Transcript Pain Management in Elderly Persons Case Studies

Pain Management in Elderly Persons
Case Studies
UCLA Multicampus Program of
Geriatrics and Gerotontology
Case Study #1
A graceful and delicate lady, 69 years
old, has pain under her left arm. She
first noticed it two days ago while trying
on a new dress. Yesterday the pain
became worse. She describes "sharp,
like lightening" pain near her shoulder
blade and traveling under her left arm
and breast. It hurts when she raises her
arm.
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Today, the pain is so severe she could not
put on her bra or pull her dress over her
head. She states she has never had
anything like this. Her neighbor told her
she probably has shingles.
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1. What is the most likely cause of this
patient’s pain (differential diagnosis)?
2. What is the physiologic mechanism of
pain in this condition?
3. What is the natural history of pain in
this condition?
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4. What is the appropriate treatment in this
case?
A. Treatment for underlying disease?
B. Pain Management strategy?
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One month later, she returns. She is
depressed, looks disheveled, and tired.
She is still unable to wear a bra or dress.
The pain remains intense. She now
complains of extreme sensitivity of the skin
over the healed rash. Anything that
touches the skin "sets me on fire!".
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5. What are your recommendations now?
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The patient has been taking oxicodone 5mg
(Percocet), two tablets every 6 hours. She describes
good pain relief just after taking each dose, but it
doesn’t last very long. She wakes from sleep with
pain every night. Moreover, she describes
breakthrough pain every four hours after she takes
her usual dose. She has experienced no drowsiness,
cognitive impairment, nausea or constipation as
long as she drinks her prune juice every morning.
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6. What are your pharmacologic options to
improve pain management at this time?
7. What issues should be considered in the
initiation of sustained released opioid
medications?
8. What is the equi-potent analgesic dose of
sustained release oxycodone for this patient?
Equianalgesic Conversion
A cancer patient is taking 2 Percocet every 4
hours. Calculate the initial starting dose of
MS Contin based on equivalent analgesic
potency.
Equianalgesic Conversion
First: Calculate the 24 hour dose of Percocet
(2 tabs) (5mg) ) (6 doses/24 hr) = 60mg oxycodone/24hr
Second: Calculate the 24hr oral morphine equivalents
from potency table: 20mg oxicodone = 30mg oral morphine
(60mg oxicodone/24hr) (30mg morphine / 20mg oxidodone) =
90mg oral morphine/24hr
Third: Calculate the divided 24 hour dose for
sustained release morphine
90mg / 2 = 45mg MS Contin q12h