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MANAGEMENT OF CHRONIC PAIN IN OLDER ADULTS

LEANNE R. CIANFRINI, PHD

Clinical Psychologist

Program Director

The Doleys Clinic

OVERVIEW OF TOPICS

We’ll discuss:

• How important effective pain management is for older

adults

• Unique physiological and psychosocial factors that

influence chronic pain perception and response to

treatment modalities in older adults

• Practical methods for assessing and managing pain

• Nonpharmacological

• Pharmacological

• Guidelines

THE PREVALENCE AND NATURE OF PAIN IN OLDER ADULTS (1 OF 2)

• High prevalence of pain in general American

population

• As much as 50% of the older adult population

report chronic pain.

• Studies show up to 80% of nursing home residents

have clinically significant pain.

• Older adults more likely to be affected by joint

pain and other forms of musculoskeletal pain.

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Diseases associated with chronic pain in later life, by system or specialty

• Dermatology — pressure or ischemic ulcers, burns, scleroderma

• Gastrointestinal — constipation, diverticulitis, IBD

• Cardiovascular — advanced heart disease, peripheral vascular disease

• Pulmonary — advanced COPD, pleurisy

• Rheumatology — OA, RA, gout, polymyalgia rheumatica, spinal stenosis

and other low back syndromes, myofascial syndromes, osteoporotic

related fractures

• Endocrine — diabetic neuropathy

• Nephrology — chronic cystitis, end stage renal disease

• Immune — herpes zoster, post-herpetic neuralgia, HIV/AIDs

neuropathy

• Neurology — headache, peripheral neuropathies, compressive

neuropathies, radiculopathies, Parkinson’s disease, post-stroke pain

• Oncology — cancer

• Miscellaneous — depression, tendonitis, bursitis

THE PREVALENCE AND NATURE OF PAIN IN OLDER ADULTS (2 OF 2)

•We have an aging population.

•Pain is still under-recognized and under-treated

in older adults.

WHY IS THIS IMPORTANT?

• Undertreated pain is associated with:• Sleep disturbance

• Functional decline

• Risks associated with polypharmacy

• Malnutrition

• Prolonged hospital stay

• Challenging behaviors

• Cognitive decline

• Increased healthcare utilization

• Lawsuits

• Impact on family

• Impact on society

“I must die. But must I die groaning?” -- Epictetus, 135 AD

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CHRONIC PAIN BASICS (1 OF 3)

DEFINITIONS:

• IASP: “An unpleasant sensory and emotional experience…”

• McCaffery: “Whatever the experiencing person says it is, existing whenever the experiencing person says it does.” --SUBJECTIVE

• A disease in its own right.Chapman, Tuckett, Song. J Pain, 2008; 9 (2): 122-45

ACUTE VS. CHRONIC

• Acute pain: Makes sense to focus on location, sensory aspects for rehabilitation purposes

• Chronic pain: Danger of too much focus on peripheral “generators”

CHRONIC PAIN BASICS (2 OF 3)

Sensory-Discriminative

Cognitive-Evaluative

Affective-Motivational

Sensory-Discriminative

Cognitive-Evaluative

Affective-Motivational

WHO ‘GETS’ THE DISEASE OF CHRONIC PAIN?

From Birth• Genetics, female sex, ethnicity,

congenital disorders, prematurity• Parental anxiety, irregular feeding and

sleeping• Parents’ pain exposure and reactions• Temperament and personality

Childhood• Physical/sexual abuse and other

traumatic events• Low SES• Emotional, conduct, and peer

problems• Hyperactivity

Adolescence• Changes of puberty, gender roles• Educational level, learning

(behavioral reactions to pain)• Injuries• Obesity• Low fitness levels

Adulthood• Vivid recall of childhood trauma• Lack of social support; accum. stress• Surgery• Overuse of joints and muscles• Occupational exposures, job

dissatisfaction, low work status• Development of chronic disease• Aging

Relieving Pain in America. Institute of Medicine. National Academic Press. Washington, D.C. 2011

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Woolf C. Ann Intern Med. 2004;140:441-451.

Central Pain Amplification

Abnormal pain processing by CNS

(ie, Fibromyalgia)

Nociceptive Pain

Noxious stimuli

(ie, Burn)

Inflammatory Pain

Inflammation

(ie, Rheumatoid arthritis)

Neuropathic Pain

Neuronal damage

(ie, Herpes zoster)

CHRONIC PAIN BASICS (3 OF 3)

CONSIDER A “MECHANISTIC-BASED” APPROACH TO PAIN ASSESSMENT AND TREATMENT

Neuroanatomy of Nociception

AGE-RELATED CHANGES IN PAIN PROCESSING AND PRESENTATION

• Pain modulatory imbalance• Bio:

• Systemic inflammation (increased “inflamm-aging”)• Changes in structure of peripheral nerves that transmit pain

signals• Studies of pain threshold

• Brain structure and function changes (reduction in gray matter in certain regions of the brain)

• Psychosocial: • Cope with pain differently? E.g., under-reporting• Present with more behavioral expressions• Late life depression in OA (risk factor)• Social (isolation is more likely)

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ASSESSMENT

“TO HEAR ABOUT PAIN IS TO HAVE DOUBT;

TO EXPERIENCE PAIN IS TO HAVE CERTAINTY”.

-ELAINE SCARRY, THE BODY IN PAIN: THE MAKING AND UNMAKING OF THE WORLD

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IS PAIN PRESENT?

• Ask about the presence of pain in regular and frequent

intervals:• Upon admission

• During periodic scheduled assessments

• Whenever a change occurs in patient’s condition

• Considerations:

• Simply ask the patient!

• Myth – pain is a normal part of aging

• Assume pain if patient has conditions or procedures that are

typically painful

• Involve family, staff

• In nonverbal patients, may need to use observation – at rest and

during activity (e.g., repositioning)

BEHAVIORAL OBSERVATIONSINDICATIVE OF CHRONIC PAIN

• Facial expressions: grimacing, fearful expression, grinding of teeth

• Vocalizations: crying, moaning, groaning, sighing, breathing heavily

• Body movements: bracing, guarding, rubbing

• Change in movement: rigid posture, limping, resistance to motion during care, fidgeting/restlessness

• Change in interpersonal interactions: combative, resistant, withdrawm

• Change in mental status: confusion, irritability, agitation, crying

• Change in usual activity: refusing food/appetite change, increased wandering, change in sleep habits Loss of function

OBSERVATIONAL PAIN TOOLS

• 2006 BMC Geriatrics systematic review

• Compared psychometric qualities and criteria

for 12 observational tools

• Concluded that PACSLAC & DOLOPLUS2 most

appropriate scales

• The APS recommends ABBEY or PAINAD.

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PAIN CHARACTERISTICS

• Pain Intensity: VAS, NRS, Facial Pain Scales, Pain Thermometer

• Location: pain map

• Explore different descriptive words, such as “aching,” “burning,” “stabbing”

• Distinguishes muscular, nerve, inflammatory pain and can guide treatment

• E.g., McGill Pain Questionnaire

• Basic sensory questions:• Please tell me all of the places you experience pain or discomfort.

What does it feel like? What words come to mind?

• Is your pain or discomfort with you all of the time or does it come and go? How long has it been present? What makes it better, what makes it worse?

Faces Pain Scale

Horizontal Visual Analogue Scale

Iowa Pain Thermometer McGill Pain Questionnaire

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DETERMINE CAUSES OF PAIN

• Physical exam

• Musculoskeletal, neurologic

• Performance-based measures

• Rule out: Is it something as basic as toileting needs?

• Laboratory, radiologic, and other diagnostic tests as appropriate

• Can be overused, does not “prove” presence or absence of pain

• Consultation if needed

BIOPSYCHOSOCIAL PERSPECTIVE –EFFECT ON FUNCTIONING

• Functional impact:• Has pain affected your ability to do every day activities?

To do things you enjoy?

• How about relating with others? If so, how?

• Emotional impact:• Has pain affected your mood, sense of wellbeing, energy

level?

• Are you worried about your pain or what may be causing

it?

• Consider PHQ9 or PHQ2

• Other psychosocial factors:• History of mood disorders or mental illness?• History of addiction?• Family involvement?

• Is there anyone at home or in the community that you can turn to for help and support when your pain is really bad?

• Does patient act differently around family members?

• Do family members seem insistent on a particular treatment?

BIOPSYCHOSOCIAL PERSPECTIVE –PSYCHOSOCIAL HISTORY

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• Attitudes and beliefs• Do you have any thoughts or opinions about experiencing pain at this point in

your life that you believe would be important for me to know?

• Do you have any thoughts or opinions about specific pain treatments that you

believe would be important for me to know?

• Coping styles• What things do you do to help you cope with your pain? This could be listening

to your favorite music, praying, sitting still, or isolating yourself from others

• Treatment expectations and goals• What do you think is likely to happen with the treatment I have recommended?

• What are the most important things you hope will happen as a result of the

treatment?

BIOPSYCHOSOCIAL PERSPECTIVE –OTHER QUESTIONS

TREATMENT

“If we know that pain and suffering can be alleviated, and we do nothing about it, then

we ourselves become the tormentors.”

- Primo Levi

MULTIMODAL APPROACHTO PAIN MANAGEMENT

Treatment Approaches

Pharmacotherapy Physical Therapy

Complementaryand Alternative

Medicine

Psychological Support

Exercise

Interventional

Approaches

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NON-PHARMACOLOGICAL: INTERVENTIONAL TECHNIQUES

Degenerative conditions precipitating spinal stenosis, herniated discs, foraminal stenosis, compression fractures, or degenerative joint disease

• Spinal surgical techniques

• Kyphoplasty

• Epidural steroids

• Facet joint injections

• Cortisone injections

• Trigger point injections

• Radiofrequency ablation

NON-PHARMACOLOGICAL: PHYSICAL AND CBT TECHNIQUES

Physical Modalities:• Heat & cold, TENS, massage

• Moderate exercise – active vs. passive

• Occupational therapy

Cognitive-Behavioral Approaches:• Self-management (e.g., moderation/modification, pacing)

• Biofeedback, relaxation

• Setting realistic expectations

Other general health strategies:• Anti-inflammatory diet, bowel health, and weight management

• Sleep hygiene

• Increasing social engagement

WHO 3-STEP ANALGESIC LADDER

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GENERAL PHARMACOLOGIC CONSIDERATIONS

• Tailor to type of pain

• Does benefit outweigh the risk?• All meds have risk (not just opioids)

• Medications must be monitored closely to avoid over- or under-medicating

• What are goals?• Disease management• Quality of life• Improve or maintain functional status• Comfort near end of life

SPECIAL PHARMACOLOGIC CONSIDERATIONS FOR OLDER ADULTS

(1 OF 3)

• Older adults are at increased risk for adverse drug reactions

• Pharmacokinetics vs. pharmacodynamics

• Drug-Drug interactions -- Polypharmacy

• Drug-Disease interactions

• Drug-Food and Drug-Herb interactions

• Smaller body size/different body composition

SPECIAL PHARMACOLOGIC CONSIDERATIONS FOR OLDER ADULTS

(2 OF 3)

• Increased risk for adverse drug reactions (continued)

• Increased sensitivity to anticholingeric effects

• Decreased blood-pressure maintaining ability

• Decreased temperature compensation

• Inadequate testing of drugs in older adults before FDA approval

• Problems with vision, hearing or memory

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• Decreased ability of the

kidneys to clear drugs

out of the body

• Decreased ability of the

liver to process drugs

• Decreased liver mass and

variable blood flow

• Metabolism through the

Cytochrome P450 system

decreases with age

SPECIAL PHARMACOLOGIC CONSIDERATIONS FOR OLDER ADULTS

(3 OF 3)

RENAL CHANGES IN OLDER ADULTS

HEPATIC CHANGES IN OLDER ADULTS

MEDICATIONS TO AVOID

• Meperidine (Demerol)

• Ketorolac (Toradol)

• Mixed agonist-antagonists like Talwin (pentazocine-naloxone)

• Tramadol

• Caution with muscle relaxants, amitriptyline, NSAIDs

• Products containing diphenhydramine (e.g., Tylenol PM)

Check the Beers criteria

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NON-OPIOID MEDICATION OPTIONS

• Acetaminophen

• NSAIDs • Use judiciously due to increased risk of GI bleeding and

renal toxic side effects; not for chronic, prolonged use

• Cox-2 inhibitors • Celebrex contraindicated in pts with sulfa sensitivity

• Topicals• OTC vs. RX/compounded

For neuropathic pain: • Anticonvulsants• Antidepressants (SSRIs > SNRIs)

OPIOID BASICS

• Bind to one or more of the mu, kappa, delta mu receptors (in periphery, DRG, PAG, midbrain, gut)

• Long-acting/extended-release vs. short-acting/immediate-release

• Need for continuous vs. intermittent dosing• “Breakthrough” vs. incident pain

• MEDD

• Risk stratification

• Route of administration (e.g., IV, transdermal, PO)

• Dependence vs. Addiction

• START LOW AND GO SLOW

OPIOID OPTIONS

• Codeine

• Tramadol

• Tapentadol

• Hydrocodone

• Morphine

• Buprenorphine

• Oxycodone

• Hydromorphone

• Fentanyl

• Oxymorphone

• Methadone

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SIDE EFFECTS OF OPIOIDS

• Constipation• Never resolves

• Prevent with scheduled softeners plus stimulants

• Avoid bulking agents (eg, Metamucil) (dehydration + fiber = worse)

• Nausea and vomiting

• Sedation and delirium

• Respiratory depression (unintentional overdose)

• Concomitant use of opioids/benzos

• Prone to respiratory issues (COPD, sleep apnea, URIs)

• Others: endocrine dysfunction with long-term use; dry mouth

(avoid anticholinergics); urinary retention; fall risk; immune

system suppression

AT FACILITIES: INVEST IN THE SYSTEM AND THE INDIVIDUAL (1 OF 2)

• Arrange presentations on Nature of Pain, Evaluation

Tools, and Treatment Modalities

• Arrange easily accessible printed materials for review

and use

• Assign a “point person” or expert in Pain Management

who can consult/assist as needed on challenging cases

• Provide and seek prompt feedback for specific cases,

and overall progress

AT FACILITIES: INVEST IN THE SYSTEM AND THE INDIVIDUAL (2 OF 2)

• Evaluation of systemic approach ongoing

• What tools are cumbersome/not working

• Is inter-team communication working?

• Is documentation adequate?

• Evaluation of Personal Approach as well…

• Knowledge Deficits

• Past Personal Experience vs. “Expert” Opinion

• Personal Biases re: Pain

• Fear of Negative Consequences

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OTHER RESOURCES

• 2009 AGS Panel on Pharmacological

Management of Persistent Pain in Older Persons

• Summary in handouts

• JAGS AUGUST 2009–VOL. 57, NO. 8

• PAINAD

• Example in handouts

THANK YOU

QUESTIONS?