Pain Management in Frail and Medically Complex Elders

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Pain Management in Frail and Medically Complex
Elders

• Laura Hanson MD, MPH
• Division of Geriatric Medicine
• Program on Aging, UNC Chapel Hill

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Impact of Pain
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Pain and suffering

• Pain an unpleasant sensory and emotional
  experience associated with actual or potential
  tissue damage. International Association for the
  Study of Pain, 1980
• Pain is what the person in pain says it is
• Sufferingpain experience modified by
  psychological adaptations, experience of other
  physical symptoms, and broader spiritual or
  social concerns

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Pain is common

• 40-80 of NH residents have pain
• 14.7 have daily moderate to severe pain
• 29 of NH residents with advanced cancer have
  daily pain
• 26 of them receive no pain medication
• 10 of bereaved family members believe pain was
  undertreated

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Pain has consequences

• IT HURTS!
• Depression
• Decreased mobility and increased dependency
• Decreased quality of life
• Interferes with spiritual and emotional well-being

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Health providers myths

• Pain is normal when youre old
• Older patients feel less pain
• Older patients cant tolerate pain medications
• Failure to recognize chronic pain
• Legal risks of using opioids
• 15 million damages for failure to treat NH
  residents pain with opioids
• NC Boards all endorse right to effective pain
  control

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Resident / family barriers

• Pain is normal when youre old
• Value stoicism, being strong
• Fear of addiction
• Problems communicating pain
• unable to talk
• confusion / dementia

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CMS Quality Measure - Pain

• Tracked in nursing homes
• of all residents with daily moderate pain OR
  with horrible / excruciating pain at any
  frequency
• In NC 48 daily pain 62 moderate pain, 4
  excruciating pain
• Nationally, 15 persistent over 60 d.

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To Improve Care for Pain . . .

• SCREEN
• ASSESS
• TREAT / CARE PLAN
• Re-ASSESS

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Screening and Assessment
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Screening Questions

• Do you have any pain or discomfort?
• Do you hurt or feel sore?
• Are you uncomfortable right now?
• IF YES, then
• How bad is your pain or discomfort? (rate
  using a pain scale)

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ASSESSMENT is critical

• If a resident is in pain, then ask . . .
• Severity use a pain scale
• Location
• Duration how long
• Frequency how often
• Description what does it feel like
• Factors that increase or decrease
• Impact on function, quality of life

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Pain Scales - Verbal
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Pain Scales Non-verbal
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Assess Pain in Dementia

• Verbal residents with dementia
• 67-83 of residents with dementia are able to use
  a pain scale
• Words are easier than numbers
• Ask in the present pain now?
• Give time to respond

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Assess Pain in Dementia

• Non-verbal residents with dementia
• Use changes in behavior -- just not herself
• more passive, withdrawn, not eating, OR
• more agitated, aggressive, restless
• Observe behaviors during personal care
• Moaning, guarding, resisting, grimacing

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Duration Acute Behaviors

• Residents with acute (new) pain may be
• Crying
• Guarding
• Grimacing and moaning
• High BP, pulse
• Restless or extremely still

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Duration - Chronic Behaviors

• Residents with chronic (long-standing) pain may
• not express pain by telling you about it
• express pain with depressed mood, withdrawal
• have no abnormal vital signs
• come to expect and endure pain

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Treatment
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Non-medication Treatments

• Consider for every patient in pain
• Music
• Soft lighting, decreased noise, OR added
  distractions
• Massage
• Warm or cold packs
• Repositioning, exercise
• Emotional and spiritual support

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Medication for Chronic Pain

• Medication choice based on mechanism, severity,
  toxicity
• scheduled, not PRN
• long-acting breakthrough agent
• provide breakthrough pain treatment
• order bowel regimen with every opioid
• Combining medications at low doses can increase
  effect with fewer side effects

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Non-opioid favorites

• Scheduled Tylenol
• SHORT TERM NSAIDS (1-2 weeks)
• Vit D, calcitonin for bone pain
• Non-opioid desipramine 10-25 mg
• corticosteroid taper or injection
• gabapentin 100-1000 mg q8

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Opioid favorites

• Non-opioid low dose opioid
• Step 2 opioids
• codeine 30-100 mg q4-6, oxycodone 5-10 mg q4-6
• Step 3 opioids
• morphine 10-40 mg PO q4, hydromorphone 4 mg q4
• Hold for excessive sedation or Rlt8 per min

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Treatment / Care Plan Pearls

• Non-medication treatments for all residents in
  pain
• Scheduled, not PRN if pain is daily
• Combine low doses of 2 medications
• Bowel medications if opioid used
• Plan to re-assess effectiveness
• Communicate plan with NA, team