Pain Assessment & Management in Dementia

December 19, 2005

Tracy Marx, D.O.Assistant Professor, Geriatric

MedicineOUCOM

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

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

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

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

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

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

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

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

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

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

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

Initial Assessment

Detailed history Physical examination Psychosocial assessment Diagnostic evaluation

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

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)

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

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

Multiple Causes of Pain

Physical Emotional

Anxiety, depression Social

Isolation, abandonment, financial Spiritual

Search for meaning/purpose, being punished

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

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

Pain Signs in Cognitively Impaired

Facial expressions Verbalizations Body Movement Change in Interaction Change in Activity or Routine Mental Status Changes

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

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

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

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

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

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

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.

Approach to Pain

Need accurate diagnosis Review patient goals Assess, treat, reassess, treat If unsuccessful, review type of

pain and history

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

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

Pathophysiology of Mixed Chronic Pain

Mixed or unknown mechanisms Examples include recurrent

headaches, vasculitic pain syndromes

Treatment often unpredictable, requiring various trials

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

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

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

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

WHO Ladder

1. Mild AspirinAPAPNSAIDs+/-

Adjuvants

2. ModerateCodeineHydrocodoneOxycodoneDihydroxycodon

eTramadol+/- Adjuvants

3. SevereMorphineHydromorpho

neMethadoneLevorphanolFentanylOxycodone+/- Adjuvants

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

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)

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

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).

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

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

Nonpharmacologic Treatments Alone or in combination with drugs Many modalities exist such as:

Osteopathic manipulation Physical therapy TENS Acupuncture Massage Exercise programs Psychological counseling

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.

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

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