Pain In The Older Patient 20.6.05

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Pain In The Older Patient

Presented to the Care of the Elderly department, St Marys Hospital, London.

20th June 2005

Published in: Health & Medicine
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Pain In The Older Patient 20.6.05

  1. 1. Pain in the Older Patient. Dr. Christopher A. Jenner Consultant in Anaesthesia and Pain Medicine, SMH 20 th June 2005
  2. 2. Agenda <ul><li>Definition </li></ul><ul><li>Physiology </li></ul><ul><li>Acute </li></ul><ul><li>Chronic </li></ul><ul><li>Neuropathic </li></ul><ul><li>Differences </li></ul><ul><li>NSAID/ COX 2 controversy </li></ul>
  3. 3. Definitions <ul><li>Pain. ‘An unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of tissue damage, or both.’ (IASP 2001) </li></ul><ul><li>Time-course: acute/ chronic </li></ul><ul><li>Type: nociceptive/ neuropathic </li></ul>
  4. 4. Pain Physiology (boring)
  5. 5. Pain Physiology (funky)
  6. 7. Prevalence <ul><li>Acute pain </li></ul><ul><li>• SMH 13,213 operations p.a. (Nov 03-04, DSU 41%) </li></ul><ul><li>• SMH 484 operations p.m. (Sep 04, Main, 15% PCA/ epi) </li></ul><ul><li>• Chronic pain </li></ul><ul><li>• 7-14% UK population </li></ul><ul><li>• ‘ 1 in 7’ figure </li></ul>
  7. 8. The Challenges of Acute Pain <ul><li>• Primary Care </li></ul><ul><li>• ↑ healthcare utilisation </li></ul><ul><li>• Secondary Care </li></ul><ul><li>• ↑ length stay/ complications </li></ul><ul><li>• 10-15% post-op chronic pain (Macrae) </li></ul>
  8. 9. The Challenges of Chronic Pain <ul><li>Bio-psycho-social model </li></ul><ul><li>Individual and societal costs </li></ul><ul><li>Biological- pain/ suffering/ disability </li></ul><ul><li>Psychological- anxiety/ depression </li></ul><ul><li>Social- work/ relationship/ family/ benefits </li></ul>
  9. 10. Acute Pain Management <ul><li>Non-pharmacological </li></ul><ul><li>• RICE </li></ul><ul><li>Pharmacological </li></ul><ul><li>• WHO ladder (amended from cancer) </li></ul><ul><li>Step 1 paracetamol/ NSAID/ COX 2 </li></ul><ul><li>Step 2 + weak opioids </li></ul><ul><li>Step 3 + strong opioids </li></ul>
  10. 11. Massive Financial Burden <ul><li>NHS/ DWP/ tax-payers </li></ul><ul><li>• Lower back pain (CSAG 1994) </li></ul><ul><li>• NHS £481 million </li></ul><ul><li>• The Exchequer £1.4 billion </li></ul>
  11. 12. Chronic Pain Management <ul><li>Non-pharmacological </li></ul><ul><li>• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR </li></ul><ul><li>• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage </li></ul><ul><li>• Alternative- acupuncture </li></ul>
  12. 13. Headache!
  13. 14. 5. (a) Veterinary practitioners?
  14. 15. Chronic Pain Management <ul><li>• Nerve block techniques: </li></ul><ul><li>epidurals </li></ul><ul><li>facets </li></ul><ul><li>tenoperiostial </li></ul><ul><li>ON </li></ul><ul><li>SSN </li></ul><ul><li>Occipital N </li></ul><ul><li>Ilioinguinal </li></ul>
  15. 20. Chronic Pain Management <ul><li>• Nerve stimulation- </li></ul><ul><li>spinal cord stimulation </li></ul><ul><li>peripheral nerve stimulation </li></ul><ul><li>• Pumps- </li></ul><ul><li>Intrathecal pump delivery systems </li></ul>
  16. 21. Chronic Pain Management <ul><li>Pharmacological </li></ul><ul><li>• WHO analgesic ladder (abridged) </li></ul><ul><li>• + tramadol </li></ul><ul><li>• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD </li></ul><ul><li>• (New: sufentanyl TDD/ product X ) </li></ul>
  17. 24. Neuropathic Pain Management <ul><li>Non-pharmacological </li></ul><ul><li>• Nerve blockade- lumbar sympathectomy/ stellate/ guanethidine </li></ul>
  18. 25. Neuropathic Pain Management <ul><li>Antidepressants- Amitryptilline </li></ul><ul><li>Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate </li></ul><ul><li>Opiods </li></ul><ul><li>Local Anaesthetics- Lignocaine/ EMLA </li></ul><ul><li>NMDA antagonists </li></ul><ul><li>Sympatholytics </li></ul><ul><li>GABA ergics </li></ul><ul><li>Capsaicin </li></ul>
  19. 26. Future Agents in Neuropathic Pain <ul><li>Ziconotide (sea snail, conus magnus) </li></ul><ul><li>P2X3- (purine) receptor antagonists (ATP) (knockout mice) </li></ul><ul><li>Epibatidine (Equadorian poison dart frog) </li></ul><ul><li>Morphine and ketamine </li></ul><ul><li>Regular gabapentin </li></ul><ul><li>Dexmetomidine </li></ul>
  20. 27. Differences <ul><li>‘ Intense pain which interferes with functioning is not a normal part of ageing and should never be accepted as such.’ Textbook of Pain. Melzack and Wall 1984 </li></ul>
  21. 28. Physiological Differences <ul><li>↑ pain threshold/ tolerance </li></ul><ul><li>↓ discrim. to suprathreshold noxious </li></ul><ul><li>CVS- ↑ ihd/ ↓ compliance/ ↓ CO/ ↓ bf organs/ HT/ DVT </li></ul><ul><li>RS- ↑ close capacity/ ↓ response hypercapnia/ hypoxia/ ↑ atelectasis/ ↑ chest infections </li></ul>
  22. 29. Physiological Differences <ul><li>Metabolic- ↓ BMR/ ↓ renal function/ ↓ rbf/ dehydration/ heat loss </li></ul><ul><li>CNS- cerebrovascular disease/ confusion (hypoxia/ drugs/ hospital/ illness)/ ↓ hearing n memory </li></ul><ul><li>↑ systemic disease </li></ul><ul><li>Biological age versus Chronological age </li></ul>
  23. 30. Pharmacological Differences <ul><li>↓ TBW so ↑ proportion body wt. fat </li></ul><ul><li>↑ sensitivity many drugs esp. CNS depressants </li></ul><ul><li>↓ plasma proteins- binding/ ↑ free unbound </li></ul><ul><li>↑ t ½ many drugs </li></ul><ul><li>↑ multiple drug treatments (Bdz n LBP patient) </li></ul><ul><li>Start low, go slow! </li></ul>
  24. 31. Psychological Differences <ul><li>Stoical </li></ul><ul><li>Afraid of diagnosis </li></ul><ul><li>Take me home/ kept in </li></ul><ul><li>Not seen as capable </li></ul><ul><li>Adverse effects </li></ul><ul><li>Concern over drugs- newspaper cuttings </li></ul>
  25. 32. Clinical Differences <ul><li>Less reporting </li></ul><ul><li>↓ post-op </li></ul><ul><li>undertreated </li></ul><ul><li>MDT </li></ul><ul><li>non-pharmacological </li></ul><ul><li>Pain- the 5 th vital sign! </li></ul>
  26. 33. Clinical Differences <ul><li>Beware- no complaints/ pain on movement or resisting movement/ lying quietly/ ask, don’t assume/ pain scores/ friends and relatives/ prejudices </li></ul>
  27. 34. The NSAID/ COX 2 controversy
  28. 35. The NSAID/ COX 2 controversy <ul><li>COX 1/ 2/ 3 </li></ul><ul><li>Asthma/ GI/ renal/ platelets/ bone healing </li></ul>
  29. 36. The NSAID/ COX 2 controversy <ul><li>VIGOR ( Vioxx- Rofecoxib)- ↑ CVS/ change labelling </li></ul><ul><li>APPROVE (Vioxx)- Colonic polyps/ 18/12 ↑ CVS ↑ stroke </li></ul><ul><li>23/12/04 FDA warning- celecoxib/ valdecoxib/ naproxen </li></ul><ul><li>7/4/04 FDA Pfizer Valdecoxib withdrawal/ celecoxib box warning </li></ul>
  30. 37. The NSAID/ COX 2 controversy <ul><li>4/05 FDA </li></ul><ul><li>‘ Long-term controlled clinical trials have not been conducted on most NSAIDs. However, available data suggests that use of COX 2 may increase cardiovascular risk. Difficult to draw conclusions about relative cardiovascular risk of COX 2 and NSAIDs with the data available.’ </li></ul>
  31. 38. The NSAID/ COX 2 controversy <ul><li>FDA- no rank for valdecoxib/ rofecoxib/ celecoxib </li></ul><ul><li>BMJ 2005; 330; 1366 ↑ MI </li></ul>521 diclofenac 695 rofecoxib 1005 ibuprofen NNH
  32. 39. The NSAID/ COX 2 controversy <ul><li>S/T L/T- risk- benefit </li></ul>
  33. 40. The Future?
  34. 41. The Future? <ul><li>Demographics </li></ul><ul><li>• Healthcare advances </li></ul><ul><li>• ↑ Patient expectations and involvement </li></ul>
  35. 42. Summary <ul><li>Very common </li></ul><ul><li>Time course- acute n chronic </li></ul><ul><li>Nociceptive and neuropathic </li></ul><ul><li>Differences </li></ul><ul><li>Start low, go slow! </li></ul><ul><li>NSAID/ COX2 controversy </li></ul>
  36. 43. <ul><li>Any Questions </li></ul>

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