1. Managing pain in the older person
Linda Nazarko
Consultant Nurse London North West
Healthcare NHS Trust
22nd
September 2015

2. Aims and objectives
To be aware of:
 The prevalence of pain in older people
 Types of pain experienced
 How to determine treatment options
 How to assess pain in older people
 The effects of aging and comorbidities
 Drug interactions
 How to work with the older person to
identify and manage side effects
 How to improve concordance

3. What is pain?
 “An unpleasant
sensory or emotional
experience
associated with actual
or potential tissue
damage or described
in terms of such
damage”
 (IASP, 1994)

4. Prevalence
 Increases with
age
 Affects 53% older
people
 Affects ability,
mobility, mood,
sleep, quality of
life

5. Musculoskeletal Pain
 “Pain perceived within a
region of the body, and
believed to arise from the
muscles, ligaments, bones,
or joints” (IASP, 2009).
 Tender, aching, stiff,
throbbing
 Causes include:
Fibromyalgia, gout,
osteoarthritis, rheumatoid
arthritis, tendinitis

6. Neuropathic pain
 “Pain arising as a direct consequence
of a lesion or disease affecting the
somatosensory system either at
peripheral or central level” (Haanpää
et al, 2011).
 Shooting and burning, tingling &
numbness, stabbing, electric shock
like.
 Alcoholism,amputation, back, leg, &
hip problems, chemotherapy,
diabetes, facial nerve problems,HIV
infection or AIDS, Multiple sclerosis,
shingles, spinal surgery

7. Visceral: Pain arising from internal organs
 “True visceral pain’ arises as a diffuse
and poorly defined sensation usually
perceived in the midline of the body, at
the lower sternum or upper
abdomen”( Procacci et al, 1986).
 Poorly localised, nonspecific regional
or whole-body motor responses, strong
autonomic & affective responses.
 Appendicitis, bowel obstruction, cancer
pain, dysmenorrhea, indigestion,
irritable bowel syndrome, renal colic,
urinary retention

8. Differentiating neuropathic & muscle
pain
(Nazarko, 2014)

9. Determining treatment options
Be aware that not everyone likes to complain
Be alert to non verbal signs
Enquire about pain
Detailed clinical assessment of causes, types
Be alert to sensory & cognitive impairment

10. Eyesight
 20% of people aged over 75 and
50% of people aged 90 and over
have sight loss (Access
Economics, 2009). Be as visible
as possible
 Ensure lighting is good
 Some older people with impaired
hearing lip read so ensure they
can see your face and mouth
 Be receptive

11. Hearing
More than 70% of over 70
year-olds and 40% of over 50
year-olds have some form of
hearing loss (Action on Hearing Loss, 2011)
Minimise noise, be visible,
don’t cover your mouth
Speak clearly and slow down
slightly
Check that you have been
understood

12. Dementia
 Be aware that the incidence of
dementia rises with age and
around 25% of 85 year olds and
50% of 90 year olds have
dementia (Knapp & Prince, 2007).
 Ensure that you have picked a
time when the person is
receptive.
 Take account of any cognitive or
sensory difficulties

13. The value of nursing
"Nursing is rooted from the needs of humanity
and is founded on the ideal of service. And
that, “the nurse is temporarily the
consciousness of the unconscious, the
love of life for the suicidal, the leg of the
amputee, the eyes of the newly blind, a
means of locomotion for the infant,
knowledge and confidence for the mother
and the mouthpiece for those too weak or
withdrawn to speak”

14. “Only when I move” syndrome
 Be aware of the need to
check that even though
the person doesn’t have
pain now they might have
when they are active.

15. “Ten” syndrome
 This is when a person
consistently rates pain at
10 even though staff
observe that it seems to
vary.

16. “Mustn’t grumble” syndrome
 Be aware of those
who don’t like to
complain or who fear
side effects of
analgesia

17. Use the right tools
 Pictures, body maps, Abbey pain scale
 Evaluate regularly

18. Age related chages
 Age related changes cause reduced ability to absorb and
excrete drugs (Wooten, 2012: Miller, 2007: Miller, 2000: Nguyen & Goldfarb, 2012: Esposito et al,
2007: Mühlberg & Platt, 1999).
 >Gastrointestinal motility and >gastro-intestinal blood flow
 Changes in distribution of drugs due to > in muscle mass
& < in fat
 > ability to metabolise drugs due to > hepatic blood flow &
liver mass
 Reduced ability to excrete drugs due to decline in renal
function
 Changes at molecular level that alter receptor binding and
may < or > sensitivity to particular classes of drugs.

19. Comorbidities
 Cardiac failure- 12-13% over 75s
 CKD -33% over 75s
 Gastro-intestinal disease, peptic ulcers, oesophageal
varices, diverticular disease
 Asthma- 10% over 65s
 Dysphagia – 11% upwards
 Dementia 25% at 85 and 50% at 90

20. How comorbidities affect treatment
 Cardiac failure -NSAIDs > oedema, worsen
failure – contraindicated
 Renal failure- NSAIDS nephrotoxic, opiates
and codeine with great caution
 Dysphagia- soluble meds > Na, BP and
stroke risk
 Dementia, tramadol, codeine, opiates, > falls
risk
 Depression – anti-depressants + tramadol =
seratonin syndrome

21. Drug interactions
 Remember falls risk
 “Sedatives, analgesics and anti-
depressants dangerous
 Opiods double risk injurious falls
 Non opiods can > risk by 15-75%
 Tramadol and anti-depressants
 High doses, small people, > metabolism

23. Concordance
 40% non concordant
why?
 Side effects
 Worried addition
 Difficulty swallowing
 Forgetting to take
 Unsure of then to take
 How many pills
prepared to take

24. Identify and manage side effects
 Explain possible side
effects
 Discuss, be partners and
negotiate
 Work out if its worth
managing side effects or
changing tack
 Have a dialogue

25. Treating pain
1. “By mouth":
2. “By the Clock”
3. “Around the clock
4. "By the Ladder":
5. For the individual

26. Treating pain

27. Codeine metabolism
 CYP2D6 responsible codeine
metabolism
 Genetic differences, slow and fast
metabolisers
 Ineffective in slow metabolisers
 Fast metabolisers at risk of toxicity
Be alert to differences and use clinical
judgement to guide treatment.

28. Prevalence rates of CYP2D6
polymorphisms by ethnicity
Ethnicity Slow metabolisers Ultra-fast metabolisers
Western European 8–10% 1–4%
Southern European 7–10%
African 0–20% 5–30%
Eastern Asian 0–1%
Arabian Up to 20%

29. Tramadol
 Tramadol centrally acting synthetic analgesic
compound (EMC, 2014).
 Tramadol 100 mg = paracetamol & codeine (1000
mg/60 mg) (Kaye, 2004).
 Risk factor post operative delirium (Künig et al,
2006)
 Increases falls risk X10 )Costa-Dias et al,2014)
 Increased risk falls, #, mortality (Gogol et al, 2014)
Use tramadol with extreme caution in older
people.

30. NSAIDS
 17 million NSAID prescriptions are
issued in the UK each year
 Can improve quality of life but treatment
can be risky
 Co-prescription of NSAIDs, diuretics
and ACE inhibitors = > renal perfusion<
renal dysfunction

31. NSAIDS (2)
 Worsen heart failure contraindicated
severe failure
 Contraindicated asthma
 Increased risk heart attack, heart failure
 Nephrotoxic
 Naproxen lower cardiac risk, higher
bleeding risk
 Use NSAIDS only after careful
evaluation of individual risk

32. Opiates
 Hazardous in older people
 Increased risk toxicity due to renal and
hepatic changes
 Start at doses 25-50% lower than in
younger adults
Monitor with great care

33. Last words
 Assess to work out
what the problems
are and how to treat
 Its not a pill for every
ill
 Therapy and non
drug options
 Sometimes a poodle
is better than a pain
killer

34. Thank you for listening
Any questions?