Transcript PAIN MANAGEMENT

PAIN MANAGEMENT
IN ELDERLY PERSONS
UCLA Multicampus Program of
Geriatrics and Gerontology
Physicians Have a Moral Obligation to
Provide Comfort and Pain Management
Especialy for those near the end of life!
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Pain is the most feared complication of illness
Pain is the second leading complaint in
physicians’ offices
Often under-diagnosed and under-treated
Effects on mood, functional status, and quality
of life
Associated with increased health service use
18% of Elderly Persons
Take Analgesic Medications Regularly
(daily or more than 3 times a week)
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71 % take prescription analgesics
– 63% for more than 6 months
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72% take OTC analgesics
– Median duration more than 5 years
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26% report side-effects
– 10% were hospitalized
– 41% take medications for side-effects
ELDERLY PATIENTS TAKING PAIN
MEDICATIONS FOR CHRONIC PAIN WHO
HAD SEEN A DOCTOR IN THE PAST YEAR
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79% had seen a primary care physician
17% had seen a orthopedist
9% had seen a rheumatologist
6% had seen a neurologist
5% had seen a pain specialist
5% had seen a chiropractor
20% had seen more than 5 doctors
Common Causes of Pain
In Elderly Persons
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Osteoarthritis
– back, knee, hip
Night-time leg cramps
 Claudication
 Neuropathies
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– idiopathic, traumatic, diabetic, herpetic
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Cancer
MISCONCEPTIONS ABOUT PAIN
Myth: Pain is expected with aging.
Fact: Pain is not normal with aging.
PAIN THRESHOLD WITH AGING
Author
Stimulus
Threshold
Shumacher, 1940
Thermal
No Change
Birren, 1950
Thermal
No Change
Sherman, 1964
Electric/Tooth
Higher
Collins, 1968
Electric/Skin
Lower
Harkins, 1977
Electric/Tooth
No Change
Tucker, 1989
Electric/Skin
Higher
Age Related Differences in
Sensory Receptor Function
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Encapsulated end organs
– 50% reduction in Pacini’s
– 10-30% reduction Meissner’s/Merkels Disks
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Free nerve endings
– no age change
Age Related Differences in
Peripheral Nerve Function
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Myelinated nerves
 Reduction in density (all sizes including small)
 Increase in abnormal/degenerating fibres
 Decrease in action potential/slower conduction velocity
Unmyelinated nerves
 Reduction in number (1.2-1.6un) not (.4un)
 Substance P, CGRP content decreased
 Neurogenic inflammation reduced
Age Related Differences in
Central Nervous System Function
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Loss of dorsal horn spinal neurons
 Altered endogenous inhibition, hyperalgesia.
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Loss of neurons in cortex, midbrain, brain stem
 (18% reduction in thalamus, no change cingulum
cortex)
 Altered cerebral evoked responses (increased latency,
reduced amplitude)
 Reduced catecholamines, acetylcholine, GABA, 5HT, not
neuropeptides
MISCONCEPTIONS ABOUT PAIN
Myth: If they don’t complain, they don’t have pain
Fact: There are many reasons patients may be
reluctant to complain, despite pain that
significantly effects their functional status and
mood.
REASONS PATIENTS MAY
NOT REPORT PAIN
Fear of diagnostic tests
 Fear of medications
 Fear meaning of pain
 Perceive physicians and nurses too busy
 Complaining may effect quality of care
 Believe nothing can or will be done
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The most reliable indicator
of the existence pain and its
intensity is the patient’s
description.
There is a lot we can do to
relieve pain!
Analgesic drugs
 Non-drug strategies
 Specialized pain
treatment centers
 Patient and caregiver
education and support
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Analgesic Drugs
Acetaminophen
 NSAIDs
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– Non-selective COX inhibitors
– Selective COX-2 inhibitors
Opioids
 Others
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Antidepressants
Anticonvulsants
Substance P inhibitors
NMDA inhibitors
Others
CAUTION
Meperidine (Demerol)
 Butorphanol (Stadol)
 Pentazocine (Talwin)
 Propoxiphene (Darvon)
 Methadone (Dolophine)
 Transderm Fentanyl (Duragesic)
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Do Not Use Placebos!
Unethical in clinical practice
 They don’t work
 Not helpful in diagnosis
 Effect is short lived
 Destroys trust
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Non-Drug Strategies
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Exercise
– PT, OT, stretching,
strengthening
– general conditioning
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Physical methods
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– ice, heat, massage
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Cognitivebehavioral therapy
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Chiropracty
Acupuncture
TENS
Alternative therapies
– relaxation, imagery
– herbals
PATIENT AND CAREGIVER
EDUCATION
Diagnosis, prognosis, natural history of
underlying disease
 Communication and assessment of pain
 Explanation of drug strategies
 Management of potential side-effects
 Explanation of non-drug strategies
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