Pragnesh Patel, M.D. Assistant Professor Board certified in Internal Medicine, Hospice/Palliative...
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Transcript of Pragnesh Patel, M.D. Assistant Professor Board certified in Internal Medicine, Hospice/Palliative...
Pragnesh Patel MDAssistant Professor
Board certified in Internal Medicine HospicePalliative Medicine and
GeriatricsDivision of Geriatrics
Wayne State UniversityDetroit Michigan
Pain Management inElderly Patients
ObjectiveUnderstand how to define and classify painLearn social and environmental factors
affecting the perception of pain and its treatment
Know the scales available to assess painLearn medical and non-medical treatments
available for pain
DemographicsUS population 306 milliongt 65 years represents about 36 million by 2020
54millionFastest growing segment of the population is gt 85
years Currently 5 million 20 million by 20501900rsquos - 3 million elderly (1 in 25 Americans) by 2020
54 million (1 in 6 Americans)2011 - first baby boomers will reach 65
US Census BureauCDCgov
Return to top
In 2000 42 of population gt65 and over reported long lasting disability
What is PainPain is an unpleasant sensory and emotional
experienceThe International Association for the Study of Pain
(IASP) defines pain in terms of both actual or potential tissue damage and the emotional experiences associated with pain
Acute Pain is often limited warns of tissue damage Often with signs of autonomic nervous system
activation Intensity of pain indicates severity of injury or diseaseChronic persistent ( gt 3 months) - pain no longer
signals tissue damage Autonomic signs are often absent IASP website
Hix MD Pain Management in elderly patients Journal of pharmacy Practice 2049-63 2007
Mechanism of pain based on PathophysiologyNociceptive pain Results from stimulation of pain
receptors Somatic damage to body tissue well localized Visceral from viscera poorly localized may have
nauseaNeuropathic pain Results from dysfunctions or
lesions in either the central or peripheral nervous systems
Mixed pain syndromes multiple or unknown mechanisms (eg headaches vasculitic syndromes)
Psychogenic Pain somatoform disorders conversion reactions
NeurobiologyMyelinated A-delta and Unmyelinated C fibers
respond to thermal mechanical electrical or chemical stimuli
Release of excitatory neurotransmitter glutamate and substance P
Information transmitted to thalamus by spinothalamic tract
Pain modulation frontal cortex hypothalamus descending pathway endogenous analgesia by releases of beta-endorphin enkephalins opioid peptides
Age related changesReduction in number and function of peripheral
nociceptive neuronsSensory threshold for thermal and vibratory stimuli
increase with agePain receptors 50 decrease in Pacinis
corpuscles10-30 decrease in MeissnersMerkles disks
Diminished endogenous analgesic response (endorphins)
in the older patients
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesPeripheral nerves Myelinated nerves Decreased density Increase abnormaldegenerating fibers Slower conduction velocity Unmyelinated nerves Decreased number of large fibers (12-16 mm No change in small fibers (04 mm) Substance P content decreased
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesCentral nervous system Loss in dorsal horn neurons Altered endogenous inhibition hyperalgesia Loss of neurons in cortex midbrain brainstem 18 loss in thalamus Altered cerebral evoked responses Decreased catacholamines acetylcholine
GABA serotonin Endogenous opioids mixed changes Neuropeptides no change
Geriatric medicine An evidence based approach 4 th edition 2003
Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had
experienced pain in the past month that persisted for more than 24 hours
Almost three-fifths of adults 65 and older 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)
CDCprimes National Center for Health Statistics 2006
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
ObjectiveUnderstand how to define and classify painLearn social and environmental factors
affecting the perception of pain and its treatment
Know the scales available to assess painLearn medical and non-medical treatments
available for pain
DemographicsUS population 306 milliongt 65 years represents about 36 million by 2020
54millionFastest growing segment of the population is gt 85
years Currently 5 million 20 million by 20501900rsquos - 3 million elderly (1 in 25 Americans) by 2020
54 million (1 in 6 Americans)2011 - first baby boomers will reach 65
US Census BureauCDCgov
Return to top
In 2000 42 of population gt65 and over reported long lasting disability
What is PainPain is an unpleasant sensory and emotional
experienceThe International Association for the Study of Pain
(IASP) defines pain in terms of both actual or potential tissue damage and the emotional experiences associated with pain
Acute Pain is often limited warns of tissue damage Often with signs of autonomic nervous system
activation Intensity of pain indicates severity of injury or diseaseChronic persistent ( gt 3 months) - pain no longer
signals tissue damage Autonomic signs are often absent IASP website
Hix MD Pain Management in elderly patients Journal of pharmacy Practice 2049-63 2007
Mechanism of pain based on PathophysiologyNociceptive pain Results from stimulation of pain
receptors Somatic damage to body tissue well localized Visceral from viscera poorly localized may have
nauseaNeuropathic pain Results from dysfunctions or
lesions in either the central or peripheral nervous systems
Mixed pain syndromes multiple or unknown mechanisms (eg headaches vasculitic syndromes)
Psychogenic Pain somatoform disorders conversion reactions
NeurobiologyMyelinated A-delta and Unmyelinated C fibers
respond to thermal mechanical electrical or chemical stimuli
Release of excitatory neurotransmitter glutamate and substance P
Information transmitted to thalamus by spinothalamic tract
Pain modulation frontal cortex hypothalamus descending pathway endogenous analgesia by releases of beta-endorphin enkephalins opioid peptides
Age related changesReduction in number and function of peripheral
nociceptive neuronsSensory threshold for thermal and vibratory stimuli
increase with agePain receptors 50 decrease in Pacinis
corpuscles10-30 decrease in MeissnersMerkles disks
Diminished endogenous analgesic response (endorphins)
in the older patients
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesPeripheral nerves Myelinated nerves Decreased density Increase abnormaldegenerating fibers Slower conduction velocity Unmyelinated nerves Decreased number of large fibers (12-16 mm No change in small fibers (04 mm) Substance P content decreased
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesCentral nervous system Loss in dorsal horn neurons Altered endogenous inhibition hyperalgesia Loss of neurons in cortex midbrain brainstem 18 loss in thalamus Altered cerebral evoked responses Decreased catacholamines acetylcholine
GABA serotonin Endogenous opioids mixed changes Neuropeptides no change
Geriatric medicine An evidence based approach 4 th edition 2003
Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had
experienced pain in the past month that persisted for more than 24 hours
Almost three-fifths of adults 65 and older 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)
CDCprimes National Center for Health Statistics 2006
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
DemographicsUS population 306 milliongt 65 years represents about 36 million by 2020
54millionFastest growing segment of the population is gt 85
years Currently 5 million 20 million by 20501900rsquos - 3 million elderly (1 in 25 Americans) by 2020
54 million (1 in 6 Americans)2011 - first baby boomers will reach 65
US Census BureauCDCgov
Return to top
In 2000 42 of population gt65 and over reported long lasting disability
What is PainPain is an unpleasant sensory and emotional
experienceThe International Association for the Study of Pain
(IASP) defines pain in terms of both actual or potential tissue damage and the emotional experiences associated with pain
Acute Pain is often limited warns of tissue damage Often with signs of autonomic nervous system
activation Intensity of pain indicates severity of injury or diseaseChronic persistent ( gt 3 months) - pain no longer
signals tissue damage Autonomic signs are often absent IASP website
Hix MD Pain Management in elderly patients Journal of pharmacy Practice 2049-63 2007
Mechanism of pain based on PathophysiologyNociceptive pain Results from stimulation of pain
receptors Somatic damage to body tissue well localized Visceral from viscera poorly localized may have
nauseaNeuropathic pain Results from dysfunctions or
lesions in either the central or peripheral nervous systems
Mixed pain syndromes multiple or unknown mechanisms (eg headaches vasculitic syndromes)
Psychogenic Pain somatoform disorders conversion reactions
NeurobiologyMyelinated A-delta and Unmyelinated C fibers
respond to thermal mechanical electrical or chemical stimuli
Release of excitatory neurotransmitter glutamate and substance P
Information transmitted to thalamus by spinothalamic tract
Pain modulation frontal cortex hypothalamus descending pathway endogenous analgesia by releases of beta-endorphin enkephalins opioid peptides
Age related changesReduction in number and function of peripheral
nociceptive neuronsSensory threshold for thermal and vibratory stimuli
increase with agePain receptors 50 decrease in Pacinis
corpuscles10-30 decrease in MeissnersMerkles disks
Diminished endogenous analgesic response (endorphins)
in the older patients
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesPeripheral nerves Myelinated nerves Decreased density Increase abnormaldegenerating fibers Slower conduction velocity Unmyelinated nerves Decreased number of large fibers (12-16 mm No change in small fibers (04 mm) Substance P content decreased
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesCentral nervous system Loss in dorsal horn neurons Altered endogenous inhibition hyperalgesia Loss of neurons in cortex midbrain brainstem 18 loss in thalamus Altered cerebral evoked responses Decreased catacholamines acetylcholine
GABA serotonin Endogenous opioids mixed changes Neuropeptides no change
Geriatric medicine An evidence based approach 4 th edition 2003
Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had
experienced pain in the past month that persisted for more than 24 hours
Almost three-fifths of adults 65 and older 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)
CDCprimes National Center for Health Statistics 2006
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Return to top
In 2000 42 of population gt65 and over reported long lasting disability
What is PainPain is an unpleasant sensory and emotional
experienceThe International Association for the Study of Pain
(IASP) defines pain in terms of both actual or potential tissue damage and the emotional experiences associated with pain
Acute Pain is often limited warns of tissue damage Often with signs of autonomic nervous system
activation Intensity of pain indicates severity of injury or diseaseChronic persistent ( gt 3 months) - pain no longer
signals tissue damage Autonomic signs are often absent IASP website
Hix MD Pain Management in elderly patients Journal of pharmacy Practice 2049-63 2007
Mechanism of pain based on PathophysiologyNociceptive pain Results from stimulation of pain
receptors Somatic damage to body tissue well localized Visceral from viscera poorly localized may have
nauseaNeuropathic pain Results from dysfunctions or
lesions in either the central or peripheral nervous systems
Mixed pain syndromes multiple or unknown mechanisms (eg headaches vasculitic syndromes)
Psychogenic Pain somatoform disorders conversion reactions
NeurobiologyMyelinated A-delta and Unmyelinated C fibers
respond to thermal mechanical electrical or chemical stimuli
Release of excitatory neurotransmitter glutamate and substance P
Information transmitted to thalamus by spinothalamic tract
Pain modulation frontal cortex hypothalamus descending pathway endogenous analgesia by releases of beta-endorphin enkephalins opioid peptides
Age related changesReduction in number and function of peripheral
nociceptive neuronsSensory threshold for thermal and vibratory stimuli
increase with agePain receptors 50 decrease in Pacinis
corpuscles10-30 decrease in MeissnersMerkles disks
Diminished endogenous analgesic response (endorphins)
in the older patients
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesPeripheral nerves Myelinated nerves Decreased density Increase abnormaldegenerating fibers Slower conduction velocity Unmyelinated nerves Decreased number of large fibers (12-16 mm No change in small fibers (04 mm) Substance P content decreased
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesCentral nervous system Loss in dorsal horn neurons Altered endogenous inhibition hyperalgesia Loss of neurons in cortex midbrain brainstem 18 loss in thalamus Altered cerebral evoked responses Decreased catacholamines acetylcholine
GABA serotonin Endogenous opioids mixed changes Neuropeptides no change
Geriatric medicine An evidence based approach 4 th edition 2003
Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had
experienced pain in the past month that persisted for more than 24 hours
Almost three-fifths of adults 65 and older 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)
CDCprimes National Center for Health Statistics 2006
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
What is PainPain is an unpleasant sensory and emotional
experienceThe International Association for the Study of Pain
(IASP) defines pain in terms of both actual or potential tissue damage and the emotional experiences associated with pain
Acute Pain is often limited warns of tissue damage Often with signs of autonomic nervous system
activation Intensity of pain indicates severity of injury or diseaseChronic persistent ( gt 3 months) - pain no longer
signals tissue damage Autonomic signs are often absent IASP website
Hix MD Pain Management in elderly patients Journal of pharmacy Practice 2049-63 2007
Mechanism of pain based on PathophysiologyNociceptive pain Results from stimulation of pain
receptors Somatic damage to body tissue well localized Visceral from viscera poorly localized may have
nauseaNeuropathic pain Results from dysfunctions or
lesions in either the central or peripheral nervous systems
Mixed pain syndromes multiple or unknown mechanisms (eg headaches vasculitic syndromes)
Psychogenic Pain somatoform disorders conversion reactions
NeurobiologyMyelinated A-delta and Unmyelinated C fibers
respond to thermal mechanical electrical or chemical stimuli
Release of excitatory neurotransmitter glutamate and substance P
Information transmitted to thalamus by spinothalamic tract
Pain modulation frontal cortex hypothalamus descending pathway endogenous analgesia by releases of beta-endorphin enkephalins opioid peptides
Age related changesReduction in number and function of peripheral
nociceptive neuronsSensory threshold for thermal and vibratory stimuli
increase with agePain receptors 50 decrease in Pacinis
corpuscles10-30 decrease in MeissnersMerkles disks
Diminished endogenous analgesic response (endorphins)
in the older patients
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesPeripheral nerves Myelinated nerves Decreased density Increase abnormaldegenerating fibers Slower conduction velocity Unmyelinated nerves Decreased number of large fibers (12-16 mm No change in small fibers (04 mm) Substance P content decreased
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesCentral nervous system Loss in dorsal horn neurons Altered endogenous inhibition hyperalgesia Loss of neurons in cortex midbrain brainstem 18 loss in thalamus Altered cerebral evoked responses Decreased catacholamines acetylcholine
GABA serotonin Endogenous opioids mixed changes Neuropeptides no change
Geriatric medicine An evidence based approach 4 th edition 2003
Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had
experienced pain in the past month that persisted for more than 24 hours
Almost three-fifths of adults 65 and older 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)
CDCprimes National Center for Health Statistics 2006
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Mechanism of pain based on PathophysiologyNociceptive pain Results from stimulation of pain
receptors Somatic damage to body tissue well localized Visceral from viscera poorly localized may have
nauseaNeuropathic pain Results from dysfunctions or
lesions in either the central or peripheral nervous systems
Mixed pain syndromes multiple or unknown mechanisms (eg headaches vasculitic syndromes)
Psychogenic Pain somatoform disorders conversion reactions
NeurobiologyMyelinated A-delta and Unmyelinated C fibers
respond to thermal mechanical electrical or chemical stimuli
Release of excitatory neurotransmitter glutamate and substance P
Information transmitted to thalamus by spinothalamic tract
Pain modulation frontal cortex hypothalamus descending pathway endogenous analgesia by releases of beta-endorphin enkephalins opioid peptides
Age related changesReduction in number and function of peripheral
nociceptive neuronsSensory threshold for thermal and vibratory stimuli
increase with agePain receptors 50 decrease in Pacinis
corpuscles10-30 decrease in MeissnersMerkles disks
Diminished endogenous analgesic response (endorphins)
in the older patients
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesPeripheral nerves Myelinated nerves Decreased density Increase abnormaldegenerating fibers Slower conduction velocity Unmyelinated nerves Decreased number of large fibers (12-16 mm No change in small fibers (04 mm) Substance P content decreased
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesCentral nervous system Loss in dorsal horn neurons Altered endogenous inhibition hyperalgesia Loss of neurons in cortex midbrain brainstem 18 loss in thalamus Altered cerebral evoked responses Decreased catacholamines acetylcholine
GABA serotonin Endogenous opioids mixed changes Neuropeptides no change
Geriatric medicine An evidence based approach 4 th edition 2003
Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had
experienced pain in the past month that persisted for more than 24 hours
Almost three-fifths of adults 65 and older 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)
CDCprimes National Center for Health Statistics 2006
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
NeurobiologyMyelinated A-delta and Unmyelinated C fibers
respond to thermal mechanical electrical or chemical stimuli
Release of excitatory neurotransmitter glutamate and substance P
Information transmitted to thalamus by spinothalamic tract
Pain modulation frontal cortex hypothalamus descending pathway endogenous analgesia by releases of beta-endorphin enkephalins opioid peptides
Age related changesReduction in number and function of peripheral
nociceptive neuronsSensory threshold for thermal and vibratory stimuli
increase with agePain receptors 50 decrease in Pacinis
corpuscles10-30 decrease in MeissnersMerkles disks
Diminished endogenous analgesic response (endorphins)
in the older patients
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesPeripheral nerves Myelinated nerves Decreased density Increase abnormaldegenerating fibers Slower conduction velocity Unmyelinated nerves Decreased number of large fibers (12-16 mm No change in small fibers (04 mm) Substance P content decreased
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesCentral nervous system Loss in dorsal horn neurons Altered endogenous inhibition hyperalgesia Loss of neurons in cortex midbrain brainstem 18 loss in thalamus Altered cerebral evoked responses Decreased catacholamines acetylcholine
GABA serotonin Endogenous opioids mixed changes Neuropeptides no change
Geriatric medicine An evidence based approach 4 th edition 2003
Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had
experienced pain in the past month that persisted for more than 24 hours
Almost three-fifths of adults 65 and older 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)
CDCprimes National Center for Health Statistics 2006
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Age related changesReduction in number and function of peripheral
nociceptive neuronsSensory threshold for thermal and vibratory stimuli
increase with agePain receptors 50 decrease in Pacinis
corpuscles10-30 decrease in MeissnersMerkles disks
Diminished endogenous analgesic response (endorphins)
in the older patients
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesPeripheral nerves Myelinated nerves Decreased density Increase abnormaldegenerating fibers Slower conduction velocity Unmyelinated nerves Decreased number of large fibers (12-16 mm No change in small fibers (04 mm) Substance P content decreased
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesCentral nervous system Loss in dorsal horn neurons Altered endogenous inhibition hyperalgesia Loss of neurons in cortex midbrain brainstem 18 loss in thalamus Altered cerebral evoked responses Decreased catacholamines acetylcholine
GABA serotonin Endogenous opioids mixed changes Neuropeptides no change
Geriatric medicine An evidence based approach 4 th edition 2003
Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had
experienced pain in the past month that persisted for more than 24 hours
Almost three-fifths of adults 65 and older 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)
CDCprimes National Center for Health Statistics 2006
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Age related changesPeripheral nerves Myelinated nerves Decreased density Increase abnormaldegenerating fibers Slower conduction velocity Unmyelinated nerves Decreased number of large fibers (12-16 mm No change in small fibers (04 mm) Substance P content decreased
Geriatric medicine An evidence based approach 4th edition 2003
Age related changesCentral nervous system Loss in dorsal horn neurons Altered endogenous inhibition hyperalgesia Loss of neurons in cortex midbrain brainstem 18 loss in thalamus Altered cerebral evoked responses Decreased catacholamines acetylcholine
GABA serotonin Endogenous opioids mixed changes Neuropeptides no change
Geriatric medicine An evidence based approach 4 th edition 2003
Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had
experienced pain in the past month that persisted for more than 24 hours
Almost three-fifths of adults 65 and older 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)
CDCprimes National Center for Health Statistics 2006
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Age related changesCentral nervous system Loss in dorsal horn neurons Altered endogenous inhibition hyperalgesia Loss of neurons in cortex midbrain brainstem 18 loss in thalamus Altered cerebral evoked responses Decreased catacholamines acetylcholine
GABA serotonin Endogenous opioids mixed changes Neuropeptides no change
Geriatric medicine An evidence based approach 4 th edition 2003
Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had
experienced pain in the past month that persisted for more than 24 hours
Almost three-fifths of adults 65 and older 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)
CDCprimes National Center for Health Statistics 2006
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had
experienced pain in the past month that persisted for more than 24 hours
Almost three-fifths of adults 65 and older 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)
CDCprimes National Center for Health Statistics 2006
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety
of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report
pain in 3 or more sites
AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med
123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home
health services A pathway Home health care management and practice 17294-3012005
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Factors affecting perception of painPain affects quality of life far beyond the local
region of injuryFeeling of loneliness is predictor of
psychological distressLack of intimate relationships dependency
and loss increase lonelinessLoneliness has been shown to lower pain
threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-
2012008
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Factors affecting the perception of pain Depression lack of energy avoidance of
diversional activities decreased engagement in treatment
Anxiety may inhibit participation in rehab efforts
Sleep disturbance pain is best predictor of sleep disturbance
Increased health care needs Isolation and reduced independence
Involvement with family and friends can provide pleasurable experience
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Factors affecting perception of painFocusing ones attention on pain makes the
pain worsePatients who have low levels of pain remember
it as being worse than they originally reportedPain can be a learned response rather than a
purely physical problemPsychosocial issues like patientrsquos belief about
their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and
caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers
perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001
Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Pain Assessment Unidimensional Scales A single item that
usually relates to pain intensity aloneAdvantages Easy to administer and require
little time or training to produce reasonably valid and reliable results
Disadvantages Some require vision hearing and attention pencil and paper
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
No pain
Slight pain
Mild pain
Severe pain
Moderate pain
Extreme pain
Pain as bad as it could be
(Herr and Mobily 1993)
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Pain AssessmentObtain history of painAsk about onset pattern duration location
intensity and characteristics of the pain Find out aggravating or palliating factors
and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family
involvement
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Pain Assessment ScalesMultidimensional scales evaluate pain in
multiple domains ( McGill Pain Questionnaire)
Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question
Disadvantage long time consuming and difficult to administer
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are
also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall
information from past
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia
(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score
more severe the pain
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans
groans cries)Facial grimacingBracing (clutching or holding onto furniture
equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo
Feldt K S Pain Manag Nurs 1(1)13-212000
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50
changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management
Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or
pharmacy an absence of high doses of opioids at the pharmacy
Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Patient related barriers to effective pain management Communication Patients with communication
problems with physician had worse pain control
Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms
Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of
decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing
enzymes Decreased serum protein concentrations Decreased pulmonary function
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which
higher doses do not provide greater pain relief
3) Maximum dose 4 gmday
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal
impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only
one currently available in US) Reduced gastrointestinal side-effects and
platelet inhibition
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic
effects and have been shown to relieve all types of pain
Elderly people compared to younger people may be more sensitive to the analgesic properties
Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
OpioidsMorphine Hepatic metabolism and renally excreted not
dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)
topical sublingual parenteral intrathecal epidural and rectal routes
High doses can lead to myoclonus and hyperalgesia
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs
and acetamenophen Available in long-tacting slow release form ndash OxyContin)
Methandone Blocks NMDA receptors inexpensive lacks active
metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several
days
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with
acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia
and neurotoxicity twofold higher risk of hip fractures
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
OpioidsAll oral opioids (except methadone) have a
duration of action of 3-4 hours with normal metabolism
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
OpioidsMeperidine (Demerol) Metabolized to active metabolite
normeperidine Lowers seizure threshold risk for falls
confusion sedation Should be AVOIDED as analgesic
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
OpioidsFentanyl Patch
100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue
TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake
15th as potent as morphine Lowers threshold for seizure and multiple
drug-grug interactions
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
OpioidsCan cause drowsiness nausea respiratory
depressionTolerance diminished effect of a drug associated
with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic
laxatives or stimulant laxatives)Dependency uncomfortable side effects when the
drug is withheld abruptly Drug dependence requires constant exposure to
the drug for at least several days
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Opioid AddictionAddiction drug use despite negative
physical and social consequences (harm to self and others) and the craving for effects other than pain relief
Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Non-opioid medications for painTricyclic antidepressants ( amytriptyline desipramine)
for neuropathic pain depression sleep disturbance Not used often due to side-effects
Duloxetine (Cymbalta ) is newer antidepressant FDA approved for neuropathic pain
Anticonvulsants ( gabapentin pregabalin carbamazepine) for neuropathic pain Carbamazepine can be used for
trigeminal neuralgia may cause pancytopeniaMuscle relaxants for muscle spasm monitor for sedation Local anesthetics (lidocaine patch topical voltaren gel
capsaicin) Capsaicin depletes substance P may take weeks to reach full effect adverse effects include burning and erythema Lidocain patch FDA approved for post herpetic neuralgia
Placebos unethical
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Non-opioid treatmentMassage reduces pain including release of
muscle tension improved circulation increased joint mobility and decreased anxiety
TENS unit Can be considered for diabetic neuropathy but not for chronic low back pain
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Non-drug treatmentEducation basic knowledge about pain (diagnosis
treatment complications and prognosis) other available treatment options and information about over-the-counter medications and self-help strategies
Exercise tailored for individual patient needs and lifestyle moderate-intensity exercise 30 min or more 3-4 times a week and continued indefinitely
Physical modalities (heat cold and massage) Cold for acute injuries in first 48 hours to
decrease bleeding or hematoma formation edema and chronic back pain Heat works well for relief of muscle aches and abdominal cramping
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Non-drug treatmentPhysical or occupational therapy should be
conducted by a trained therapistChiropractic Effective for acute back pain
Potential spinal cord or nerve root impingement should be ruled out before any spinal manipulation
Acupuncture Performed by qualified acupuncturist Effects may be short lived and require repetitive treatments
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Non-drug treatmentsRelaxation repetitive focus on sound sensation
muscle tension inattention towards intrusive thoughts Requires individual acceptance and substantial training
Meditation Guided or self-directed technique for calming the mind allows thoughts emotions and sensations to travel through conscious awareness without judgment
Progressive muscle relaxation Individual tensing and relaxing of certain muscle groups
Hypnosis effective analgesic state of inner absorption and focused attention Reduces pain by distraction altered pain perception increased pain threshold
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Non-drug treatmentCognitive-behavioral therapy Pain is influenced by
cognition affect and behavior Conducted by a trained therapist focuses on
changing individual cognitive activity to modify associated behavior thoughts and emotions
10-12 weekly individual or group sessions Participants have to be cognitively intactOperant behavior therapy Use of negative and
positive consequences to modify the behaviorsMind-body conditioning practices Yoga tai chi
qigong
Norelli L J etal Behavioral approaches to pain management in the elderly 24(2) Clinics in Geriatric Medicine 2008
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
Consequences of untreated pain Impaired function Pain can lead to decreased activity and ambulation
leading to de-conditioning gait disturbances and injuries from falls
Sleep deprivation decrease pain thresholds limit the amount of daytime energy increased risk of depression and mood disturbances
Increases financial and care giving burdens placed on families and friends by increased utilization of health care services
Diminished quality of life by isolating individuals from important social stimulation amplifying the functional and emotional losses already experienced from undertreated pain
Jakobsson U etal Old people in pain A comparative study Journal of Pain and Symptom Management 26 625-6362003 Weiner DK etal Pain in nursing home residents management strategies Drugs and Aging 18(1) 13-192001
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-
References Brucenthal P Assessment of pain in the elderly adult 24(2)
Clinics in Geriatric Medicine 2008 Bjoro K Herr K Assessment of pain in the nonverbal or
cognitively impaired Older adult 24(2) Clinics in Geriatric Medicine 2008
Fine P G Chronic pain management in older adultsspecial considerations J Pain Symptom Manage38S4-S142009
Reyes-Gibby C C etal Impact of pain on self-rated health in the community-dwelling older adults Pain 9575-822002
Improving pain management for older adults an urgent agenda for the educator investigator and practitioner Pain 972002
Landi F Onder G etal Pain management in frail community-living elderly patients Arch Intern Med 161 2721-27242001
- Slide 1
- Objective
- Demographics
- Slide 4
- What is Pain
- Mechanism of pain based on Pathophysiology
- Neurobiology
- Slide 9
- Age related changes
- Slide 11
- Slide 12
- Prevalence of pain in Elderly
- Prevalence of Pain in Elderly
- Factors affecting perception of pain
- Factors affecting the perception of pain
- Slide 17
- Challenges of pain assessment in older patients
- Pain Assessment
- Slide 20
- Slide 21
- Pain Assessment
- Pain Assessment Scales
- Slide 24
- Pain Assessment in Dementia
- Pain assessment in advanced dementia
- Pain assessment in nonverbal patients
- Barriers to Effective Pain Management
- Health care system barriers
- Patient related barriers to effective pain management
- Treatment
- Slide 32
- Slide 33
- Slide 34
- Slide 35
- Treatment with Opioids
- Opioids
- Slide 38
- Slide 39
- Slide 40
- Slide 41
- Slide 42
- Slide 43
- Opioid Addiction
- Non-opioid medications for pain
- Non-opioid treatment
- Non-drug treatment
- Slide 48
- Non-drug treatments
- Slide 50
- Consequences of untreated pain
- References
-