Transcript Pain Management in Older Adults in Adult Family Homes

Pain Management
in Older Adults in the
Adult Family Home
Mary Shelkey, PhD, ARNP
[email protected]
Cause of Death/
Demographic and Social Trends
Early 1900s
Current
Medicine's Focus
Comfort
Cure
Cause of Death
Infectious Diseases/
Communicable Diseases
1720 per 100,000
(1900)
50
Chronic Illnesses
And Cancer
799 per 100, 000
(2010)
78.7
(2010)
Institutions
Death rate
Average Life
Expectancy
Site of Death
Home
Caregiver
Family
Disease/Dying
Trajectory
Relatively Short
Family/Strangers/
Health Care Providers
Prolonged
Varying Trajectories of Dying
Sudden Death
Functional Status
Predictable Decline
(cancer)
Hospice Chronic
Longstanding Chronic
Time
Connor SR, New Initiatives
Transforming Hospice Care. The
Hospice Journal, 1999. 14 (3/4);
p.193-203
Chronic Conditions
The most common chronic conditions
among Medicare beneficiaries are:
High blood pressure (58%),
High cholesterol (45%),
Heart disease (31%),
Arthritis (29%) and
Diabetes (28%).
Number of deaths for leading
causes of death (2010)
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Heart disease: 597,689
Cancer: 574,743
Chronic lower respiratory diseases: 138,080
Stroke (cerebrovascular diseases): 129,476
Accidents (unintentional injuries): 120,859
Alzheimer's disease: 83,494
Diabetes: 69,071
Nephritis, nephrotic syndrome, and nephrosis: 50,476
Influenza and Pneumonia: 50,097
Intentional self-harm (suicide): 38,364
World Health Organization (WHO)
Definition of Palliative Care
Palliative care (from Latin palliare, to cloak)
is an approach that improves the quality of life of
patients and their families facing the problem
associated with life-threatening illness, through the
prevention and relief of suffering by means of early
identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial and spiritual.
The Cure - Care Model:
The Old System
Life Prolonging
Care
D
Palliative/
E
Hospice
A
Care
T
H
Disease Progression
A New Vision of Palliative Care
Modifying Therapy,
Curative, restorative intent
Life
Closure
Risk
Disease
Condition
Palliative and Hospice Care
Death &
Bereavement
NHWG; Adapted from work of the Canadian Palliative Care Association & Frank Ferris, MD
Definition of Pain
Unpleasant sensory and emotional
experience or
Anything the person says it is
Incidence of Pain in Older Adults
Research has shown that 50 percent of older
adults who live on their own and 75-85
percent of the elderly in care facilities suffer
from chronic pain. Yet, pain among older
adults is largely undertreated, with serious
health consequences, such as depression,
anxiety, decreased mobility, social isolation,
poor sleep, and related health risks.
(NIH Medline Plus)
Sources of Pain
Consequences of Pain
Cognitive Function
Where does cognitive function
originate?
What do we mean when we say
cognitive disorders or dementia?
Cognitive Functions:
Orientation
Memory
Language
Calculation
Insight
Judgment
Executive Functioning
Causes of Cognitive Impairments
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Delirium
Dementia (all types)
Psychiatric Disorders
Mood and Psychotic Disorders
Previous Impairments (Developmental
Disability)
Alzheimer’s Disease
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It is impossible to confirm the diagnosis
without a brain autopsy
However, in a live patient it is possible to
make the diagnosis of AD with 90 – 95 %
accuracy
Early diagnosis is vital for optimum treatment
results
No Known Etiology / No Cure
Types of Dementia
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Alzheimer’s Disease (66%)
Vascular dementia / Mixed (15%)
Dementia with Lewy Bodies (20%)
Dementia with Lewy Bodies Parkinson
Disease (7%)
Other (10%)
Medications Used to Treat
Behavioral Symptoms
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Cholinesterase inhibitors and NMDA antagonist
Anti-depressants
Atypical: Trazodone
Anti-psychotics
Haldol
Risperdal
Olanzapine
Benzodiazepines
Mood Stabilizer
Valproic Acid
Tegretol
Pain Assessment
Behavioral Pain Indicators
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Grimacing or wincing
Bracing/Guarding
Rubbing
Changes in activity level
Sleeplessness, restlessness
Resists movement
Withdrawal/apathy
Increased agitation, anger, etc.
Decreased appetite
Vocalizations (e.g., moans)
Attitudes that Hinder Pain Reporting,
Assessment & Treatment in Older Adults
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Stoicism, not wanting to be a “complainer”
Concerns about addiction, side effects,
tolerance
Pain in old age is inevitable
Nothing can be done to relieve pain
Older adults cannot tolerate strong
analgesics
Older adults are less sensitive to pain
What Descriptors Do Older
Adults Use For Pain?
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Soreness
Ache……
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Assess for functional limitations…
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Good Communication is Critical!
Confused Older Adults Are Even
More Untreated for Pain
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Pain is often not considered as a cause of
agitation
Health professionals are not proficient in
assessing pain in confused older adults
Antipsychotics are often used to control
behaviors rather than treat pain, the
underlying cause of the adverse behaviors
Pain medications doses are often inadequate
Let’s Use Another Species as an
Example…….
MYTH: Quiet Rabbits Are
Not Having Any Pain
FACT: Rabbits Don’t Make Noise…
Maybe a Thump or Two
Rabbit in pain: Quiet, legs pulled in,
make look like they’re sleeping
Rabbit comfortable: stretched
out, eating, moving freely
Opioids Need to be used with Caution in
Rabbits because Cats are Sensitive….
(and the science is weak….)
Assessment Tools Are Not Fool-Proof
Q: Can you tell if we are a 0 or
10 on this pain scale?
A: I don’t how to read……
CLINICIANS and FRIENDS OF THE OLDER ADULTS
… hone your assessment skills and act accordingly!!
Pain Assessment & Monitoring
Pain assessment must be
 appropriate
 ongoing
 with frequent evaluation of effectiveness
 adjustment of treatment as needed
Choosing Analgesics
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Begin treatment for mild to moderate pain
with a nonopioid
Add an opioid for moderate to severe pain
Administer acetaminophen with an opioid
(unless contraindicated)
Consider previous experience with other
analgesics in choosing agents
Check liver and renal function
WHO-3 Step Ladder
Opioids
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Opioids are safe to use in the management
of moderate to severe acute pain in older
adults
Begin with opioids with short half-lives
(e.g., morphine, hydromorphone,
oxycodone)
May want to use the term “opioid” rather
than “narcotic”
Opioids
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Morphine sulfate is considered the opioid
analgesic of choice
However, Hydromorphone and oxycodone
are acceptable alternatives to morphine
Hydrocodone is an acceptable opioid for
short term mild and some moderate acute
pain in older adults
Avoid codeine use (less potent & more side
effects)
Side Effects of Opioids
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Sedation
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Nausea and vomiting
Orthostatic hypotension
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Urinary retention
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Dysphoria or euphoria
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Constipation
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Respiratory depression
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Pruitus
Opioids and Delirium
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Delirium may be caused by factors other than
opioids
Post-op delirium associated with unrelieved
pain rather than opioid use
If other causes of delirium are not found and
pain is effectively managed, consider
decreasing the opioid dose
Consider short-term use of haloperidol;
caution – may mask pain behaviors
Case Study
86 year old gentleman living in an adult family home. He
has moderate dementia, ambulates throughout the unit
and has severe language impairments.
Active diagnoses include: Alzheimer’s disease,
Hypertension, Hyperlipidemia, Osteoarthritis. Not on pain
meds.
He has no history of physical aggression however this
morning starts hitting other residents at breakfast table.
VSs BP: 134/86; P=96; R=22; T=98.2 F
What should we consider?
Pitfalls in Assessment
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Not getting verbal pain assessment from
resident
Not checking for bruising/injuries
Looking for the ever-present bacteria in his
urine
Asking how he was over the last 24 hours
and what unusual activities may have
occurred in the home
How to Proceed
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While you are waiting for the million dollar
work-up results… start some pain meds
Acetaminophen 3 x/ day scheduled (650 mg to
1000 mg) never to exceed 3000 mg/day
Avoid NSAIDS like Motrin (can cause GI
bleeding)
If you see good results but cannot sleep at night
try Oxycodone 2.5 – 5 mg QHS
Case Study
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78 year old female with CVA 3 years ago with
dominant sided hemiplegia. She has modsevere vascular dementia. Two months ago
she started yelling out at all hours of the day,
no pattern. No pain meds. Vital signs normal.
Labs, back x-ray; U/A all negative.
What should we consider?
How to Proceed
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You started Acetaminophen 650 mg 3 times a day.
There has been ~ 25% decrease in yelling out but she
continues to yell out with the same frequency at night.
You added Oxycodone 5 mg at night with ~ 25%
improvement and added Oxycodone after 5 days in the
AM with another 20% improvement.
You will now need to consider a neuropathic medication
(eg Neurontin). Maybe Gabapentin 100 mg before bed
to start
Adjuvant Therapies for
Neuropathic Pain
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Cortiocosteroids (e.g. Dexamethasone)
Anti-convulsants (e.g. Gabapentin)
Tricyclic antidepressants (e.g.
Nortriptyline)
Local anesthetics (e.g. Lidocaine)
Anticancer (e.g. radiation therapy,
surgery)
Nondrug Pain Management
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Education
Exercise
Cognitive-Behavioral Support
Physical modalities (heat, cold, massage)
Physical or occupational therapy
Chiropractic
Acupunture
Transcutaneous Electrical Nerve Stimulation
Relaxation and Distraction
Nonpharmacologic Interventions
Should Be Used Only When
Optimal Analgesia Has Been
Achieved……
Summary….
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Palliative care, including pain
management, improves quality of care
for our sickest and most vulnerable
patients and families.
Pain is a universal human experience
and universal health professional
obligation.
Questions?