PAIN MANAGEMENTIN ELDERLY PERSONS

UCLA Multicampus Program of Geriatrics and Gerontology

Physicians Have a Moral Obligation to Provide Comfort and Pain Management

Especialy for those near the end of life!

Pain is the most feared complication of illness Pain is the second leading complaint in

physicians’ offices Often under-diagnosed and under-treated Effects on mood, functional status, and quality

of life Associated with increased health service use

18% of Elderly PersonsTake Analgesic Medications Regularly

(daily or more than 3 times a week)

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

ELDERLY PATIENTS TAKING PAIN MEDICATIONS FOR CHRONIC PAIN WHO

HAD SEEN A DOCTOR IN THE PAST YEAR

79% had seen a primary care physician 17% had seen a orthopedist 9% had seen a rheumatologist 6% had seen a neurologist 5% had seen a pain specialist 5% had seen a chiropractor 20% had seen more than 5 doctors

Common Causes of PainIn Elderly Persons

Osteoarthritis– back, knee, hip

Night-time leg cramps Claudication Neuropathies

– idiopathic, traumatic, diabetic, herpetic Cancer

MISCONCEPTIONS ABOUT PAIN

Myth: Pain is expected with aging.

Fact: Pain is not normal with aging.

PAIN THRESHOLD WITH AGING

Author Stimulus Threshold

Shumacher, 1940 Thermal No Change

Birren, 1950 Thermal No Change

Sherman, 1964 Electric/Tooth Higher

Collins, 1968 Electric/Skin Lower

Harkins, 1977 Electric/Tooth No Change

Tucker, 1989 Electric/Skin Higher

Age Related Differences in Sensory Receptor Function

Encapsulated end organs– 50% reduction in Pacini’s– 10-30% reduction Meissner’s/Merkels Disks

Free nerve endings– no age change

Age Related Differences inAge Related Differences inPeripheral Nerve FunctionPeripheral Nerve Function

Myelinated nervesMyelinated nerves Reduction in density (all sizes including small)Reduction in density (all sizes including small) Increase in abnormal/degenerating fibresIncrease in abnormal/degenerating fibres Decrease in action potential/slower conduction velocityDecrease in action potential/slower conduction velocity

Unmyelinated nervesUnmyelinated nerves Reduction in number (1.2-1.6un) not (.4un)Reduction in number (1.2-1.6un) not (.4un) Substance P, CGRP content decreasedSubstance P, CGRP content decreased Neurogenic inflammation reducedNeurogenic inflammation reduced

Age Related Differences inAge Related Differences inCentral Nervous System FunctionCentral Nervous System Function

Loss of dorsal horn spinal neuronsLoss of dorsal horn spinal neurons Altered endogenous inhibition, hyperalgesia.Altered endogenous inhibition, hyperalgesia.

Loss of neurons in cortex, midbrain, brain stemLoss of neurons in cortex, midbrain, brain stem (18% reduction in thalamus, no change cingulum (18% reduction in thalamus, no change cingulum

cortex)cortex) Altered cerebral evoked responses (increased latency, Altered cerebral evoked responses (increased latency,

reduced amplitude)reduced amplitude) Reduced catecholamines, acetylcholine, GABA, 5HT, Reduced catecholamines, acetylcholine, GABA, 5HT,

not neuropeptidesnot neuropeptides

MISCONCEPTIONS ABOUT PAIN

Myth: If they don’t complain, they don’t have pain

Fact: There are many reasons patients may be reluctant to complain, despite pain that significantly effects their functional status and mood.

REASONS PATIENTS MAY NOT REPORT PAIN

Fear of diagnostic tests Fear of medications Fear meaning of pain Perceive physicians and nurses too busy Complaining may effect quality of care Believe nothing can or will be done

The most reliable indicator of the existence pain and its intensity is the patient’s description.

There is a lot we can do to relieve pain!

Analgesic drugs Non-drug strategies Specialized pain

treatment centers Patient and caregiver

education and support

Analgesic Drugs Acetaminophen NSAIDs

– Non-selective COX inhibitors

– Selective COX-2 inhibitors

Opioids Others

– Antidepressants

– Anticonvulsants

– Substance P inhibitors

– NMDA inhibitors

– Others

CAUTION

Meperidine (Demerol)

Butorphanol (Stadol)

Pentazocine (Talwin)

Propoxiphene (Darvon)

Methadone (Dolophine)

Transderm Fentanyl (Duragesic)

Do Not Use Placebos!

Unethical in clinical practice They don’t work Not helpful in diagnosis Effect is short lived Destroys trust

Non-Drug Strategies Exercise

– PT, OT, stretching, strengthening

– general conditioning

Physical methods– ice, heat, massage

Cognitive-behavioral therapy

Chiropracty Acupuncture TENS Alternative therapies

– relaxation, imagery– herbals

PATIENT AND CAREGIVER EDUCATION

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