Transcript Caring for Geriatric Patients in the ED Setting: Part V

Caring for Geriatric Patients in the
Emergency Department Setting
Part V: Pain Management Challenges
Laurie A. Hanly, BA, BSN, RN, MS
Emergency Department, VA Medical Center, Portland, OR
Ula Hwang, MD, MPH
Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY
Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, NY, NY
Timothy F. Platts-Mills, MD, MSc
Department of Emergency Medicine, University of North Carolina School of Medicine,
Chapel Hill, NC
February 2014
Discussion today
1.
2.
3.
4.
5.
Introduction (Hwang)
Assessment (Hanly)
Pharmacological treatment options (Platts-Mills)
Non-pharmacological treatment options (Platts-Mills)
General challenges and recommendations (Hanly)
VETERANS HEALTH ADMINISTRATION
1
Part I. Introduction - Pain in the ED
• Pain as 5th vital sign
• Identified as an area for quality improvement
• Pain is common ED cc
– 70% of ED conditions
– 34% of all medications used in ED for pain
• Inconsistent & inadequate analgesia
(oligoanalgesia)
VETERANS HEALTH ADMINISTRATION
2
Disparities in Analgesia
• Differences in prescribing patterns found in
cancer pain, fracture treatment, and
postoperative pain patients across gender, AGE ,
and race/ethnicity
• In the ED setting, blacks or Latinos (vs. whites)
received less analgesia for long bone fractures
Awareness of disparities may allow for targeting
to reduce
VETERANS HEALTH ADMINISTRATION
3
Pain and Outcomes
• Under treated and untreated pain associated
with increased risk of developing delirium
• Patients with higher pain scores at rest with
longer hospital LOS, delays in functional recovery,
and risk of long-term functional impairment
VETERANS HEALTH ADMINISTRATION
4
Pain in Older Adults
• High prevalence of pain in older adults
– Self-doubt, reluctant, and reticent to complain
• 50% ED MDs uncomfortable giving analgesics to
elderly
• Co-morbidities, drug-drug interactions, age-related
drug metabolism changes, and fear of adverse
reactions makes giving analgesia a challenge
VETERANS HEALTH ADMINISTRATION
5
Polypharmacy
•
•
•
•
90% older adults on  1 medications
40% on >5 medications
30-50% receive new prescription at ED discharge
Risk adverse drug reaction with
–
–
–
–
Multiple meds
Severity of illness
Multiple comorbidities
Changes in physiologic reserve
VETERANS HEALTH ADMINISTRATION
6
Physiologic Reserve Loss
Lower body mass, total body water, hepatic and
renal function, increased fatty tissue…
– Pharmacodynamics
(how drugs act at receptor sites and affect the body)
– Pharmacokinetics
(drug distribution/elimination)
 Caution and awareness in analgesia choice
and dosing (do no harm…start low and go slow…)
VETERANS HEALTH ADMINISTRATION
7
Geriatric ED Pain Care
• Frequent assessments
• Do no harm
• (Start low and go slow)  Start low and REASSESS
VETERANS HEALTH ADMINISTRATION
8
Beers Criteria
• Consensus based pharmacologic guidelines for
older adults
• Defines “inappropriate use of medications”
• List of medications to avoid
• Most recent update in 2012
VETERANS HEALTH ADMINISTRATION
9
Geriatric ED Pain Care Quality Indicators
Quality indicators describe minimum level of care
– Pain assessed <1 hour arrival
– F/U assessment <6 hours
– F/U prior to discharge if received pain med
– Pain med if mod-sev pain
– Avoid meperidine
– Bowel regimen if discharged with opioid Rx
(Terrell KM, et.al. Quality indicators for geriatric emergency care. Acad
Emerg Med. 2009)
VETERANS HEALTH ADMINISTRATION
10
Part II. Pain Assessment - Laurie Hanly
1.
2.
3.
4.
5.
Introduction (Hwang)
Assessment (Hanly)
Pharmacological treatment options (Platts-Mills)
Non-pharmacological treatment options (Platts-Mills)
General challenges and recommendations (Hanly)
VETERANS HEALTH ADMINISTRATION
11
The first step toward improving patient comfort is
recognizing pain
66% of geriatric nursing home residents have chronic pain but
34% had pain that went undetected by their physician
Basic pain rating assessment tools:
1. Verbal
Numerical rating scale
Verbal rating scale
Functionally descriptive
2. Non-verbal
Pictorial
Behavioral
(Kay AD, Baluch A, Scott J. Pain Management in the Elderly Population: A Review. Ochsner Journal. 2010)
VETERANS HEALTH ADMINISTRATION
12
Verbal Pain Scales
1. Numerical pain rating scale: Rate your pain from 0 – 10
2. Verbal rating scale: Choose the phrase that best describes your pain
No -pain
mild -pain
VETERANS HEALTH ADMINISTRATION
moderate
pain
--
severe
pain
--
unbearable
pain
13
Verbal Pain Scales continued
3. Functional Pain Scale:
0
1
2
3
4
No Pain (pain free)
Functional:
pain is present but does not get in the way of my daily activities or quality of life
5
6
7
Uncomfortable:
8
9
Severe: Not able to leave home, unable to do anything, spends time in bed
10
Unbearable: pain out of control, overwhelmed, can not tolerate, seeks immediate care
hard to move, cannot concentrate, impacts ability to function and enjoyment of life
high effect on daily activities and quality of life
(Evans CM, Chronic Pain is a Chronic Condition, Not Just a Symptom. Permanente Journal. 2005)
VETERANS HEALTH ADMINISTRATION
14
Non-verbal Pain Scales
1.
Wong Baker Pain Faces Scale:
2. Visual Analog Scale: 10 cm in length
No pain
VETERANS HEALTH ADMINISTRATION
Worst pain
imaginable
15
Other Non-verbal Pain Scales
3. Behavioral Scale:
Facial Expressions
Vocalizations
Body Movements
Social Interactions
Clenched teeth
Crying
Restlessness
Silence
Wrinkled forehead
Moaning
Protective body
movement
Withdrawal
Biting lips
Grasping
Reduced attention
Muscle tension
Scowling
Groaning
Immobility
Closes eyes tightly
Focus on pain relief
measures
Grunting
Widely opened
eyes or mouth
VETERANS HEALTH ADMINISTRATION
Rhythmic
movements
16
Assessing Pain “O” to “T”
• O: origin (when, what was the patient doing)
• P:
provocation and palliation
• Q: quality (sharp, achy, throbbing, tingly, burning, dull, etc….)
• R:
region, radiation
• S:
severity
• T:
treatment
(What do you take or do for your pain?)
Remember to use open-ended questions.
VETERANS HEALTH ADMINISTRATION
17
Tim Platts-Mills
1.
2.
3.
4.
5.
Introduction (Hwang)
Assessment (Hanly)
Pharmacological treatment options (Platts-Mills)
Non-pharmacological treatment options (Platts-Mills)
General challenges and recommendations (Hanly)
VETERANS HEALTH ADMINISTRATION
18
Part III. Selecting Pharmacologic Therapies for Pain
•
•
•
•
•
Acetaminophen
NSAIDs
Opioids
Other Medications
Shared Decision Making
VETERANS HEALTH ADMINISTRATION
19
Acetaminophen
•
•
•
•
•
Safe except in patients with liver disease, chronic alcohol use
First-line therapy for outpatient treatment of pain in older adults
Dose in older adults: 500 mg every 4 hours
Max dose: 3 gm in 24 hours
Increase dosing interval if renal impairment:
– CrCl 10-50 mL/min = q 6 hours
– CrCl < 10 mL/min = q 8 hours)
• Adjust dosing in patients taking combination opioid +
acetaminophen
VETERANS HEALTH ADMINISTRATION
20
NSAIDs - Risks
• More effective for pain than acetaminophen
• But due to risks, prescribed on a case-by-case basis
• Risks: cardiovascular events, upper GI bleeding, acute renal failure,
CHF exacerbations
• Most common cause of severe adverse drug reactions leading to
hospitalization
• Considered inappropriate for long-term treatment of pain in older
adults by most experts
(Onder G, et.al. Adverse drug reactions as a cause of hospital
admissions: results from the Italian group of pharmacoepidemiology in
the elderly. JAGS. 2002)
VETERANS HEALTH ADMINISTRATION
21
NSAIDs - Risks
• Even short-term use (i.e. <48 hours) of NSAIDs unsafe in high risk
patients
• Avoid NSAIDs (including Ketorolac/Toradol) in high risk patients:
–
–
–
–
Renal failure
CHF
History of upper GI bleed
Taking ACE Is, ARBs, of metformin
(Platts-Mills TF, et al. Life-threatening hyperkalemia after 2 days of
ibuprofen. Am J Emerg Med. 2012)
VETERANS HEALTH ADMINISTRATION
22
NSAIDs – which one?
• In low risk patients, consider NSAIDs for short-term or intermittent
pain management.
• Naproxen (Aleve)
– lowest cardiovascular risk
– similar GI bleeding risk to ibuprofen.
• COX-2’s (e.g. Celebrex)
– lowest risks of upper GI bleeding
– use of proton pump inhibitor further reduces risk of GI bleeding
(Bhala, N et al. Vascular and upper gastrointestinal effects of nonsteroidal anti-inflammatory drugs: meta-analyses of individual
participant data from randomised trials." Lancet. 2013)
VETERANS HEALTH ADMINISTRATION
23
IV Opioids
• IV Opioids are appropriate for acute severe pain
• Typical agents are morphine or dilaudid
• Use lower doses (i.e. 2-4 mg morphine) for frail, small individuals
who are opioid naïve and those with respiratory conditions
• Reassess and give more as needed frequently (q 20 minutes): “start
low but reassess often”
• Use continuous cardiac and oxygen saturation monitor
• Pre-treat for anticipated pain (e.g. during movements for x-rays)
VETERANS HEALTH ADMINISTRATION
24
Oral Opioids, Short-Term Use
• Use oral opioids for moderate or severe pain in patients who can
tolerate oral medications and for outpatient treatment of pain
• Prescribed as supplement to scheduled acetaminophen
• Side effects among older adults in first week of opioid treatment:
–
–
–
–
Tiredness (30%)
Constipation (20%)
Nausea (20%)
Dizziness (17%)
(Hunold KM et al. Side effects from oral opioids in older adults during
the first week of treatment for acute musculoskeletal pain. Acad Emerg
Med. 2013)
VETERANS HEALTH ADMINISTRATION
25
Oral Opioids, Short-Term Use
• Prevent constipation. Tell your patients to:
– Drink plenty of water
– Eat at least 30 grams of fiber a day
– Stay physical active (especially walking)
– Senna 17 mg / day (increases bowel motility)
– If history of constipation, Senna plus stool softener
• Polyethylene glycol (e.g. Miralax)
• Docusate (e.g. Colace).
VETERANS HEALTH ADMINISTRATION
26
Oral Opioids, Long-Term Use
• Safety concerns – all are increased compared to NSAID therapy:
– cardiovascular events
– fractures
– hospitalizations
• Best if managed by a single provider to
– Ensure consistent dosing
– Reduce risk of inappropriate use, overdose
(Solomon DH et al. The comparative safety of analgesics in older adults
with arthritis. Arch Intern Med. 2010)
VETERANS HEALTH ADMINISTRATION
27
Questions to Consider When Deciding on Long-Term
Opioid Treatment for Older Adults
1.
2.
3.
4.
5.
What is usual practice for this type of pain?
Are there safer, effective alternatives?
Does this patient have increased risk of opioid-related adverse effects?
Can patient take opioids responsibly?
Are patient’s medical, behavioral, or social circumstances so complex as to
warrant referral to a pain medicine specialist?
VETERANS HEALTH ADMINISTRATION
28
Opioids – which one?
Safest
Most Dangerous
All Cause Mortality:
Tramadol/Hydrocodone
Fractures:
Tramadol
GI events:
CV Events:
Oxycodone
Hydrocodone/Oxycodone
No Difference
Tramadol/Hydrocodone
Oxycodone
(Solomon DH et al. The comparative safety of opioids for nonmalignant
pain in older adults. Arch Intern Med. 2010)
VETERANS HEALTH ADMINISTRATION
29
Other Medications to Treat Pain
• SNRIs (duloxetine, venlafaxine) – neuropathic pain. Side effects: nausea,
dizziness.
• Gabapentin –neuropathic pain, may be safer than SNRIs
• Muscle relaxants – baclofen or benzodiazepines favored
• Calcitonin –inhibits osteoclast activity – effective in reducing bone pain
from fractures, metastases. Side effect: nausea.
• Topical Treatments
– Topical NSAIDs –not demonstrated to be better than placebo after first
2 weeks (BMJ 2004 systematic review)
– Lidoderm patch 5% – good for post-herpetic neuralgia
VETERANS HEALTH ADMINISTRATION
30
Femoral Nerve Block
• Use in patients with hip fractures, particularly those without good and
long-lasting relief from an initial dose of opioids
• Technique:
– Use ultrasound to identify femoral nerve or find nerve 1 cm lateral to femoral artery
pulse (see next slide)
– Bupivicaine 0.5% 20 mL
• Provides pain relief in first 12-24 and reduces need for opioids
• Side effect – short-term quadriceps muscle weakness/falls
(Fletcher AK et al. Three-in-one femoral nerve block as analgesia for
fracture neck of femur in the emergency department: a randomized,
controlled trial. Ann Emerg Med. 2010)
VETERANS HEALTH ADMINISTRATION
31
(Fletcher AK et al. Three-in-one femoral nerve block as analgesia for
fracture neck of femur in the emergency department: a randomized,
controlled trial. Ann Emerg Med. 2010)
32
Selecting Medications for Outpatient Treatment of
Pain – Shared Decision Making
•
Choosing the best pain medication is difficult:
– acetaminophen often insufficient
– NSAIDs and opioids significant risks
•
•
•
Patients often know what works for them
Or, they have preferences regarding balance between pain relief and risks
Provide patients with information and working with them to reach decision
– fewer side effects
– better pain relief.
•
Shared decision making takes time, but the extra time is likely to help your patient.
(Isaacs CG et al. Shared decision making in the selection of
outpatient analgesics in older adults. JAGS. 2013)
VETERANS HEALTH ADMINISTRATION
33
Part IV: Non-Pharmacologic Treatments for Pain
Generally more appropriate for chronic pain, but emergency providers
should be aware of these issues.
• Conceptual Basis
• Cognitive Behavioral Therapy / Pain Coping Skills Training
• Treatment of Depression
• Other Non-pharmacologic Therapies
VETERANS HEALTH ADMINISTRATION
34
Conceptual Basis
• Biopsychosocial model – pain is a complex experience that is
influenced by biological, psychological, and social context
• Evidence for the biopsychosocial model of pain in older adults:
– Pain often not correlated with tissue injury
– Treatments that correct tissue injury often fail to relieve pain
– Psychological and social factors strongly associated with pain
• If we accept this model, it makes sense to consider treatment the
psychological and social factors
(Keefe FJ et al. Psychosocial interventions for managing pain in older
adults: outcomes and clinical implications. Br J Anesth. 2013)
VETERANS HEALTH ADMINISTRATION
35
Cognitive Behavioral Therapy /
Pain Coping Skills Training
• Goal: Alter pain-related thoughts, emotions, and behaviors so that
patients experience less pain.
• Best approach in older adults is pain coping skills training, including:
–
–
–
–
Muscle relaxation
Imagery
Identifying and challenging negative thoughts
Problem solving
• Benefit shown for osteoarthritis and cancer pain
• Active learning better than didactic
• More benefit if you include a spouse / significant other
(Keefe FJ et al. Effects of spouse-assisted coping skills training and exercise
training in patients osteoarthritic knee pain: a randomized controlled study.
Pain. 2004)
VETERANS
HEALTH ADMINISTRATION
36
Treatment of Depression
• Two question screen for depression:
– In past month, have you been bothered by feeling down, depressed, or
hopeless?
– In past month, have you been bothered by little interest or pleasure in
doing things?
• Antidepressant medication + psychotherapy focused on problem
solving
• Results:
– Less pain
– Improved function
(Lin EH et al. Effect of improving depression care on pain and functional
outcomes among older adults with arthritis: a randomized controlled trial.
JAMA. 2003)
VETERANS HEALTH ADMINISTRATION
37
Other Non-Pharmacologic Therapies
• Physical Therapy – mostly studied for low back pain; no benefit or
small benefit over usual care
• Spinal Manipulation – mostly studied for low back pain; no benefit
or small benefit over usual care
• Electrical nerve stimulation – some evidence of benefit for knee
osteoarthritis
(Cherkin DC et al. A comparison of physical therapy, chiropractic
manipulation, and provision of an educational booklet for the treatment
of patients with low back pain. NEJM. 1998)
(Osiri M et al. Transcutaneous electrical nerve stimulation for knee
osteoarthritis (Review). The Cochrane Library. 2009)
VETERANS HEALTH ADMINISTRATION
38
Part IV. General Challenges and Recommendations Laurie Hanly
1.
2.
3.
4.
5.
Introduction (Hwang)
Assessment (Hanly)
Pharmacological treatment options (Platts-Mills)
Non-pharmacological treatment options (Platts-Mills)
General challenges and recommendations (Hanly)
VETERANS HEALTH ADMINISTRATION
39
Pain Management Challenges in Geriatric Patients
Major Challenge Areas
• Generational differences
• Assessment of Pain
• Psychosocial issues
• Lack of pain related education in physician and nursing programs
• Disconnect between knowledge and practice
• Nurse-Physician Communication
(Kay, A.D., Baluch, A., Scott, J.: Pain Management in the Elderly Population: A Review. Ochsner Journal 2010)
VETERANS HEALTH ADMINISTRATION
40
Generational Pain Management Challenges
• Differences in acceptance of pain
• Pain generally accepted as an inevitable part of aging
• Under-reported by patients out of fear of potential diagnosis
• WWII population stoic, therefore less likely to admit to pain or
request pain medication
• Increased incidence of dementia with aging
• Narrower view of how pain is defined
VETERANS HEALTH ADMINISTRATION
41
The Psychosocial Components of Pain Management
•
Subtherapeutic and/or compliance of home pain management
•
Support systems
–
–
–
–
•
Family relationships (particularly spousal support)
Caregiver involvement
Faith or faith-based association
Other Social supports
Mood
-- depression
-- suicidality
•
Potential of/for abuse
(Koizumy Y et al. Association between social support and depression status in the elderly: results of a 1-year community-based
prospective cohort study in Japan. Psychiatry Clin Neurosci. 2005)
(Martire LM et al. Older Spouses’ Perceptions of Partners’ Chronic Arthritis Pain: Implications for Spousal Responses, Support
Provision, and Caregiving Experiences. Psychology and Aging, 2006)
VETERANS HEALTH ADMINISTRATION
42
Physician/Nurse Education Related Challenges
• Many physician and nursing programs devote minimal, if any, time to
pain management.
• Lack of knowledge specific for geriatric care:
Recent study showed 50% of geriatric patients got pain medication administered IM
• Inability to assess pain in patients with dementia
(Titler MG et al. Acute pain Treatment for Older Adults Hospitalized with Hip Fracture: Current Nursing Practices and Perceived
Barriers. Applied Nursing Research. 2003)
VETERANS HEALTH ADMINISTRATION
43
Disconnect Between Knowledge and Practice
• Medications contraindicated or those needing to be dose
adjusted for geriatric patients
• Around the clock medication administration
• Routes of medication administration
(Titler MG et al. Acute pain Treatment for Older Adults Hospitalized with Hip Fracture: Current Nursing Practices and
Perceived Barriers. Applied Nursing Research. 2003)
VETERANS HEALTH ADMINISTRATION
44
Barriers to Effective Pain Management
in Geriatrics
• Communication between nurses and physicians
• Lack of communication between nurses and patients
• Difficulty separating the elderly and the younger patient who
may or may not look old but is physiologically old
• Fear of side effects
VETERANS HEALTH ADMINISTRATION
45
Pain Related Orders
Can Facilitate Effective Pain Management
• Scheduled
example: 2mg Morphine IV q30 minutes PRN to a maximum of 8mg
• PRN
example: 4mg Zofran IV for nausea and/or vomiting
• Parameters
example: 0.25mg Hydromorphone IV q20minutes to maximum of 1mg, hold if
respiratory rate drops below 10 or O2 < 94%
The comfort of a prescribing provider for any of these types of orders is of
course dependent upon the trust one has in the nursing staff.
VETERANS HEALTH ADMINISTRATION
46
Changing Practice to Improve Care
Studies have shown that continuing education alone leads to
only minimal changes in practice in physicians or nurses.
Reinforcing strategies such as the following have been
shown to be helpful in changing practice.
automated reminders integrated into orders
change champions
audits and/or peer feedback
(Titler MG et al. Acute pain Treatment for Older Adults Hospitalized with Hip Fracture: Current Nursing Practices and Perceived
Barriers. Applied Nursing Research. 2003)
VETERANS HEALTH ADMINISTRATION
47
Pain Improvement Programs
currently in place at Portland VA MC
1. ED Pain Reassessment
2. Pain Resource Nurse Program (PR-RN)
If you would like more information on the ongoing
Pain Resource Nurse Program or Pain Reassessment Study at PVAMC
feel free to contact me at [email protected]
VETERANS HEALTH ADMINISTRATION
48
Older patients are likely to continue to be untreated
or undertreated for pain until we adopt in practice
what we know from research…
Thank you for joining us today!
VETERANS HEALTH ADMINISTRATION
49