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Persistent Pain in the Elderly
Veeraindar Goli , MD, FAPA
Medical Director. , Pain Evaluation and Treatment Services
Associate Director ., Pain & Palliative Program
Duke University Medical Center , Durham , N.C. 27705
(919)684-2154
Objectives

Discuss the scope of the problem

Identify key issues in undertreatment of pain

Define Pain and discuss mechanisms

Age related differences in Pain Mechanisms and
Presentations

Assessment of pain in the Elderly

Treatment strategies and AGS Guidelines
2
Nine in Ten Americans Suffer from
Regular Pain
Frequency of Pain Suffered
11% Suffer less often
89%
Suffer once a month or more
Arthritis Foundation Survey. 1999.
3
Pain in the United States

Pain is the most common reason
people seek medical attention

50 Million people in the US are
partially disabled or totally disabled
by pain

45% of Americans seek care for their
persistent pain at some point in their
lives.
(Source: American Pain Society)
4
Pain in the Elderly

Pain is reported to be twice as prevalent in the elderly
as in younger individuals

Elderly in the community reported to have prevalence
of pain ranging from 25-50%

In LTC settings, prevalence can be as high as 85%

1/6 of all nursing home residents experience pain daily
( Source: “The Prevalence and Treatment of Pain in US Nursing Homes)

Chronic pain in the LTC setting is generally under
recognized and often under treated
( Source: American Geriatric Society Panel
5
Societal Attitudes and
Misconceptions Toward Pain

The elderly have a higher tolerance toward pain

The elderly or cognitively impaired cannot be
accurately assessed for pain

Residents complain of pain just to get more
attention

Elderly patients are likely to become addicted
to medication

Chronic Pain means death is imminent
6
Barriers to Recognition of Pain in
the Elderly

Racial, ethnic, religious and gender
biases

Cognitive impairment

Coexisting medical conditions

Staff training and access to
appropriate tools.

System Barriers
7
Barriers to Pain Treatment




Healthcare professionals

inadequate knowledge/ poor assessment

fear of tolerance, addiction and side effects

concern with regulatory issues
Patients

inadequate knowledge

fear of addiction and side effects
Healthcare System

access to specialists

inadequate reimbursement
State/Federal Regulations

scheduling

triplicates
8
Importance of Pain Relief?

It is an individual’s right to be pain free –
JCAHO Standards

Pain in the elderly associated with anxiety and
depression

Associated with significant medical morbidity

Pain negatively impacts the quality of life in
the older person

APS adapted it as the 5th vital sign
9
Almost all long term care residents have
predisposing factors for developing
pain.
For this reason, a high index of
suspicion regarding the presence of
pain is warranted.
Source: The Management of Chronic Pain in Older Persons, AGS Panel on
Chronic Pain in Older Persons.
10
Pain
Definition

An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage, or described
in terms of such damage (IASP)

Pain is whatever the patient says it is
and occurs whenever they say it
does !! (McCaffrey)
Merskey H, Bogduk N, eds. Classification of Chronic Pain. 1994:209-14.
11
What is pain, really?

Transduction

Transmission

Modulation

Perception
12
Neuroanatomy of Pain Pathways
Scientific American Medicine
13
Pain Classification
Pain
Acute
Headache
(migraine)
Chronic
Injury
Postoperative
Flare
Neuropathic
Diabetic neuropathy
(DN)
Post-herpetic neuralgia
(PHN)
Radiculopathy (RADIC)
Mixed
Cancer pain
Low back pain
Nociceptive
Osteoarthritis
Rheumatoid
arthritis
Fibromyalgia
Visceral
IBS
Pancreatitis
Bladder pain
Noncardiac chest pain
Abdominal pain syndrome
14
Pain Physiology

Nociceptive Pain

Neuropathic Pain

--Peripheral sensitization

--Central sensitization

--Neuroplastic changes

Mixed Pain
15
Pain types- features
Nociceptive (Acute)
(Physiological)
Neuropathic (Chronic)
(Pathological)

Pain serves a protective
function

Pain is pathological, associated
with nerve injury; no biological
function

Transient

Outlasts stimulus

Well localized

Spreads to noninjured regions
“linear” stimulusresponse pattern as other
sensory modalities

Occurs with sensitization of
peripheral and central nervous
systems
Pain (A-d & C fibers) can
be differentiated from
touch (A-b fibers)

Pain elicited from A-b, as well as
A-d & C fibers


16
Normal Events That Produce Nociception: Paper
Cut

Tissue injury

Immediate activation of
Ad fibers(first pain)
More
 Fast
 Localize the injury

Later activation of
C fibers(second pain)
 Slower
 Less ability to localize
injury
 Tissue reaction to
injury
Less
Time (seconds)
17
Characteristics of Neuropathic Pain

Spontaneous pain: Due to spontaneous
firing of axons or dorsal horn neurons
- Lancinating, paroxysmal
- Burning, constant
- Cramping

Evoked pain: Due to damage and alterations
in peripheral and central sensory neurons
- Allodynia
- Hyperalgesia
- Hyperpathia
18
Pathologic Pain Functions
hyperpathia
hyperalgesia
Magnitude
of pain
normal
allodynia
Stimulus intensity
19
Peripheral Sensitization
Tissue damage
Inflammation
Sympathetic
terminals
SENSITIZING “SOUP”
Hydrogen ions Histamine
Purines
Leukotrienes
Noradrenaline Potassium ions Cytokines Nerve growth factor
Bradykinin
Prostaglandins 5-HT
Neuropeptides
Decreased threshold of nociceptors
Ectopic discharges
Abnormal accumulation of Na+ channels
Adapted from Siddal, Cousins. In: Cousins, Bridenbaugh, eds. Neural Blockade. 1998:675-699.
20
Central Sensitization
Mechanisms of Pain
21
Physiological Sensations
Siddal &Cousins in: Cousins & Bridenbaugh: Neural Blockade, 1998: 675-699.
22
Neuropathic Pain
Double Amplification
Neuropathic Pain
Siddal & Cousins. In: Cousins & Bridenbaugh, eds. Neural Blockade. 1998:675-699.
23
Neuropsychiatric aspects of Pain
cortical
modulation

Attentional
processes

state of
consciousness

“Ultimate”
psychosomatic
phenomenon
cognitive factors

Attention to Pain

Meaning

Mood disorders
24
Multidimensional Model of Pain
Pain Behavior
Suffering
Pain
Nociception
Nociception
Loeser JD. In: Bonica’s Management of Pain. Philadelphia;
Lippincott Williams & Wilkins: 2001.
25
Abnormal Pain Mechanisms
Abnormal Nociception

Peripheral Sensitization

Abnormally low pain threshold (hyperalgesia )

Central sensitization to Pain .

Recruitment of Novel Inputs ( Allodynia )
Abnormal Pain Perception

meaning of pain

memory of pain


Mood disorders
Neuropsychiatric aspects of pain
26
Aging - what is the impact on pain ?

Two major sources of Information
1) Studies of aging and pain in the absence of disease
Decrease in thermal ,mechanical sensitivity. Decrease in
discriminative capacity , changes in C and Ad fibers.
2) Studies of aging and pain in the presence of disease
Arthritis , Post herpetic neuralgia , cancer on one hand and unusual
presentations( silent MI , Painless intraabdominal catastrophies
on the other. Decrease in pain tolerance .
27
Causes of Chronic Pain in Aging

Predominantly Musculoskelatal (OA, RA )

Myofascial pain syndromes

Herpes Zoster , temporal arteritis , Polymyalgia

Post - Cancer Pain

Iatrogenic , related to therapies.
28
Pain Assessment

Initial Pain Assessment:

A detailed history including assessment of PainIntensity
and Character
A physical and neurological examination.
A psychosocial examination.
Appropriate diagnostic workup to determine the cause of
Pain.




Ongoing Pain Assessment:


At regular intevals after starting the treatment plan .
With each new report of Pain .

Assessment of New Pain.
29
Pain Treatment Guidelines

World Health Organization (1990, 1996)

American College of Rheumatology
(1995, 2000)

American Geriatrics Society (1998 and
2002)

American Medical Directors Association
(1999)

American Pain Society (2002)

AHCPR Guidelines
30
Treatment Approach (AHCPR)

Ask pain and goal , and Assess pain

Believe the patient and family
(Validate! but do not enable.)

Choose pain control options wisely

Deliver interventions timely

Enpower the patient and family

Follow up to reassess the pain

From CMDT 2003 p66
31
AGS Practice Guidelines

GUIDELINE OBJECTIVE(S)

To update and revise previous recommendations
from the clinical practice guideline titled "The
Management of Chronic Pain in Older Persons,"
using the latest information about pain management
in elderly persons

To provide the reader with an overview of the
principles of pain management as they apply
specifically to older people and specific
recommendations to aid in decision making about
pain management for this population
32
AGS Practice Guidelines

NUMBER OF SOURCE DOCUMENTS

More than 4,122 citations were
identified from sources

More than 2,089 abstracts were
obtained for further analysis

More than 520 full-text data-based
articles were obtained and
summarized for detailed analysis
33
American Geriatric Society (AGS)
Clinical Practice Guidelines

Older persons should be assessed for pain on initial
presentation to any health care setting.

Any persistent or recurrent pain that has a significant
impact on function or quality of life should be
recognized as a significant problem.

A variety of terms synonymous with pain should be
used to screen older patients (e.g. ache, discomfort,
soreness, heaviness, tightness)
34
Common Pain Indicators

Self-report

Report from significant other

Condition or procedure that usually
causes pain

Behaviors

Physiologic Measures
35
Getting to Know
the Pain

Words – McGill’s Pain Questionnaire

Intensity – VAS pain scale

Location – More than one location

Duration – constant or breakthrough

Aggravating and Alleviating Factors
36
Challenges in Pain
Assessment
Patients With
Communication
Difficulties
Challenges in Pain Assessment
1.
Cognitive Impairment
2.
Three D’s-Dementia, Delirium, Depression
3.
Conscious but unable to speak
4.
Unconscious and unable to speak
5.
Residents with wide range of
communication difficulties
38
Pain Assessment in the Cognitively
Impaired Resident

Cognitive impairment is major obstacle to pain
assessment ,50%-60% of residents have some
form of progressive dementia

Study of 758 cognitively impaired nursing home
residents

Self report of pain is no less valid than that of
cognitively intact residents
(Source: Parmelee, Smith,Katz 1993)
39
Use of Pain Rating Scales in
Cognitively Impaired

Residents with substantial cognitive impairment may
still be able to use a pain rating scale

217 residents; dependent in most ADL’s

Mean age of 84.9; substantial cognitive impairment

30 seconds to respond; scale repeated three times

0 to 5 scale preferable with this population rather than
0-10 scale
Source: (Ferrell, Ferrell & Rivera 1995)
40
Proxy Pain Rating

Family members or clinicians who know the resident well
may be asked to rate pain

Family members may be better able to identify behaviors
that suggest the possibility of pain

Family members may be more sensitive to changes in
behavior

Used as a guess; not used with self reports of pain
41
Do’s







Use an Instrument with
simple language
Use simple descriptors
(“aching”, “hurting”)
Ask yes/no questions
Listen for clues in
fragmented speech
Palpate areas thought to
be painful when asking
questions
Observe for behaviors
that may indicate pain
Assess pain following or
during movement
&





Don’ts
Don’t discount behaviors
as part of dementia
Don’t interrupt attempts at
responses
Assume that anti-anxiety
medications will relieve
pain
Don’t forget to include
family members
Don’t assume that
persons with dementia
don’t experience pain
42
2) Assessment in Residents with
Advanced Dementia


Discomfort in Dementia of the Alzheimer’s Type
(DS-DAT)
Scale of 9 indicators of discomfort/comfort:
- noisy breathing
- negative vocalizations
- content facial expression
- sad facial expression
- frightened facial expression
- frown
- relaxed body language
-
- tense body language
Fidgeting
(Source: Hurley, Volicer, Hanrahan et al 1992)
43
3) Assessment and Treatment of Pain in
the Nonverbal Patient

Feedback from the patient

Offer writing materials or simple pain scales

Treat with analgesics or other pain relief measures

If interventions modify pain behaviors, continue
with treatment

R/O other potential problems
44
Behavioral Cues

Grimacing, frowning, grinding teeth

Agitation, striking out

Restlessness, fidgeting

Moaning/crying , groaning

Guarding, changes in gait

Appetite and activity changes

Irritability/swearing

Sleeping poorly
45
4) Unconscious Residents


Pain may not be easily determined, assumed pain free
Residents who appear to be unconscious &
unresponsive to painful stimuli actually feel & recall
pain

Residents with endotracheal tubes or residents who
have received a neuromuscular blocking agent
(pancuronium) may be fully capable of feeling pain

Clinicians should assume that the unconscious
resident may feel pain & provide analgesics if
anything known to be painful is present
46
5) Pain in Terminally Ill
Residents

When patients are no longer able to verbally
communicate whether they are in pain or not, the best
approach is to assume that their cancer is still painful
and to continue them on their regular medications

Therapeutic opioid (narcotic) level should be
maintained

Continued opioids simply ensure that the death will
be as peaceful and as painless as possible
(Levy 1985)
47
Assessment Tools for Cognitively
Impaired

FACES Scale

VAS and 0-5 Scale

Verbal Descriptor Scale

Flow Sheets

Pain Thermometer

Discomfort Scale for the Dementia of
Alzheimer’s Type

Face, Legs, Activity, Crying, Consolability
(FLACC) Scale
48
49
Federal Regulations

Skilled nursing facilities function under a clear
mandate from the federal government regarding the
responsibility to assess, treat and manage pain

Nursing Home Federal Requirements and
Guidelines to Surveyors, Code of Federal
Regulations (CFR) 483.25, F309
Facilities are surveyed to assure necessary care is
provided based on findings on the Resident
Assessment Instrument (RAI)
Pain is mandated to be a part of the Minimum Data
Set (MDS)



Sections J2a, J2b and J3 meet this requirement
50
Section J2/ Pain Symptoms and J3
Pain Site ( MDS )
J 2.
Pain
(Code the highest level of pain present in the last 7 days)
Symptoms a. FREQUENCY with which
b. INTENSITY of pain
1. Mild pain
resident complains or shows
evidence of pain.
2. Moderate pain
J 3. Pain Site
0. No pain (skip to J4)
3. Times when pain is
1. Pain less than daily
horrible or excruciating
2. Pain daily
(If pain present, check all sites that apply in last 7 days)
Back pain
a.
Incisional pain
f.
Bone pain
b.
Joint pain (other than hip)
g.
Chest pain while doing usual
activities
c.
Soft tissue pain (e.g.,
lesion, muscle)
h.
Headeache
d.
Stomach pain
I.
Hip pain
e.
Other
j.
51
Summary of Pain Assessment

Ask residents about their pain

Observe nonverbal behaviors

Accept and respect what they say

Consult family members

Use appropriate assessment scales

Intervene to relieve their pain

Ask them again about their pain

Circle of assessment, intervention and
reassessment
52
“If we cannot assess pain, we
will never be able to treat pain.”
Betty Ferrell
53
Under Treatment- Just the fact

Pain in the elderly


JAMA, 1998 – Elderly Cancer Patients in LTC

>25% received nothing for pain

Highest risk = >85, women, minorities
Advanced dementia pts with hip fractures

Received 1/3 morphine equivalent dose compared
to others

76% were without standing analgesic orders

50 – 90% fail to take meds correctly

Vertebral fractures >65 years old is 21 – 27%
54
Pain Treatment Continuum
Least
invasive
Most
invasive
Continuum not related to efficacy
Psychological/physical approaches
Topical medications
Oral medications
Injections
Interventional techniques
Mackin GA. J Hand Ther. 1997(April-June);10(2):96-109; Katz N. Clin J Pain. 2000(June);16(2
suppl):S41-48; Leland JY. Geriatrics. 1999(Jan);54(1):23-28, 33-34, 37; Belgrade MJ. Postgrad
Med. 1999(Nov);
106(6):127-132, 135-140; Galer BS et al. A Clinical Guide to Neuropathic Pain. 2000, p. 97;
55
Generic Treatment Goals
(Mission Impossible ?)

Validate Patients Condition

“Shrink” pain to the Lowest level possible.

Identify treatable conditions

Streamline Medications

Improve Quality of life

Provide Pain Coping Skills

Increase Socialization
56
Multidisciplinary Management !

Multiple studies demonstrate the best outcomes

A team approach is recommended

Consistent with other geriatric program models

A comprehensive assessment to include medical ,
neurological ,psychosocial evaluations.

Integrating Invasive and non invasive techniques

Physical therapy , alternative therapies

Specific goal setting a shift of focus to rehabilitation
model of pain management , rather than cure.
57
Treatment Modalities

Pharmacological

Non-Pharmacological

Physical

psychosocial

Invasive Techniques

Alternative Medicine
58
Pharmacologic Management
of Chronic Pain
Antidepressants
Amitriptyline, imipramine, desipramine,
nortriptyline
Anticonvulsants
Carbamazepine, clonazepam,
gabapentin, lamotrigine, oxcarbazepine,
phenytoin, topiramate, valproic acid
Antiarrhythmics
Mexiletine
Topical formulations
Capsaicin, lidocaine, aspirin
Analgesics
Oxycodone, methadone , tramadol
NSAIDS( non selective)
Ibuprofen , Naproxen , Meloxicam
Selective COX-2
Rofecoxib and Celecoxib
59
Mechanistic Categories of Antineuralgic
Agents
BRAIN
Descending
Inhibition
NE/5HT
Opiate receptors
PNS
Peripheral
Sensitization
Beydoun. 2001.
Na+
CBZ
OXC
PHT SPINAL
TCA
TPM
LTG
Mexiletine
Lidocaine
TCAs
SSRIs
SNRIs
Tramadol
Opiates
Central Sensitization
Ca++ : GBP; OXC
NMDA : Ketamine, TPM
Dextromethorphan
CORD
Others
Capsaicin
NSAIDs
COX-2 inhibitors
Levodopa
60
AGS Quality of Evidence
Definitions:
Quality of Evidence
Level I: Evidence from at least one properly randomized,
controlled trial
Level II: Evidence from at least one well-designed clinical trial
without randomization, from cohort or case-controlled analytic
studies, from multiple time-series studies, or from dramatic results
in uncontrolled experiments
Level III: Evidence from respected authorities, based on clinical
experience, descriptive studies, or reports of expert committees.
Strength of Evidence
(FOR) A =Good, B =Moderate , C =Poor,
(AGAINST) D=Moderate against, E=Good evidence against
61
Pharmacological treatment
Guidelines

All older patients are candidates for pharmacologic
therapy. (IA)

There is no role for placebos (IC)

The least toxic means should be used. Noninvasive
route should be considered first. (IIIA)

Acetaminophen should be the first drug to consider
in the treatment of mild to moderate pain of
musculoskeletal origin. (IB)

Avoid Traditional (nonselective) NSAIDs . The COX-2
selective agents or nonacetylated salicylates (IA)
62
AGS Guidelines- Opioids

Opioid analgesic drugs may help relieve moderate to
severe pain, especially nociceptive pain. (IA)
 Opioids for episodic (noncontinuous) pain should
be prescribed as needed, rather than around the
clock. (IA)
 Long-acting or sustained-release analgesic
preparations should be used for continuous pain.
(IA)
63
Opioids – Contd.
 Breakthrough
pain - identify and treat
by the use of fast-onset, short-acting
preparations. There are three types
of breakthrough pain: (IA)
–End-of-dose failure (IIIB)
–Incident pain. (IB)
–Spontaneous pain. (IC)
 Titration should be conducted
carefully. (IA)
64
AGS Guidelines- side effects





Constipation and opioid-related GI side effects should be
prevented. (IA)
Mild sedation and impaired cognitive performance should
be anticipated when opioid analgesic drugs are initiated or
escalated. Until these side effects cease: (IIIC)
Severe or persistent nausea may need to be treated with
anti-emetic medications, as needed. (IIIB)
Fixed-dose combinations of opioid with acetaminophen or
NSAIDs may be useful for mild to moderate pain. (IA)
Patients taking analgesic medications should be monitored
closely. (IA)
65
Pharmacotherapy AGS

Neuropathic pain – AED and TCAs (1A)

Topical Therapies (1B)

Combination therapies (IIB)

Monitor Side effects (IA)
66
Non-Pharmacological treatments
Non-Invasive Treatments

Physical
Rehabilitation

Analgesic
 Ice
 Myofascial release
 Heat
 Stretching
 Electrical
stimulation
 Reconditioning

Strength

TENS

Endurance

Interferential
 Gait and posture
training
 Body mechanics
 Pacing
 Counter-irritation
Non Pharmacological treatments
Invasive Therapies

Neurosurgical procedures:
1)Interruption of pain transmission;
Peripheral neurotomy, rhizotomy, cordotomy,
DREZ, Thalamotomy, Medullary tractotomy.
2) Stimulation of Analgesia:
TENS , DCS , Epidural Stimulation , Thalamic stimulation.
68
Non pharmacological Tx
Anesthetic approaches

Myofacial trigger point injection

peripheral nerve block

Autonomic plexi block

inhalation analgesia

neurolytic blockade

intraspinal opioid devices

spinal cord stimulation devices
69
Non -Pharmacological treatments
Psychiatric/Psychological Treatments

Cognitive

 Range of Pain
Control
 How to think

Behavioral
 What to do

Stress
management
 Relaxation
training
 Visualization
Hypnosis

Distraction

Analgesia

Anesthesia

Biofeedback

Psychotherapy
 Group
 Family
 Traditional
Cognitive Behavioral Therapy in aging

Pain adaptation ( Daily activities ,bodily responses,thoughts
/feelings)

Age does not predict response and can be effectively used in this
population

May reduce the burden of polypharmacy & serious side effects.

Severe Depression or major cognitive impairment should be
excluded ( poor Candidates )

Strategies include :
Relaxation training-Biofeedback & Progressive muscle relaxation
Activity Rest Cycles
Attention Diversion Strategies
Cognitive restructuring
71
Social context in elderly chronic pain
patients ( Roy et al )
Social network ( Buffering model of social support )
Informal Network
Formal Network
Family , spouse , friends
hospital , cultural
institutions etc
Older Adult
Semi- formal network
Clubs , church , professionals
72
Conclusion

Geriatric Pain is undertreated and understudied

A better understanding of pain mechanisms is needed

Pain must be assessed in every older adults

Pain problems unique to older adults need further
study

Better understanding of Pain Behaviors in older adult

Change in Health care providers attitude & beliefs of
aging.

A multidisciplinary approach is advocated
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“We must all die.
But that I can save him from days of
torture, that is what I feel as my great and ever new
privilege. Pain is a more terrible lord of mankind than
even death itself.”
--1931, Albert Schweitzer
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