Transcript Special Situations

Special situations
Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for
individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It
is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the
Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of
these materials, or for any errors or omissions. Last updated on January 12, 2015
Objectives
• Discuss alternative options for assessing pain in patients that
may have problems communicating
– PAINAD scale
• Review how to manage pain in elderly patients
• Determine how to assess and treat pain for patients with
sickle cell disease
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Pain in the elderly
• Chronic pain is common among the elderly
• Dementia and problems communicating often make
assessment of pain challenging
• Compliance with medications can also be a challenge
– Impaired vision
– Limited mobility
– Memory problems
Beating Pain, 2nd Ed. APCA (2012)
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Pain assessment
• Observational tools may be used to assess pain in patients who
have trouble communicating their pain or are cognitively
impaired
• Communication boards could also be used for this subset of
patients
• Health care providers should assess the pain of such patients as
accurately as possible
Beating Pain, 2nd Ed. APCA (2012)
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Options for cognitive impairment or dementia
Many patients who appear cognitively impaired may still be able
to provide useful information concerning pain
• Interview caregivers: patterns of particular behaviors may
have developed that indicate pain (e.g. placing a hand on the
forehead for a headache)
• Review medical record for known pain-inducing pathology
• Observe facial expression, body posture, vocalizations,
appetite, interactivity
• Utilize Pain Assessment in Advanced Dementia (PAINAD)
Beating Pain, 2nd Ed. APCA (2012); Guide to Pain Management in Low-Resource Settings: International Association for the Study of
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Pain, 2010
Pain Assessment in Advanced Dementia (PAINAD)
Scale
Items
0
1
2
Breathing
independent of
vocalization
Normal
Occasional labored
breathing. Short period
of hyperventilation
Noisy labored breathing.
Long periods of
hyperventilation. CheyneStokes respiration
Negative
vocalization
None
Occasional moan or
groan. Low level
speech with a negative
or disapproving quality
Repeated troubled calling
out. Loud moaning or
groaning. Crying
Facial expression
Smiling or
inexpressive
Sad. Frightened. Frown
Facial grimacing (an ugly or
disapproving facial
expression)
Body language
Relaxed
Tense. Distressed
pacing. Fidgeting
Rigid. Fists clenched. Knees
pulled up. Pulling or
pushing away. Striking out
Consolability
No need to
console
Distracted or reassured
by voice or touch
Unable to console, distract,
or reassure
Beating Pain, 2nd Ed. APCA (2012), adapted from Warden et al, 2003
Score
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Managing pain in the elderly
• Include family in the process
• Provide written information and in clear writing, enlarged as
needed
• Anticipate pain and treat accordingly
• Titrate doses individually
– Start low and titrate upward slowly
• Use care with adjuvant co-analgesia to avoid drug interactions
and unwanted side effects
Beating Pain, 2nd Ed. APCA (2012)
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Pain in sickle cell disease
• Most patients with sickle cell disease experience pain on a
daily basis
• Crisis pain: the most severe pain experienced by sickle cell
patients
– Patient feels that “all my bones are breaking”
– Reported to occur about 13% of all days
– Characterized by abrupt onset, episodic and unpredictable,
and with severe pain
– May last several hours to a week or more
Oxford Textbook of Palliative Medicine, (2010); Guide to Pain Management in Low-Resource Settings: International Association for
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the Study of Pain, 2010
Pain in sickle cell disease
• Patients may need chronic pain management and rescue
medication for acute pain crises
• Those with three or more pain crises per year are candidates
for hydroxyurea therapy, which significantly decreases their
occurrence
Oxford Textbook of Palliative Medicine, (2010); Guide to Pain Management in Low-Resource Settings: International Association for
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the Study of Pain, 2010
Sickle cell pain treatment
• Assess pain frequently and treat as an emergency
• Maintain adequate hydration
• Investigate other possible causes of pain, including
complications of the diseases (acute chest syndrome,
priapism, splenic sequestration, cholelithiasis)
• Do not withhold opioids when pain is severe: treat according
to the WHO analgesic ladder
• Some patients may require chronic use of opioids on a daily
basis to manage pain and improve function
Oxford Textbook of Palliative Medicine, (2010); Guide to Pain Management in Low-Resource Settings: International Association for
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the Study of Pain, 2010
Alternative routes of administration
• Use the oral route whenever possible
• Exceptions may be:
– Need for rapid pain relief in pain emergencies: intravenous
or subcutaneous route
– Oral route is not accessible: rectal, buccal, intravenous,
subcutaneous, nasogastric, or transdermal
– Check to see if dose conversion is needed to move from
oral to alternative route
• Avoid intramuscular injection: causes more pain
Beating Pain, 2nd Ed. APCA (2012).
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Take home messages
• Though chronic pain is common in the elderly, pain can be
assessed and managed, even for those suffering from
dementia
• Sickle cell pain should be assessed frequently
• Sickle cell crisis should be treated as an emergency
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References
•
African Palliative Care Association. Beating Pain: a pocketguide for pain
management in Africa, 2nd Ed. [Internet]. 2012. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/beating_pain.pdf
•
African Palliative Care Association. Using opioids to manage pain: a pocket guide
for health professionals in Africa [Internet]. 2010. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/using_opiods.pdf
•
Amery J, editor. Children’s Palliative Care in Africa [Internet]. 2009. Available from:
http://www.icpcn.org/wp-content/uploads/2013/08/Childrens-Palliative-Care-inAfrica-Full-Text.pdf
•
Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings
[Internet]. 2010. Available from: http://www.iasppain.org/files/Content/ContentFolders/Publications2/FreeBooks/Guide_to_Pain_
Management_in_Low-Resource_Settings.pdf
•
The Palliative Care Association of Uganda and the Uganda Ministry of Health.
Introductory Palliative Care Course for Healthcare Professionals. 2013.
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