Pain Assessment

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

2
Definition of Pain
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• 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
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• 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
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• 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
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• Back and neck pain
• Myofascial pain/fibromyalgia
• Headache
• Arthritis pain
• Neuropathic pain
• From American Pain Society http//www.ampainsoc.o
  rg/ce/npc/ Pain Current Understanding of
  Assessment, Management and Treatments, July 2004

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Painful Conditions in the Elderly
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• 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

7
Older People with Pain Experience
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• 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
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• 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
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• 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

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Patient Barriers to Mgmt.
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• 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

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Barriers in LTC setting
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• 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

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Pain Assessment
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• 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

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Initial Assessment
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• Detailed history
• Physical examination
• Psychosocial assessment
• Diagnostic evaluation

14
Detailed History
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• 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 (contd)
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• 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)

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Detailed History (contd)
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• What are the patients goals of pain control?
• Some merely want an accurate diagnosis
• Others want total pain relief
• Most fall somewhere in the middle

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Categorize Type of Pain
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• 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
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• Physical
• Emotional
• Anxiety, depression
• Social
• Isolation, abandonment, financial
• Spiritual
• Search for meaning/purpose, being punished

19
Pain Assessment in Terminal Patients
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• 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

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Pain Assessment in Cognitively Impaired
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• Can often verbalize how they feel at the moment
• Pain can be just as severe not able to
  communicate effectively
• Often dont receive adequate analgesics

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

22
Pain Assessment Tools
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• 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
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• Verbal description
• No pain---slight---mild---moderate---severe---extr
  eme---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
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• 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

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Severe Dementia
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• 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

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Observation Assumptions
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• 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

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Pain Assessment for the Dementing Elderly (PADE)
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• 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 residents 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

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Assessment of Chronic Pain
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• 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
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• Need accurate diagnosis
• Review patient goals
• Assess, treat, reassess, treat
• If unsuccessful, review type of pain and history

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

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Pathophysiology of Psychogenic Pain
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• 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

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Pharmacologic Treatment General Principles
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• 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
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• 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
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• 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
WHO Ladder
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• 3. Severe
• Morphine
• Hydromorphone
• Methadone
• Levorphanol
• Fentanyl
• Oxycodone
• /- Adjuvants

?

• 2. Moderate
• Codeine
• Hydrocodone
• Oxycodone
• Dihydroxycodone
• Tramadol
• /- Adjuvants

?

• 1. Mild
• Aspirin
• APAP
• NSAIDs
• /- Adjuvants

38
Stepwise Approach to Pain (WHO)
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• 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

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Stepwise Approach to Pain
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• 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
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• 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
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• 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
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• 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
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• 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
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• Alone or in combination with drugs
• Many modalities exist such as
• Osteopathic manipulation
• Physical therapy
• TENS
• Acupuncture
• Massage
• Exercise programs
• Psychological counseling

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

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Nonpharmacologic Tx Results
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• 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

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Conclusions
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• Make an accurate diagnosis
• If youre not sure, consider trial of pain
  management
• Review patient goals
• Assess, treat, reassess, treat
• If unsuccessful, review type of pain and history