Transcript NonCognitive Behavioral/neuropsychiatric and Functional

•No conflicts of interest
•Opinions are not that of
VAMC or UA
ASSESSMENT AND TREATMENT OF
PAIN AND DISTRESS
FOR FRAIL AND DEMENTED
OLDER ADULTS
A. LYNN SNOW, PHD
ASSOCIATE PROFESSOR,
UNIVERSITY OF ALABAMA
CENTER FOR MENTAL HEALTH AND AGING
& DEPT. OF PSYCHOLOGY;
CLINICAL RESEARCH PSYCHOLOGIST,
TUSCALOOSA VA MEDICAL CENTER
Pain is Associated with Poor
Outcomes
 Under-treatment associated with: gait
disturbances, falls, malnutrition, morbidity,
mortality, functional disability, agitated
behavior
 Over-medication associated with: functional
disability, increased falls, decreased activity,
deconditioning, decubitus ulcers
Pain is Under-Treated
 In Homes
 In Hospitals
 In Nursing Homes
Barriers to Pain Control
 The health care system through
regulation, lack of priority on pain
treatment, cost-cutting measures,
staffing issues.
 The health care professional
through misinformation, biased
attitudes, fear of addiction, fear of
disciplinary action, lack of
knowledge and skill in pain
management.
 The public/patients/families
through fear (of addiction)
misinformation, cultural beliefs,
concern about side effects.
Older Adults Often Don’t Report Their Pain
1.
Belief that pain is a normal part of aging
2.
Fear of the cause
3.
Stoicism
4.
Fear of losing independence
5.
Don’t want to bother family or others
6.
Fear of addiction
7.
Fear of tolerance or side effects
8.
Impaired cognition
FEAR…What fears impact our
ability to appropriately treat
pain in frail and demented
older adults?
 Addiction
 Delirium
 Side Effects Worse than the Pain
 Kill the Patient or Make Them Very Sick
 Because they are more sensitive to drugs
 Drug-drug interactions
 Drug-disease interactions
Reality
 Addiction versus
 Physical Dependence
 Tolerance
 Delirium and Side Effects can be controlled
through Starting Low and Going Slow,
anticipating and proactively treating side
effects, and good caregiver advocacy
 A knowledgeable geriatrician and/or pain
specialist, especially in collaboration with a
pharmacist and good caregiver advocacy can
avoid drug interactions
Dementia Pain Facts
 Pain thresholds are not altered, but pain tolerance is
significantly increased
 Conclusion: demented individuals experience the
same pain sensations as non-demented individuals,
but fail to interpret such sensations as painful
Huffman, J. C. & Kunik, M. E. (2000). Assessment and understanding
of pain in patients with dementia. Gerontologist, 40, 574 – 581.
Persons with Dementia are at
High Risk for Under-Diagnosis
of Pain
 Self-report capacity is at least diminished
 Memory, Language, & Abstract Thought Deficits
 Typically manifest pain through behaviors - but
wide overlap with behaviors due to other etiologies
(e.g., agitation, boredom, depression)
 5 of 8 NH residents on psychotropics to control “difficult”
behavior were successfully removed from the medications
when placed on scheduled acetaminophen (Douzijan et al.,
1998).
Dementia Patients are at
High Risk for UnderTreatment of Pain
 Patients hospitalized for hip fractures with
advanced dementia received three times less
the amount of opioid analgesics administered
to cognitively intact patients (Morrison & Siu, 2000).
 Several studies report that less than 25% of
the demented individuals identified as in pain
were receiving analgesics .
What is Pain?
Pain is
 “… an unpleasant sensory and emotional
experience which we primarily associate
with tissue damage, or, describe in terms of
such damage, or both.” (International
Association for the Study of Pain)
Source: C. Kovach, U. Wis. Milwaukee
What is Pain?
McCaffery (Pasero,
Paice, & McCaffery,
1999) says,
"Pain is whatever the
experiencing person
says it is, existing
whenever he says it
does".
But what if they can’t tell you?
Distress Behaviors
 Distress Expressions
 Noises and words (“ow”, “ouch”, “that hurts”, “stop”,
crying, moaning/groaning)
 Facial expressions (grimacing)
 Distress Movements (restlessness, guarding, bracing)
 Other Distress Behaviors




Agitation, Aggression, Resisting care
Negative Affect (Depressed, Blue, Sad, Apathy)
Sleep and appetite disturbances
Change in activity level
Distress Behaviors are:
Communications of Pain
by Persons with Dementia
 Distress Expressions
 Noises and words (“ow”, “ouch”, “that hurts”, “stop”, crying,
moaning/groaning)
 Facial expressions (grimacing)
 Distress Movements (restlessness, guarding, bracing)
 Other Distress Behaviors




Agitation, Aggression, Resisting care
Negative Affect (Depressed, Blue, Sad, Apathy)
Sleep and appetite disturbances
Change in activity level
Distress Behaviors are:
Communication of Other Unmet
Needs
by Persons with Dementia
 Distress Expressions
 Noises and words (“ow”, “ouch”, “that hurts”, “stop”, crying,
moaning/groaning)
 Facial expressions (grimacing)
 Distress Movements (restlessness, guarding, bracing)
 Other Distress Behaviors




Agitation, Aggression, Resisting care
Negative Affect (Depressed, Blue, Sad, Apathy)
Sleep and appetite disturbances
Change in activity level
CONCEPTUALIZATION:
Number One Question:
WHY IS THIS
HAPPENING?
What is causing the
behavior?
CAUSATION THEORIES:
Unmet Needs Model
 The behavior of persons with dementia
represents efforts of the person with
dementia to get unmet needs addressed
Algase, DL, Beck C, Kolanowski A, Whall A, et al. Need-driven dementia-compromised
behavior: An alternative view of disruptive behavior. Am J Alz Dis. 1996;11:12–19.
Needs of All People With
Dementia
 Physical Needs: Hunger, Thirst, Restroom,





Pain/Discomfort, Rest
Feel Safe and Secure
Meaningful Positive Human Contact
Meaningful Activity
Feel That Are Contributing
Have Success Experiences
CAUSATION THEORIES:
Learning/Behavioral Models
 Problem behaviors have been
inadvertently reinforced in the
environment, or positive behaviors have
not been reinforced.
 ABC Model:
 Antecedent->Behavior->Consequence
CAUSATION THEORIES:
Environmental Vulnerability
/Reduced Stress Threshold Model
 Dementia causes a lowered ability to cope with
stimulation from the environment.a
Behaviors are due to person being
overstressed/overstimulated.
 Corollary: Under-stimulation is also problematic.b
aLawton
MP, Nahemo L. An ecological theory of adaptive behavior and aging. In: Eiserdorfer
C, Lawton MP, eds. The Psychoogy of Adult Development and Aging. Washington, DC:
American Psychological Assocation; 1973:657-667.
bKovach CR, Taneli Y, Dohearty P, et al. Effect of the BACE Intervention on Agitation of People
With Dementia. Gerontologist. 2004;44:797-806.
CAUSATION THEORIES:
Biological Models
 Neuropathology leads to neurotransmitter
imbalances which lead to neuropsychiatric
symptoms or disturbances in drives which
lead to Behaviors.
Cause Models are
Complementary and not
Mutually Exclusive
 Implication: Nonpharmacologic interventions
can be developed to address these causes,
even for behaviors caused in large part by
biological problems
Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia:
a review, summary, and critique. AJGP. 2001;9:361-381.
Decisional Models
 A good decisional model is the cornerstone of
developing effective nonpharmacologic
treatment plans
 A decisional model provides a map to follow
to decide how to approach treatment
Serial Trials Protocol
 IDENTIFY the problem
 ASSESS for all possible causes
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Unmet physical/functional needs
Understimulation/Overstimulation
Whose problem is it?
Behavior/Learning Causes
ADDRESS possible physical causes
ADDRESS possible environmental causes
ADDRESS possible behavior/learning causes
Still a problem?
 REASSESS
 READDRESS
 Still a problem? REFER AND CONSULT (Geropsychiatry, Pain,
etc.)
 DON’T GIVE UP…SERIAL trials…SERIAL!!! There Empirical
Evidence that Persistence is Key to Success
15Kovach
CR, Logan BR, Noonan PE, Schlidt AM, Smerz J, Simpson M, Wells T. Effects of
the Serial Trial Intervention on discomfort and behavior of nursing home residents with
dementia. Am J Alzheimers Dis Other Demen. 2006; 21:147-55.
 You can never know that you have achieved
an accurate pain assessment by observation
alone...you can only develop a hypothesis
based on the collected data...that hypothesis
must then be tested through intervention
trials and re-assessment
Use of analgesics for
assessment
 Commonly done for other disease entities (such
as Nitroglycerine for chest pain)
 Christine Kovach RN PhD has conducted an RCT
of this approach in Wisconsin, and shown it to be
effective. Their nursing home state regulators
know about her work and have approved of this
use of pain meds.
 Usually the drug Kovach’s group starts with is
acetaminophen extra strength BID.
Common Pain Beliefs
 I am familiar with the patient so I know if they are in pain





or not…anyone not familiar with the patient will not
know what their behaviors mean…
There will be behavior change if pain is present
If a person is on routine pain medications, they can’t be in
pain
The behavior is just part of dementia
The resident just does that for attention
Staff conceptualization/assessment of discomfort is
different for verbal patients…their verbal reports are
given more weight
Treating Pain
Non-pharmacologic Treatment
 Basic Non-pharmacologic Pain Management
 Repositioning, hot packs, cold packs, cushions and pillows
 Psychology
 Relaxation, Biofeedback, Cognitive retraining, Distraction/reinterpretation Techniques, Sleep hygiene, caregiver training
 Physical Therapy
 Reconditioning, Stretching, Exercise, Massage
 Occupational Therapy
 Pacing skills, work simplification, body mechanics
 Recreation Therapy
Meaningful and Pleasant Activities
 Particularly for Persons with Dementia:
 Sensory Activities (touch, music, 1:1 attention)
 Be Particularly Aware of Basic comfort needs
Use of Analgesics for
Geriatric Pain
Source: C. Kovach, U. Wis. Milwauk
WHO 3-Step Analgesic Ladder
Step 3
Severe Pain
Step 2
Moderate Pain
Step 1
Mild Pain
ASA, Tylenol,
NSAIDS+/Adjuvants
Weak opioids ± non-opioids
(e.g. A/Codeine,
A/Hydrocodone, A/Oxycodone,
Tramadol)
Potent opioids ± nonopioids
(e.g. morphine,
Oxycodone,
Hydromorphone,
Methadone, Fentanyl)
2 Pitfalls:
 Over-aggressive Treatment
 Treatment That’s Not Aggressive Enough
Treatment Considerations:
Geriatric Physiological Changes
 Near EOL, loss of muscle mass and body fat
 Altered volume of distribution for lipid-soluble drugs
leading to prolonged half-lives (benzodiazepines,
methodone, psychotropics)
 In Older Adults, Renal clearance decreases
 Drugs like meperidine that rely on renal excretion
become problematic
 In Older Adults, Altered hepatic metabolism
 Elimination by Cytochrome oxidation affected
 Elimination by conjugation not affected (morphine)
 Dementia = Sensitivity to anticholinergic
effects
 antihistamines, tranquilizers, antiemetics
Ferrell, Annals of
LTC, 2004, vol 12
Acetaminophen
 “Drug of choice for most elderly persons with
mild-to-moderate musculoskeletal pain”
 Preferred in pts with gastric, renal, or
hematologic disease (Marcus)
 “A common mistake is not giving enough..6501000mg q6hrs or qid”
 Caution patients about acetaminophen in other
prescription and OTC drugs, which might add up
to a problematic dose
Ferrell, Annals of
LTC, 2004, vol 12
Source: C. Kovach, U. Wis. Milwaukee
When is Tylenol
Inappropriate?
 If a person is already on
something stronger than
tylenol, yet continues to
have pain
 If they have an allergy or
sensitivity to tylenol
 If someone has a high or
chronic alcohol intake or
has impaired liver
function
Opioids
 “Opioids are effective for elderly patients
with most pain types, and are probably
underutilized in this population, and may be
safer than NSAIDS or other drug strategies
used in older persons”
Ferrell, Annals of
LTC, 2004, vol 12
Why We Are Reluctant to Give
Opioids:
Opioid Side Effects
 Constipation (lactulose and senna)
 Nausea
 Somnolence and psychomotor
retardation…tolerance usually develops in a few
days of reaching steady-state drug levels
 Respiratory Depression…”for most patients opioid
medications should never be held in the presence of
severe pain and usually should not be held unless
patients are poorly arousable and have a respiratory rate
of less than 6 to 8 breaths per minute”
Ferrell, Annals of
LTC, 20004, vol 12
Marcus DA. 2003. Clinical Geriatrics. Vol 11 (11);
Caracci G. 2003. Clinical Geriatrics. Vol 11(11).
Opioid Side Effects
 Older adults have 10-25% higher risk of
developing adverse drug reactions vs pts<30yrs
old
 “Drug induced cognitive impairment accts for 1130% of delirium in hospitalized pts and in 2-12%
of those evaluated for suspected dementia”
 Patients with dementia are at higher risk of
developing increased confusion with opioids
 THESE ARE NOT REASONS TO AVOID
OPIOIDS…these are issues to monitor and to
prepare patients and family for
Caracci G. 2003. Clinical Geriatrics. Vol 11(11).
Opioids
 Avoid for chronic pain
 Propoxyphene
 Long half-life and metabolite norpropoxyphene is
toxic
 Meperidine
 Its neurotoxic metabolite, normeperidine, causes
tremor, irritability, cognitive changes, seizures
 agonist-antagonist opioids
(e.g.,
pentazocine, nalbuphin)
 High incidence of delirium
Opioids
Caracci G. 2003. Clinical Geriatrics. Vol 11(11
Ferrell, Annals of LTC, 2004, vol
12
 Morphine has most predictable metabolism
 Hydromorphone is a good alternative to
morphine – more potent and better tolerated
(Caracci)
 Oxycodone has fewer metabolites and side
effects than codeine (Caracci)
 Methadone can be helpful, but should be
prescribed by clinicians with expertise with its
use or in closely monitored settings because of
unpredictable pharmokinetics in older persons
 Fentanyl can be difficult to titrate…don’t start
with it…don’t use in opioid-naïve pts
Caracci G. 2003. Clinical Geriatrics. Vol 11(11).
Opioid dosing
 “Most studies on dosages of opioids in geriatric
populations indicate an inverse relation between
dosage used and age independent of other
factors….[but]…focus on attempting to adapt the
dose to the pt’s needs, rather than treating pain with
fixed doses. This process calls for carefully
monitored titration depending on the pt’s response
and the emergence of side effects.”
Marcus DA. 2003. Clinical Geriatrics. Vol 11 (11
Rules of Thumb
 Start low and go slow
 Start pt on low doses of short-acting opioids
(oxycodone, morphine)
 Educate caregiver on side effects to watch for so if
they appear they won’t become severe before you are
alerted
 Once daily dose requirement established, switch to
sustained-release formulation at scheduled intervals,
with prn for rescue doses
 Review prn admin regularly…if rescue doses used
regularly, the scheduled dose needs to change
Source: C. Kovach, U. Wis. Milwaukee
Dose Escalation
Done in percentages based upon the patient’s pain rating or
prevalence/severity of behavioral symptoms.
A guideline is:
• Pain mild (or rated at 1 to 3/10), dose escalation is 25% of
current dose
• Pain moderate (or rated as 4 to 6/10), dose escalation in 25%
50% of current dose
• Pain severe (or rated as 7 to 10/10), dose escalation is 50% to
100% of current dose
to
To Appropriately Make
Analgesic Dosage Decisions
you Need to Know…
 What Quality Of Life Looks Like In…
 The geriatric patient with serious chronic illness
and disability
 The patient with mild dementia
 The patient with moderate dementia
 The patient with severe dementia