Michael DiMarco, Jr. Psy.D.

1. Caring for Geriatric Patients in the Emergency Department SettingPart 6: Caring for Older Patients with Pain who are High Utilizers of the ED Michael DiMarco, Jr. Psy.D. Emergency Department Consult Psychologist Clement J. Zablocki VA Medical Center Assistant Professor, Psychiatry & Behavioral Medicine Medical College of Wisconsin

2. Disclosures • Michael DiMarco, Jr. Psy.D. • No disclosures. • No conflicts of interest to report.

3. A Common ED Dilemma • Patient comes to ED with complaint of low back pain, longstanding, but recent increase has been unbearable. • There is an opiate agreement in the EHR. • Patient has a PCP who prescribes pain medication, including opiates. • What do you do?

4. Managing the Dilemma • Believe the patient’s report of pain • Assess pain using numerical, visual, or other standard pain scale • Determine diagnosis • Acute pain issue • Exacerbation of a chronic non-cancer condition • Disease progression

5. Managing the Dilemma • Review the opiate agreement in the EHR • Make a decision • Administer Rx the ED i.e. injection • Write a prescription to be filled • Provide non-opiate medication • Discuss the benefits of follow up with the PCP/PS

6. Staff Reactions to Pain Patients • Empathy • Mistrustful • Frustration • Confrontation • Anger • Lecturing • Investigation • Delay treatment • Rush treatment – aka “treat & street”

7. “Frequent Flyers” • Common terminology used in the ED • Terminology may have pejorative connotations • The terminology may negatively impact pain care. • Consider the impact of the term. • Consider replacing the term with “Reoccurring” “Mr. Matthews is a 69 year old man reoccurring to the emergency department due to persistent lower extremity neuropathic pain.”

8. “Frequent Flyers” Reasons Patients Come to the ED for Pain Control • Lack health insurance • No established primary care provider (PCP) or pain specialist (PS) • Disagreement with PCP/PS regarding the pain management plan • Abrupt pain increase that may be exacerbated by a recent physical activity • Pain increase due to rapid disease progression • Fear/catastrophizing beliefs about pain

9. “Frequent Flyers” Reasons Patients Come to the ED for Pain Control • Regimen is not effective • Developed a physical tolerance to the RX • Under medicated in the first place • Running out of RX before time of refill –Rx overuse • Poor planning of routine prescription refills • Addiction (personal use, self-medicating of MH condition) • Criminal behavior -intent to sell Rx (diversion) • Victim of abuse (patient’s Rx is being taken from them)

10. Screening for Abuse(Screen the Patient Alone) • “Who helps you organize your pain medications?” • “Where do you keep your pain medications?” • “Have you ever had to hide your medications from anyone?” If so, “Tell me about that.” • “Has anyone ever offered you any money for some of your medications.” If so, “For which medications?” • “Has anyone ever offered you food or other kind of help in exchange for some of your medications?” • “Has anyone ever taken your medication from you?”

11. Aberrant Medication Taking Behavior: “To abuse or not to abuse…is the question!” • Addiction • Escalating Rx use with no therapeutic benefit on reducing pain • Tolerance • The need for increase doses of Rx to maintain the same level of pain relief • Pseudo-addiction • Patient appears drug-seeking but not due to addiction. Drug seeking is in the context of being under medicated in the first place. • Drug seeking behavior diminishes once appropriate analgesia is achieved

12. Consequences of Untreated Pain in Elderly • Further physical limitations • Loss of independence • Decreased socialization • Depression • Impaired sleep • Cognitive impairment • Increase risk for falls and other injuries • Increased healthcare utilization/cost • Lacas & Rockwood, 2012

13. Myths About Treating Pain in the Elderly • Analgesics are too dangerous. • Analgesics will cause more cognitive dysfunction. • Older people cannot accurately report pain –they’re just demented. • Older people don’t understand pain rating scales.

14. Assessment Issues • ED culture –fast paced and not “geriatric-friendly.” • Assessment biases based on gender, race, age • Differences in how younger vs older patients experience pain psychologically • Cognitive Impairment

15. Biases in Pain Treatment • Patients who are members of racial or ethnic minorities are under evaluated and undertreated for painful conditions in the emergency department. • Some literature suggests females may receive more analgesia in the ED than males • Some literature suggests that elderly patients receive less analgesia compared to their younger counterparts. • Reference: Motov & Khan, 2009

16. Age Bias • Jones et al. (1996) found that out of a sample of 231 hospital patients, 66% of elderly patients received less analgesia compared to 80% of their younger counterparts. • The study also found that elderly patients had a prolonged wait time for administration of pain Rx, significant under dosing of pain Rx, and received less opiate analgesics.

17. Age Bias • Lee et al. (2006) did not find any association between advanced age, gender, ethnicity in pain management including delays in administration of analgesic agents among the elderly presenting with abdominal pain to an emergency department. • The study was unique in that it looked at the interaction of gender, race, and age. The original hypothesis was that female, non-Caucasian, an advanced age would expect delays in the administration of analgesia in comparison to their younger counterparts.

18. Differences in Pain-Related Fear: Older vs. Younger • Younger people have more generalized pain-related fears – global catastrophizing. • Older people are more fearful of re-injury and further loss of autonomy and control that comes with aging. • Gagliese, L. (2009)

19. Pain Assessment in the Elderly • Cognitively Impaired • Cognitively Intact

20. General Considerations for Pain Assessment in Elderly • Ask about pain. • Be aware that older patients may deny pain but endorse other descriptions such as aching, soreness, stiffness. • Be aware that a decrease in physical activity may be the only indicator of pain because geriatric patients may not verbalize pain.

21. Vertical Pain Scales Use assessment approaches that include both self-report and observational measures when possible. Involve the family in the assessment of pain.

22. General Considerations for Pain Assessment • Be aware that pain recall may pose some challenges • pain yesterday versus pain today. • Be aware that deficits in language skills may pose challenges in the report of pain and explanation of pain • i.e. stroke. • Be aware that facial expression associated with pain may be reduced/masked in the elderly. • Be aware that impairments in executive function pose problems in noticing the early emergence of lower level pain intensity.

23. Strategies for Cognitively Impaired Patients • Don’t write these patients off. • Reassess pain frequently. • Minimize distractions when making a pain assessment.

24. Strategies for Cognitively Impaired Patients • Account for both visual and auditory deficits if possible. • Use a nonverbal rating scale. • Pain assessment during a movement (activity during transferring, bathing, dressing, and ambulating) is more likely to identify an underlying persistent pain problem than observation at rest.

25. Pain Assessment in Advanced Dementia (PAINAD)

26. Coordinated Care • View alert • PCP • PC-SW • PC-psychologist • Referral to the PC Home-Based Program

27. Management & Follow-up Care Coordination for Older Patients with Pain in the ED Jelili A. Apalara,MD, MPH, FACP, CPE, FACHE. Assistant Clinical Professor of Medicine, University of California, San Francisco Medical Director – Emergency Dept. VA Central California Healthcare System MARCH 2014

28. Disclosure No Conflict of Interest!

29. Objectives By the End of this Presentation, participants will be able to: • acquaint themselves with the consequences of inadequate pain treatment in the Elderly. • familiarize  themselves with the legal position on pain management. • describe different modalities for pain management in the Elderly. • recognize their roles in subsequent follow-up and management of the patients.

30. Recommendation Grading

31. Introduction • In 2009, the Elderly population, persons 65 years and older, represents only one out of every eight Americans. • This denoted 12.9% of the US population., or 39.6 million people in that year.

32. Introduction (Based on online data from the U.S. Census Bureau’s 1) Population Estimates and Projections; 2) Table 1. Projected Population by Single Year of Age (0-99, 100+), Sex, Race, and Hispanic Origin for the United States: July 1, 2012 to July 1, 2060, Release Date: 2012; and 3) Table 5. Population by Age and Sex for the United States: 1900 to 2000, Part A. Hobbs, Frank and Nicole Stoops, Census 2000 Special Reports, Series CENSR-4, Demographic Trends in the 20th Century.)

33. One major challenge faced by the elderly people is physical disability. Physical disability in this group often worsens with age. Majority have at least one chronic medical problem, and many have multiple chronic conditions. Arthritis and degenerative joint disease top the list, and often associated with Pain. Realities and Challenges

34. Types of Pain

35. Pain should be Evaluated and Treated in the Elderly.

36. Treating Pain is Both a MORAL and an ETHICAL responsibility for Healthcare Providers.

37. The mission of DEA's Office of Diversion Control is to prevent, detect, and investigate the diversion of controlled pharmaceuticals and listed chemicals from legitimate sources while ensuring an adequate and uninterrupted supply for legitimate medical, commercial, and scientific needs.

38. Consequences of Untreated Pain Functional Impairment. Depression. Increased Suicide Risk. Increased Mortality.

39. Treatment Modalities Pharmacologic TREATMENT MODALITIES Physical Therapy Interventional Behavioral Medicine Surgical Procedure Neuromodulation

40. Treatment Modalities NSAIDs Tramadol Opioids Muscle Relaxants Antidepressants α2 adrenergic agonists NMDA-ra Anti-epileptics Topical Agents

41. Pharmacological Treatment WHO’s Pain Relief Ladder WHO 1980.

42. Pharmacological Treatment • WHO recommends a progressive increment in doses and types of analgesic to ensure effective pain management. • Modality of treatment is not static, it changes with the characteristics of the pain. • Mild pain should be treated with acetaminophen, aspirin or other Non-steroidal Anti-inflammatory Drugs (NSAIDs). • Moderately persistent or worsening pain requires addition of opioid such as codeine or hydrocodone.

43. Pharmacological Treatment • Opioids with fixed dose acetaminophen provides additive analgesia. • If pain worsens, and higher doses of opioid are necessary, separate dosage of opioid and non-opioid analgesic. • This ensures maximally recommended doses of acetaminophen or NSAIDs are not surpassed. • Severe pain requires more potent opioids, such as morphine, hydromorphone, methadone or fentanyl.

44. Pharmacological Treatment • Patients with persistent cancer-related pain should be on around-the-clock schedule, with additional “PRN" doses. • Patients who have moderate to severe pain when first seen by the clinician should be started at the second or third step of the ladder. • Adjuvant drugs should be used at any step as necessary to enhance analgesic efficacy and treat concurrent symptoms exacerbating pain.

47. Geriatrics Pain Management

48. Physician’s Role Social Work PHYSICIAN & PATIENT Interventional Behavioral Medicine Physical Therapy Physicians and Other Healthcare Providers are central to ensuring effective interdisciplinary pain management.

49. Interdisciplinary Pain Management GOALS • Pain Reduction. • Increased activity levels. • Increased functionalilty. • Early return to work or vocation. • Reduced opioids use or more appropriate dosing. • Reduced depression and anxiety. • Improved coping skills. • Reduced use of medical resources

50. Interdisciplinary Pain Management Proc (Bayl UnivMed Cent). Jul 2000; 13(3): 240–243.