastrointestinal bleeding, nephrotoxicity and fluid retention – to all of which the older population are well known to exhibit increased susceptibility.

NICE Guidelines

Nerve blocks are sometimes administered to patients to reduce pain if simple analgesics and opioids have not proven to be sufficient. They are also thought to improve pain scores and mobility and to help avoid excessive opioid usage.

NICE Guidelines

Hip Fracture Program: From admission, offer all patients a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Program.

NICE Guidelines

Orthogeriatric assessment Rapid optimisation of fitness for surgery Early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture residence and long-term wellbeing Continued, coordinated, orthogeriatric and multidisciplinary review Liaison or integration with related services Clinical and service governance responsibility for all stages of the pathway of care and rehabilitation.

NICE Guidelines

NICE Guidelines

If a hip fracture complicates or precipitates a terminal illness, consider the role of surgery as part of a palliative care approach that:

minimises pain and other symptoms and

establishes patients' own priorities for rehabilitation and

considers patients' wishes about their end-of-life care.

Cochrane Review Cochrane Database Syst Rev. 2002;(1):CD001159.

Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures.

OBJECTIVES:

To determine the effects of nerve blocks (inserted either pre-operatively, operatively or post-operatively) as part of the treatment for a hip fracture.

SEARCH STRATEGY:

We searched the Cochrane Musculoskeletal Injuries Group specialised register (October 2001), MEDLINE -OVID WEB (1996 to October 2001) and reference lists of relevant articles. Randomised and quasi-randomised trials involving the use of nerve blocks as part of the care of a hip fracture patient.

MAIN RESULTS:

Eight randomised or quasi-randomised trials involving 328 patients were included. Three trials related to insertion of a nerve block pre-operatively and the remaining five to peri-operative insertion. Nerve blocks resulted in a reduction of the quantity of parenteral or oral analgesia administered to control pain from the fracture/operation or during surgery and/or a reduction in reported pain levels. It was not possible to demonstrate if this reduction in analgesia use was associated with any other clinical benefit.

REVIEWER'S CONCLUSIONS:

Because of the small number of patients included in this review and the differing type of nerve blocks and timing of insertion, it is not possible to determine if nerve blocks confer any significant benefit when compared with other analgesic methods as part of the treatment of a hip fracture. Further trials with larger numbers of patients and full reporting of clinical outcomes would be justified.

Nerve blocks compared to systemic analgesia

National Clinical Guideline Centre (UK). The Management of Hip Fracture in Adults [Internet]. London: Royal College of Physicians (UK); 2011. (NICE Clinical Guidelines, No. 124.) 7, Analgesia.

Available from: http://www.ncbi.nlm.nih.gov/books/NBK83020/

Nerve blocks compared to systemic analgesia

No additional studies were retrieved

Nerve blocks compared to systemic analgesia

There is a statistically significant but not clinically significant reduction in pain when using nerve blocks compared to systemic analgesia. (LOW QUALITY).

There is a statistically significant but not clinically significant reduction in pneumonia when using nerve blocks compared to systemic analgesia (MODERATE QUALITY).

There is no statistically significant difference between nerve blocks and systemic analgesia in all other outcomes (LOW QUALITY).

No studies on the cost effectiveness of nerve blocks for hip fracture patients were identified.

Nerve Blocks Nerve blocks may potentially find an important role in the management of hip fracture pain, both pre- and postoperatively, because of their potential to reduce the requirement for opioids and their associated unwanted effects.

Economically there are considerations for staff training, but also for the potential benefits in terms of duration of stay and early mobilisation.

It is not possible from the existing literature to determine this with any confidence and there is a pressing need for a definitive trial comparing these outcomes with nerve blocks against a defined protocol of systemic opioid use.

Key Recommendations: Early assessment, in the ED or on the ward, should include a formal recording of: ……….Pain…… If the patient’s overall medical condition allows, mobilisation and multidisciplinary rehabilitation should begin within 24 hours postoperatively.

Pain relief should be tailored to the individual patient. Adequate and appropriate analgesia is best achieved by titration of intravenous opiates. In selected cases local nerve block may be appropriate. Analgesia must be administered early, in anticipation of painful procedures, such as the movement of the patient for radiological investigation. If delay occurs, repeat administration of analgesia may be required.

Conclusion

Early and ongoing regular assessment of pain

Awareness of the pharmacokinetic and pharmacodynamic changes associated with aging.

A team approach.

Multimodal analgesia, with paracetamol, opioids +/- local anaesthesia.

Further studies are necessary!!

Research

Assessment of pain

Drug administration strategies utilising the pharmacokinetic and pharmacodynamic changes associated with aging.

Optimal team approach.

Multimodal analgesia, with paracetamol, opioids +/- local anaesthesia.

T'ain't What You Do (It's the Way That You Do It)