Pain Management in Pain Management in Geriatric MedicineGeriatric Medicine

Smith, Howard. Clinics in Geriatric Medicine, May 2008; Vol 24, Smith, Howard. Clinics in Geriatric Medicine, May 2008; Vol 24, No.2; 1549 - 1556No.2; 1549 - 1556

Zachary LapaquetteZachary LapaquettePharmD CandidatePharmD Candidate

University of GeorgiaUniversity of Georgia

Background

❖ In 2000, 65-and-older population comprised 35 million people, 12.4% of U.S. population

❖ Beginning in 2011, the first members of the Baby Boom will reach 65

❖ By 2050, 79 million Americans will be age 65 or older, 20% of the projected population

Background

❖ 73.5% of population over 65 reported pain in 3 month period

❖ Significant correlation between loneliness and psychologic distress/pain

❖ Older persons with pain are almost twice as likely to have sleep disturbances as older persons without pain

Overview

❖ Pain assessment in the non-verbal patient

❖ Pharmacotherapy of pain in older patient

❖ Special consideration and evaluation of older patient with pain

Assessment of Pain in the Nonverbal or

Cognitively Impaired Older AdultBjoro, K, Herr, K. Clin Geriatr Med, 24 (2008)237-262

Source: http://www.artexpertswebsite.com/pages/artists/novelli.php

Background

❖ Pain is a highly subjective experience

❖ Self-report is gold standard of pain assessment

❖ Loss of ability to communicate can occur with several states:

❖ Dementias

❖ Delirium

❖ State of unconsciousness

❖ Severe depression

❖ Psychosis

❖ Mental disability

Pain Assessment

❖ 5 key principles of pain assessment in nonverbal populations:

1. Obtain self-report

2. Investigate possible pathologies

3. Observe behavior

4. Solicit surrogate report

5. Use analgesic trial

1. Self-Report

❖ Even “yes”/ “no” response is helpful

❖ Simple test to assess reliability:

❖ Patient provides number from 0 to 3 and a word to describe pain. After 1 minute of distracting conversation, patient is asked to provide same number and word.

2. Pathologies

❖ Concept that pain can be assumed and treated due to certain disease states

❖ Musculoskeletal, neurologic disorders, etc.

❖ Pain should be prophylactically treated before undergoing any procedure

3. Pain-Associated Behaviors

❖ Inherently subjective, it relies on observed behaviors

❖ Changes in vital signs are not reliable as indicators of pain

❖ Observations of behaviors should occur during movement or activity that is likely to elicit a pain response if pain is present

❖ Serial observations should be performed under similar circumstances to ensure objectivity

3. Pain-Associated Behaviors

BehaviorBehavior ExamplesExamples

Facial expression Frown, grimacing, distorted expression

VerbalizationsGroaning, calling out, noisy breathing,

verbal abusiveness

Body movementsTense body posture, guarding, fidgeting,

increased pacing, rocking, gait or mobility changes

Interpersonal interactions

Aggressive, combative, decreased social interactions, socially inappropriate

Activity patternsRefusing food, appetite changes, sleep, sudden cessation of common routines

Mental status changes

Crying, increased confusion, irritability or distress

4. Surrogate Reporters

❖ Family and care-givers (e.g. nurses’s assistant) of patient are more sensitive to patient behaviors

❖ Training of care-givers is important to safeguard reliability of behavioral observation

❖ Raters should compare observations with each other

5. Analgesia Trial

❖ Trial of patients with dementia receiving 3g/day of acetaminophen showed greater social activity v. placebo

❖ 2.6g/day trial unsuccessful

❖ Analgesic trial method has not been appropriately studied, but is promising approach

Dementia and Pain

❖ Alzheimer’s disease and vascular dementia patients experience language disturbance and mutism in late stages of disease

❖ Frontotemporal dementia and primary progressive aphasia show earlier onset

❖ It’s been determined that patients with dementia experience greater incidence of pain

Dementia and Pain

❖ Subtype of dementia impacts pain response:

❖ In frontotemporal dementia, a decrease in affective pain response has been documented

❖ In vascular dementia and AD, an increase in affective response is reported

Delirium and Pain

❖ Delirium is a transient cognitive impairment characterized by fluctuating awareness and change in cognition or perceptual disturbance, in the presence of underlying illness

❖ Considerable overlap between delirium and pain-associated behaviors

❖ Consider analgesic trial

Critical Illness

❖ Patients tend to experience constant baseline aching pain with intermittent sharp, stinging pain due to procedures

❖ Identification of pain in ICU is complex

❖ Sixty-two percent of older patients in ICU experience delirium

Pharmacotherapy of Pain in Older Adults

Strassels, McNicol, Suleman. Clin Geriatr Med, 24 (2008)275-298

Source: http://www.archives.gov.on.ca/english/on-line-exhibits/connon/pics/11585_port_elderly_man_520.jpg

Geriatric Considerations

❖ Pharmacokinetic changes:

❖ e.g. absorption, distribution, fat composition, renal function

❖ Pharmacodynamic changes:

❖ e.g. decrease in Mu opioid receptors, sensitivity to anti-cholinergics

Salicylates

❖ Substantially higher doses needed for anti-inflammatory activity than for antiplatelet, antipyretic and analgesic effects

❖ Excreted renally

❖ A/E’s include GI irritation and bleeding. Do not use in patients with h/o gastric or peptic ulcers

ASA, diflunisal, magnesium salicylate, salsalate

Acetaminophen

❖ Inhibits central PG synthesis

❖ No clinically significant reductions in inflammation or A/E’s on gastric mucosa or platelet function

❖ Metabolized via several pathways in liver

❖ Overdose forces metabolism via N-hydroxylation pathway NAPQI

❖ Use caution in patients with liver disease, malnutrition. Max dose: 4g/day

NSAIDs

❖ Inhibit central PG synthesis via cyclooxygenase inhibition

❖ COX 1 selective - ASA, ketoprofen, indomethacin, piroxicam

❖ Slightly COX 2 selective - etodalac, nabumetone and meloxicam

❖ COX 2-selective - Celecoxib

❖ A/E’s include nausea, vomiting, bleeding, nephro- and hepatotoxicity

❖ Ketoralac and celecoxib thought to have less GI bleeding

❖ Causes increased levels of other highly protein-bound drugs - warfarin, methotrexate, digoxin, cyclosporine, anticonvulsants

Ibuprofen, naproxen, ketoralac, diclofenac, naproxenindomethacin, ketoprofen, nabumetone, meloxicam

Opioids

❖ Classified according to affected receptor:

❖ Mu-receptor agonists generally produce analgesia, affect numerous body systems and have addictive characteristics

❖ Kappa agonists have less respiratory depression and miosis, but can cause dysphoria

❖ Delta agonists are still in Stage I experimentation, with potential uses in depression

Opioids

Mu-agonistsMu-agonists

Alfentanil, codeine, hydrocodone, hydromorphone, fentanyl, levorphanol,

meperidine, methadone, morphine, opium, oxycodone, oxymorphone, remifentanil,

sufentanil, tramadol

Kappa-agonists/Kappa-agonists/mu-antagonistsmu-antagonists

Butorphanol, nalbuphine, pentazocine

Mu-antagonistsMu-antagonists Nalmefene, naloxone, naltrexone

Mu partial-agonist/Mu partial-agonist/kappa-antagonistskappa-antagonists

Buprenorphine

Opioids❖ Adverse effects:

❖ Respiratory depression - can reverse with naloxone

❖ Nausea and vomiting - recommend non-drowsy medications

❖ Constipation - stool softener + stimulant laxative

❖ Increased bladder spasms and increased sphincter tone

❖ Itching - switch opioid agent or use less-sedating anti-histamine

Opioids

❖ Failure of one opioid does not preclude failure of class

❖ Reduce calculated dose of new drug by 25-50% for opioid-tolerant patients

❖ Increase total daily dose by 10-20% for breakthrough pain

ParentaParental (mg)l (mg)

Oral Oral (mg) (mg)

Duration Duration (h)(h)

CodeineCodeine 120 200 3-4

HydromorphoHydromorphonene 1.5 7.5 2-4

MeperidineMeperidine 75 300 2-4

MethadoneMethadone 5 10 6-8

MorphineMorphine 10 30 2-4

OxycodoneOxycodone NA 20 2-4

Special Issues and Concerns in the Evaluation of Older Adults Who

Have PainKirsh, K, Smith, H. Clin Geriatr Med, 24 (2008)263-274

Source: http://www.shopping-guides.info/antiques/opium-morphine-oklahoma-drugs-medicine-bottle-labels.html

Introduction

❖ Prescription abuse is increasing in U.S., at all ages

❖ Substance abuse disorders occur in 19-26% of hospitalized population

❖ Chronic severe pain present in 37% of methadone maintenance patients and 24% of inpatient addiction patients

❖ At the same time, pain continues to be under-treated

❖ Cancer patients who are an ethnic minority, female, elderly, or a substance abuser are more likely to have inadequate treatment of pain

❖ Essential to successfully evaluate patient for substance-abuse

RiskAssessment

Lynn Webster, MD

❖ CAGE

❖ Drug Abuse Screening Test

❖ Opioid Risk Tool

❖ Screener and Opioid Assessment for Patients in Pain

Documentation

❖ Clearly chart

❖ Pain relief

❖ Functional outcomes

❖ Side effects

❖ Drug-seeking behaviors

❖ Documentation must be easy to access and suitable to compare trends

Documentation

❖ Include aberrant behavior in assessment of patient, nurses’ notes and encounter notes

❖ Include goals of pain management in patient plan

❖ Include risk assessment tests in chart

Other Notes

❖ Difficult to assess, define addiction

❖ Specialists and primary care physicians each have role in care and identification

❖ With a standardized, objective approach, we may be more successful in treating older patients equally and broaching sensitive topics