Pain Management for Geriatric Patients

1
Pain Management for Geriatric Patients

• Laura Hanson MD, MPH
• Program on Aging and Division of Geriatrics, UNC
  School of Medicine

2
Objectives

• To discuss pain prevalence in geriatric
  populations
• To discuss unique barriers to pain treatment for
  older patients
• To discuss aging changes that lead to modified
  treatment strategies

3
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

4
Pain is common for older patients

• 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
• Ferrell BA JAGS 38409
• 
  Bernabei JAMA 2791877

5
Pain is undertreated

• 18-24 of bereaved family members believe pain
  was undertreated
• Less if in hospice (18)
• More if in home health (43) or nursing home
  (32)
• 41 of cancer patients undertreated
• Primary risk factor age 70
• Hanson JAGS 451339
• 
  Teno JAMA 29188
• Cleeland NEJM 330592

6
Barriers patient / family attitudes

• Pain is normal when youre old
• Value stoicism, being strong
• Fear of addiction
• Problems communicating pain
• unable to talk
• confusion / dementia
• Gloth FM JAGS 49188
• AGS Panel JAGS 50S205

7
Barriers provider attitudes

• Pain is normal when youre old
• Older patients feel less 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
• Failure to recognize chronic persistent pain
• Older patients cant tolerate pain medications

8
Acute Behaviors

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

9
Chronic Behaviors

• Residents with chronic persistent pain
• may not express pain by telling you
• express pain with depressed mood, withdrawal
• have no abnormal vital signs
• come to expect and endure pain

10
Assess verbal, dementia

• 67-83 of residents with dementia are able to use
  at least one scale
• Present Pain Intensity
• Words are easier than numbers
• Ask in the present Are you in pain now?
• Ask several ways discomfort
• Give time to respond
• Ferrell BA JPSM 10591
• Herr KA Clin J Pain 1429
• 
  Krulewitch H JAGS
  481607

11
Assess non-verbal

• Use changes in behavior -- just not herself
• more passive, withdrawn, not eating, OR
• more agitated, aggressive, restless
• Hurley observational scale (DS-DAT), PAINAD
• Observe behaviors during personal care
• breakthrough or incident pain
• Hurley AC Res Nurs Health 15369
• Buffum MD JAGS
  521093

12
Pain Treatment
13
Geriatric Pharmacology

• Absorption no change
• Distribution larger VD lipophilic (trazodone,
  benzos) smaller VD hydrophilic (ethanol,
  lithium, morphine)
• Metabolism decreased hepatic blood flow
• Clearance decreased RBF and CrCl slower
  clearance

14
Morphine Pharmacology

• Double-blind cross-over study of 8 mg vs. 16 mg
  IM doses stratified by age
• Weight and initial pain intensity did not differ
  by age
• Peak pain relief occurred at nearly the same
  time greatest for oldest patients
• 50 elders (70-89) in pain at 5 hours 50
  youngest (18-29) in pain at 3 hours
• Kaiko RF Clin Pharm Ther 28823

15
Morphine pharmacology

• Peak effect slightly higher
• Use slightly lower dose
• Half-life longer
• Increase interval
• BUT, every elder is an individual . . .

16
BEFORE medication

• Test baseline mental status exam
• Know baseline renal function
• CrCl (140-age) x wt (kg)
• 72 x SCr x 0.85 if female
• Know concurrent chronic illnesses
• hepatic function
• hydration status

17
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
• tramadol (Ultram)

18
What about acetominophen?

• Randomized trial of scheduled vs PRN
  acetominophen 2600 mg / d
• N39 NH residents with severe dementia
• Baseline discomfort DS-DAT7.4
• NO EFFECT
• Re-assess for effectiveness
• Avoid in EtOH, hepatic disease
• Buffum MD JAGS 521093

19
Musculoskeletal pain

• Osteoporosis, fracture
• Several studies show pain reduction with
  calcitonin
• Vitamin D deficiency causes diffuse pain
  replacement improves this symptom
• Osteoarthritis
• Scheduled acetominophen tramadol short courses
  of steroids or NSAID injections salsalate low
  potency opioids

20
Opioid favorites

• Non-opioid low dose opioid
• Step 2 opioids
• oxycodone 5-10 mg q4-6
• Step 3 opioids
• morphine 10-40 mg PO q4, hydromorphone 4 mg q4
• Hold for excessive sedation or R

21
Renal disease

• Morphine 6-glucuronide potent active metabolite
• Renally secreted slow to cross BBB
• Half-life may exceed 24 hours in renal failure
• AVOID NSAIDs reduce tramadol doses
• Hydromorphone, methadone, oxycodone, fentanyl
  somewhat better tolerated Angst MS Anes 921473
• Dean M JPSM 28497

22
Opioids and delirium

• Cohort study of n541 hip fx patients 16
  delirious
• Dementia greatest risk factor for delirium
• delirium
• Opioids cause delirium however, so does
  untreated post-op pain
• Morrison RS J Geron 58A76

23
Non-medication Treatments

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

24
Medication for Persistent 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

25
Treatment Pearls

• Non-medication treatments
• Scheduled med if
• pain is daily
• patient is cognitively impaired
• Opioids longer interval (/- lower dose)
• Combine low doses of 2 classes of medication
• Bowel medications
• Know hepatic, renal function, mental status

26
Educate patients and families

• Address fears about opioids
• Addiction to pain medicine is rare
• Patients develop tolerance to sedation, nausea
  in a few days to weeks
• Constipation is monitored and treated
• Morphine does not cause death

27
Communication tips

• Discuss pain care plan with patient, family
• Ask consultant pharmacists for help
• Communicate pain care plan to other involved
  health care providers consulting MDs, nursing
  aides, nurses, etc.

28
CMS Quality Measure - Pain

• of all residents with daily moderate pain OR
  with horrible / excruciating pain at any
  frequency
• Provides you with a target population to review
  care plan for pain assessment and treatment