AMDA Clinical Practice Guideline (CPG) for Pain Management

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AMDA Clinical Practice Guideline(CPG) for Pain
Management

• For Medical Directors and Attending Physicians

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Introduction to Pain

• Pain is common in the long-term care setting.
• Unrelieved chronic pain is not an inevitable
  consequence of aging
• Aging does not increase pain tolerance or
  decrease sensitivity to pain
• Most chronic pain in the long-term care setting
  is related to arthritis and musculoskeletal
  problems
• Pain may be associated with mood disturbances
  (for example, depression, anxiety, and sleep
  disorders)

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Introduction to Pain

• The use of pain scales
• Acute vs. chronic pain
• Long-term care interventions

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Pain in the Elderly

• Definition of PainAn individuals unpleasant
  sensory or emotional experience
• Acute pain is abrupt usually abrupt in onset and
  may escalate
• Chronic pain is pain that is persistent or
  recurrent

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Pain in the Elderly

• The most common reason for unrelieved pain in the
  U.S. is failure of staff to routinely assess for
  pain
• Therefore, JCAHO has incorporated assessment of
  pain into its practice standards
• The fifth vital sign

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Pain in the Elderly
Sources of pain in the nursing home Source Stein
et al, Clinics in Geriatric Medicine 1996
Condition causing pain Frequency ()
Low back pain 40
Arthritis 37
Previous fractures 14
Neuropathies 11
Leg cramps 9
Claudication 8
Headache 6
Generalized pain 3
Neoplasm 3
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Pain in the Elderly
Conditions Associated with the Development of
Pain in the Elderly

• Degenerative joint disease
• Gastrointestinal causes
• Fibromyalgia
• Peripheral vascular disease

• Rheumatoid arthritis
• Post-stroke syndromes
• Low back disorders
• Improper positioning

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Pain in the Elderly
Conditions Associated with the Development of
Pain in the Elderly

• Crystal-induced arthropathies
• Renal conditions
• Gastrointestinal disorders
• Osteoporosis
• Immobility, contracture

• Neuropathies
• Pressure ulcers
• Headaches
• Amputations
• Oral or dental Pathology

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Pain in the Elderly
Barriers to the Recognition of Pain in the LTC
setting

• Different response to pain
• Staff training
• Cognitive or sensory impairments
• Practitioner limitations

• Social or Cultural barriers
• System barriers
• Co-existing illness and multiple medications

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Pain in the Elderly Myths

• To acknowledge pain is a sign of personal
  weakness
• Chronic pain is an inevitable part of aging
• Pain is a punishment for past actions
• Chronic pain means death is near
• Chronic pain always indicates the presence of a
  serious disease
• Acknowledging pain will mean undergoing intrusive
  and possible painful tests.

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Pain in the Elderly Myths

• Acknowledging pain will lead to loss of
  independence
• The elderly especially cognitively impaired
  have a higher pain tolerance
• The elderly and cognitively impaired cannot be
  accurately assessed for pain
• Patients in LTC say they are in pain to get
  attention
• Elderly patients are likely to become addicted to
  pain medications

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Pain in the Elderly

• Consequences of untreated pain
• Depression
• Suffering
• Sleep disturbance
• Behavioral disturbance
• Anorexia, weight loss
• Deconditioning, increased falls

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Pain in the Elderly

• Inferred Pain Pathophysiology 6
• Nociceptive pain Explained by ongoing tissue
  injury
• Neuropathic pain Believed to be sustained by
  abnormal processing in the peripheral or central
  nervous system
• Psychogenic pain Believed to be sustained by
  psychological factors
• Idiopathic pain Unclear mechanisms

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AMDA Pain Management CPGSteps

1. Recognition
2. Assessment
3. Treatment
4. Monitoring

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Pain in the Elderly-Recognition

• Possible Indicators of Pain in MDS Version 2.0
• Restlessness, repetitive movements (B5)
• Sleep cycle (E1)
• Sad, apathetic, anxious appearance (E1)
• Change in mood (E3)
• Resisting care (E4)
• Change in behavior (E5)
• Functional limitation in range of motion (G4)
• Change in ADL function (G9)

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Pain in the Elderly-Recognition

• Possible Indicators of Pain in MDS Version 2.0
• Pain site (J3)
• Pain symptoms (J2)
• Restlessness, repetitive movements (B5)
• Sleep cycle (E1)
• Sad, apathetic, anxious appearance (E1)
• Change in mood (E3)
• Resisting care (E4)

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Pain in the Elderly-Recognition

• Possible Indicators of Pain in MDS Version 2.0
• Loss of sense of initiative or involvement (F1)
• Any disease associated with pain (I1)
• Pain symptoms (J2)
• Pain site (J3)
• Mouth pain (K1)
• Weight loss (K3)

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Pain in the Elderly-Recognition

• Possible Indicators of Pain in MDS Version 2.0
• Oral status (L1)
• Skin Lesions (M1)
• Other skin problems (M4)
• Foot Problems (M6)
• ROM restorative care (P3)

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Pain in the Elderly Recognition

• Non-specific signs and symptoms suggestive of
  pain
• Frowning, grimacing, fearful facial expressions,
  grinding of teeth
• Bracing, guarding, rubbing
• Fidgeting, increasing or recurring restlessness
• Striking out, increasing or recurring agitation
• Eating or sleeping poorly

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Pain in the Elderly Recognition

• Non-specific signs and symptoms suggestive of
  pain
• Sighing, groaning, crying, breathing heavily
• Decreasing activity levels
• Resisting certain movements during care
• Change in gait or behavior
• Loss of function

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Pain Management CPG Recognition Steps

• Is pain present?
• Have characteristics and causes of pain been
  adequately defined?
• Provide appropriate interim treatment for pain.

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Pain Management CPG Recognition
Pain Intensity Scales for Use with Older Patients
Visual Analogue Scale No pain
Terrible pain l______l_____l_____l______l_____l___
___l_____l______l______l 1 2
3 4 5 6
7 8 9 10 Ask the patientPlease point to
the number that best describes your pain
Scale has worst possible pain at a 10
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Pain Management CPG RecognitionDocumenting an
Initial Pain Assessment

• Pattern Constant_________ Intermittent__________
  
• Duration __________
• Location __________
• Character Lancinating____ Burning______
  Stinging_____
• Radiating______ Shooting_____
  Tingling______
• Other Descriptors________________________________
  
• Exacerbating Factors_____________________________
  _
• Relieving Factors________________________________
  _

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• Pain Intensity (None, Moderate, Severe)
• 1 2 3 4 5 6 7 8
  9 10
• Worst Pain in Last 24 Hours (None, Moderate,
  Severe)
• 
  1 2 3 4 5 6 7 8 9 10
• Mood ________________________________________
• Depression Screening Score ______________________
  
• Impaired Activities _____________________________
  _
• Sleep Quality __________________________________
• Bowel Habits __________________________________
• Other Assessments or Comments__________________
• ______________________________________________
• ______________________________________________
• Most Likely Causes Of Pain ______________________
  _
• ______________________________________________
• Plans ________________________________________
• ______________________________________________

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Pain Management Assessment Steps

• Perform a pertinent history and physical
  examination
• Identify the causes of pain as far as possible
• Perform further diagnostic testing as indicated
• Identify causes of pain
• Obtain assistance/consultations as necessary
• Summarize characteristics and causes of the
  patients pain and assess impact on function and
  quality of life

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Pain Management Assessment Steps

• Pain History 7 Important Elements to Include
• Known etiology and treatments previous
  evaluation, pain diagnoses and treatments
• Prior prescribed and non-prescribed treatments
• Current therapies

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Pain Management Assessment StepsChronic Pain
History

• ?PQRST
• Provocative/palliative factors (e.g., position,
  activity, etc.)
• Quality (e.g., aching, throbbing, stabbing,
  burning)
• Region (e.g., focal, multifocal, generalized,
  deep, superficial)
• Severity (e.g., average, least, worst, and
  current)
• Temporal features (e.g., onset, duration, course,
  daily pattern)
• ? Medical History
• Existing comorbidities
• Current medications
• Source Valley, MA. Pain measurement. In Raj PP.
  Pain Medicine. St. Louis
• MO. Mosby, Inc. 199636-46.

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Pain Management Treatment Steps

• Adopt an interdisciplinary care plan
• Set goals for pain relief
• Implement the care plan

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Pain Management Treatment Steps

• Provide a Comforting and Supportive Environment
  
• Reassuring words/touch
• Topical or low-risk analgesic
• Talk with patient/caregivers about pain
• Back rub, hot or cold compresses
• Whirlpool, shower
• Comforting music
• Chaplain services

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Pain Management Treatment StepsEthics and Pain

• The old ethic of under-prescribing
• ? just say no
• ? it hurts so good
• The new ethic
• ? trust believing what patients say
• ? commitment formalized mutual
  agreement
• ? standardized care guidelines on assessment
  and treatment
• ? collaboration working together
• Source Marino A. J Law, Med Ethics, 2001

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Pain Management Treatment

• General Principles for Prescribing Analgesics in
  the Long-Term Care Setting
• Evaluate patients overall medical condition and
  current medication regimen
• Consider whether the medical literature contains
  evidence-based recommendations for specific
  regimens to treat identified causes
• For example, acetaminophen for musculoskeletal
  pain narcotics may not help fibromyalgia
• In most cases, administer at least one medication
  regularly (not PRN)

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Pain Management Treatment

• General Principles for Prescribing Analgesics in
  the Long-Term Care Setting
• Use the least invasive route of administration
  first
• For chronic pain begin with a low dose and
  titrate until comfort is achieved
• For acute pain begin with a low or moderate
  dose as needed and titrate more rapidly
• Reassess/adjust the dose to optimize pain relief
  while monitoring side effects

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Pain Management Treatment

• Appropriateness of regular or PRN dosing
• Intermittent/less severe pain
• ? Start with PRN then switch to regular if
  patient uses more than occasionally.
• ? Start with a lower regular dose and
  supplement with PRN for breakthrough pain.
• ? Adjust regular dose depending on
  frequency/severity of breakthrough pain.

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Pain Management Treatment

• Appropriateness of regular or PRN dosing
• More severe pain
• ? Standing order for more potent, longer-acting
  analgesic and supplement with a shorter acting
  analgesic PRN
• Severe/recurrent acute or chronic pain
• ? Regular, not PRN dosage of at least one
  medication
• Start with low to moderate dose,
• then titrate upwards

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Pain Management Treatment

• Goal of treatment is to decrease pain, improve
  functioning, mood and sleep
• Strength of dosage should be limited only by side
  effects or potential toxicity

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Pain Management CPG Treatment Non-Opioid
Analgesics Used in the Long-Term Care Setting
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Pain Management CPG Treatment

• Opioid Therapy Prescribing Principles and
  Professional Obligations 9
• Drug Selection
• Dosing to optimize effects
• Treating side effects
• Managing the poorly responsive patient

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Pain Management CPG Treatment Opioid
Analgesics Used in the Long-Term Care Setting
(Oral and Transdermal)
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Pain Management CPG Treatment
Duration of effect increases with repeated use
due to cumulative effect of drug
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Pain Management CPG TreatmentOral Morphine to
Transdermal Fentanyl NOTE This table is
designed to convert from morphine to transdermal
fentanyl and is based on a conservative
equianalgesic dose. Using this table to convert
from transdermal fentanyl to morphine could lead
to overestimation of dose.
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TreatmentTopical Analgesics

• Counterirritants (menthol, methyl salicylate)
• Supplied as liniments, creams, ointments, sprays,
  gels or lotions
• May be effective for arthritic pain (not
  multiple joint pain)

• Capsaicin cream (0.025) and (0.075)
• Derived from red peppers
• Depletes substance P, desensitizes nerve fibers
  associated with pain
• Main limitations are skin irritation and need for
  frequent application
• Need to use routinely for optimal effectiveness

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TreatmentAnalgesics of Particular Concern in the
Long-Term Care Setting

• Chronic use of the following drugs are not
  recommended
• Indomethacin
• Piroxicam
• Tolmetin
• Meclofenamate
• Propoxyphene

• Meperidine
• Pentazocine, butorphanol and other
  agonist-antagonist combinations

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Treatment Non-Analgesic Drugs Sometimes Used
for Analgesia

• Neuropathic pain
• Antidepressants
• Anticonvulsants
• Antiarrhythmics
• Baclofen

• Inflammatory diseases
• Corticosteroids
• Osteoporotic fractures
• Calcitonin

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Treatment Factors to evaluate when considering
complementary therapies

• Patients underlying diagnosis and co-existing
  conditions
• Effectiveness of current treatment
• Preferences of the patient and family or advocate
• Past patient experience with the therapy
• Availability of skilled experienced providers

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Pain Management CPG Monitoring Steps

• Re-evaluate the patients pain
• Adjust treatment as necessary
• Repeat previous steps until pain is controlled

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Pain Management CPG MonitoringOpioid Therapy
Monitoring Outcomes

• Critical outcomes The Four As
• Analgesia Is pain relief meaningful?
• Adverse events Are side effects tolerable?
• Activities - Has functioning improved?
• Aberrant drug-related behavior

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Pain Management CPG Monitoring

• When patient is unresponsive to clinical
  management consider referral to
• Geriatrician
• Neurologist
• Physiatrist
• Pain clinic
• Physician certified in palliative medicine
• Psychiatrist (if patient has co-existing mood
  disorder)

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Dilemmas in Pain Management

• While addressing pain management, have strategies
  in mind for common problems
• Patient refusal of potentially beneficial
  medication
• Patient and family pressure to prescribe certain
  drugs
• Patient and family misconceptions about illness
• Unrecognized or denied psychiatric disturbances

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Reviewing the Physicians Role

• Prevention strategies
• Communication with patients/families
• Documentation
• Participate in Quality Improvement
• Follow policies and procedures

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Summary

• Views about management of pain in the elderly
  have changed in recent years
• It is an expectation that pain be managed
• Pain can be effectively treated in the long-term
  care setting
• A culture of patient comfort should permeate all
  aspects of facility operations