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Pain in the Older Adult: Clinical Interventions and Recommendations for Care

Pain in the Older Adult: Clinical Interventions and Recommendations for Care. Allison H. Burfield, RN, MSN, PhD Associate Professor School of Nursing & Gerontology Affiliate Faculty University of North Carolina at Charlotte, College of Health & Human Services. *Grant funded through the.

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Pain in the Older Adult: Clinical Interventions and Recommendations for Care

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  1. Pain in the Older Adult: Clinical Interventions and Recommendations for Care Allison H. Burfield, RN, MSN, PhD Associate Professor School of Nursing & Gerontology Affiliate Faculty University of North Carolina at Charlotte, College of Health & Human Services *Grant funded through the

  2. Pain is… • An important sense for survival • Subjective • World Health Organization defines pain “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (McCance & Huether, 2019, pp 469)

  3. Outline of Topics • Introduce recent research conducted and presented in Berlin at the World Aging & Rejuvenation Conference • Highlight the importance of HOW we assess pain in older adults, especially those with dementia • Review types of pain • Discuss regulatory requirements • Review pain treatments • Non-pharmacological • Pharmacological • Homeopathic • CBD

  4. Concept Map of Pain. (Kaempf, 2019; McCance & Huether, 2019; Rosenthal & Burchum, 2018; McCaffery, 1968)

  5. Start of this story…My passion and why.10 residentsDouzjian M, Wilson C, Schults M, Berger J. A program to use pain control medication to reduce psychotropic drug use in residents with difficult behavior. Annals of Long Term Care. 1998;6(5):174-8. 4-80% Residents report pain, why gap? (multiple sources) *Written consent given by Henning family to share letter

  6. Aims: To test the efficacy of regularly scheduled acetaminophen in reducing pain behaviors • Examine if there are differences in pain behaviors without/with acetaminophen use. • Examine the mediating effects of regular acetaminophen use with decreasing pain disruptive behaviors and increasing social engagement. • Examine if there are differences in pain behaviors moderated by varying amounts of psychotropic drugs/total psychoactive load. • Examine the incident and correlation of medication use with falls, injury, hospitalization, medication costs and social engagement scores. A. Burfield, aburfiel@uncc.edu

  7. Participant Enrollment • Three research sites in Southeast US

  8. Demographics • Pain mostly osteoarthritic • Important to use the correct assessment methods of pain, not just verbal reports • Important to match the type of pain with appropriate medication treatment

  9. Methods Repetitive vocalizations • Delayed treatment design • Usual Care 30 days Observation of: • Overall Health, CMP, B12, Folate • Pain: In addition to pain frequency, intensity and number of pain sites • Cognition • Social Engagement • Psychoactive Load • Training CNAs • Coordination of medication regimen review with Consultant Pharmacist on team and at site, prescribers Change in Mood, Sad Facial Expressions Repetitive Physical Movements Hitting out Inappropriate Behavior Crying, Negative Statements • Intervention Period, Day 31-60 • Start participant specific APAP dose (325-500 mg), not to exceed 2.6 grams given every 4-6 hours • Baseline health, CMP, B12, Folate (and week 5) • Pain, Cognition, Social Engagement • CNA Illness Warning Trigger Tool Use • Psychoactive load, APAP use

  10. Improve How We Assess Pain* & Provide Regularly Scheduled Acetaminophen *Burfield, A., Wan, T. T. H., Sole, M. L., & Cooper, J. W. (2012). Behavioral cues to expand a pain model of the cognitively impaired elderly in long-term care. Clinical Interventions in Aging, 7, 207-223.

  11. Findings Research Team Dr. James W. Cooper, PharmD Shaquana Sutton, RN CNA Education Specialist Catherine Skahen-Recruitment Laura Andrade,RN-Lead Clinician Jeanine Hutchinson, RN CNA Education Specialist Kim Parsons, RN-Clinician Mounica Chirva-Data Entry & Analyst

  12. Insights & Conclusions • Important information about: • Improving quality of life in pain management • Type & location pain • Resolution: what were trends in pain individual pain, and what worked, until pain scores decline? • Contributing factors: gender, racial, or co-morbidities • Pain Index indicators • Increase in indicators as cognition declines (model of n=52,996 residents*) • Psychoactive load: differences by site, prescriber, consideration for care gaps in Medicaid settings

  13. Further Research Next Steps • Correlation between pain, socialization and • wandering behaviors • Go back to the data on a larger scale: • MDS RAI examine large dataset, CMS—pain, polypharmacy, • wandering behaviors, psychoactive load • Recidivism in to acute settings due to pain behaviors and injuries from fall

  14. Person-Centered Care: What are the steps in pain assessment and treatment? • Careful consideration in to location, type, duration and mitigating factors of THEIR individual pain • Careful attention to potential pain behaviors, especially with CI • What works to lessen pain? • Get a comprehensive history of injuries, falls, syncopal episodes and orthostatic hypotension • Incredibly important to evaluate total psychoactive load! (Beer’s Criteria) • The first step is assessment • Trial of non-pharm interventions • Pharm interventions taking in to account combination with TOTAL psychoactive load • Continually re-evaluate what works AND document, document, document

  15. Let’s Revisit A Review on Types of Pain Pain can be acute, chronic or referred • Emotional or psychological pain: an unpleasant feeling (a suffering) of a psychological, non-physical origin. Can manifest somatic symptoms • Nociceptive: Free nerve endings, known as nociceptors, may be stimulated by chemical, mechanical or thermal stimuli, AKA acute pain • Neuropathic: chronic, long term pain initiated by damage or dysfunction to the central nervous system or peripheral nervous system think diabetes, shingles or fibromyalgia • Osteoarthritic: Sometimes called degenerative joint disease • (OA) is the most common chronic condition of the joints, affecting approximately 27 million Americans. ... In the final stages of OA, the cartilage wears away and bone rubs against bone leading to joint damage and more pain

  16. (McCance & Huether, 2010)

  17. Regulatory Requirements for Pain Treatment in Long-Term Care Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Pain Assessment and Management Standards for hospitals: “Identify pain assessment and pain management, including safe opioid prescribing, as an organizational priority (LD.04.03.13). Actively involve the organized medical staff in leadership roles in organization performance improvement activities to improve quality of care, treatment, and services and patient safety (MS.05.01.01). Assess and manage the patient’s pain and minimize the risks associated with treatment (PC.01.02.07). Collect data to monitor its performance (PI.01.01.01). Compile and analyze data (PI.02.01.01). (The Joint Commission, 2018). Medicare Residents in Long-term Care: Minimum Dataset Resident Assessment Instrument (MDS-RAI)

  18. Non-Pharmacological Interventions for Pain • Important as clinicians we start here… • Instruct patients in massage, deep breathing and relaxation techniques, guided imagery (Shropshire, et al, 2018) • Provide music therapy as a form of relaxation (Van Der Wal-Huisman, 2019) • Using heat therapy or cool compresses (reduce inflammation) • Exercise/yoga (Zhang, 2019) or passive range of motion (ROM)—warming the joints up • Nurses or CNAs should reposition patients with use of pillows/wedges to promote comfort • Careful consideration in to physical transfers—using draw sheets, protecting joints, not pulling against potentially painful areas • Implement these techniques, however if ineffective, pharmacological management should be considered or in addition to

  19. Pharmacological Management of Pain • Pain medications prescribed for acute pain should begin with the least potent, specific to type of pain i.e. kidney stones—Dilaudid (hydromorphone) • Define Half-Life: “the time required for the amount of drug in the body to decrease by 50%” (Rosenthal & Burchum, 2019, pp. 40) • The half-life of a drug should determine the intervals of administration

  20. Pharmacological Considerations • Non-opioid analgesics • Acetaminophen (history of ETOH abuse) • NSAIDS (caution with GI and BP) • Opioid Analgesics (should only be used for moderate to severe pain) • Morphine • Codeine • Oxycodone • Fentanyl • Mixed Action analgesics (Tramadol—really a Tramadon’t!, tapentadol) • Anticonvulsants • Antidepressants (mostly TCAs—which should not be used in older adults) • Alpha2 agonists (clonidine) • Corticosteroids

  21. Potency is important to understand… Within 5 days of regular use of an opiate, physical dependency occurs (Truth Initiative, 2018) Assess risk for falls and further injury Important to consider safety: Falls risk Full assessment of orthostatic hypotension (sitting, standing BP) Constipation Still important to provide comfort…

  22. Let’s pause for a clinical question • In light of prescribing restrictions on gabapentin, if we have severe restrictions (now in most states a controlled substance) what are alternatives for neuropathic pain? What can we recommend as clinicians?

  23. Homeopathic Treatments • Nutrition, diet focused • Rose hip (biochemical makeup similar to precursor of fish oil)—seeds or oil, lower joint pain (Dr. Kaj Winther, 2019, University of Copenhagen), lower use of rescue pharmaceuticals, rebuild cartilage • Turmeric-anti-inflammatory, clinical trials only in adults (Ghaffari, Rafraf, Navekar, & Asghari-Jaaraadabi, 2018) • Ginger (caution as can cause a rise in blood pressure) • Gingko Bilbao (Dr. Winther, 2019) no clinical trials

  24. What is the difference between CBD and THC? • In recent years, cannabidiol (CBD), a non-intoxicating compound found in cannabis, has garnered increasing attention and popularity among patients for the treatment of pain, insomnia, and anxiety, though more data are needed from well-controlled trials to confirm any real therapeutic benefits (Beairsto, 2019) • CBD derived from the hemp plant • May help treat conditions like pain, insomnia, and anxiety • Can be inhaled, delivered orally, or applied topically • Headlines: CBD for Pain Hype or Hope? Almost overnight, cannabidiol explode into a $1 billion industry. Is it the latest fad or the future of pain relief? • This summer, the Food and Drug Administration (FDA) issued a warning letter to Curaleaf Inc. of Wakefield, Massachusetts, for illegally CBD with claims that their products treat cancer, Alzheimer's disease, opioid withdrawal, pain, and "pet anxiety," among other conditions and diseases (Kopf, 2019)

  25. Psych Congress 2019, held October 3 to 6 in San Diego, California • Difference between [THC and CBD] is not black and white… THC is not the bad guy, CBD is not the good guy — it is much more complicated than that (Penn, 2019) • There really is not enough evidence yet… • One small double-blind crossover study, researchers examined the pharmacologic effects of THC and CBD in the same adult healthy participants • While THC increased heart rate, intoxication, and physical and mental sedation 2 hours after administration, CBD did not increase any of these factors more than the placebo (Martin-Santos et al, 2019)

  26. A 65-year-old female admitted to your rehab unit post operatively hip replacement. History and physical states that this is her first hospital admission in over 20 years. The hospitalist writes an order for Fentanyl patch 100mcg to be changed every 3 days. Based on this medication order, you best response would be: • Contact the prescriber for order clarification • Assess for medication allergies • Apply the patch when the patient complains of pain • Ensure a patch is applied the third day post op

  27. A 65-year-old female admitted to your rehab unit post operatively hip replacement. History and physical states that this is her first hospital admission in over 20 years. The hospitalist writes an order for Fentanyl patch 100mcg to be changed every 3 days. Based on this medication order, you best response would be: • Contact the prescriber for order clarification • Assess for medication allergies • Apply the patch when the patient complains of pain • Ensure a patch is applied the third day post op

  28. Clinical Question 2: As care provider’s, what should we tell our patients about CBD if asked? • In older adults, the evidence and efficacy is not there to support its safe use • From a clinical perspective safety cautions: • Given emerging evidence of vaping-induced pulmonary injury DO NOT VAPE  • Penn (2019) recommends for ADULTS a maximum recommended oral dose of CBD of 0.25 mg/kg. Dosing should be started low and titrated upward on an individual basis • “At this point I (Penn) do not see CBD replacing existing medications in most cases, but instead being added to them. To somebody who has patients who are coming into their office, I would invite them, first of all, to get curious and to try and understand what the patient is trying to do [with CBD] and then to…encourage the patient to understand what they are taking and to understand how much of the cannabinoids are in it”

  29. Any questions? aburfiel@uncc.edu

  30. References Beairsto, R. (Oct. 7, 2019). Understanding CBD: How to advise patients about existing laws, clinical evidence, and more, Psychiatry Advisor, Retrieved from https://www.psychiatryadvisor.com/home/conference-highlights/us-psych-congress-2019/understanding-cbd-how-to-advise-patients-about-existing-laws-clinical-evidence-and-more/?utm_source=newsletter&utm_medium=email&utm_campaign=pa-update-hay-20191008&cpn=psych_all&hmSubId=#NAME?&hmEmail=T-yhJKHL86bNLNO0vsDdDVeRWY7ycbnr0&NID=&email_hash=492c3c376be6d822c1561d21cb72c480&mpweb=1323-70770-156819 Ghaffari, A., Rafraf, M., Navekar, R., & Asghari-Jaaraadabi, M. (2018). Effects of tumeric and chicory seed supplementation on antioxidant and inflammatory biomarkers in patients with non-alcoholic fatty liver disease (NAFLD). Advances in Integrative Medcine, 5(3), 89-95. doi: http://dx.doi.org/10.1016/j.aimed.2018.01.002 Martin-Santos R, Crippa JA, Batalla A, et al.(2012).  Acute effects of a single, oral dose of d9-tetrahydrocannabinol (THC) and cannabidiol (CBD) administration in healthy volunteers. Curr Pharm Des.,18(32):4966-4979. McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man- environment interactions. Los Angeles, CA: University of California at Los Angeles. McCance, K. L., & Huether, S. E. (2019). Pathophysiology (8th ed.). St. Louis, Missouri: Elsevier. Penn A. (2019). Cannabidiol popularity raises questions for clinicians. Psych Congress Newsroom. September 4, 2019. http://www.psychcongress.com/article/cannabidiol-popularity-raises-questions-clinicians. Accessed October 2, 2019. Penn A. (2019). Confused about cannabidiol (CBD)? A scientific and rational examination of its risks and benefits in psychiatry. Presented at: Psych Congress 2019; October 3-6, 2019; San Diego, CA. Rosenthal, L., & Burchum, J. (2018). Lehne’s Pharmacotherapeutics for Advanced Practice Providers. St Louis, MO: Elsevier. Shropshire, M., Stapleton, S., Dyck, M., Myoungjin, K., & Mallory, C. (2018). Nonpharmacological interventions for persistent, noncancer pain in elders residing in long-term care facilities: An integrative review of the literature. Nursing Forum, 53(4), 538-548. doi: http://dx.doi.org/10.1111/nuf.12284 Truth Initiative.(2018). Opioid dependence can happen in just 5 days. Retrieved Oct. 10, 2019 from https://truthinitiative.org/research-resources/substance-use/opioid-dependence-can-happen-after-just-5-days Zhang, Q., Young, L., & Feng, L. (2019). Pain relief in older adults with osteoarthritis. American Journal of Physical Medicine & Rehabilitation, 98(6), 469-478. doi: http://dx.doi.org/10.1097/PHM.0000000000001130

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