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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) 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 Delirium Dementia (all types) Psychiatric Disorders Mood and Psychotic Disorders Previous Impairments (Developmental Disability) Alzheimer’s Disease 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 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 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 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 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? Soreness Ache…… Assess for functional limitations… Good Communication is Critical! Confused Older Adults Are Even More Untreated for Pain 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 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 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 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 Sedation Nausea and vomiting Orthostatic hypotension Urinary retention Dysphoria or euphoria Constipation Respiratory depression Pruitus Opioids and Delirium 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 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 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 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 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 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 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…. • • 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?