AMDA Clinical Practice Guideline (CPG) on Pain Management
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Transcript AMDA Clinical Practice Guideline (CPG) on Pain Management
AMDA Clinical Practice
Guideline
(CPG) for Pain Management
For Medical Directors and
Attending Physicians
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)
Introduction to Pain
The use of pain scales
Acute vs. chronic pain
Long-term care interventions
Pain in the Elderly
Definition of Pain—An individual’s
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
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”
Pain in the Elderly
Sources of pain in the nursing home
Source: Stein et al, Clinics in Geriatric Medicine: 1996
Condition causing pain
Low back pain
Arthritis
Previous fractures
Neuropathies
Leg cramps
Claudication
Headache
Generalized pain
Neoplasm:
Frequency (%)
40
37
14
11
9
8
6
3
3
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
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
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
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.
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
Pain in the Elderly
Consequences of untreated pain:
Depression
Suffering
Sleep disturbance
Behavioral disturbance
Anorexia, weight loss
Deconditioning, increased falls
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
AMDA Pain Management
CPG—Steps
1.
2.
3.
4.
Recognition
Assessment
Treatment
Monitoring
Pain in the ElderlyRecognition
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)
Pain in the ElderlyRecognition
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)
Pain in the ElderlyRecognition
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)
Pain in the ElderlyRecognition
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)
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
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
Pain Management CPG—
Recognition Steps
Is pain present?
Have characteristics and causes of
pain been adequately defined?
Provide appropriate interim treatment
for pain.
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 patient:“Please point to the number that best describes your pain”
Scale has worst possible pain at a # 10
Pain Management CPG—
Recognition
Documenting an Initial Pain Assessment
Pattern: Constant_________ Intermittent__________
Duration: __________
Location: __________
Character: Lancinating____ Burning______ Stinging_____
Radiating______ Shooting_____ Tingling______
Other Descriptors:________________________________
Exacerbating Factors:______________________________
Relieving Factors:_________________________________
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: ________________________________________
______________________________________________
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 patient’s pain and assess impact on
function and quality of life
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
Pain Management–
Assessment Steps
Chronic 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. 1996:36-46.
Pain Management–
Treatment Steps
Adopt an interdisciplinary care plan
Set goals for pain relief
Implement the care plan
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
Pain Management–
Treatment Steps
Ethics 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
Pain Management–
Treatment
General Principles for Prescribing Analgesics
in the Long-Term Care Setting
Evaluate patient’s 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)
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
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.
Pain Management–
Treatment
Appropriateness of regular or PRN dosing
More severe pain
Standing order for more potent, longeracting 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
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
Pain Management CPG–
Treatment
Non-Opioid Analgesics Used in the Long-Term Care Setting
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
Pain Management CPG–
Treatment
Opioid Analgesics Used in the Long-Term Care Setting
(Oral and Transdermal)
Pain Management CPG–
Treatment
* Duration of effect increases with repeated use due to cumulative effect of drug
Pain Management CPG–
Treatment
Oral 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.
Treatment
Topical Analgesics
Counterirritants
Capsaicin cream
(0.025%) and (0.075%)
(menthol, methyl
salicylate)
Derived from red peppers
Supplied as liniments,
Depletes substance P,
creams, ointments,
desensitizes nerve fibers
sprays, gels or lotions
associated with pain
May be effective for
Main limitations are skin
arthritic pain (not multiple
irritation and need for
joint pain)
frequent application
Need to use routinely for
optimal effectiveness
Treatment
Analgesics of Particular Concern
in the Long-Term Care Setting
Chronic use of the following drugs are not
recommended:
Meperidine
Indomethacin
Pentazocine,
Piroxicam
butorphanol and
Tolmetin
other agonist Meclofenamate
antagonist
Propoxyphene
combinations
Treatment
Non-Analgesic Drugs Sometimes
Used for Analgesia
Neuropathic pain
Antidepressants
Anticonvulsants
Antiarrhythmics
Baclofen
Inflammatory
diseases
Corticosteroids
Osteoporotic
fractures
Calcitonin
Treatment
Factors to evaluate when considering
complementary therapies
Patient’s underlying diagnosis and coexisting conditions
Effectiveness of current treatment
Preferences of the patient and family or
advocate
Past patient experience with the therapy
Availability of skilled experienced providers
Pain Management CPG–
Monitoring Steps
Re-evaluate the patient’s pain
Adjust treatment as necessary
Repeat previous steps until pain is
controlled
Pain Management CPG–
Monitoring
Opioid Therapy: Monitoring Outcomes
Critical outcomes: The “Four A’s”
Analgesia – Is pain relief meaningful?
Adverse events – Are side effects
tolerable?
Activities - Has functioning improved?
Aberrant drug-related behavior
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)
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
Reviewing the Physician’s
Role
Prevention strategies
Communication with patients/families
Documentation
Participate in Quality Improvement
Follow policies and procedures
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 longterm care setting
A culture of patient comfort should
permeate all aspects of facility operations