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Boston Medical Center is the primary teaching affiliate

Pain Management in the Elderly. Swapneel Shah, MD. Fernando Almenas, MD. Cesar Castillo, MD. Anesthesiology Residents. Edward Vaynberg, MD. Assistant Professor of Anesthesiology. Boston Medical Center is the primary teaching affiliate. of the Boston University School of Medicine.

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Boston Medical Center is the primary teaching affiliate

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  1. PainManagementintheElderly SwapneelShah,MD FernandoAlmenas,MD CesarCastillo,MD AnesthesiologyResidents EdwardVaynberg,MD AssistantProfessorofAnesthesiology BostonMedicalCenteristheprimaryteachingaffiliate oftheBostonUniversitySchoolofMedicine.

  2. Acknowledgments •SupportedbyagrantfromtheGeriatricEducationfor SpecialtyResidentsProgram(GSR)whichisadministeredby theAmericanGeriatricsSocietyandfundedbytheJohnA. HarfordfoundationofNewYorkCity

  3. 3 Objectives •Discusssourceofpainintheelderlypatient •Reviewassessmentmethodstoevaluatepainin theelderlypatient •Describetherapeuticregimesfortheolderadult

  4. Whyisthisimportant? •Painiscommonintheelderly •Painisunder-recognizedandunder-treated •JCAHO,ACGME/RRCrequirements •Lackofformaleducationonpaincontrol

  5. Whyispaincontroloftennotoptimal? •Clinicianunfamiliaritywithassessmentand treatment •Opioidsmisconceptionsbypatients,families, andclinicians –Fearofsideeffects –Concernsaboutaddiction,regulatoryreprimands,and lawsuits

  6. Sourcesofpainintheelderly • • • • • Post-strokesyndrome Improperpositioning Fibromyalgia Cancerpain Contractures •Degenerativejoint disease •Spinalstenosis •Fractures •Pressureulcers •Postherpetic neuralgia •Oral/dental •Constipation •Neuropathicpain •Urinaryretention

  7. Consequencesofunrelievedpain • • • • • • • • • Sleepdisturbance Functionaldecline Depression,anxiety Polypharmacy Malnutrition ProlongedLOS Challengingbehaviors Increasedhealthcareutilization Lawsuits

  8. AgeDifferencesinPain Changesinperception –Decreaseinpainreceptorsattheskinareapossible mechanism,butnouniformconsensusamongstudies –Regardlessofnumber,functioninpainreceptors(both CandAδ)aredecreased –Conductionvelocitiesareimpairedinbothmyelinated andun-myelinatedfibersattheCNS –Lossofneuronsatdorsalhornshasbeendocumented

  9. AgeDifferencesinPain OtherChanges –Normalagingmaybeassociatedwithimpairmentin descendingendogenouspaininhibitionnetworks –Thismaysuggestthatadaptationtopainfulstimuliis reducedintheelderlywithagerelateddysfunctionof bothopiodandhormonalsystems

  10. AgeDifferencesinPain BrainPerception –DecreaseinEEGamplitudeandincreaseinlatencyto painfulstimulihavebeenreported –Painfulthermalstimuliactivatesmidlineandcentral corticalregionsinyoungandold,butolderadultsshow activationoffrontalandlateralsites.Thisimplieswider recruitmentofneuronsandslowercognitiveprocessing –Onbehaviorallevel,elderlyshowtobemorereluctant thanyoungpeopletoreportpainfulstimuli

  11. AgeDifferencesinPain Presentation –Whatmaybepainfultoayoungadult;maypresentin theelderlyasbehavioralchangessuchasconfusion, restlessness,aggression,anorexia,andfatigue

  12. AgeDifferencesinPain Presentation –Whenpainisreported,itmaybereferredfromthesite oforigininanatypicalmanner –Example:AtypicalorasymptomaticMIisrarein youngerpt’s.Inelderlysurvivors,30%donotreport acutesymptoms,and30%hadatypicalpresentations –Elderlywomenaremorelikelytopresentwithan atypicalpaincomparedtoelderlymen

  13. PainintheSettingofCognitiveImpairment -Intheclinicalsetting,theintensityofpainful conditionsandtheadministrationofanalgesic medicationseemtobeinverselyrelatedas dementiaprogresses -Difficultyinmanagementfromeitherdifficultyin expressingtheexperienceorfrominabilityto associatetheactualexperiencedueto neuropathologicalchanges

  14. PainintheSettingofCognitiveImpairment -Inresponsetopain,cognitivelyimpairedpeoplemight showmorefacialexpressiveness.Thismightberelated togeneralizedemotionalandbehavioraldisinhibition rathertopainperse -Asdementiaworsens,selfreportbecomesimpossible anditisnecessarytorelyonpainbehaviorsandfacial expressions -Abruptchangesinbehaviorandfunctionmightbethe bestassessmentsofpain.Familymemberandfrequent caregiversmightaidinobtainingthisinformation

  15. One-dimensionalScales AcutePainManagementGuidelinePanel.AcutePainManagementin Adults:OperativeProcedures.QuickReferenceGuideforClinicians. Rockville,MD:USDepartmentofHealthandHumanServices,Public HealthService,AgencyforHealthCarePolicyandResearch.February 1992.AHCPRPub.No.92-0019.

  16. FacesPainScaleandPainThermometer

  17. NonverbalPainIndicators •Facialexpressions:grimacing •Vocalizations:crying,moaning,groaning -Lessobvious:grunting,chanting,callingout, noisybreathing,askingforhelp •Bodymovements(guarding) -Lessobvious:rigid,tenseposture,fidgeting, pacing,rocking,limping,resistancetomoving

  18. NonverbalPainIndicators •Facialexpressions(grimacing) -Lessobvious:slightfrown,rapidblinking, sad/frightened,anydistortion •Vocalizations(crying,moaning,groaning) -Lessobvious:grunting,chanting,callingout, noisybreathing,askingforhelp •Bodymovements(guarding) -Lessobvious:rigid,tenseposture,fidgeting, pacing,rocking,limping,resistancetomoving

  19. NonverbalPainIndicators •Changesininterpersonalinteractions –combative,disruptive,resistingcare,decreased socialinteractions,withdrawn •Changesinmentalstatus –confusion,irritability,agitation,crying •Changesinusualactivity –refusingfood/appetitechange,increased wandering,changeinsleephabits

  20. Assessingpain:Nonverbal,ModeratetoSevere Impairment(AGSPanel2002) 1)Presenceofnon-verbalpainbehaviors? -assessatrestandwithmovement 2)Timely,thoroughphysicalexam 3)Insurebasiccomfortneedsarebeingmet (e.g.hunger,toileting,loneliness,fear) 4)Ruleoutothercausativepathologies (e.g.urinaryretention,constipation,infection) 5)Considerempiricanalgesictrial

  21. MultimodalApproachtoPainManagement Pharmacotherapy PhysicalTherapy TreatmentApproaches Interventional Approaches ComplementaryAlternative Medicine Exercise PsychologicalSupport

  22. MedicationSelection •Goodpainhistory •Targettothetypeofpain –neuropathic,nociceptive •Considernon-pharmacologicornon-systemic therapiesaloneorasadjuvanttherapy •UsetheWHO3-Stepladder

  23. WHO3-Stepladder Source:WorldHealthOrganization.TechnicalReportSeriesNo.804,Figure 2.Geneva:WorldHealthOrganization;1990.

  24. Adjuvants •Topicals –lidocainepatch,capsaicin •Acetaminophen •NSAIDS –celecoxib,steroids •Anticonvulsants •Antidepressants •Non-pharmacologic(TENS,PT/OT)

  25. Step1(Mild):Non-opioids • • • • • • Acetaminophen NSAIDS Cox-2 Non-systemictherapies Non-medicationmodalities +/-otheradjuvants

  26. Step2(Moderate):MildOpioids,Opioid-like • • • • • Codeine(e.g.T#3®) Hydrocodone(e.g.Vicodin®) Oxycodone(e.g.Percocet®) Tramadol(Ultram®) +/-Adjuvants

  27. Step3(Severe):StrongOpioids • • • • • • • Morphine Oxycodone Hydromorphone(Dilaudid®) Fentanyl Oxymorphone Methadone +/-Adjuvants

  28. TransdermalFentanyl •Duration24-72hours •12-24hourstoreachfullanalgesiceffect •Notrecommendedasfirst-lineinopiatenaïve patients •Lipophilic •SimpleConversionrule: –1mgpomorphine=½mcgfentanyl –(60mgmorphineroughly25mcgpatch)

  29. OtherFentanyl •Intravenous –equivalenttopatchdose,e.g.Duragesic100mcg/72 =100mcg/hrIV •Transmucosal –Actiq® –Fentora® •IontophoreticFentanylPatch –Ionsys®

  30. Methadone,aComplicatedDrug •Shouldonlybeusedbythosewithexperience! •Mu,kappa,deltaagonist •Inhibitsreuptakeofserotoninandnorepinephrine •NMDAantagonist(neuropathicpain) •Significantinter-individualvariability •Druginteractions(coumadin-like)

  31. Methadone(cont.) •Initialrapidtissuedistribution •Sloweliminationphase •Longandvariablehalf-life(13-58hours) •Doseintervalisvariable(q6orq8hours) •Doseusuallyadjustedq4-7days •Minimallyimpactedbyrenaldisease •Inexpensive,lessstreetvaluethanotheropioids

  32. DrugstoAvoid •Meperidine –Demerol® •Mixedagonist-antagonist –e.g.Pentazocine(Talwin®) •Propoxyphene –Darvon®,Darvocet®

  33. OpioidPharmacology •Blockthereleaseofneurotransmittersinthedorsalhornof spinalcord •Mu,delta,kappaexpresseddifferently,dependingonopioid medication •Conjugatedinliver •Excretedviakidney(90%–95%) •Exception:methadone,excretedfecally

  34. OpioidUseinRenalFailure •Avoid:meperidine,codeine, dextropropoxyphene,morphine •Usewithcaution:oxycodone,hydromorphone •Safest:fentanyl,methadone •OpioiddosingbyCrCl –>50mL/minnormal –10-50mL/min75%ofnormal –<10mL/min50%ofnormal

  35. ClearanceConcerns Dehydration,renalfailure,severehepaticfailure ↓↓dosinginterval(extendtime)or ↓↓dosagesize –ifoliguriaoranuria •STOParoundtheclockdosingofopioids (suchasmorphine) •useONLYprn

  36. Opioidadverseeffects Common Constipation Drymouth Nausea/vomiting Sedation Sweats Uncommon Baddreams/hallucinations Dysphoria/delirium Myoclonus/seizures Pruritus/urticaria Respiratorydepression Urinaryretention Hypogonadism SIADH

  37. GISideEffects Constipation -NEVERresolves -PreventwithscheduledsoftenersPLUSstimulants -Avoidbulkingagents(e.g.Metamucil®) NauseaandVomiting –Encouragepatientstoeatfrequent,smallmeals –Treatwithpromotilityagents(metoclopramide),serotonergicblocking agents(odansetron)ordopaminergicblockingagents(haloperidol, metoclopramide,prochlorperazine)

  38. SedationandDelirium •Considertryingoneofthefollowing: 1)Ifpaincontrolisadequate,decreasedoseby25% 2)Rotatetoadifferentopioidpreparation 3)Usesmalldosesofpsychostimulants(2.5to5mg methylphenidateordextroamphetamine)forexcessive somnolence •Usenonsedatingantipsychotics(haloperidol, risperidone)fordelirium

  39. References • • • • • • • • LevyM.Drugtherapy:Pharmacologictreatmentofcancerpain. NEJM1996;335(15):1124-1132. EPECProject,TheRobertWoodJohnsonFoundation,1999. StoreyPandKnightCF.UNIPAC3:AssessmentandTreatmentof PainintheTerminallyIll.AAHPM2003. Gazelle.Methadoneforthetreatmentofpain.JPallMed. 2003;6(4):620 AGSPanelonPersistentPaininOlderPersons.JAGS. 2002;50:S205-S224. AmericanPainSociety.APSGlossaryofPainTerminology. http://www.ampainsoc.org/links/pain_glossary.htm. BrueraEandPortenoyR.CancerPainAssessmentand Management.CambridgeUniversityPress,2003. ChernyN,RipamontiC,PereiraJ,etal.Strategiestomanagethe adverseeffectsoforalmorphine:anevidence-basedreport.JCli Oncol.2001;19:2542-2554.

  40. References • • • • • • DeanM.Opioidsinrenalfailureanddialysispatients.JPian SymptomManage2004;28(5):497-504. GordonDB,StevensonKK,GriffieJ,etal.Opioidequianalgesic calculations.JPalliatMed.1999;2(2):209-218. HerrK,BjoroK,DeckerS.Toolsforassessmentofpainin nonverbalolderadultswithdementia:Astate-of-the-sciencereview. JPainSymptomManage2006;31(2):170-192. HewittDJ,PortenoyRK.Adjuvantdrugsforneuropathiccancer pain.TopicsinPalliativeCare.NewYork:OxfordUniversityPress 1998:31-62. KirshKL,PassikSD.Palliativecareoftheterminallyilldrugaddict. CancerInvest2006;24:425-431. KlaschikE,NauckF,OstgatheC.Constipation–modernlaxative therapy.SupportCareCancer2003;11:679-685.

  41. References • • • • • • DeanM.Opioidsinrenalfailureanddialysispatients.JPian SymptomManage2004;28(5):497-504. GordonDB,StevensonKK,GriffieJ,etal.Opioidequianalgesic calculations.JPalliatMed.1999;2(2):209-218. HerrK,BjoroK,DeckerS.Toolsforassessmentofpainin nonverbalolderadultswithdementia:Astate-of-the-sciencereview. JPainSymptomManage2006;31(2):170-192. HewittDJ,PortenoyRK.Adjuvantdrugsforneuropathiccancer pain.TopicsinPalliativeCare.NewYork:OxfordUniversityPress 1998:31-62. KirshKL,PassikSD.Palliativecareoftheterminallyilldrugaddict. CancerInvest2006;24:425-431. KlaschikE,NauckF,OstgatheC.Constipation–modernlaxative therapy.SupportCareCancer2003;11:679-685.

  42. References • • • • • • McCleaneG.Topicalanalgesics.MedClinNAm2007;91:125-139. MercadanteSandBrueraE.Opioidswitching:Asystematicand criticalreview.CancerTreatmentReviews2006;32:304-315. MeuserT,PietruckC,RadbruchL,etal.Symptomsduringcancer paintreatmentfollowingWHOguidelines:alongitudinalfollow-up studyofsymptomprevalence,severity,andetiology.Pain 2001;93:247-257. SkaerTL.Transdermalopioidsforcancerpain.HealthandQuality ofLifeOutcomes206;4(24):1-9. SwegleJMandLogemannC.Managementofcommonopioid- inducedadverseeffects.AmFamPhysician2006;74:1347-1354. WHOladder:CancerPainReliefandPalliativeCare.Technical ReportSeries804.Geneva:WorldHealthOrganization;1990.

  43. References • • • EPERC.End-of-life/PalliativeEducationResourceCenter http://www.mywhatever.com/cifwriter/library/eperc/fastfact/ff_index.h tml http://www.ama-cmeonline.com/pain_mgmt/module12/index.htm BrueraEandSweeneyC.Methadoneuseincancerpatientswith pain:Areview.JPalliatMed.2002;5(1):127-137.

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