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PAIN MANAGEMENT IN ELDERLY PERSONS

PAIN MANAGEMENT IN ELDERLY PERSONS. UCLA Multicampus Program of Geriatrics and Gerontology. Physicians Have a Moral Obligation to Provide Comfort and Pain Management Especialy for those near the end of life!. Pain is the most feared complication of illness

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PAIN MANAGEMENT IN ELDERLY PERSONS

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  1. PAIN MANAGEMENTIN ELDERLY PERSONS UCLA Multicampus Program of Geriatrics and Gerontology

  2. Physicians Have a Moral Obligation to Provide Comfort and Pain ManagementEspecialy for those near the end of life! • Pain is the most feared complication of illness • Pain is the second leading complaint in physicians’ offices • Often under-diagnosed and under-treated • Effects on mood, functional status, and quality of life • Associated with increased health service use

  3. 18% of Elderly PersonsTake Analgesic Medications Regularly(daily or more than 3 times a week) • 71 % take prescription analgesics • 63% for more than 6 months • 72% take OTC analgesics • Median duration more than 5 years • 26% report side-effects • 10% were hospitalized • 41% take medications for side-effects

  4. ELDERLY PATIENTS TAKING PAIN MEDICATIONS FOR CHRONIC PAIN WHO HAD SEEN A DOCTOR IN THE PAST YEAR • 79% had seen a primary care physician • 17% had seen a orthopedist • 9% had seen a rheumatologist • 6% had seen a neurologist • 5% had seen a pain specialist • 5% had seen a chiropractor • 20% had seen more than 5 doctors

  5. Common Causes of PainIn Elderly Persons • Osteoarthritis • back, knee, hip • Night-time leg cramps • Claudication • Neuropathies • idiopathic, traumatic, diabetic, herpetic • Cancer

  6. MISCONCEPTIONS ABOUT PAIN Myth: Pain is expected with aging. Fact: Pain is not normal with aging.

  7. PAIN THRESHOLD WITH AGING

  8. Age Related Differences in Sensory Receptor Function • Encapsulated end organs • 50% reduction in Pacini’s • 10-30% reduction Meissner’s/Merkels Disks • Free nerve endings • no age change

  9. Age Related Differences in Peripheral Nerve Function • Myelinated nerves • Reduction in density (all sizes including small) • Increase in abnormal/degenerating fibres • Decrease in action potential/slower conduction velocity • Unmyelinated nerves • Reduction in number (1.2-1.6un) not (.4un) • Substance P, CGRP content decreased • Neurogenic inflammation reduced

  10. Age Related Differences in Central Nervous System Function • Loss of dorsal horn spinal neurons • Altered endogenous inhibition, hyperalgesia. • Loss of neurons in cortex, midbrain, brain stem • (18% reduction in thalamus, no change cingulum cortex) • Altered cerebral evoked responses (increased latency, reduced amplitude) • Reduced catecholamines, acetylcholine, GABA, 5HT, not neuropeptides

  11. MISCONCEPTIONSABOUT PAIN Myth: If they don’t complain, they don’t have pain Fact: There are many reasons patients may be reluctant to complain, despite pain that significantly effects their functional status and mood.

  12. REASONS PATIENTS MAY NOT REPORT PAIN • Fear of diagnostic tests • Fear of medications • Fear meaning of pain • Perceive physicians and nurses too busy • Complaining may effect quality of care • Believe nothing can or will be done

  13. The most reliable indicator of the existence pain and its intensity is the patient’s description.

  14. There is a lot we can do to relieve pain! • Analgesic drugs • Non-drug strategies • Specialized pain treatment centers • Patient and caregiver education and support

  15. Analgesic Drugs • Acetaminophen • NSAIDs • Non-selective COX inhibitors • Selective COX-2 inhibitors • Opioids • Others • Antidepressants • Anticonvulsants • Substance P inhibitors • NMDA inhibitors • Others

  16. CAUTION • Meperidine (Demerol) • Butorphanol (Stadol) • Pentazocine (Talwin) • Propoxiphene (Darvon) • Methadone (Dolophine) • Transderm Fentanyl (Duragesic)

  17. Do Not Use Placebos! • Unethical in clinical practice • They don’t work • Not helpful in diagnosis • Effect is short lived • Destroys trust

  18. Exercise PT, OT, stretching, strengthening general conditioning Physical methods ice, heat, massage Cognitive-behavioral therapy Chiropracty Acupuncture TENS Alternative therapies relaxation, imagery herbals Non-Drug Strategies

  19. PATIENT AND CAREGIVER EDUCATION • Diagnosis, prognosis, natural history of underlying disease • Communication and assessment of pain • Explanation of drug strategies • Management of potential side-effects • Explanation of non-drug strategies

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