Pain in the Elderly presentation

1. Pain in the Elderly
Prof. Chit Soe
Dr. Cho Mar Lwin
Ward 1&2 , YGH
18-10-2013
Myanmar Society for the Study of Pain
Training of Trainers on Development of Pain
Management in Myanmar

2. Pain
An unpleasant sensory & emotional
experience derived from sensory stimuli,
modified by individual memory, expectations
and emotions
Pain Management in elderly patients, Journal of pharmacy Practice, 20:49-63, 2007
2

3. Pain is common for older people
 1 in 5 elderly have pain
• 3 in 5 adults > 65 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)
18.10.13 Pain-Elderly 3
CDC′s National Center for Health Statistics 2006,

4. Common Causes of Pain
In Elderly Persons
• Osteoarthritis
– back, knee, hip
• Night-time leg cramps
• Claudication
• Neuropathies
– idiopathic, traumatic, diabetic,
herpetic
• Cancer
4

5. Pain in the Elderly
Sources of pain in the nursing home
Condition causing pain Frequency (%)
Low back pain 40
Arthritis 37
Previous fractures 14
Neuropathies 11
Leg cramps 9
Claudication 8
Headache 6
Generalized pain 3
Neoplasm: 3
18.10.13 Pain-Elderly 5
Stein et al, Clinics in Geriatric Medicine: 1996

6. Magnitude of the problem
• 71% take prescription analgesics
– 63% for more than 6 months
• 72% take OTC analgesics
– Median duration more than 5 years
• 26% report side-effects
– 10% were hospitalized
– 41% take medications for side-effects
6

7. Pain is undertreated
• 18-24% of bereaved family members believe
pain was undertreated
– Less if in hospice (18%)
– More if in home health (43%) or nursing home
(32%)
• 41% of cancer patients undertreated
– Primary risk factor age > 70
7
Hanson JAGS 45: 1339, Teno JAMA 291: 88, Cleeland NEJM 390: 592

8. Pain in the Elderly
Consequences of untreated pain:
• Depression
• Suffering
• Sleep disturbance
• Behavioral disturbance
• Anorexia, weight loss
• Deconditioning, increased falls
18.10.13 Pain-Elderly 8

9. 27.2.04 9 Pain
Considered as vital sign
• After a crisis, controlling vital signs include
– Blood pressure
– Heart rate
– Respiratory rate
– Temperature
– Pain !! (5th Vital sign)

10. Barriers – Patient / Family Attitudes
• Pain is normal when you are old
• Value stoicism, “being strong”
• Fear of addiction
• Problems communicating pain
– Unable to talk
– Confusion/ dementia
10

11. Barriers – provider attitudes
• Pain is normal when you are old
• Older patients feel less pain
• Legal risks of using opioids
• Failure to recognize chronic persistent pain
• Older patients can’t tolerate pain medications
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12. Acute Behaviours
• An elderly with acute pain may be
– Crying
– Guarding
– Grimacing and moaning
– High BP, pulse
– Restless or extremely still
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13. Chronic Behaviours
• An elderly with chronic pain
– May not express pain by telling you
– Express pain with depressed mood, withdrawal
– Have no abnormal vital signs
– Come to expect and endure pain
13

14. Assess
• 67 -83% of elderly with dementia are able to use
at least one scale
• Words are easier than numbers
• Ask in the present – “Are you in pain now?
• Ask in several ways – “Discomfort”
• Give time to respond
• Changes in behavior – Just not herself – passive,
withdrawn, agitated, restless, not eating
14Ferrell BA JPSM 10: 591, Herr KA Clin J Pain 14: 29, Krulewitch H JAGS 48: 1607

15. Assessment overview
1. Complete history and physical examination, focus on pain issues
2. Review of location of pain, intensity, exacerbating and/or
alleviating factors, and impact on mood and sleep
3. Screen for cognitive impairment (eg MMSE)
4. Screen for depression
5. Review of the patient’s ADLs (bathing, dressing, toileting,
transfers, feeding, and continence) and instrumental ADLs (use
of phone, travel, shopping, food preparation, housework,
laundry, taking medicine, handling finances)
6. Assessment of gait and balance
7. Screen for sensory depression to examine basic visual and
auditory function 15

16. 16

17. The most reliable
indicator of the
existence pain and
its intensity is the
patient’s
description.
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18. Total Pain
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19. Pain Treatment
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20. Physiological
Changes and
Altered
Pharmacology
Cognitive
Impairment
and
Compliance
Perception
of Pain
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Challenges in the
Management of
Pain in the Elderly

21. Geriatric Pharmacology
• Absorption – no change
• Distribution – larger VD for lipophilic (benzos,
trazodone) ; smaller VD hydrophilic (eg.
Morphine)
• Metabolism – decreased hepatic blood flow
• Clearance – decreased RBF and Cr Cl; slower
clearance
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22. Before medication
• Test baseline mental status
• Know baseline renal function
• Know concurrent chronic illnesses
– Hepatic function
– Hydration status
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23. Renal Disease
• AVOID NSAIDs
• Reduce tramadol doses
• Hydromorphone, methadone, oxycodone,
fentanyl somewhat better tolerated
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24. Analgesic Drugs
• Acetaminophen
• NSAID's
– Non-selective COX inhibitors
– Selective COX-2 inhibitors
• Opioids
• Others
– Antidepressants
– Anticonvulsants
– Substance P inhibitors
– NMDA inhibitors
– Others
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25. WHO 3-step Ladder
1 mild
2 moderate
3 severe
Morphine
Hydromorphone
Methadone
Fentanyl
Oxycodone
± Adjuvants
Codeine
Oxycodone
± Adjuvants
Acetaminophen
NSAIDs
± Adjuvants Adjuvant Therapy: Anticonvulsants,
Antidepressants, Corticosteroids, Dermal
analgesics, Muscle relaxants, Stimulants
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26. Opioids and delirium
• Cohort study of n=541 hip fracture patients;
16% delirious
– Dementia greatest risk factor for delirium
– <10 mg morphine per day increased risk of
delirium
• Opioids cause delirium; however so dose
untreated pain
26Morrison RS J Geron 58A: 76

27. Musculoskeletal Pain
• Osteoporosis, fracture
– Several studies show pain reduction with
calcitonin
– Vit D deficiency causes diffuse pain; replacement
improves this symptom
• Osteoarthritis
– Scheduled acetaminophen; tramadol; short
courses of steroids or NSIDS; injections; low
potency opioids
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28. Non – medication Treatments
Use for every elder in pain
• Soft lighting, decreased noise, or added distractions
• Massage
• Warm or cold packs
• Repositioning
• Exercise
• Emotional and spiritual support
• Meditation
• Music
• Hypnosis
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29. Treatment Pearls
• Non-medication treatments
• Scheduled med if
– Pain is daily
– Patient is cognitively impaired
• Opioids – longer interval (+/- lower dose)
• Combine low doses of different classes of
medication
• Bowel medications
• Know hepatic, renal function, mental status
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30. Communication tips
Patient and Caregiver Education
• Discuss pain care plan with patient, family
• Diagnosis, prognosis, natural history of underlying disease
• Communication and assessment of pain
• Explanation of drug strategies
• Management of potential side-effects
• Explanation of non-drug strategies
Health care workers
• Communicate pain care plan to other involved health care
providers – nurses, physiotherapists etc.
• Ask pharmacists for help
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31. Reasons Patients May Not Report Pain
• Fear of diagnostic tests
• Fear of medications
• Fear meaning of pain
• Cultural cues misread by patient and/or providers
• Communications and misinterpretations
• Cannot adequate describe “pain” or discomfort
• Perceive physicians, nurses, health providers too busy
• Complaining may effect quality of care
• Believe nothing can or will be done
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32. 27.2.04 32 Pain
AIMS of Management are to:
• Educate the patient
• Control pain
• Optimize function
• Beneficially modify the disease process
• Look at the social environment and
create best support

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