Pain Assessment & Management in Dementia

1. Pain Assessment & Management in Dementia 0 December 19, 2005 Tracy Marx, D.O. Assistant Professor, Geriatric Medicine OUCOM

2. Definition of Pain 0 • Pain is an “unpleasant sensory and emotional experience.” • Chronic pain is difficult to define but understood as persistent pain that is not amenable to routine pain control methods

3. Pain Statistics 0 • 75 million Americans live with “serious pain” • 50 million suffer from chronic pain • Many have lived with this more than 5 years and experience pain almost 6 days/wk • American Pain Society http://www.ampainsoc.org/ce/npc/Pain: Current Understanding of Assessment, Management and Treatments, 7/2004

4. Geriatric Statistics 0 • Chronic pain is common in older adults • Arthritis, bone & joint disorders, many chronic conditions • 25 – 50% community adults suffer with chronic pain • 45 – 80% in nursing home substantial pain, undertreated • 1 in 5 older Americans taking analgesic medications regularly

5. Common Causes of Chronic Pain 0 • Back and neck pain • Myofascial pain/fibromyalgia • Headache • Arthritis pain • Neuropathic pain • From American Pain Society http://www.ampainsoc.org/ce/npc/Pain: Current Understanding of Assessment, Management and Treatments, July 2004

6. DJD Rheumatoid arthritis Fibromyalgia Low back disorders Arthropathies (gout) Osteoporosis Neuropathies Pressure Ulcers Amputations Immobility, contractures GI conditions (ulcers, ileus, gastritis) Renal Conditions (kidney stones, bladder distension) Headaches Oral/dental pathology Peripheral vascular disease Post-stroke syndromes Painful Conditions in the Elderly 0

7. Older People with Pain Experience 0 • Deconditioning • Gait disturbances • Falls • Slow rehabilitation • Multiple medication use • Cognitive impairment • Malnutrition • Ferrell, Ann Int. Med 1995; 123 (9): 681-687

8. Consequences of Chronic Pain 0 • Depression • Decreased socialization • Sleep disturbance • Impaired ambulation • Increased health care utilization and costs • Lavsky-Shulan et al, JAGS 1985; 33(1): 23-28

9. Physician Barriers to Mgmt 0 • Inadequate knowledge of pain management • Poor assessment of pain • Concern about regulation of controlled substances • Fear of patient addiction or misuse • Concern about side effects, tolerance • According to U. S. Dept. of Health & Human Services, Agency for Health Care Policy & Research

10. Patient Barriers to Mgmt. 0 • Older adults often expect pain with age • Use other words than “pain’ (aching, hurting, throbbing, “a misery”) • Fear need for diagnostic tests or medications that have side effects • For some, pain is a metaphor for serious disease or death • For others, pain and suffering represent atonement for past actions

11. Barriers in LTC setting 0 • Different response (may not show typical sx) • Cognitive and communication barriers • Cultural and social barriers • Co-existing illnesses and multiple meds • Staff training and access to appropriate tools • Practitioner limitations • System barriers

12. Pain Assessment 0 • Failure to assess pain is critical factor leading to under treatment • Should occur initially • Occur at regular intervals after initiation of treatment • At each new report of pain • At suitable interval after pharmacologic or nonpharmacologic intervention

13. Initial Assessment 0 • Detailed history • Physical examination • Psychosocial assessment • Diagnostic evaluation

14. Detailed History 0 • Goal is to characterize pain by location, intensity, and etiology • Listen to descriptive words about quality, location, radiation • Evaluate intensity or severity, aggravating factors (have patient keep a log) • Impact on activity, mood, mentation, sleep, functioning in daily activities

15. Detailed History (cont’d) 0 • Previous episodes, relation to physical or stress-related etiological factors • Previous diagnostics and findings • Previous treatment and its effects • Concurrent medical problems (cardiac, respiratory, anxiety, depression)

16. Detailed History (cont’d) 0 • What are the patient’s goals of pain control? • Some merely want an accurate diagnosis • Others want total pain relief • Most fall somewhere in the middle

17. Categorize Type of Pain 0 • Bone/Soft Tissue (Somatic) Pain • “tender,” “deep,” “aching” • arthritis, myofascial pain, bony mets • Neuropathic Pain • “shooting,” “burning,” “stabbing,” “scalding” • trigeminal neuralgia, diabetic neuropathy, post stroke, reflex sympathetic dystrophy • Visceral Pain • “spasms,” “cramping” • bowel obstruction, adhesions

18. Multiple Causes of Pain 0 • Physical • Emotional • Anxiety, depression • Social • Isolation, abandonment, financial • Spiritual • Search for meaning/purpose, being punished

19. Pain Assessment in Terminal Patients 0 • 40-50% of cancer patients report moderate to severe pain (30% severe) • 80% more than one type of pain • At least 25% of all cancer patients die without adequate pain relief due to under treatment • Need aggressive assessment, treatment, and reassessment

20. Pain Assessment in Cognitively Impaired 0 • Can often verbalize how they feel at the moment • Pain can be just as severe – not able to communicate effectively • Often don’t receive adequate analgesics

21. Pain Signs in Cognitively Impaired 0 • Facial expressions • Verbalizations • Body Movement • Change in Interaction • Change in Activity or Routine • Mental Status Changes

22. Pain Assessment Tools 0 • completed by the patient • flexible enough to be adapted • simple enough to be used consistently over time • No one scale works for all patients

23. Pain Assessment Tools 0 • Verbal description • No pain---slight---mild---moderate---severe---extreme---worst pain ever • Rating Scale • 0-10 with 10 being worst pain ever experienced • 0-5 with 5 being worst pain • Faces • Have patient point to most accurate representation

24. Pain and Longterm Care 0 • “in order to assist long-term care residents in improving their activities of daily living, decreasing pain is likely to yield the greatest overall improvements” Cipher and Clifford, International Journal of Geriatric Psychiatry, 2004 Vol. 19: 741-748

25. Severe Dementia 0 • Found that facial expressions and vocalizations are accurate means for assessing the presence of pain, but NOT its intensity • Manfredi, Journal of Pain and Symptom Management, 2003; 25: 48-52

26. Observation Assumptions 0 • Facial characteristics, body posture, and movement patterns can indicate the presence of pain • Pain can interfere with ADLs such as dressing and eating • Caregivers can reliably observe and rate such behavior • Villanueva, JAMDA, J/F 2003; 4: 1-8

27. Pain Assessment for the Dementing Elderly (PADE) 0 • PADE Part I (selected items): Physical • “Is the resident frowning? Restless?” • PADE Part II: Global Assessment • “Place a mark on the line that you feel best represents the resident’s level of pain at the time of observation” • PADE Part III (selected items): Functional • “During the hours that the resident has been awake, what percentage of time was the resident out of bed?” • Villanueva, JAMDA, J/F 2003; 4: 1-8

28. Assessment of Chronic Pain 0 • Any persistent or recurrent pain that has significant effect on function or quality of life should be recognized as a significant problem. • For those with cognitive or language impairments, nonverbal pain behavior, recent changes in function, and vocalizations suggest pain as possible cause. Interview caregiver for more information.

29. Approach to Pain 0 • Need accurate diagnosis • Review patient goals • Assess, treat, reassess, treat • If unsuccessful, review type of pain and history

30. Pathophysiology of Nociceptive Pain 0 • Somatic (well localized) or visceral (often referred) -- most often derived from stimulation of pain receptors • May arise from tissue inflammation, mechanical deformation, ongoing injury or destruction. • Examples include inflammatory or traumatic arthritis, myofascial pain syndromes, ischemic disorders • responds well to traditional pain meds

31. Pathophysiology of Neuropathic Pain 0 • involves central or peripheral nervous system • Often poorly localized, unusual • Examples: trigeminal neuralgia, post-herpetic neuralgia, phantom limb pain, reflex sympathetic dystrophy, poststroke • Poorly responsive to conventional analgesics; may respond to antidepressants, anticonvulsants, or antiarrhythmics

32. Pathophysiology of Mixed Chronic Pain 0 • Mixed or unknown mechanisms • Examples include recurrent headaches, vasculitic pain syndromes • Treatment often unpredictable, requiring various trials

33. Pathophysiology of Psychogenic Pain 0 • Psychological factors judged to have a major role in onset, severity, exacerbation, or persistence of pain • Examples include conversion reactions and somatoform disorders • Treatment consists of psychiatric referral and treatment

34. Pharmacologic Treatment: General Principles 0 • “Start low and go slow” • Continuity of care • same physician if possible, utilize team approach (social worker, nurse, physical therapist) • Be proactive • treat pain and symptoms as they arise • Re-evaluate frequently

35. Pharmacologic Treatment: General Principles 0 • Regular dosing around the clock • Establish good relationship • patient as active, responsible participant • consider use of an opioid contract • Document, document, document • symptoms, signs, progression, side effects • consider second opinion

36. Pharmacologic Treatment: General Principles 0 • Whenever you establish a pain control program, also set up a bowel regimen to prevent constipation!! • Analgesic drugs should supplement other medications directed at definitive treatment of underlying disease

37. 1. Mild Aspirin APAP NSAIDs +/- Adjuvants 2. Moderate Codeine Hydrocodone Oxycodone Dihydroxycodone Tramadol +/- Adjuvants WHO Ladder 0 3. Severe Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone +/- Adjuvants  

38. Stepwise Approach to Pain (WHO) 0 • Treat “mild to moderate pain” initially with acetaminophen or NSAIDs • acetaminophen has ceiling dose (max 4g) • NSAIDs often with GI side effects • Consider salsalate (Disalcid) or trisalicylate (Trilisate) as options to NSAIDs, with less GI effect

39. Stepwise Approach to Pain 0 • Then progress to a mixed agent (acetaminophen or NSAID with codeine, oxycodone or hydrocodone) or oxycodone alone. • acetaminophen/propoxyphene (Darvocet) considered no more effective than acetaminophen • oxycodone SR (Oxycontin) long acting (12 hrs.) controlled release compound • oxycodone - short acting (4 hours)

40. WHO Step 3 - Severe 0 • morphine sulfate or a derivative • No ceiling dose • Long acting morphine sulfate such as MS Contin, Avinza, Kadian • Short acting preparations are available in tablets (MSIR), rectal suppositories or a highly concentrated sublingual from (Roxanol) • Fentanyl (Duragesic) is available in a transdermal prep that provides pain relief for 72 hours (takes 12 hours to reach a steady state) • AVOID meperidine (Demerol) and mixed agonist

41. Approach to Pain 0 • Fears of drug dependency and addiction do not justify the failure to relieve pain. • Monitor the side effect of opioid therapy (sedation, hypoxia, myoclonus, pruritus).

42. Adjuvant Analgesics 0 • may decrease total opioid needed • NSAIDs often used for musculoskeletal pain • soft tissue and bone involvement • limited due to side effects • Tricyclic antidepressants and SSRIs useful in neuropathic pain, insomnia, and depression • High doses of TCAs associated with side effects but often low doses are effective

43. Adjuvant Analgesics 0 • Anticonvulsants effective in neuropathic pain • gabapentin (Neurontin), carbamazepine (Tegretol) • start low and dose upwards • Corticosteroids used in terminal patients to help with bony metastases, increased intracranial pressure, abdominal distention or inflammatory disease • Use is limited due to long term side effects

44. Nonpharmacologic Treatments 0 • Alone or in combination with drugs • Many modalities exist such as: • Osteopathic manipulation • Physical therapy • TENS • Acupuncture • Massage • Exercise programs • Psychological counseling

45. Nonpharmacologic Treatments 0 • Biofeedback • Hypnosis • Relaxation therapy • Religious practice • Cognitive therapy • Herbal medicine • Homeopathy • Importance of patient education is paramount--giving patients knowledge gives them control.

46. Nonpharmacologic Tx Results 0 • Body has self regulatory and self healing abilities • Touch alone has been shown to reduce anxiety and pain • Postulated that retraining of nervous system to reestablish more neural connections through use of exercise and psychologic treatment can effectively diminish chronic pain

47. Conclusions 0 • Make an accurate diagnosis • If you’re not sure, consider trial of pain management • Review patient goals • Assess, treat, reassess, treat • If unsuccessful, review type of pain and history