Transcript Pain Management in Geriatric Medicine Smith, Howard. Clinics in

Pain Management in
Geriatric Medicine
Smith, Howard. Clinics in Geriatric Medicine, May 2008; Vol 24, No.2; 1549 1556
Zachary Lapaquette
PharmD Candidate
University of Georgia
Background
❖
In 2000, 65-and-older population comprised 35 million
people, 12.4% of U.S. population
❖
Beginning in 2011, the first members of the Baby Boom
will reach 65
❖
By 2050, 79 million Americans will be age 65 or older,
20% of the projected population
Background
❖
73.5% of population over 65 reported pain in 3 month
period
❖
Significant correlation between loneliness and
psychologic distress/pain
❖
Older persons with pain are almost twice as likely to have
sleep disturbances as older persons without pain
Overview
❖
Pain assessment in the non-verbal patient
❖
Pharmacotherapy of pain in older patient
❖
Special consideration and evaluation of older patient with
pain
❖
Assessment of Pain in
the Nonverbal or
Cognitively Impaired
Older
Adult
Bjoro, K, Herr,
K. Clin Geriatr
Med, 24 (2008)237-262
Source: http://www.artexpertswebsite.com/pages/artists/novelli.php
Background
❖
Pain is a highly subjective experience
❖
Self-report is gold standard of pain assessment
❖
Loss of ability to communicate can occur with
several states:
❖
Dementias
❖
Severe depression
❖
Delirium
❖
Psychosis
❖
State of unconsciousness
❖
Mental disability
Pain Assessment
❖
5 key principles of pain assessment in nonverbal
populations:
1. Obtain self-report
2. Investigate possible pathologies
3. Observe behavior
4. Solicit surrogate report
5. Use analgesic trial
1. Self-Report
❖
Even “yes”/ “no” response is helpful
❖
Simple test to assess reliability:
❖
Patient provides number from 0 to 3 and a
word to describe pain. After 1 minute of
distracting conversation, patient is asked to
provide same number and word.
2. Pathologies
❖
Concept that pain can be assumed and treated
due to certain disease states
❖
❖
Musculoskeletal, neurologic disorders, etc.
Pain should be prophylactically treated before
undergoing any procedure
3. Pain-Associated
Behaviors
❖
Inherently subjective, it relies on observed
behaviors
❖
Changes in vital signs are not reliable as
indicators of pain
❖
Observations of behaviors should occur during
movement or activity that is likely to elicit a pain
response if pain is present
❖
Serial observations should be performed under
similar circumstances to ensure objectivity
3. Pain-Associated
Behaviors
Behavior
Examples
Facial expression
Frown, grimacing, distorted expression
Verbalizations
Groaning, calling out, noisy breathing, verbal
abusiveness
Body movements
Tense body posture, guarding, fidgeting,
increased pacing, rocking, gait or mobility
changes
Interpersonal interactions
Aggressive, combative, decreased social
interactions, socially inappropriate
Activity patterns
Refusing food, appetite changes, sleep, sudden
cessation of common routines
Mental status changes
Crying, increased confusion, irritability or distress
4. Surrogate Reporters
❖
Family and care-givers (e.g. nurses’s assistant) of
patient are more sensitive to patient behaviors
❖
Training of care-givers is important to safeguard
reliability of behavioral observation
❖
Raters should compare observations with each
other
5. Analgesia Trial
❖
Trial of patients with dementia receiving 3g/day
of acetaminophen showed greater social activity
v. placebo
❖
2.6g/day trial unsuccessful
❖
Analgesic trial method has not been appropriately
studied, but is promising approach
Dementia and Pain
❖
Alzheimer’s disease and vascular dementia
patients experience language disturbance and
mutism in late stages of disease
❖
Frontotemporal dementia and primary
progressive aphasia show earlier onset
❖
It’s been determined that patients with
dementia experience greater incidence of pain
Dementia and Pain
❖
Subtype of dementia impacts pain response:
❖
In frontotemporal dementia, a decrease in
affective pain response has been documented
❖
In vascular dementia and AD, an increase in
affective response is reported
Delirium and Pain
❖
Delirium is a transient cognitive impairment
characterized by fluctuating awareness and
change in cognition or perceptual disturbance,
in the presence of underlying illness
❖
Considerable overlap between delirium and
pain-associated behaviors
❖
Consider analgesic trial
Critical Illness
❖
Patients tend to experience constant baseline
aching pain with intermittent sharp, stinging
pain due to procedures
❖
Identification of pain in ICU is complex
❖
Sixty-two percent of older patients in ICU
experience delirium
Pharmacotherapy of
Pain in Older Adults
❖
Strassels, McNicol, Suleman. Clin Geriatr Med, 24 (2008)275-298
Source: http://www.archives.gov.on.ca/english/on-line-exhibits/connon/pics/11585_port_elderly_man_520.jpg
Geriatric Considerations
❖
Pharmacokinetic changes:
❖
❖
e.g. absorption, distribution, fat composition,
renal function
Pharmacodynamic changes:
❖
e.g. decrease in Mu opioid receptors,
sensitivity to anti-cholinergics
Salicylates
ASA, diflunisal, magnesium salicylate, salsalate
❖
Substantially higher doses needed for antiinflammatory activity than for antiplatelet,
antipyretic and analgesic effects
❖
Excreted renally
❖
A/E’s include GI irritation and bleeding. Do not
use in patients with h/o gastric or peptic ulcers
Acetaminophen
❖
Inhibits central PG synthesis
❖
No clinically significant reductions in
inflammation or A/E’s on gastric mucosa or
platelet function
❖
Metabolized via several pathways in liver
❖
❖
Overdose forces metabolism via Nhydroxylation pathway NAPQI
Use caution in patients with liver disease,
malnutrition. Max dose: 4g/day
NSAIDs
Ibuprofen, naproxen, ketoralac, diclofenac, naproxen
indomethacin, ketoprofen, nabumetone, meloxicam
❖
❖
Inhibit central PG synthesis via cyclooxygenase inhibition
❖
COX 1 selective - ASA, ketoprofen, indomethacin, piroxicam
❖
Slightly COX 2 selective - etodalac, nabumetone and meloxicam
❖
COX 2-selective - Celecoxib
A/E’s include nausea, vomiting, bleeding, nephro- and hepatotoxicity
❖
❖
Ketoralac and celecoxib thought to have less GI bleeding
Causes increased levels of other highly protein-bound drugs warfarin, methotrexate, digoxin, cyclosporine, anticonvulsants
Opioids
❖
Classified according to affected receptor:
❖
Mu-receptor agonists generally produce analgesia,
affect numerous body systems and have addictive
characteristics
❖
Kappa agonists have less respiratory depression and
miosis, but can cause dysphoria
❖
Delta agonists are still in Stage I experimentation,
with potential uses in depression
Opioids
Mu-agonists
Alfentanil, codeine, hydrocodone,
hydromorphone, fentanyl, levorphanol,
meperidine, methadone, morphine, opium,
oxycodone, oxymorphone, remifentanil, sufentanil,
tramadol
Kappa-agonists/
mu-antagonists
Butorphanol, nalbuphine, pentazocine
Mu-antagonists
Nalmefene, naloxone, naltrexone
Mu partial-agonist/
kappa-antagonists
Buprenorphine
Opioids
❖
Adverse effects:
❖
Respiratory depression - can reverse with naloxone
❖
Nausea and vomiting - recommend non-drowsy
medications
❖
Constipation - stool softener + stimulant laxative
❖
Increased bladder spasms and increased sphincter
tone
❖
Itching - switch opioid agent or use less-sedating
anti-histamine
Opioids
Parental
(mg)
Oral
(mg)
Duration
(h)
120
200
3-4
1.5
7.5
2-4
Meperidine
75
300
2-4
Methadone
5
10
6-8
Morphine
10
30
2-4
Oxycodone
NA
20
2-4
Codeine
Hydromorphone
❖
Failure of one opioid does not
preclude failure of class
❖
Reduce calculated dose of
new drug by 25-50% for
opioid-tolerant patients
❖
Increase total daily dose by
10-20% for breakthrough pain
Special Issues and Concerns in the
Evaluation of Older Adults Who
Have Pain
❖
Kirsh, K, Smith, H. Clin Geriatr Med, 24 (2008)263-274
Source: http://www.shopping-guides.info/antiques/opium-morphine-oklahoma-drugs-medicine-bottle-labels.html
Introduction
❖
Prescription abuse is increasing in U.S., at all ages
❖
Substance abuse disorders occur in 19-26% of hospitalized
population
❖
Chronic severe pain present in 37% of methadone maintenance
patients and 24% of inpatient addiction patients
❖
At the same time, pain continues to be under-treated
❖
❖
Cancer patients who are an ethnic minority, female, elderly, or a
substance abuser are more likely to have inadequate treatment
of pain
Essential to successfully evaluate patient for substance-abuse
Risk
Assessment
❖
CAGE
❖
Drug Abuse
Screening Test
❖
Opioid Risk Tool
❖
Screener and
Opioid Assessment
for Patients in Pain
Lynn Webster, MD
Documentation
❖
❖
Clearly chart
❖
Pain relief
❖
Functional outcomes
❖
Side effects
❖
Drug-seeking behaviors
Documentation must be easy to access and
suitable to compare trends
Documentation
❖
Include aberrant behavior in assessment of
patient, nurses’ notes and encounter notes
❖
Include goals of pain management in patient plan
❖
Include risk assessment tests in chart
Other Notes
❖
Difficult to assess, define addiction
❖
Specialists and primary care physicians each have
role in care and identification
❖
With a standardized, objective approach, we may
be more successful in treating older patients
equally and broaching sensitive topics