Pain Management in Geriatric Medicine

1. Pain Management in Geriatric Medicine • Smith, Howard. Clinics in Geriatric Medicine, May 2008; Vol 24, No.2; 1549 - 1556 Zachary Lapaquette PharmD Candidate University of Georgia

2. 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

3. 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

4. Overview • Pain assessment in the non-verbal patient • Pharmacotherapy of pain in older patient • Special consideration and evaluation of older patient with pain

5. Assessment of Pain in the Nonverbal or Cognitively Impaired Older Adult • Bjoro, K, Herr, K. Clin Geriatr Med, 24 (2008)237-262 Source: http://www.artexpertswebsite.com/pages/artists/novelli.php

6. 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

7. Pain Assessment • 5 key principles of pain assessment in nonverbal populations: • Obtain self-report • Investigate possible pathologies • Observe behavior • Solicit surrogate report • Use analgesic trial

8. 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.

9. 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

10. 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

11. 3. Pain-Associated Behaviors

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Salicylates ASA, diflunisal, magnesium salicylate, salsalate • 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

21. 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

22. NSAIDs Ibuprofen, naproxen, ketoralac, diclofenac, naproxen indomethacin, ketoprofen, nabumetone, meloxicam • 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

23. 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

24. Opioids

25. 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

26. 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

27. Special Issues and Concerns in the Evaluation of Older Adults Who Have Pain • Kirsh, 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

28. 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

29. RiskAssessment • CAGE • Drug Abuse Screening Test • Opioid Risk Tool • Screener and Opioid Assessment for Patients in Pain Lynn Webster, MD

30. Documentation • Clearly chart • Pain relief • Functional outcomes • Side effects • Drug-seeking behaviors • Documentation must be easy to access and suitable to compare trends

31. 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

32. 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