Chronic Pain in the Elderly

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Chronic Pain in the Elderly

• Management Strategies for a vexing problem

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Outline

• The usual statistics!
• Assessing pain in the elderly
• causes of chronic pain
• prescribing caveats
• therapeutic options
• non-pharmacological approaches

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An attempt at definitions

• Pain an unpleasant sensory emotional
  experience derived from sensory stimuli, modified
  by individual memory, expectations and emotions

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How to define chronic?

• Lasting longer than expected time frame
• pain not amenable to routine control mechanisms
• definition needs to be flexible

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Lots of aches and pains!

• 18 of older Americans taking regular analgesics
• 45 of these had seen 3 or more MDs
• 24-50 of older people have significant pain
• 45-80 of N.H. residents have undertreated pain

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Where is the pain?

• More commonly multiple sources
• some pains more common in elderly
• post-herpetic neuralgia
• cancer-related pain
• spinal stenosis
• diabetic neuropathy
• osteoarthirits

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Does pain perception change with aging?

• Older people expect more pain
• few older patients feel that pain cannot be
  controlled because of their age
• typical pains may present atypically
• no consistent age-related changes
• dementia may alter presentation of pain

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Factors contributing to ? Increased threshold

• Psychosocial models
• decreased financial/social supports-----gt poor
  response to chronic pain
• do not wish to displease their physician
• different coping skills

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Assessing pain in older patients

• Recognition of pain is crucial
• 35 of communicative patients had pain not
  identified by MD
• dementia is a huge barrier
• caregiver information is important
• depression may present with pain
• use of validated tools may be helpful

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Can pain-intensity scales be used ?

• Yes- with caution
• limited by cognitive changes, impaired vision,
  physical limitation
• no specific scale more user friendly
• 83 of nursing home residents could complete a
  pain scale

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Some example of scales...
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Some more examples.
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Targeting your approach

• Organization
• NOCICEPTIVE PAIN
• arthropathies
• ischemic dosorders
• visceral pain
• NEUROPATHIC PAIN
• neuropathy
• PHN
• post-stroke pain (central)

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Getting organized

• MIXED OR UNDETERMINED
• chronic recurrent headaches
• PSYCHOLOGICALLY BASED PAIN SYNDROMES
• somatization disorder
• conversions disorders

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Putting it all together
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Using Pharmacological options safely

• Pharmacokinetics
• pharmacodynamics
• compliance
• cost
• polypharmacy

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Safe prescribing

• Remember basic principles
• use WHO pain ladder
• take a careful drug history
• know the pharmacology of the Rx
• start low, go slow
• regularly review the regimen
• remember that drugs may cause illness

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More specifically!

• Non-opiates
• Acetominophen
• NSAIDs
• ASA
• TCAs
• anticonvulsants
• Opiates

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Using acetaminophen effectively

• First-line agent for OA
• safe alternative to NSAIDs for non-inflammatory
  pain
• safe given ii q4H to max 4000mg/day
• caution with liver disease or heavy EtOH
• ??? Interaction with coumadin

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NSAIDs Guidelines for use

• 40-60 of NSAID use is by older people
• in many circumstances can be replaced by an
  analgesic
• avoid chronic use in high risk patients
• when initiated, use low doses with prostaglandin
  analogue

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Further guidelines...

• consider alternatives with nephrotoxic risk
  factors
• avoid in elderly with CHF,renal impairment, on
  warfarin or corticosteroids
• monitor INR if NSAID necessary
• MDs should always askl about concomitant
  medications, esp. OTC

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Treating neuropathic pain

• Tricyclic antidepressants
• classically for burning dysasthesic pain
• caution with cardiactoxicity, anticholinergic
  effects
• effective dose lower than for depression
• choose your agent appropriately
• monitor specific side effects

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Neuropathic pain...

• Anticonvulsants
• lancinating pain
• ?? Safer than TCAs
• need to monitor CBC, LFTs
• newer agents may be safer but not ODB

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Using Opiates safely and legally

• In 1992 tylenol with codeine the 1 drug in
  Ontario!!
• May be used safely but many concerns
• increase in common side effects