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Pain Assessment

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    Pain Assessment Pain Assessment Presentation Transcript

    • Pain Assessment & Management in Dementia
      • December 19, 2005
      • Tracy Marx, D.O.
      • Assistant Professor, Geriatric Medicine
      • OUCOM
      0
    • Definition of Pain
      • Pain is an “unpleasant sensory and emotional experience.”
      • Chronic pain is difficult to define but understood as persistent pain that is not amenable to routine pain control methods
      0
    • Pain Statistics
      • 75 million Americans live with “serious pain”
        • 50 million suffer from chronic pain
      • Many have lived with this more than 5 years and experience pain almost 6 days/wk
      • American Pain Society http://www.ampainsoc.org/ce/npc/ Pain: Current Understanding of Assessment, Management and Treatments, 7/2004
      0
    • Geriatric Statistics
      • Chronic pain is common in older adults
        • Arthritis, bone & joint disorders, many chronic conditions
        • 25 – 50% community adults suffer with chronic pain
        • 45 – 80% in nursing home substantial pain, undertreated
        • 1 in 5 older Americans taking analgesic medications regularly
      0
    • Common Causes of Chronic Pain
      • Back and neck pain
      • Myofascial pain/fibromyalgia
      • Headache
      • Arthritis pain
      • Neuropathic pain
      • From American Pain Society http:// www.ampainsoc.org/ce/npc / Pain: Current Understanding of Assessment, Management and Treatments, July 2004
      0
    • Painful Conditions in the Elderly
      • DJD
      • Rheumatoid arthritis
      • Fibromyalgia
      • Low back disorders
      • Arthropathies (gout)
      • Osteoporosis
      • Neuropathies
      • Pressure Ulcers
      • Amputations
      • Immobility, contractures
      • GI conditions (ulcers, ileus, gastritis)
      • Renal Conditions (kidney stones, bladder distension)
      • Headaches
      • Oral/dental pathology
      • Peripheral vascular disease
      • Post-stroke syndromes
      0
    • Older People with Pain Experience
      • Deconditioning
      • Gait disturbances
      • Falls
      • Slow rehabilitation
      • Multiple medication use
      • Cognitive impairment
      • Malnutrition
      • Ferrell, Ann Int. Med 1995; 123 (9): 681-687
      0
    • Consequences of Chronic Pain
      • Depression
      • Decreased socialization
      • Sleep disturbance
      • Impaired ambulation
      • Increased health care utilization and costs
      • Lavsky-Shulan et al, JAGS 1985; 33(1): 23-28
      0
    • Physician Barriers to Mgmt
      • Inadequate knowledge of pain management
      • Poor assessment of pain
      • Concern about regulation of controlled substances
      • Fear of patient addiction or misuse
      • Concern about side effects, tolerance
      • According to U. S. Dept. of Health & Human Services, Agency for Health Care Policy & Research
      0
    • Patient Barriers to Mgmt.
        • Older adults often expect pain with age
        • Use other words than “pain’ (aching, hurting, throbbing, “a misery”)
        • Fear need for diagnostic tests or medications that have side effects
        • For some, pain is a metaphor for serious disease or death
        • For others, pain and suffering represent atonement for past actions
      0
    • Barriers in LTC setting
      • Different response (may not show typical sx)
      • Cognitive and communication barriers
      • Cultural and social barriers
      • Co-existing illnesses and multiple meds
      • Staff training and access to appropriate tools
      • Practitioner limitations
      • System barriers
      0
    • Pain Assessment
      • Failure to assess pain is critical factor leading to under treatment
      • Should occur initially
      • Occur at regular intervals after initiation of treatment
      • At each new report of pain
      • At suitable interval after pharmacologic or nonpharmacologic intervention
      0
    • Initial Assessment
      • Detailed history
      • Physical examination
      • Psychosocial assessment
      • Diagnostic evaluation
      0
    • Detailed History
      • Goal is to characterize pain by location, intensity, and etiology
      • Listen to descriptive words about quality, location, radiation
      • Evaluate intensity or severity, aggravating factors (have patient keep a log)
      • Impact on activity, mood, mentation, sleep, functioning in daily activities
      0
    • Detailed History (cont’d)
      • Previous episodes, relation to physical or stress-related etiological factors
      • Previous diagnostics and findings
      • Previous treatment and its effects
      • Concurrent medical problems (cardiac, respiratory, anxiety, depression)
      0
    • Detailed History (cont’d)
      • What are the patient’s goals of pain control?
        • Some merely want an accurate diagnosis
        • Others want total pain relief
        • Most fall somewhere in the middle
      0
    • Categorize Type of Pain
      • Bone/Soft Tissue (Somatic) Pain
        • “ tender,” “deep,” “aching”
        • arthritis, myofascial pain, bony mets
      • Neuropathic Pain
        • “ shooting,” “burning,” “stabbing,” “scalding”
        • trigeminal neuralgia, diabetic neuropathy, post stroke, reflex sympathetic dystrophy
      • Visceral Pain
        • “ spasms,” “cramping”
        • bowel obstruction, adhesions
      0
    • Multiple Causes of Pain
      • Physical
      • Emotional
        • Anxiety, depression
      • Social
        • Isolation, abandonment, financial
      • Spiritual
        • Search for meaning/purpose, being punished
      0
    • Pain Assessment in Terminal Patients
      • 40-50% of cancer patients report moderate to severe pain (30% severe)
      • 80% more than one type of pain
      • At least 25% of all cancer patients die without adequate pain relief due to under treatment
      • Need aggressive assessment, treatment, and reassessment
      0
    • Pain Assessment in Cognitively Impaired
      • Can often verbalize how they feel at the moment
      • Pain can be just as severe – not able to communicate effectively
      • Often don’t receive adequate analgesics
      0
    • Pain Signs in Cognitively Impaired
      • Facial expressions
      • Verbalizations
      • Body Movement
      • Change in Interaction
      • Change in Activity or Routine
      • Mental Status Changes
      0
    • Pain Assessment Tools
      • completed by the patient
      • flexible enough to be adapted
      • simple enough to be used consistently over time
      • No one scale works for all patients
      0
    • Pain Assessment Tools
      • Verbal description
        • No pain---slight---mild---moderate---severe---extreme---worst pain ever
      • Rating Scale
        • 0-10 with 10 being worst pain ever experienced
        • 0-5 with 5 being worst pain
      • Faces
        • Have patient point to most accurate representation
      0
    • Pain and Longterm Care
      • “ in order to assist long-term care residents in improving their activities of daily living, decreasing pain is likely to yield the greatest overall improvements”
      • Cipher and Clifford, International Journal of Geriatric Psychiatry, 2004 Vol. 19: 741-748
      0
    • Severe Dementia
      • Found that facial expressions and vocalizations are accurate means for assessing the presence of pain, but NOT its intensity
      • Manfredi, Journal of Pain and Symptom Management, 2003; 25: 48-52
      0
    • Observation Assumptions
      • Facial characteristics, body posture, and movement patterns can indicate the presence of pain
      • Pain can interfere with ADLs such as dressing and eating
      • Caregivers can reliably observe and rate such behavior
      • Villanueva, JAMDA, J/F 2003; 4: 1-8
      0
    • Pain Assessment for the Dementing Elderly (PADE)
      • PADE Part I (selected items): Physical
        • “ Is the resident frowning? Restless?”
      • PADE Part II: Global Assessment
        • “ Place a mark on the line that you feel best represents the resident’s level of pain at the time of observation”
      • PADE Part III (selected items): Functional
        • “ During the hours that the resident has been awake, what percentage of time was the resident out of bed?”
      • Villanueva, JAMDA, J/F 2003; 4: 1-8
      0
    • Assessment of Chronic Pain
      • Any persistent or recurrent pain that has significant effect on function or quality of life should be recognized as a significant problem.
      • For those with cognitive or language impairments, nonverbal pain behavior, recent changes in function, and vocalizations suggest pain as possible cause. Interview caregiver for more information.
      0
    • Approach to Pain
      • Need accurate diagnosis
      • Review patient goals
      • Assess, treat, reassess, treat
      • If unsuccessful, review type of pain and history
      0
    • Pathophysiology of Nociceptive Pain
        • Somatic (well localized) or visceral (often referred) -- most often derived from stimulation of pain receptors
        • May arise from tissue inflammation, mechanical deformation, ongoing injury or destruction.
        • Examples include inflammatory or traumatic arthritis, myofascial pain syndromes, ischemic disorders
        • responds well to traditional pain meds
      0
    • Pathophysiology of Neuropathic Pain
        • involves central or peripheral nervous system
        • Often poorly localized, unusual
        • Examples: trigeminal neuralgia, post-herpetic neuralgia, phantom limb pain, reflex sympathetic dystrophy, poststroke
        • Poorly responsive to conventional analgesics; may respond to antidepressants, anticonvulsants, or antiarrhythmics
      0
    • Pathophysiology of Mixed Chronic Pain
        • Mixed or unknown mechanisms
        • Examples include recurrent headaches, vasculitic pain syndromes
        • Treatment often unpredictable, requiring various trials
      0
    • Pathophysiology of Psychogenic Pain
        • Psychological factors judged to have a major role in onset, severity, exacerbation, or persistence of pain
        • Examples include conversion reactions and somatoform disorders
        • Treatment consists of psychiatric referral and treatment
      0
    • Pharmacologic Treatment: General Principles
      • “ Start low and go slow”
      • Continuity of care
        • same physician if possible, utilize team approach (social worker, nurse, physical therapist)
      • Be proactive
        • treat pain and symptoms as they arise
        • Re-evaluate frequently
      0
    • Pharmacologic Treatment: General Principles
      • Regular dosing around the clock
      • Establish good relationship
        • patient as active, responsible participant
        • consider use of an opioid contract
      • Document, document, document
        • symptoms, signs, progression, side effects
        • consider second opinion
      0
    • Pharmacologic Treatment: General Principles
      • Whenever you establish a pain control program, also set up a bowel regimen to prevent constipation!!
      • Analgesic drugs should supplement other medications directed at definitive treatment of underlying disease
      0
    • WHO Ladder
      • 1. Mild
      • Aspirin
      • APAP
      • NSAIDs
      • +/- Adjuvants
      • 2. Moderate
      • Codeine
      • Hydrocodone
      • Oxycodone
      • Dihydroxycodone
      • Tramadol
      • +/- Adjuvants
      3. Severe Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone +/- Adjuvants   0
    • Stepwise Approach to Pain (WHO)
      • Treat “mild to moderate pain” initially with acetaminophen or NSAIDs
        • acetaminophen has ceiling dose (max 4g)
        • NSAIDs often with GI side effects
        • Consider salsalate (Disalcid) or trisalicylate (Trilisate) as options to NSAIDs, with less GI effect
      0
    • Stepwise Approach to Pain
      • Then progress to a mixed agent (acetaminophen or NSAID with codeine, oxycodone or hydrocodone) or oxycodone alone.
        • acetaminophen/propoxyphene (Darvocet) considered no more effective than acetaminophen
      • oxycodone SR (Oxycontin) long acting (12 hrs.) controlled release compound
      • oxycodone - short acting (4 hours)
      0
    • WHO Step 3 - Severe
      • morphine sulfate or a derivative
        • No ceiling dose
        • Long acting morphine sulfate such as MS Contin, Avinza, Kadian
        • Short acting preparations are available in tablets (MSIR), rectal suppositories or a highly concentrated sublingual from (Roxanol)
        • Fentanyl (Duragesic) is available in a transdermal prep that provides pain relief for 72 hours (takes 12 hours to reach a steady state)
        • AVOID meperidine (Demerol) and mixed agonist
      0
    • Approach to Pain
      • Fears of drug dependency and addiction do not justify the failure to relieve pain.
      • Monitor the side effect of opioid therapy (sedation, hypoxia, myoclonus, pruritus).
      0
    • Adjuvant Analgesics
      • may decrease total opioid needed
      • NSAIDs often used for musculoskeletal pain
        • soft tissue and bone involvement
        • limited due to side effects
      • Tricyclic antidepressants and SSRIs useful in neuropathic pain, insomnia, and depression
        • High doses of TCAs associated with side effects but often low doses are effective
      0
    • Adjuvant Analgesics
      • Anticonvulsants effective in neuropathic pain
        • gabapentin (Neurontin), carbamazepine (Tegretol)
        • start low and dose upwards
      • Corticosteroids used in terminal patients to help with bony metastases, increased intracranial pressure, abdominal distention or inflammatory disease
        • Use is limited due to long term side effects
      0
    • Nonpharmacologic Treatments
      • Alone or in combination with drugs
      • Many modalities exist such as:
        • Osteopathic manipulation
        • Physical therapy
        • TENS
        • Acupuncture
        • Massage
        • Exercise programs
        • Psychological counseling
      0
    • Nonpharmacologic Treatments
        • Biofeedback
        • Hypnosis
        • Relaxation therapy
        • Religious practice
        • Cognitive therapy
        • Herbal medicine
        • Homeopathy
      • Importance of patient education is paramount--giving patients knowledge gives them control.
      0
    • Nonpharmacologic Tx Results
      • Body has self regulatory and self healing abilities
      • Touch alone has been shown to reduce anxiety and pain
      • Postulated that retraining of nervous system to reestablish more neural connections through use of exercise and psychologic treatment can effectively diminish chronic pain
      0
    • Conclusions
      • Make an accurate diagnosis
      • If you’re not sure, consider trial of pain management
      • Review patient goals
      • Assess, treat, reassess, treat
      • If unsuccessful, review type of pain and history
      0