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7/25/2019 Pain in Older Patients.pptx
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PAIN IN THEOLDER
PERSONDr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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A national telephone-based survey in US:
lder adultsreported si!ilar prevalence ratesof current pain as their younger counterparts
"ersistent pain:
ver age #$ people are twice as li%ely asyoungercounterparts
y '$( adults are three ti!es !ore li%ely tohave than those under )' years of age
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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Aging alters functions(
Degeneration of peripheral neuronalstructure
Slows transduction &
trans!ission
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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nce pain is established*
the lower density of descendinginhibitory circuitsand an i!pairedability to recover fro! hyperalgesicor allodynic states is attributed toaging
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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+he decline in function of theendogenous
antinociceptive!echanis!s as well asthe capacity to reverse spinal andsupraspinal sensitization places olderpatients
at greater ris% for developingpersistent pain following an illness(surgery( or trau!a
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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"revalence of pain !ay be as high as,. to $. in co!!unity-dwellingolder persons and /. to '$. in
nursing ho!e residents
Many physicians and patientsincorrectly
view pain as an e0pected part of aging
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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1n presence of !ultiple co!orbidconditions(
and their !edical care ( 2ittle attention!ay be paid to the alleviation ofassociated sy!pto!s such as pain
"ain is unrecognizedandundertreated
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Signi3cant portion of those over age #do not receive analgesics:
over a 4uarterof older adults with cancer
pain(
/$. of elders with hip fracture in the5!ergency
Depart!ent/$. to '$. of elders living with pain in
the co!!unity
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Uncontrolled pain
6unctional status
"sychosocial well-being and 4uality of life
1!paired !obility
Decreased socialization
Depression
Sleep disturbances
1ncreased health use and costs(
7ait i!pair!ent ( falls("olyphar!acy
8ognitive dysfunction
Malnutrition
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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1t is ti!e to
Replace unrealistic fearsand!ista%en beliefs
7reatest opportunity for i!prove!entis:
9altingthe practices of usingplacebos
9alting reco!!ending treat!entssuch as aceta!inophen alone forsevere pain
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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8hange in "ain +hreshold and+olerance
5vidence supports an age-relatedincreasein thresholds to ther!al(pressure(
and electrical sti!ulation
1n advancing age( pain thresholdincreases while tolerance of paindecreases
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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8linical "resentation ofAcute "ain
1n older
adults pain !ay be absent or atypicalin acute infectious( !etabolic( ortrau!atic disorders
5g: Up to ;$. of older adults with M1report an absence of acute
sy!pto!scult to score at the bedside
nidimensional instruments
+hese tools ta%e less ti!e to ad!inister
andare !ore practical for use in various
clinical settings
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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"ain Assess!ent
in the 8ognitively1!paired
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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1n patients with !ild to !oderatecognitive i!pair!ent the "ain
+her!o!eterand the ?DSaregenerally reco!!ended for use
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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1n patients with severe cognitivei!pair!ent:
)-May be able to convey through @yesand @no answers to si!ple 4uestions
,-bservational indicatorsof pain
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6acial e0pressionis often the 3rstor!ost co!!onindication of pain( and1t !ay be the only one
+he !ost reliable behavior !ay relateto guardingduring e0a!ination orroutine activitiessuch as wal%ing(!orning care( and transfers
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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An atypical behavior in a patient withsevere
de!entia should trigger assess!entfor pain
6a!ily !e!bers( caregivers( andothers
who %now the patient well !ay provideuseful 4ualitativeinfor!ation
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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59A?1RA2 MA=165S+A+1=S 6"A1= 1= +95 87=1+1?52B 1M"A1R5D
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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"9ARMA82718+R5A+M5=+
6 "A1= 1=
2D5R "5RS=SDr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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Cith the e0ception of the rectal route(the rate of !edication absorption is
typically not aected by aging
less total body water( and !ore body
fat is seen in older adults
1ncrease distribution and
accu!ulation of lipophilic fentanyl
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
S f " d t S l ti d U f
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Safe "roduct Selection and Use ofpioids
0ycodone and !orphine are probablythe best 3rst-line opioid agents for anopioid na1ve patient with acute pain
9ydrocodoneis another reasonable3rstline
option* it is available only in 30ed-doseco!binations with aceta!inophen
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+ra!adol is co!!only chosen( but ithas low potency and an associationwith seizures
1n 5urope( buprenorphineis e!ergingas a potential 3rst-line opioid
+he transder!al buprenorphine patchis ideally suited for older adults( butnot e0ist in US
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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AD!"ANTS
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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A!itriptylineis the best studiedadJuvant for pain( but it shouldbeavoided in the elderly due to its
cardiac( anticholinergic( and sedativeeects
=ortriptyline or desipra!ine are better
choices with a K. lower incidenceof side eects at co!parable doses
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Dulo0etine( has approved labeling forcertain pains and appears to be abetter tolerated antidepressant for
older adults
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Antie#ile#tic dru$s are 3rst-lineagents to treat neuro#athic #aininolder persons
7abapentinandpregabalin havelabeled
indications for speci3c neuropathicpain disorders
Dosing should be initiated as low as
)$$ !g at bedti!eDr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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8arba!azepine also has UFSF 6DAapproved labeling for trige!inalneuralgia( but li%e !any older
antiepileptic agents( drug-druginteraction( liver( and he!atologicto0icity
!a%e the! less than ideal in olderadults
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
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when pain is co!ple0 and refractory toinitial
treat!ent atte!pt:
Additional co!ple!entary andalternative !edicine
Multidisciplinary pain treat!ent
progra!s are li%ely the !ost bene3cialin opti!izing
the outco!es
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