Transcript Module 10. Pain and Palliation of Older Adults

Pain /
Palliation of
Older Adults
Objectives
• Identify the incidence of pain in older
adults
• Assess pain using client self-report
and / or validated pain instrument
• Discuss barriers to pain relief in the
older adult
• Identify problems and strategies in
assessing pain in cognitively impaired
older adults
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Objectives
• Describe adverse consequences
associated with pain in older adults
• Identify considerations and specific
strategies in treating pain in older
adults
• Plan care for assessing and
managing pain in an older adult,
combining traditional and alternative
pain treatment strategies
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Objectives
• Explain the dimensions of palliative
care
• Identify the dimensions of quality of life
• Describe assessment parameters
important in palliative care
• Describe the nurse’s role in supporting
a multidisciplinary team approach to
palliative and end-of-life care and
identify the rationale for the team
approach to care management
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Pain defined……
• Pain – unpleasant sensory
emotional suffering experience
• “Whatever the experiencing
person says it is, existing
whenever he says it does?
(McCaffery)
• Acute v. chronic pain
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Incidence
• Prevalence of chronic pain
increases with age; increases 3X
between 18 – 80 years of age
• 50% of community dwelling older
adults; 70% - 80% of nursing home
residents
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Incidence
• Associated with chronic and
degenerative conditions with
adverse consequences –
osteoarthritis, degenerative
musculoskeletal processes,
cardiovascular system, fractures,
neuropathy, bone and joint disorders,
back problems, and phantom limb pain
• Pain is undertreated
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Assessment
• Most accurate evidence: client’s
description and self-report
• ASK at regular and frequent
intervals
• Reluctance to report pain – fear of
tests or medication side effects;
metaphor for death, atonement for
past actions
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Assessment
•
Intensity, quality, onset, duration,
expression, aggravating factors,
relief factors
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Examples of Assessment
Instruments
– Try This Assessment Series
•
•
Assessing Pain in Older Adults
Assessing Pain in Persons with Dementia
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Assessment Instruments
Visual Analog Scale
Visual Analog Scale (VAS)
No
Unbearable
distress
distress
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Verbal Descriptor Scale
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Assessment Instruments
Wong-Baker FACES Scale
Figure 1. From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.:
Wong’s Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p.1301. Copyrighted by Mosby,
Inc. Reprinted by permission.
FACES Pain Scale - Revised
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Assessment Instruments
• Numerical Scale
0-10 Numeric Pain Distress Scale
No
Distressing
Unbearable
pain
pain
pain
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0
1
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Barriers to Assessment
and Pain Relief
•
Older patients experience less pain
•
Older patients cannot tolerate
opioids.
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Failure to apply standardized
assessment instruments.
•
Cognitively impaired older adult
cannot be assessed for pain.
•
Misinterpretation of behavior as
being unrelated to pain.
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Assessment of Cognitively
Impaired Older Adult
• Non-verbal pain behavior
• Recent changes in function and
vocalization
• Moaning, crying, withdrawal or agitation
• Use objective pain assessment
instruments:
• Accommodate for sensory losses,
fatigue, slower processing, timing
• Present pain vs. recalled pain; evaluate
analgesic use
• Caregiver Reports
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Adverse Consequences
• Decreased quality of life
• Depression
• Decreased socialization
• Sleep disturbances
• Impaired ambulation
• Suicidal ideation
• Decreased appetite and food intake
• Increased health care utilization and
cost
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Considerations
• Physiologic changes influence
pharmacodynamics and
pharmacokinetics
• Assess every older adult for
evidence of chronic pain
• Continue to treat until patient is
comfortable
• Underlying conditions must be
treated
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Considerations
• Pain Log or Diary
• Reassess regularly for improvement,
deterioration, or complications
• Know and recognize physiological,
psychological, and emotional
responses to pain
• Oral medications are best for longterm management
• Be prepared to treat the side effects
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Pharmacologic Treatment
• Least invasive route – careful
titration, frequent assessment,
adjustments, monitoring and
managing side effects
• WHO Ladder: non-opioid, lowpotency opioids, high-potency
opioids
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Pharmacologic Treatment
• SHORT TERM: fast-onset, shortacting analgesic
• MILD-TO-MODERATE pain:
Acetaminophen
• EPISODIC or CHRONIC PAIN:
opioid analgesics
• Monitor patients using NSAIDs –
contraindicated with abnormal
renal function, peptic ulcer,
bleeding
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Pharmacologic Treatment
Precautionary measures:
• Encourage extra fluid
• Exercise
• Combination stool softener and
non-bulk-forming laxative
• Patient safety concerns
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Nonpharmacologic Strategies
• Education program
• Cognitive program: imagery,
relaxation, biofeedback, hypnosis
• Behavioral program
• Exercise
• Acupuncture
• Physical methods: heat, cold, massage
• Chiropractic
• Spiritual healing
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Assessing and Managing
Pain
• Based on Nursing Diagnosis:
Alteration in Comfort
• Determine tolerable level of pain,
activity, sedation
• Integrate pharmacological and
nonpharmacological strategies
• Ongoing evaluation
• Teach nursing assistants to use
scales to assess and identify pain
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WHO definition….
….the active total care of patients
whose disease is not responsive
to curative treatment.
• Enhance maximum comfort and
function
• Open and active communication
among patient, family and other
disciplines
• Holistic intervention
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Goal of Palliative Care
…to prevent and relieve
suffering and to support the
best possible quality of life for
patients and their families,
regardless of the stage of the
disease or the need for other
therapies.
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Dimensions of Quality of
Life
• Physical
• Function
• Interpersonal
• Well-being
• Transcendent
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Assessment Parameters
• Physical, psychosocial, and
spiritual problems
• Accomplishment of
developmental tasks of life
• Family dynamics / relationship
issues / opportunities
• Grief / loss / bereavement issues
• Functional status / environmental
status
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Nurse’s role
• Identifies patient and family needs
• Recruits health care team members
• Coordinate interdisciplinary pain
program and manage chronic
coexisting problems
• Identify patient appropriateness for
Hospice services
• Encourage family to participate in
goals, processes and evaluation of
care
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Summary
• Incidence of pain in older adults
• Pain assessment – instruments
and scales
• Barriers to pain relief
• Problems and strategies in
assessing pain in patients with
cognitive impairment
• Adverse consequences
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Summary
• Considerations and treatment
strategies: pharmacologic and
nonpharmacologic
• Dimension of palliative care and
quality of life
• Assessment parameters in
palliative care
• Nurse’s role: interdisciplinary
coordination
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