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PAIN MANAGEMENT IN ELDERLY PERSONS. UCLA Multicampus Program of Geriatrics and Gerontology. Physicians Have a Moral Obligation to Provide Comfort and Pain Management Especialy for those near the end of life!. Pain is the most feared complication of illness - PowerPoint PPT Presentation
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PAIN MANAGEMENTIN ELDERLY PERSONS
UCLA Multicampus Program of Geriatrics and Gerontology
Physicians Have a Moral Obligation to Provide Comfort and Pain Management
Especialy for those near the end of life!
Pain is the most feared complication of illness Pain is the second leading complaint in
physicians’ offices Often under-diagnosed and under-treated Effects on mood, functional status, and quality
of life Associated with increased health service use
18% of Elderly PersonsTake Analgesic Medications Regularly
(daily or more than 3 times a week)
71 % take prescription analgesics– 63% for more than 6 months
72% take OTC analgesics– Median duration more than 5 years
26% report side-effects– 10% were hospitalized– 41% take medications for side-effects
ELDERLY PATIENTS TAKING PAIN MEDICATIONS FOR CHRONIC PAIN WHO
HAD SEEN A DOCTOR IN THE PAST YEAR
79% had seen a primary care physician 17% had seen a orthopedist 9% had seen a rheumatologist 6% had seen a neurologist 5% had seen a pain specialist 5% had seen a chiropractor 20% had seen more than 5 doctors
Common Causes of PainIn Elderly Persons
Osteoarthritis– back, knee, hip
Night-time leg cramps Claudication Neuropathies
– idiopathic, traumatic, diabetic, herpetic Cancer
MISCONCEPTIONS ABOUT PAIN
Myth: Pain is expected with aging.
Fact: Pain is not normal with aging.
PAIN THRESHOLD WITH AGING
Author Stimulus Threshold
Shumacher, 1940 Thermal No Change
Birren, 1950 Thermal No Change
Sherman, 1964 Electric/Tooth Higher
Collins, 1968 Electric/Skin Lower
Harkins, 1977 Electric/Tooth No Change
Tucker, 1989 Electric/Skin Higher
Age Related Differences in Sensory Receptor Function
Encapsulated end organs– 50% reduction in Pacini’s– 10-30% reduction Meissner’s/Merkels Disks
Free nerve endings– no age change
Age Related Differences inAge Related Differences inPeripheral Nerve FunctionPeripheral Nerve Function
Myelinated nervesMyelinated nerves Reduction in density (all sizes including small)Reduction in density (all sizes including small) Increase in abnormal/degenerating fibresIncrease in abnormal/degenerating fibres Decrease in action potential/slower conduction velocityDecrease in action potential/slower conduction velocity
Unmyelinated nervesUnmyelinated nerves Reduction in number (1.2-1.6un) not (.4un)Reduction in number (1.2-1.6un) not (.4un) Substance P, CGRP content decreasedSubstance P, CGRP content decreased Neurogenic inflammation reducedNeurogenic inflammation reduced
Age Related Differences inAge Related Differences inCentral Nervous System FunctionCentral Nervous System Function
Loss of dorsal horn spinal neuronsLoss of dorsal horn spinal neurons Altered endogenous inhibition, hyperalgesia.Altered endogenous inhibition, hyperalgesia.
Loss of neurons in cortex, midbrain, brain stemLoss of neurons in cortex, midbrain, brain stem (18% reduction in thalamus, no change cingulum (18% reduction in thalamus, no change cingulum
cortex)cortex) Altered cerebral evoked responses (increased latency, Altered cerebral evoked responses (increased latency,
reduced amplitude)reduced amplitude) Reduced catecholamines, acetylcholine, GABA, 5HT, Reduced catecholamines, acetylcholine, GABA, 5HT,
not neuropeptidesnot neuropeptides
MISCONCEPTIONS ABOUT PAIN
Myth: If they don’t complain, they don’t have pain
Fact: There are many reasons patients may be reluctant to complain, despite pain that significantly effects their functional status and mood.
REASONS PATIENTS MAY NOT REPORT PAIN
Fear of diagnostic tests Fear of medications Fear meaning of pain Perceive physicians and nurses too busy Complaining may effect quality of care Believe nothing can or will be done
The most reliable indicator of the existence pain and its intensity is the patient’s description.
There is a lot we can do to relieve pain!
Analgesic drugs Non-drug strategies Specialized pain
treatment centers Patient and caregiver
education and support
Analgesic Drugs Acetaminophen NSAIDs
– Non-selective COX inhibitors
– Selective COX-2 inhibitors
Opioids Others
– Antidepressants
– Anticonvulsants
– Substance P inhibitors
– NMDA inhibitors
– Others
CAUTION
Meperidine (Demerol)
Butorphanol (Stadol)
Pentazocine (Talwin)
Propoxiphene (Darvon)
Methadone (Dolophine)
Transderm Fentanyl (Duragesic)
Do Not Use Placebos!
Unethical in clinical practice They don’t work Not helpful in diagnosis Effect is short lived Destroys trust
Non-Drug Strategies Exercise
– PT, OT, stretching, strengthening
– general conditioning
Physical methods– ice, heat, massage
Cognitive-behavioral therapy
Chiropracty Acupuncture TENS Alternative therapies
– relaxation, imagery– herbals
PATIENT AND CAREGIVER EDUCATION
Diagnosis, prognosis, natural history of underlying disease
Communication and assessment of pain Explanation of drug strategies Management of potential side-effects Explanation of non-drug strategies