Pain in Long Term Care: It Takes a Team

Pain in Long Term Care:It Takes a Team

Department of Medicine, Anesthesiology & PsychiatryUniversity of Pittsburgh

Geriatric Research Education & Clinical Center VA Pittsburgh Healthcare System

Debra K. Weiner, M.D.

January 24, 2013

DISCLOSURE

• No conflict of interest

Learning Objectives

1. Understand the drivers of pain behaviors in long term care (LTC) residents.

2. Formulate an interdisciplinary approach to identifying, treating and tracking the LTC resident’s unique pain signature.

Principles of Pain in LTC

• Principle #1: Most pain that nursing home residents experience is chronic.

• Chronic pain:– Lasts beyond the expected time of healing– > 3-6 months

• Corollary: Since chronic pain cannot be eradicated, residents will continue to report/manifest pain even after it is treated well.

• 10 clinical trials, 2724 subjects• DPN, PHN, CLBP, FM, OA• “much improved” or “very much improved”

correlated with 30% or 2 point decrease

Who are we evaluating/treating?

Impaired reporters

Impaired non-reporters

Intact


• Principle #2: If a LTC resident can speak, (s)he can usually report pain reliably.

Pain Thermometer(verbal descriptor scale)

NO PAIN

LITTLE PAIN

MODERATE PAIN

QUITE BAD PAIN

VERY BAD PAIN

THE PAIN IS ALMOST UNBEARABLE

Weiner 1998; Aging Clin Exp Res 10: 411-20

Weiner 1998; Pain 76: 249-57

• N = 60 LTC residents• MMSE = 21 (6-30)• Test-retest: 1 hour• Kappa: 0.6-0.9

Pain Behaviors

• Pain reporting• Body posturing or facial expressions that

imply a patient is experiencing pain• Interactive behaviors

– Social behaviors– Cooperation with staff

Pain Behaviors: Those Unable to Report Pain

• Body posturing or facial expressions that imply a patient is experiencing pain

• Interactive behaviors– Social behaviors– Cooperation with staff

PAINAD (Pain Assessment in Advanced Dementia)

1. Breathing independent of vocalization2. Negative vocalization3. Facial expression4. Body language5. Consolability

0-10 scaleSummary score based on 5 items, 0-2 each

Warden 2003; J Am Med Dir Assoc 4: 9–15

PACSLAC(Pain Assessment Checklist for Seniors with

Limited Ability to Communicate)

• 60 items• 4 categories

– Facial Expression– Activity/Body Movement– Social/Personality/Mood– Other (Physiological Changes/Eating &

Sleeping Changes/Vocal Behavior)

Fuchs-Lacelle 2004; Pain Manage Nurs 5: 37-49


• Principle #3: Behavioral indicators of “pain” may or may not indicate that a patient is experiencing pain.

CLBP Pain-freeCognitively Intact 1 2

Mild-ModAlzheimer’s 3 4

Shega et al 2008; J Am Geriatr Soc 56: 1631-7

Long leg sit

Bridging

Lying Prone

Supine to sit

Weiner et al 1996; Pain 67: 461

Pain Behavior

Means (SD)Effect Size Univariate

PPain-free CLBP

Guarding 2.39(2.32)

3.83(2.84)

0.56 0.02

Bracing 4.78(5.29)

5.83(7.05)

0.17 0.42

Grimacing 1.02(1.48)

3.04(2.85)

0.93 <0.001

Sighing 0.54(0.89)

0.48(0.73)

0.07 0.77

Rubbing 0.72(1.54)

1.09(2.04)

0.21 0.32

Pain Behavior

Means (SD)Effect Size Univariate

PCog. Intact

Dementia

Guarding 2.00(2.28)

3.58(2.62)

0.65 0.01

Bracing 6.39(7.17)

4.10(4.47)

0.39 0.03

Grimacing 1.67(2.49)

1.71(2.04)

0.02 0.72

Sighing 0.39(0.80)

0.63(0.85)

0.29 0.20

Rubbing 0.03(0.18)

1.50(2.10)

1.29 <0.001


• Principle #4: The presence of pain should not be interpreted as the presence of suffering.

• Corollary: Treat pain if it is causing suffering (i.e., impairing function or quality of life).

Case

• ID/CC: 80 year old LTC resident who “reports pain.”

• HPI: Patient without complaintsNo pain behaviorsCall placed to LTC staff: “Patient does not

talk about pain or appear to suffer from pain…..Just reports when we ask.”

“Why was the consult placed?”“Resident continues to report pain.”“Is either he or the staff disturbed by this

reporting?”“No.”“Would the staff be comfortable with not

treating the resident as long as they know he is not suffering?”

“Yes.”

• Rx: Staff reassurance


• Principle #5: People with dementia process pain differently than those who are cognitively intact.

sensory-dis criminative(nociceptiv e channel)motivationa l-affectivecognitiveprocessesdescendingmodulatory influences+/-skin

musclejointsviscera spinal cord

sensory-discriminative(nociceptive channel)

motivational-affective

cognitiveprocessesdescending

modulatoryinfluences

+/- NE , 5-HT, glut,NMDA, GABA

skin

muscle

joints

viscera spinal cord

What is Pain?

PCPRPittsburgh Centerfor Pain Research

Slide used with permission from Gerald F. Gebhart, PhD, Director, PCPR

Pain-related brain activity: AD vs. controls

Cole et al 2006; Brain 129, 2957

Facial Expression versus Verbal Rating of Pain

• Experimental pain (mechanical)• N = 96 (42 demented; 54 intact)• Verbal rating: none, mild, moderate,

strong, very strong, extremely strong• Facial expression: video, rated with Facial

Action Coding System

Kunz 2007; Pain 133: 221-228

Kunz et al, Pain 2007; 133: 221-228

Kunz et al, Pain 2007; 133: 221-228

AD & Facial response to acute pain

General anxietyFear of needle sticksPre-venipuncture anxiety

Porter et al 1996; Pain 68, 413

IMPLICATIONS

• Standard behavioral manifestations of pain may overestimate pain severity in those with dementia

PAINBEHAVIORSe.g. verbal pain reports

grimacingcrying for help

General signalsof distress

Pain perseveration

Pain-related suffering

?

Case

• ID/CC: 82 y.o., LBP/R leg pain X 2 yrs., SS on MRI

• HPI: Forced to retire 2 years ago. Pain is worse with standing, walking, OK at night, better with heat, no constitutional symptoms. Increasing trouble with heavy housework, afraid to go on bus by self. Reports passive suicidal ideations. Frequent near falls at home.

• PE: – Poor balance– Impaired clock-drawing test– Kyphoscoliosis, SI/ paraspinal/ TFL pain– Leg strength impaired from pain.

Medications• Gabapentin• Oxycodone CR• Celecoxib• Tramadol• Olanzapine• Escitalopram• Lorazepam

What We Prescribed

• Short NH stay for detox. and balance/gait retraining.

• D/C’ed on tramadol + acetaminophen. • Did very well while in NH.• Recommendation to family: Assisted

Living placement, but family refused and continued to focus on pain

Following Discharge…

• Immediate deterioration at home with frequent calls

• Escalation of need for analgesics.• Her condition continued to deteriorate

(eventual morphine pump trial), until she was admitted to an assisted living facility, where she did well.

Case

• ID/CC: 85 y.o. veteran whose PCP notes, “Patient continues to report pain.”

• HPI: Obtained from wife of 60 years, as patient unable to provide history because of advanced dementia. Low back pain present for many years; as patient always acknowleged pain when asked by health care providers, analgesic trial ended with fentanyl.

• Because of no change in clinical status, dose was escalated to 100 mcg/hr and patient became comatose and was hospitalized.

• In hospital, dose was weaned back to 50 mcg/hr and patient woke up and when asked about pain, he reported it.

• Presented to Pain Clinic. When wife asked whether patient was suffering from or reporting pain: “He’s just talking about it.”

• PE: NAD, sitting in wheelchair with wife and daughter at side; pleasant, smiling. When asked if anything bothering him, he smiled widely: “No.”

• Rx: 1. Taper fentanyl to off; 2. Day care for distraction and caregiver respite.


• Principle #6: Chronic pain is a multifactorial syndrome requiring multi-pronged management that is designed to optimize function and quality of life.

The Pain Signature(cognitively intact)

Does pain affect your…

Not at all

A little Somewhat A lot As much as I can imagine

Energy XMood XAppetite XSleep XAbility to do daily chores

X

Ability to enjoy yourself

X

Ability to think clearly

X

Follow-UpDoes pain affect your…

Not at all

A little Somewhat A lot As much as I can imagine

Energy X X

Mood XAppetite X X

Sleep XAbility to do daily chores

X

Ability to enjoy yourself

X X

Ability to think clearly

X

Bad Poor Fair Good ExcellentEnergy X

Mood X

Appetite X

Sleep X

Cooperation with care

X

Ability to enjoy activities

X

Interaction with other residents

X

How to Evaluate Pain in LTC?

Tips on Behavioral Observation

1. Multiple observers2. Multiple disciplines3. Multiple times of the day (i.e., all 3 shifts)

BE CREATIVE.BE FACILITY-FOCUSED.UTILIZE THE INTERDISCIPLINARY TEAM.


• Principle #7: Treatment of pain in LTC residents should utilize a multidisciplinary stepped-care approach.

Prescription of Analgesia in the Nursing Home: A Stepped-Care Approach

STEP 1: NON-PHARMACOLOGIC MODALITIES

STEP 2: TOPICAL PREPARATIONS

STEP 3: LOCAL &MINIMALLY INVASIVE RX.

STEP 4: LOCAL &MORE INVASIVE RX.

STEP 5: SYSTEMICORAL ANALGESICS

ADJUNCTIVENON-PHARMACOLOGIC

MODALITIES


ADJUNCTIVENON-PHARMACOLOGIC

MODALITIES

Should treatment focus on pain or dementia-related behaviors or fear or……?

Painperseveration

Underminedementia

Falsely escalate pain severity &impact

DISTRACTION

FEAR

Activity Avoidance

Pain

ReassuranceSupportDesensitizationPATIENCE

Step 1: Non-Pharmacological Modalities

• Distraction (i.e., CBT)• Positive communication• Alleviation of fear• Gentle touch• Massage• Assistive devices

Non-Pharmacological (cont.)

• Behavioral approaches for the treatment of dementia-associated fear/agitation

• Address all sources of discomfort (positioning, toileting, treatment of other conditions causing suffering such as depression)

How effective is non-pharmacological treatment of pain in LTC?

Evidence – Study 1

• Randomized controlled trial • 9 LTC facilities• 89 intervention residents, 36 control• Agitation = Unmet Needs (loneliness/

depression, boredom, discomfort)• Unmet needs evaluated and customized

intervention developed• Loneliness/depression, boredom, discomfort

Cohen-Mansfield et al 2012; J Clin Psychiatry 73(9): 1255-61

Outcomes

• Significant reduction in agitation, both verbal and physical

Interventions Utilized (2 weeks)Simulated social 27.2%

One-on-one interaction 16.4%

Magazine/reading/book on tape 12.7%

Music 10.3%

Videos and television 6.3%

Physical activity 4.9%

Arts and crafts 4.6%

Worklike activities 4.3%

Sensory stimulation 2.7%

Care 2.6%

Puzzles and games 2.3%

Food or drink 1.8%

Sorting 1.6%

Group activity 1.5%

Other 0.7%

Evidence – Study 2

• PARTICIPANTS: 21 NH in Rhode Island• INTERVENTION: Multi-faceted intensive

intervention to improve pain management (education, coaching, rapid cycle QI, inter-NH collaboration)

Baier R, et al. J Am Geriatr Soc 2004; 52: 1988-1995

• OUTCOMES: Chart review, MDS• RESULTS: Significantly more pain

evaluations and non-pharmacological Rx, but not pain meds.

PAIN PREVALENCE DECREASED!


STEP 2: TOPICAL PREPARATIONS

• lidocaine• capsaicin• NSAIDs

HoPrescription of Analgesia in the Nursing Home: A Stepped-Care Approach

STEP 3: LOCAL &MINIMALLY INVASIVE RX.

• Trigger point injections

• Joint injections

HPrescription of Analgesia in the Nursing Home: A Stepped-Care Approach

STEP 4: LOCAL &MORE INVASIVE RX.

• Spine injections

• Hip/SI injections

STEP 5: SYSTEMIC ORAL ANALGESICS

How effective are they?

Evidence

• Cluster randomized clinical trial• 352 LTC residents, ½ intervention, ½

control• Intervention: stepped care pain rx X 8 wks

– acetaminophen, morphine, buprenor-phine transdermal patch, pregabalin

• Control: usual care

Husebo et al 2011; BMJ 343

Do these results reflect the impact of pain treatment or the rule of double-effect?

Pharmacodynamics

Site of action

Effects TREATMENT EXPECTANCY

Dementia: Impact on Pain Processing & Treatment Implications

Analgesic

Treatment Expectation

PAIN+

PAIN

Benedetti et al 2006; Pain 121: 133

Dementia and Expectancy

Benedetti et al 2006; Pain 121: 133

IMPLICATIONS

• Because of reduced treatment expectancy, patients with advanced dementia may require larger analgesic doses to achieve similar treatment outcomes.

• “Start low….Go slow….Keep going!”

Stepped-Care Oral Analgesics

Acetaminophen

Non-Acetylated Salicylates

Strong Opioids

Other NSAIDs, Weak Opioids

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (2012)

• Tertiary TCAs (anticholinergic)– amitriptyline– clomipramine– doxepin > 6mg/d– imipramine– trimipramine

• Meperidine (inefficacy, neurotoxicity)

• Non-COX-selective NSAIDs, oral (GI bleeding, PUD)– aspirin > 325 mg/d– diclofenac– diflunisal– etodolac– fenoprofen– ibuprofen– ketoprofen– meclofenamate– mefenamic acid

– meloxicam– nabumetone– naproxen– oxaprozin– piroxicam– sulindac– tolmetin

• indomethacin• ketorolac (+ parenteral)

• Pentazocine (CNS toxicity)• Skeletal muscle relaxants (anticholinergic,

sedation, fracture risk)– carisoprodol– chlorzoxazone– cyclobenzaprine– metaxalone– methocarbamol– orphenadrine

Pre-Emptive Analgesia

• Pre-medication prior to anticipated painful episodes (e.g., prior to care that requires movement of painful areas, physical therapy).

• Use in combination with strategies to alleviate dementia-associated fear when appropriate.

Non-NSAID

Drug Recommended Dose

Special Considerations

Acetaminophen 325-1000 mg q 4-6h;Maximum dose 3000-4000 mg

SafeAcute overdose of 10 gm can be fatal

Methadone Dosing ConversionDaily Oral Morphine Dose Equivalents

Conversion Ratio of Oral Morphine to Oral Methadone

< 100 mg 3:1101-300 mg 5:1301-600 mg 10:1601-800 mg 12:1801-1000 mg 15:1> 1000 mg 20:1

Opioids: Potential Side Effects• Gastrointestinal: Constipation, Nausea,

Vomiting• Cognitive: Delirium, sedation, agitation,

depression• Mobility: Falls, hip fractures• Respiratory: Sleep-disordered breathing

(sleep apnea, resp. depression)• Genitourinary: Urinary retention• Pain: Worsening

DRUG EFFECTS

PAINEFFECTS


• Principle #8: If a patient is not responding to treatment, take a step back and re-evaluate your treatment strategy.

• Corollary 1: Make sure that you are treating all contributors to impaired function and quality of life.

• Corollary 2: Re-evaluate drug effects and appropriateness.

Case

• ID: 86 yo female LTC resident with multiple sources of pain (recent hip fracture, stage III pressure sore, CLBP, depression)

• HPI: Following hip fracture hospitalization, resident became agitated and restless. Baseline behavior without agitation.

• Medications on discharge:– Propoxyphene prn– Tramadol prn– Hydrocodone/acetaminophen prn

• Post-discharge course:– All prn analgesics d/c’ed and fentanyl started

and titrated– Agitation continued until…


• Principle #9: Apply principles of rational drug prescribing to avoid excess polypharmacy

• Corollary: If one medication has dual effects, prescribe it.– e.g. gabapentin for anxiety and peripheral

neuropathy– duloxetine for fibromyalgia or peripheral

neuropathy and depression


• Principle #10: Myofascial pain should be assessed routinely in LTC residents with pain, and treated specifically when identified as a contributor to impaired function or quality of life.

Travell & Simons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, 1999

Epidemiology

• Majority of chronic pain patientsBorg-Stein 2006; Phys Med Rehabil Clin N Am 17: 491

• >95% of older adults with CLBPWeiner et al 2006; J Am Geriatr Soc 54: 11-20

• >30% of patients in general practiceSkootsky et al 1989; West J Med 151: 157-60

www.innertraditions.com

Myofascial Pain Treatment Perpetuating factors

• Leg length discrepancy• Hip/knee arthritis• Postural abnormalities• Axial spondylosis (neuropathic MP)• Psychological & environmental stressors

• Trigger point deactivation• Local twitch response

• Resilience building• Gentle stretching• Strengthening

Borg-Stein 2006; Phys Med Rehabil Clin N Am 17: 491 Cummings & White 2001; Arch Phys Med Rehab 82: 986

Neuropathic Myofascial Pain

Gunn CC 2001; Bonica’s Management of Pain, p. 522

NeurotrophicFactors

+/- PAINRx: Low dose gabapentin?(e.g. 300-600 mg qd-bid)

Summary

1. Chronic pain cannot be cured. Patients who are well treated will continue to report/manifest some pain.

2. Defining patient-centered pain treatment outcomes (the pain signature) is critical; treatment should focus on improving function and quality of life.

3. Interdisciplinary pain evaluation and treatment is the gold standard.

Documents

Pain in Long Term Care: It Takes a Team