persistent pain in the elderly veeraindar goli, md, fapa medical director., pain evaluation and...
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Persistent Pain in the ElderlyPersistent Pain in the Elderly
Veeraindar Goli , MD, FAPAMedical Director. , Pain Evaluation and Treatment Services
Associate Director ., Pain & Palliative Program
Duke University Medical Center , Durham , N.C. 27705
(919)684-2154
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Objectives
Discuss the scope of the problem
Identify key issues in undertreatment of pain
Define Pain and discuss mechanisms
Age related differences in Pain Mechanisms and Presentations
Assessment of pain in the Elderly
Treatment strategies and AGS Guidelines
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11%
89%
Nine in Ten Americans Suffer from Nine in Ten Americans Suffer from Regular PainRegular Pain
Frequency of Pain SufferedFrequency of Pain Suffered
Suffer less oftenSuffer less often
Suffer once a month or moreSuffer once a month or more
Arthritis Foundation Survey. 1999.Arthritis Foundation Survey. 1999.
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Pain in the United States
Pain is the most common reason people seek medical attention
50 Million people in the US are partially disabled or totally disabled by pain
45% of Americans seek care for their persistent pain at some point in their lives.
(Source: American Pain Society)
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Pain in the Elderly
Pain is reported to be twice as prevalent in the elderly as in younger individuals
Elderly in the community reported to have prevalence of pain ranging from 25-50%
In LTC settings, prevalence can be as high as 85% 1/6 of all nursing home residents experience pain daily
( Source: “The Prevalence and Treatment of Pain in US Nursing Homes)
Chronic pain in the LTC setting is generally under recognized and often under treated ( Source: American Geriatric Society Panel
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Societal Attitudes and Misconceptions Toward Pain
The elderly have a higher tolerance toward pain
The elderly or cognitively impaired cannot be accurately assessed for pain
Residents complain of pain just to get more attention
Elderly patients are likely to become addicted to medication
Chronic Pain means death is imminent
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Barriers to Recognition of Pain in the Elderly
Racial, ethnic, religious and gender biases
Cognitive impairment
Coexisting medical conditions
Staff training and access to appropriate tools.
System Barriers
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Barriers to Pain Treatment Healthcare professionals
inadequate knowledge/ poor assessment
fear of tolerance, addiction and side effects
concern with regulatory issues
Patients
inadequate knowledge
fear of addiction and side effects
Healthcare System
access to specialists
inadequate reimbursement
State/Federal Regulations
scheduling
triplicates
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Importance of Pain Relief?
It is an individual’s right to be pain free – JCAHO Standards
Pain in the elderly associated with anxiety and depression
Associated with significant medical morbidity
Pain negatively impacts the quality of life in the older person
APS adapted it as the 5th vital sign
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Almost all long term care residents have predisposing factors for developing pain.
For this reason, a high index of suspicion regarding the presence of pain is warranted.
Source: The Management of Chronic Pain in Older Persons, AGS Panel on Chronic Pain in Older Persons.
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Merskey H, Bogduk N, eds. Classification of Chronic Pain. 1994:209-14.
Pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP)
Pain is whatever the patient says it is and occurs whenever they say it does !! (McCaffrey)
Definition
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What is pain, really?
Transduction
Transmission
Modulation
Perception
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Neuroanatomy of Pain Pathways
Scientific American Medicine
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Pain Classification
Headache(migraine)
Acute Chronic
Pain
NociceptiveMixedNeuropathic Visceral
Diabetic neuropathy (DN)Post-herpetic neuralgia (PHN)Radiculopathy (RADIC)
Cancer painLow back pain
OsteoarthritisRheumatoid arthritisFibromyalgia
IBSPancreatitisBladder painNoncardiac chest painAbdominal pain syndrome
InjuryPostoperativeFlare
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Pain Physiology
Nociceptive Pain
Neuropathic Pain --Peripheral sensitization
--Central sensitization
--Neuroplastic changes
Mixed Pain
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Pain types- features
Pain serves a protective function
Transient
Well localized
“linear” stimulus-response pattern as other sensory modalities
Pain (A- & C fibers) can be differentiated from touch (A- fibers)
Pain is pathological, associated with nerve injury; no biological function
Outlasts stimulus
Spreads to noninjured regions
Occurs with sensitization of peripheral and central nervous systems
Pain elicited from A-, as well as A- & C fibers
Nociceptive (Acute) Neuropathic (Chronic) (Physiological) (Pathological)
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Normal Events That Produce Nociception: Paper Cut
Tissue injury
Immediate activation of A fibers(first pain)
Fast
Localize the injury
Later activation of C fibers(second pain)
Slower
Less ability to localize injury
Tissue reaction to injury
Time (seconds)
Pai
n Le
vel
LessLess
MoreMore
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Characteristics of Neuropathic Pain Spontaneous pain: Due to spontaneous firing
of axons or dorsal horn neurons- Lancinating, paroxysmal- Burning, constant- Cramping
Evoked pain: Due to damage and alterations in
peripheral and central sensory neurons - Allodynia- Hyperalgesia- Hyperpathia
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Pathologic Pain Functions
Stimulus intensity
Magnitude of pain normal
hyperpathia
hyperalgesia
allodynia
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Adapted from Siddal, Cousins. In: Cousins, Bridenbaugh, eds. Neural Blockade. 1998:675-699.
Peripheral SensitizationTissue damage Inflammation Sympathetic
terminals
Decreased threshold of nociceptorsEctopic dischargesAbnormal accumulation of Na+ channels
SENSITIZING “SOUP”
Hydrogen ions Histamine Purines LeukotrienesNoradrenaline Potassium ions Cytokines Nerve growth factorBradykinin Prostaglandins 5-HT Neuropeptides
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Central SensitizationCentral Sensitization
Mechanisms of Pain
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Siddal &Cousins in: Cousins & Bridenbaugh: Neural Blockade, 1998: 675-699.
Physiological Sensations
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Neuropathic Pain
Siddal & Cousins. In: Cousins & Bridenbaugh, eds. Neural Blockade. 1998:675-699.
Neuropathic PainDouble Amplification
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Neuropsychiatric aspects of Pain
cortical modulation
Attentional processes
state of consciousness
“Ultimate” psychosomatic phenomenon
cognitive factors Attention to Pain
Meaning
Mood disorders
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Nociception
Nociception
Pain
Suffering
Pain Behavior
Loeser JD. In: Loeser JD. In: Bonica’s Management of PainBonica’s Management of Pain. Philadelphia; . Philadelphia; Lippincott Williams & Wilkins: 2001.Lippincott Williams & Wilkins: 2001.
Multidimensional Model of Pain
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Abnormal Pain Mechanisms
Abnormal Nociception Peripheral Sensitization
Abnormally low pain threshold (hyperalgesia )
Central sensitization to Pain .
Recruitment of Novel Inputs ( Allodynia )
Abnormal Pain Perception meaning of pain
memory of pain
Mood disorders
Neuropsychiatric aspects of pain
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Aging - what is the impact on pain ?
Two major sources of Information
1) Studies of aging and pain in the absence of disease
Decrease in thermal ,mechanical sensitivity. Decrease in discriminative capacity , changes in C and Ad fibers.
2) Studies of aging and pain in the presence of disease
Arthritis , Post herpetic neuralgia , cancer on one hand and unusual presentations( silent MI , Painless intraabdominal catastrophies on the other. Decrease in pain tolerance .
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Causes of Chronic Pain in Aging
Predominantly Musculoskelatal (OA, RA )
Myofascial pain syndromes
Herpes Zoster , temporal arteritis , Polymyalgia
Post - Cancer Pain
Iatrogenic , related to therapies.
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Pain Assessment
Initial Pain Assessment: A detailed history including assessment of PainIntensity
and Character A physical and neurological examination. A psychosocial examination. Appropriate diagnostic workup to determine the cause of
Pain.
Ongoing Pain Assessment: At regular intevals after starting the treatment plan . With each new report of Pain .
Assessment of New Pain.
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Pain Treatment Guidelines World Health Organization (1990, 1996)
American College of Rheumatology (1995, 2000)
American Geriatrics Society (1998 and 2002)
American Medical Directors Association (1999)
American Pain Society (2002)
AHCPR Guidelines
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Treatment Approach (AHCPR)
Ask pain and goal , and Assess pain
Believe the patient and family (Validate! but do not enable.)
Choose pain control options wisely
Deliver interventions timely
Enpower the patient and family
Follow up to reassess the pain
From CMDT 2003 p66
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AGS Practice Guidelines
GUIDELINE OBJECTIVE(S)
To update and revise previous recommendations from the clinical practice guideline titled "The Management of Chronic Pain in Older Persons," using the latest information about pain management in elderly persons
To provide the reader with an overview of the principles of pain management as they apply specifically to older people and specific recommendations to aid in decision making about pain management for this population
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AGS Practice Guidelines
NUMBER OF SOURCE DOCUMENTS
More than 4,122 citations were identified from sources
More than 2,089 abstracts were obtained for further analysis
More than 520 full-text data-based articles were obtained and summarized for detailed analysis
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American Geriatric Society (AGS) Clinical Practice Guidelines
Older persons should be assessed for pain on initial presentation to any health care setting.
Any persistent or recurrent pain that has a significant impact on function or quality of life should be recognized as a significant problem.
A variety of terms synonymous with pain should be used to screen older patients (e.g. ache, discomfort, soreness, heaviness, tightness)
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Common Pain Indicators
Self-report
Report from significant other
Condition or procedure that usually causes pain
Behaviors
Physiologic Measures
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Getting to Know the Pain
Words – McGill’s Pain Questionnaire
Intensity – VAS pain scale
Location – More than one location
Duration – constant or breakthrough
Aggravating and Alleviating Factors
Challenges in Pain AssessmentChallenges in Pain Assessment
Patients With Communication
Difficulties
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Challenges in Pain Assessment
1. Cognitive Impairment
2. Three D’s-Dementia, Delirium, Depression
3. Conscious but unable to speak
4. Unconscious and unable to speak
5. Residents with wide range of communication difficulties
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Pain Assessment in the Cognitively Impaired Resident
Cognitive impairment is major obstacle to pain assessment ,50%-60% of residents have some form of progressive dementia
Study of 758 cognitively impaired nursing home residents
Self report of pain is no less valid than that of cognitively intact residents
(Source: Parmelee, Smith,Katz 1993)
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Use of Pain Rating Scales in Cognitively Impaired
Residents with substantial cognitive impairment may still be able to use a pain rating scale
217 residents; dependent in most ADL’s
Mean age of 84.9; substantial cognitive impairment
30 seconds to respond; scale repeated three times
0 to 5 scale preferable with this population rather than 0-10 scaleSource: (Ferrell, Ferrell & Rivera 1995)
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Proxy Pain Rating
Family members or clinicians who know the resident well may be asked to rate pain
Family members may be better able to identify behaviors that suggest the possibility of pain
Family members may be more sensitive to changes in behavior
Used as a guess; not used with self reports of pain
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Do’s & Don’ts
Use an Instrument with simple language
Use simple descriptors (“aching”, “hurting”)
Ask yes/no questions Listen for clues in
fragmented speech Palpate areas thought to
be painful when asking questions
Observe for behaviors that may indicate pain
Assess pain following or during movement
Don’t discount behaviors as part of dementia
Don’t interrupt attempts at responses
Assume that anti-anxiety medications will relieve pain
Don’t forget to include family members
Don’t assume that persons with dementia don’t experience pain
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2) Assessment in Residents with Advanced Dementia
Discomfort in Dementia of the Alzheimer’s Type
(DS-DAT)
Scale of 9 indicators of discomfort/comfort:- noisy breathing - negative vocalizations
- content facial expression - sad facial expression
- frightened facial expression - frown
- relaxed body language - tense body language
- Fidgeting
(Source: Hurley, Volicer, Hanrahan et al 1992)
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3) Assessment and Treatment of Pain in the Nonverbal Patient
Feedback from the patient
Offer writing materials or simple pain scales
Treat with analgesics or other pain relief measures
If interventions modify pain behaviors, continue with treatment
R/O other potential problems
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Behavioral Cues
Grimacing, frowning, grinding teeth
Agitation, striking out
Restlessness, fidgeting
Moaning/crying , groaning
Guarding, changes in gait
Appetite and activity changes
Irritability/swearing
Sleeping poorly
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4) Unconscious Residents
Pain may not be easily determined, assumed pain free Residents who appear to be unconscious &
unresponsive to painful stimuli actually feel & recall pain
Residents with endotracheal tubes or residents who have received a neuromuscular blocking agent (pancuronium) may be fully capable of feeling pain
Clinicians should assume that the unconscious resident may feel pain & provide analgesics if anything known to be painful is present
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5) Pain in Terminally Ill Residents
When patients are no longer able to verbally communicate whether they are in pain or not, the best approach is to assume that their cancer is still painful and to continue them on their regular medications
Therapeutic opioid (narcotic) level should be maintained
Continued opioids simply ensure that the death will be as peaceful and as painless as possible (Levy 1985)
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Assessment Tools for Cognitively Impaired
FACES Scale
VAS and 0-5 Scale
Verbal Descriptor Scale
Flow Sheets
Pain Thermometer
Discomfort Scale for the Dementia of Alzheimer’s Type
Face, Legs, Activity, Crying, Consolability (FLACC) Scale
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Federal Regulations
Skilled nursing facilities function under a clear mandate from the federal government regarding the responsibility to assess, treat and manage pain
Nursing Home Federal Requirements and Guidelines to Surveyors, Code of Federal Regulations (CFR) 483.25, F309
Facilities are surveyed to assure necessary care is provided based on findings on the Resident Assessment Instrument (RAI)
Pain is mandated to be a part of the Minimum Data Set (MDS)
Sections J2a, J2b and J3 meet this requirement
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Section J2/ Pain Symptoms and J3 Pain Site ( MDS )
b. INTENSITY of pain 1. Mild pain 2. Moderate pain
0. No pain (skip to J4) 3. Times when pain is 1. Pain less than daily horrible or excruciating 2. Pain daily(If pain present, check all sites that apply in last 7 days)
Back pain a. Incisional pain f.
Bone pain b. g.
c. h.
Headeache d. Stomach pain I.
Hip pain e. Other j.
a. FREQUENCY with which resident complains or shows evidence of pain.
J 2. Pain Symptoms
(Code the highest level of pain present in the last 7 days)
J 3. Pain Site
Chest pain while doing usual activities
Joint pain (other than hip)
Soft tissue pain (e.g., lesion, muscle)
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Summary of Pain Assessment
Ask residents about their pain
Observe nonverbal behaviors
Accept and respect what they say
Consult family members
Use appropriate assessment scales
Intervene to relieve their pain
Ask them again about their pain
Circle of assessment, intervention and reassessment
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“If we cannot assess pain, we will never be able to treat pain.”
Betty Ferrell
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Under Treatment- Just the fact
Pain in the elderly JAMA, 1998 – Elderly Cancer Patients in LTC
>25% received nothing for pain
Highest risk = >85, women, minorities
Advanced dementia pts with hip fractures
Received 1/3 morphine equivalent dose compared to others
76% were without standing analgesic orders
50 – 90% fail to take meds correctly
Vertebral fractures >65 years old is 21 – 27%
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Pain Treatment Continuum
Least invasive
Most invasive
Psychological/physical approaches
Topical medications
Oral medications
Injections
Interventional techniquesMackin GA. J Hand Ther. 1997(April-June);10(2):96-109; Katz N. Clin J Pain. 2000(June);16(2 suppl):S41-48; Leland JY. Geriatrics. 1999(Jan);54(1):23-28, 33-34, 37; Belgrade MJ. Postgrad Med. 1999(Nov);106(6):127-132, 135-140; Galer BS et al. A Clinical Guide to Neuropathic Pain. 2000, p. 97; Gonzales GR. Neurology. 1995(Dec);45(12 suppl 9):S11-16; discussion S35-36
ContinuumContinuum not related to efficacynot related to efficacy
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Generic Treatment Goals(Mission Impossible ?)
Validate Patients Condition
“Shrink” pain to the Lowest level possible.
Identify treatable conditions
Streamline Medications
Improve Quality of life
Provide Pain Coping Skills
Increase Socialization
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Multidisciplinary Management ! Multiple studies demonstrate the best outcomes
A team approach is recommended
Consistent with other geriatric program models
A comprehensive assessment to include medical , neurological ,psychosocial evaluations.
Integrating Invasive and non invasive techniques
Physical therapy , alternative therapies
Specific goal setting a shift of focus to rehabilitation model of pain management , rather than cure.
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Treatment Modalities
Pharmacological
Non-Pharmacological Physical
psychosocial
Invasive Techniques
Alternative Medicine
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Antidepressants Amitriptyline, imipramine, desipramine,
nortriptyline
Anticonvulsants Carbamazepine, clonazepam,
gabapentin, lamotrigine, oxcarbazepine,
phenytoin, topiramate, valproic acid
Antiarrhythmics Mexiletine
Topical formulations Capsaicin, lidocaine, aspirin
Analgesics Oxycodone, methadone , tramadol
NSAIDS( non selective) Ibuprofen , Naproxen , Meloxicam
Selective COX-2 Rofecoxib and Celecoxib
Pharmacologic Management of Chronic Pain
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PNS
CBZOXCPHTTCATPMLTGMexiletineLidocaine
Na+
SPINAL CORD
BRAIN
Descending Inhibition
TCAsSSRIsSNRIsTramadolOpiates
Ca++ : GBP; OXC NMDA : Ketamine, TPM
Dextromethorphan
OthersCapsaicinNSAIDsCOX-2 inhibitorsLevodopa
Beydoun. 2001.
Mechanistic Categories of Antineuralgic Agents
Central SensitizationPeripheral Sensitization
NE/5HT Opiate receptors
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Definitions:Quality of Evidence
Level I: Evidence from at least one properly randomized, controlled trial
Level II: Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic
studies, from multiple time-series studies, or from dramatic results in uncontrolled experiments
Level III: Evidence from respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Strength of Evidence(FOR) A =Good, B =Moderate , C =Poor,
(AGAINST) D=Moderate against, E=Good evidence against
AGS Quality of Evidence
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Pharmacological treatment Guidelines
All older patients are candidates for pharmacologic therapy. (IA)
There is no role for placebos (IC)
The least toxic means should be used. Noninvasive route should be considered first. (IIIA)
Acetaminophen should be the first drug to consider in the treatment of mild to moderate pain of musculoskeletal origin. (IB)
Avoid Traditional (nonselective) NSAIDs . The COX-2 selective agents or nonacetylated salicylates (IA)
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AGS Guidelines- Opioids
Opioid analgesic drugs may help relieve moderate to severe pain, especially nociceptive pain. (IA)
Opioids for episodic (noncontinuous) pain should be prescribed as needed, rather than around the clock. (IA)
Long-acting or sustained-release analgesic preparations should be used for continuous pain. (IA)
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Opioids – Contd. Breakthrough pain - identify and
treat by the use of fast-onset, short-acting preparations. There are three types of breakthrough pain: (IA)
–End-of-dose failure (IIIB)
–Incident pain. (IB)
–Spontaneous pain. (IC) Titration should be conducted
carefully. (IA)
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AGS Guidelines- side effects
Constipation and opioid-related GI side effects should be prevented. (IA)
Mild sedation and impaired cognitive performance should be anticipated when opioid analgesic drugs are initiated or escalated. Until these side effects cease: (IIIC)
Severe or persistent nausea may need to be treated with anti-emetic medications, as needed. (IIIB)
Fixed-dose combinations of opioid with acetaminophen or NSAIDs may be useful for mild to moderate pain. (IA)
Patients taking analgesic medications should be monitored closely. (IA)
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Pharmacotherapy AGS
Neuropathic pain – AED and TCAs (1A)
Topical Therapies (1B)
Combination therapies (IIB)
Monitor Side effects (IA)
Non-Pharmacological treatmentsNon-Invasive Treatments
Physical RehabilitationPhysical Rehabilitation Myofascial releaseMyofascial release
StretchingStretching
ReconditioningReconditioning
StrengthStrength
EnduranceEndurance
Gait and posture trainingGait and posture training
Body mechanicsBody mechanics
PacingPacing
AnalgesicAnalgesic IceIce
HeatHeat
Electrical Electrical stimulationstimulation
TENSTENS
InterferentialInterferential
Counter-irritationCounter-irritation
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Non Pharmacological treatmentsInvasive Therapies
Neurosurgical procedures:
1)Interruption of pain transmission;
Peripheral neurotomy, rhizotomy, cordotomy,
DREZ, Thalamotomy, Medullary tractotomy.
2) Stimulation of Analgesia:
TENS , DCS , Epidural Stimulation , Thalamic stimulation.
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Non pharmacological TxAnesthetic approaches
Myofacial trigger point injection
peripheral nerve block
Autonomic plexi block
inhalation analgesia
neurolytic blockade
intraspinal opioid devices
spinal cord stimulation devices
Non -Pharmacological treatmentsPsychiatric/Psychological Treatments
CognitiveCognitive How to thinkHow to think
BehavioralBehavioral What to doWhat to do
Stress Stress managementmanagement Relaxation trainingRelaxation training
VisualizationVisualization
HypnosisHypnosis Range of Pain ControlRange of Pain Control
DistractionDistraction
AnalgesiaAnalgesia
AnesthesiaAnesthesia
BiofeedbackBiofeedback
PsychotherapyPsychotherapy GroupGroup
FamilyFamily
TraditionalTraditional
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Cognitive Behavioral Therapy in aging Pain adaptation ( Daily activities ,bodily responses,thoughts
/feelings)
Age does not predict response and can be effectively used in this population
May reduce the burden of polypharmacy & serious side effects.
Severe Depression or major cognitive impairment should be excluded ( poor Candidates )
Strategies include :
Relaxation training-Biofeedback & Progressive muscle relaxation
Activity Rest Cycles
Attention Diversion Strategies
Cognitive restructuring
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Social context in elderly chronic pain patients ( Roy et al )
Social network ( Buffering model of social support )
Formal Networkhospital , cultural institutions etc
Informal Network Family , spouse , friends
Semi- formal networkClubs , church , professionals
Older Adult
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Conclusion
Geriatric Pain is undertreated and understudied
A better understanding of pain mechanisms is needed
Pain must be assessed in every older adults
Pain problems unique to older adults need further study
Better understanding of Pain Behaviors in older adult
Change in Health care providers attitude & beliefs of aging.
A multidisciplinary approach is advocated
“We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new
privilege. Pain is a more terrible lord of mankind than even death itself.”
“We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new
privilege. Pain is a more terrible lord of mankind than even death itself.”
--1931, Albert Schweitzer
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