Persistent Pain in the ElderlyPersistent Pain in the Elderly

Veeraindar Goli , MD, FAPAMedical Director. , Pain Evaluation and Treatment Services

Associate Director ., Pain & Palliative Program

Duke University Medical Center , Durham , N.C. 27705

(919)684-2154

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Objectives

Discuss the scope of the problem

Identify key issues in undertreatment of pain

Define Pain and discuss mechanisms

Age related differences in Pain Mechanisms and Presentations

Assessment of pain in the Elderly

Treatment strategies and AGS Guidelines

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11%

89%

Nine in Ten Americans Suffer from Nine in Ten Americans Suffer from Regular PainRegular Pain

Frequency of Pain SufferedFrequency of Pain Suffered

Suffer less oftenSuffer less often

Suffer once a month or moreSuffer once a month or more

Arthritis Foundation Survey. 1999.Arthritis Foundation Survey. 1999.

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Pain in the United States

Pain is the most common reason people seek medical attention

50 Million people in the US are partially disabled or totally disabled by pain

45% of Americans seek care for their persistent pain at some point in their lives.

(Source: American Pain Society)

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Pain in the Elderly

Pain is reported to be twice as prevalent in the elderly as in younger individuals

Elderly in the community reported to have prevalence of pain ranging from 25-50%

In LTC settings, prevalence can be as high as 85% 1/6 of all nursing home residents experience pain daily

( Source: “The Prevalence and Treatment of Pain in US Nursing Homes)

Chronic pain in the LTC setting is generally under recognized and often under treated ( Source: American Geriatric Society Panel

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Societal Attitudes and Misconceptions Toward Pain

The elderly have a higher tolerance toward pain

The elderly or cognitively impaired cannot be accurately assessed for pain

Residents complain of pain just to get more attention

Elderly patients are likely to become addicted to medication

Chronic Pain means death is imminent

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Barriers to Recognition of Pain in the Elderly

Racial, ethnic, religious and gender biases

Cognitive impairment

Coexisting medical conditions

Staff training and access to appropriate tools.

System Barriers

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Barriers to Pain Treatment Healthcare professionals

inadequate knowledge/ poor assessment

fear of tolerance, addiction and side effects

concern with regulatory issues

Patients

inadequate knowledge

fear of addiction and side effects

Healthcare System

access to specialists

inadequate reimbursement

State/Federal Regulations

scheduling

triplicates

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Importance of Pain Relief?

It is an individual’s right to be pain free – JCAHO Standards

Pain in the elderly associated with anxiety and depression

Associated with significant medical morbidity

Pain negatively impacts the quality of life in the older person

APS adapted it as the 5th vital sign

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Almost all long term care residents have predisposing factors for developing pain.

For this reason, a high index of suspicion regarding the presence of pain is warranted.

Source: The Management of Chronic Pain in Older Persons, AGS Panel on Chronic Pain in Older Persons.

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Merskey H, Bogduk N, eds. Classification of Chronic Pain. 1994:209-14.

Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP)

Pain is whatever the patient says it is and occurs whenever they say it does !! (McCaffrey)

Definition

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What is pain, really?

Transduction

Transmission

Modulation

Perception

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Neuroanatomy of Pain Pathways

Scientific American Medicine

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Pain Classification

Headache(migraine)

Acute Chronic

Pain

NociceptiveMixedNeuropathic Visceral

Diabetic neuropathy (DN)Post-herpetic neuralgia (PHN)Radiculopathy (RADIC)

Cancer painLow back pain

OsteoarthritisRheumatoid arthritisFibromyalgia

IBSPancreatitisBladder painNoncardiac chest painAbdominal pain syndrome

InjuryPostoperativeFlare

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Pain Physiology

Nociceptive Pain

Neuropathic Pain --Peripheral sensitization

--Central sensitization

--Neuroplastic changes

Mixed Pain

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Pain types- features

Pain serves a protective function

Transient

Well localized

“linear” stimulus-response pattern as other sensory modalities

Pain (A- & C fibers) can be differentiated from touch (A- fibers)

Pain is pathological, associated with nerve injury; no biological function

Outlasts stimulus

Spreads to noninjured regions

Occurs with sensitization of peripheral and central nervous systems

Pain elicited from A-, as well as A- & C fibers

Nociceptive (Acute) Neuropathic (Chronic) (Physiological) (Pathological)

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Normal Events That Produce Nociception: Paper Cut

Tissue injury

Immediate activation of A fibers(first pain)

Fast

Localize the injury

Later activation of C fibers(second pain)

Slower

Less ability to localize injury

Tissue reaction to injury

Time (seconds)

Pai

n Le

vel

LessLess

MoreMore

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Characteristics of Neuropathic Pain Spontaneous pain: Due to spontaneous firing

of axons or dorsal horn neurons- Lancinating, paroxysmal- Burning, constant- Cramping

Evoked pain: Due to damage and alterations in

peripheral and central sensory neurons - Allodynia- Hyperalgesia- Hyperpathia

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Pathologic Pain Functions

Stimulus intensity

Magnitude of pain normal

hyperpathia

hyperalgesia

allodynia

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Adapted from Siddal, Cousins. In: Cousins, Bridenbaugh, eds. Neural Blockade. 1998:675-699.

Peripheral SensitizationTissue damage Inflammation Sympathetic

terminals

Decreased threshold of nociceptorsEctopic dischargesAbnormal accumulation of Na+ channels

SENSITIZING “SOUP”

Hydrogen ions Histamine Purines LeukotrienesNoradrenaline Potassium ions Cytokines Nerve growth factorBradykinin Prostaglandins 5-HT Neuropeptides

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Central SensitizationCentral Sensitization

Mechanisms of Pain

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Siddal &Cousins in: Cousins & Bridenbaugh: Neural Blockade, 1998: 675-699.

Physiological Sensations

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Neuropathic Pain

Siddal & Cousins. In: Cousins & Bridenbaugh, eds. Neural Blockade. 1998:675-699.

Neuropathic PainDouble Amplification

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Neuropsychiatric aspects of Pain

cortical modulation

Attentional processes

state of consciousness

“Ultimate” psychosomatic phenomenon

cognitive factors Attention to Pain

Meaning

Mood disorders

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Nociception

Nociception

Pain

Suffering

Pain Behavior

Loeser JD. In: Loeser JD. In: Bonica’s Management of PainBonica’s Management of Pain. Philadelphia; . Philadelphia; Lippincott Williams & Wilkins: 2001.Lippincott Williams & Wilkins: 2001.

Multidimensional Model of Pain

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Abnormal Pain Mechanisms

Abnormal Nociception Peripheral Sensitization

Abnormally low pain threshold (hyperalgesia )

Central sensitization to Pain .

Recruitment of Novel Inputs ( Allodynia )

Abnormal Pain Perception meaning of pain

memory of pain

Mood disorders

Neuropsychiatric aspects of pain

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Aging - what is the impact on pain ?

Two major sources of Information

1) Studies of aging and pain in the absence of disease

Decrease in thermal ,mechanical sensitivity. Decrease in discriminative capacity , changes in C and Ad fibers.

2) Studies of aging and pain in the presence of disease

Arthritis , Post herpetic neuralgia , cancer on one hand and unusual presentations( silent MI , Painless intraabdominal catastrophies on the other. Decrease in pain tolerance .

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Causes of Chronic Pain in Aging

Predominantly Musculoskelatal (OA, RA )

Myofascial pain syndromes

Herpes Zoster , temporal arteritis , Polymyalgia

Post - Cancer Pain

Iatrogenic , related to therapies.

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Pain Assessment

Initial Pain Assessment: A detailed history including assessment of PainIntensity

and Character A physical and neurological examination. A psychosocial examination. Appropriate diagnostic workup to determine the cause of

Pain.

Ongoing Pain Assessment: At regular intevals after starting the treatment plan . With each new report of Pain .

Assessment of New Pain.

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Pain Treatment Guidelines World Health Organization (1990, 1996)

American College of Rheumatology (1995, 2000)

American Geriatrics Society (1998 and 2002)

American Medical Directors Association (1999)

American Pain Society (2002)

AHCPR Guidelines

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Treatment Approach (AHCPR)

Ask pain and goal , and Assess pain

Believe the patient and family (Validate! but do not enable.)

Choose pain control options wisely

Deliver interventions timely

Enpower the patient and family

Follow up to reassess the pain

From CMDT 2003 p66

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AGS Practice Guidelines

GUIDELINE OBJECTIVE(S)

To update and revise previous recommendations from the clinical practice guideline titled "The Management of Chronic Pain in Older Persons," using the latest information about pain management in elderly persons

To provide the reader with an overview of the principles of pain management as they apply specifically to older people and specific recommendations to aid in decision making about pain management for this population

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AGS Practice Guidelines

NUMBER OF SOURCE DOCUMENTS

More than 4,122 citations were identified from sources

More than 2,089 abstracts were obtained for further analysis

More than 520 full-text data-based articles were obtained and summarized for detailed analysis

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American Geriatric Society (AGS) Clinical Practice Guidelines

Older persons should be assessed for pain on initial presentation to any health care setting.

Any persistent or recurrent pain that has a significant impact on function or quality of life should be recognized as a significant problem.

A variety of terms synonymous with pain should be used to screen older patients (e.g. ache, discomfort, soreness, heaviness, tightness)

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Common Pain Indicators

Self-report

Report from significant other

Condition or procedure that usually causes pain

Behaviors

Physiologic Measures

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Getting to Know the Pain

Words – McGill’s Pain Questionnaire

Intensity – VAS pain scale

Location – More than one location

Duration – constant or breakthrough

Aggravating and Alleviating Factors

Challenges in Pain AssessmentChallenges in Pain Assessment

Patients With Communication

Difficulties

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Challenges in Pain Assessment

1. Cognitive Impairment

2. Three D’s-Dementia, Delirium, Depression

3. Conscious but unable to speak

4. Unconscious and unable to speak

5. Residents with wide range of communication difficulties

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Pain Assessment in the Cognitively Impaired Resident

Cognitive impairment is major obstacle to pain assessment ,50%-60% of residents have some form of progressive dementia

Study of 758 cognitively impaired nursing home residents

Self report of pain is no less valid than that of cognitively intact residents

(Source: Parmelee, Smith,Katz 1993)

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Use of Pain Rating Scales in Cognitively Impaired

Residents with substantial cognitive impairment may still be able to use a pain rating scale

217 residents; dependent in most ADL’s

Mean age of 84.9; substantial cognitive impairment

30 seconds to respond; scale repeated three times

0 to 5 scale preferable with this population rather than 0-10 scaleSource: (Ferrell, Ferrell & Rivera 1995)

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Proxy Pain Rating

Family members or clinicians who know the resident well may be asked to rate pain

Family members may be better able to identify behaviors that suggest the possibility of pain

Family members may be more sensitive to changes in behavior

Used as a guess; not used with self reports of pain

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Do’s & Don’ts

Use an Instrument with simple language

Use simple descriptors (“aching”, “hurting”)

Ask yes/no questions Listen for clues in

fragmented speech Palpate areas thought to

be painful when asking questions

Observe for behaviors that may indicate pain

Assess pain following or during movement

Don’t discount behaviors as part of dementia

Don’t interrupt attempts at responses

Assume that anti-anxiety medications will relieve pain

Don’t forget to include family members

Don’t assume that persons with dementia don’t experience pain

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2) Assessment in Residents with Advanced Dementia

Discomfort in Dementia of the Alzheimer’s Type

(DS-DAT)

Scale of 9 indicators of discomfort/comfort:- noisy breathing - negative vocalizations

- content facial expression - sad facial expression

- frightened facial expression - frown

- relaxed body language - tense body language

- Fidgeting

(Source: Hurley, Volicer, Hanrahan et al 1992)

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3) Assessment and Treatment of Pain in the Nonverbal Patient

Feedback from the patient

Offer writing materials or simple pain scales

Treat with analgesics or other pain relief measures

If interventions modify pain behaviors, continue with treatment

R/O other potential problems

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Behavioral Cues

Grimacing, frowning, grinding teeth

Agitation, striking out

Restlessness, fidgeting

Moaning/crying , groaning

Guarding, changes in gait

Appetite and activity changes

Irritability/swearing

Sleeping poorly

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4) Unconscious Residents

Pain may not be easily determined, assumed pain free Residents who appear to be unconscious &

unresponsive to painful stimuli actually feel & recall pain

Residents with endotracheal tubes or residents who have received a neuromuscular blocking agent (pancuronium) may be fully capable of feeling pain

Clinicians should assume that the unconscious resident may feel pain & provide analgesics if anything known to be painful is present

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5) Pain in Terminally Ill Residents

When patients are no longer able to verbally communicate whether they are in pain or not, the best approach is to assume that their cancer is still painful and to continue them on their regular medications

Therapeutic opioid (narcotic) level should be maintained

Continued opioids simply ensure that the death will be as peaceful and as painless as possible (Levy 1985)

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Assessment Tools for Cognitively Impaired

FACES Scale

VAS and 0-5 Scale

Verbal Descriptor Scale

Flow Sheets

Pain Thermometer

Discomfort Scale for the Dementia of Alzheimer’s Type

Face, Legs, Activity, Crying, Consolability (FLACC) Scale

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Federal Regulations

Skilled nursing facilities function under a clear mandate from the federal government regarding the responsibility to assess, treat and manage pain

Nursing Home Federal Requirements and Guidelines to Surveyors, Code of Federal Regulations (CFR) 483.25, F309

Facilities are surveyed to assure necessary care is provided based on findings on the Resident Assessment Instrument (RAI)

Pain is mandated to be a part of the Minimum Data Set (MDS)

Sections J2a, J2b and J3 meet this requirement

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Section J2/ Pain Symptoms and J3 Pain Site ( MDS )

b. INTENSITY of pain 1. Mild pain 2. Moderate pain

0. No pain (skip to J4) 3. Times when pain is 1. Pain less than daily horrible or excruciating 2. Pain daily(If pain present, check all sites that apply in last 7 days)

Back pain a. Incisional pain f.

Bone pain b. g.

c. h.

Headeache d. Stomach pain I.

Hip pain e. Other j.

a. FREQUENCY with which resident complains or shows evidence of pain.

J 2. Pain Symptoms

(Code the highest level of pain present in the last 7 days)

J 3. Pain Site

Chest pain while doing usual activities

Joint pain (other than hip)

Soft tissue pain (e.g., lesion, muscle)

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Summary of Pain Assessment

Ask residents about their pain

Observe nonverbal behaviors

Accept and respect what they say

Consult family members

Use appropriate assessment scales

Intervene to relieve their pain

Ask them again about their pain

Circle of assessment, intervention and reassessment

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“If we cannot assess pain, we will never be able to treat pain.”

Betty Ferrell

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Under Treatment- Just the fact

Pain in the elderly JAMA, 1998 – Elderly Cancer Patients in LTC

>25% received nothing for pain

Highest risk = >85, women, minorities

Advanced dementia pts with hip fractures

Received 1/3 morphine equivalent dose compared to others

76% were without standing analgesic orders

50 – 90% fail to take meds correctly

Vertebral fractures >65 years old is 21 – 27%

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Pain Treatment Continuum

Least invasive

Most invasive

Psychological/physical approaches

Topical medications

Oral medications

Injections

Interventional techniquesMackin GA. J Hand Ther. 1997(April-June);10(2):96-109; Katz N. Clin J Pain. 2000(June);16(2 suppl):S41-48; Leland JY. Geriatrics. 1999(Jan);54(1):23-28, 33-34, 37; Belgrade MJ. Postgrad Med. 1999(Nov);106(6):127-132, 135-140; Galer BS et al. A Clinical Guide to Neuropathic Pain. 2000, p. 97; Gonzales GR. Neurology. 1995(Dec);45(12 suppl 9):S11-16; discussion S35-36

ContinuumContinuum not related to efficacynot related to efficacy

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Generic Treatment Goals(Mission Impossible ?)

Validate Patients Condition

“Shrink” pain to the Lowest level possible.

Identify treatable conditions

Streamline Medications

Improve Quality of life

Provide Pain Coping Skills

Increase Socialization

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Multidisciplinary Management ! Multiple studies demonstrate the best outcomes

A team approach is recommended

Consistent with other geriatric program models

A comprehensive assessment to include medical , neurological ,psychosocial evaluations.

Integrating Invasive and non invasive techniques

Physical therapy , alternative therapies

Specific goal setting a shift of focus to rehabilitation model of pain management , rather than cure.

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Treatment Modalities

Pharmacological

Non-Pharmacological Physical

psychosocial

Invasive Techniques

Alternative Medicine

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Antidepressants Amitriptyline, imipramine, desipramine,

nortriptyline

Anticonvulsants Carbamazepine, clonazepam,

gabapentin, lamotrigine, oxcarbazepine,

phenytoin, topiramate, valproic acid

Antiarrhythmics Mexiletine

Topical formulations Capsaicin, lidocaine, aspirin

Analgesics Oxycodone, methadone , tramadol

NSAIDS( non selective) Ibuprofen , Naproxen , Meloxicam

Selective COX-2 Rofecoxib and Celecoxib

Pharmacologic Management of Chronic Pain

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PNS

CBZOXCPHTTCATPMLTGMexiletineLidocaine

Na+

SPINAL CORD

BRAIN

Descending Inhibition

TCAsSSRIsSNRIsTramadolOpiates

Ca++ : GBP; OXC NMDA : Ketamine, TPM

Dextromethorphan

OthersCapsaicinNSAIDsCOX-2 inhibitorsLevodopa

Beydoun. 2001.

Mechanistic Categories of Antineuralgic Agents

Central SensitizationPeripheral Sensitization

NE/5HT Opiate receptors

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Definitions:Quality of Evidence

Level I: Evidence from at least one properly randomized, controlled trial

Level II: Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic

studies, from multiple time-series studies, or from dramatic results in uncontrolled experiments

Level III: Evidence from respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Strength of Evidence(FOR) A =Good, B =Moderate , C =Poor,

(AGAINST) D=Moderate against, E=Good evidence against

AGS Quality of Evidence

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Pharmacological treatment Guidelines

All older patients are candidates for pharmacologic therapy. (IA)

There is no role for placebos (IC)

The least toxic means should be used. Noninvasive route should be considered first. (IIIA)

Acetaminophen should be the first drug to consider in the treatment of mild to moderate pain of musculoskeletal origin. (IB)

Avoid Traditional (nonselective) NSAIDs . The COX-2 selective agents or nonacetylated salicylates (IA)

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AGS Guidelines- Opioids

Opioid analgesic drugs may help relieve moderate to severe pain, especially nociceptive pain. (IA)

Opioids for episodic (noncontinuous) pain should be prescribed as needed, rather than around the clock. (IA)

Long-acting or sustained-release analgesic preparations should be used for continuous pain. (IA)

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Opioids – Contd. Breakthrough pain - identify and

treat by the use of fast-onset, short-acting preparations. There are three types of breakthrough pain: (IA)

–End-of-dose failure (IIIB)

–Incident pain. (IB)

–Spontaneous pain. (IC) Titration should be conducted

carefully. (IA)

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AGS Guidelines- side effects

Constipation and opioid-related GI side effects should be prevented. (IA)

Mild sedation and impaired cognitive performance should be anticipated when opioid analgesic drugs are initiated or escalated. Until these side effects cease: (IIIC)

Severe or persistent nausea may need to be treated with anti-emetic medications, as needed. (IIIB)

Fixed-dose combinations of opioid with acetaminophen or NSAIDs may be useful for mild to moderate pain. (IA)

Patients taking analgesic medications should be monitored closely. (IA)

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Pharmacotherapy AGS

Neuropathic pain – AED and TCAs (1A)

Topical Therapies (1B)

Combination therapies (IIB)

Monitor Side effects (IA)

Non-Pharmacological treatmentsNon-Invasive Treatments

Physical RehabilitationPhysical Rehabilitation Myofascial releaseMyofascial release

StretchingStretching

ReconditioningReconditioning

StrengthStrength

EnduranceEndurance

Gait and posture trainingGait and posture training

Body mechanicsBody mechanics

PacingPacing

AnalgesicAnalgesic IceIce

HeatHeat

Electrical Electrical stimulationstimulation

TENSTENS

InterferentialInterferential

Counter-irritationCounter-irritation

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Non Pharmacological treatmentsInvasive Therapies

Neurosurgical procedures:

1)Interruption of pain transmission;

Peripheral neurotomy, rhizotomy, cordotomy,

DREZ, Thalamotomy, Medullary tractotomy.

2) Stimulation of Analgesia:

TENS , DCS , Epidural Stimulation , Thalamic stimulation.

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Non pharmacological TxAnesthetic approaches

Myofacial trigger point injection

peripheral nerve block

Autonomic plexi block

inhalation analgesia

neurolytic blockade

intraspinal opioid devices

spinal cord stimulation devices

Non -Pharmacological treatmentsPsychiatric/Psychological Treatments

CognitiveCognitive How to thinkHow to think

BehavioralBehavioral What to doWhat to do

Stress Stress managementmanagement Relaxation trainingRelaxation training

VisualizationVisualization

HypnosisHypnosis Range of Pain ControlRange of Pain Control

DistractionDistraction

AnalgesiaAnalgesia

AnesthesiaAnesthesia

BiofeedbackBiofeedback

PsychotherapyPsychotherapy GroupGroup

FamilyFamily

TraditionalTraditional

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Cognitive Behavioral Therapy in aging Pain adaptation ( Daily activities ,bodily responses,thoughts

/feelings)

Age does not predict response and can be effectively used in this population

May reduce the burden of polypharmacy & serious side effects.

Severe Depression or major cognitive impairment should be excluded ( poor Candidates )

Strategies include :

Relaxation training-Biofeedback & Progressive muscle relaxation

Activity Rest Cycles

Attention Diversion Strategies

Cognitive restructuring

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Social context in elderly chronic pain patients ( Roy et al )

Social network ( Buffering model of social support )

Formal Networkhospital , cultural institutions etc

Informal Network Family , spouse , friends

Semi- formal networkClubs , church , professionals

Older Adult

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Conclusion

Geriatric Pain is undertreated and understudied

A better understanding of pain mechanisms is needed

Pain must be assessed in every older adults

Pain problems unique to older adults need further study

Better understanding of Pain Behaviors in older adult

Change in Health care providers attitude & beliefs of aging.

A multidisciplinary approach is advocated

“We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new

privilege. Pain is a more terrible lord of mankind than even death itself.”

“We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new

privilege. Pain is a more terrible lord of mankind than even death itself.”

--1931, Albert Schweitzer

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