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•No conflicts of interest •Opinions are not that of VAMC or UA ASSESSMENT AND TREATMENT OF PAIN AND DISTRESS FOR FRAIL AND DEMENTED OLDER ADULTS A. LYNN SNOW, PHD ASSOCIATE PROFESSOR, UNIVERSITY OF ALABAMA CENTER FOR MENTAL HEALTH AND AGING & DEPT. OF PSYCHOLOGY; CLINICAL RESEARCH PSYCHOLOGIST, TUSCALOOSA VA MEDICAL CENTER Pain is Associated with Poor Outcomes Under-treatment associated with: gait disturbances, falls, malnutrition, morbidity, mortality, functional disability, agitated behavior Over-medication associated with: functional disability, increased falls, decreased activity, deconditioning, decubitus ulcers Pain is Under-Treated In Homes In Hospitals In Nursing Homes Barriers to Pain Control The health care system through regulation, lack of priority on pain treatment, cost-cutting measures, staffing issues. The health care professional through misinformation, biased attitudes, fear of addiction, fear of disciplinary action, lack of knowledge and skill in pain management. The public/patients/families through fear (of addiction) misinformation, cultural beliefs, concern about side effects. Older Adults Often Don’t Report Their Pain 1. Belief that pain is a normal part of aging 2. Fear of the cause 3. Stoicism 4. Fear of losing independence 5. Don’t want to bother family or others 6. Fear of addiction 7. Fear of tolerance or side effects 8. Impaired cognition FEAR…What fears impact our ability to appropriately treat pain in frail and demented older adults? Addiction Delirium Side Effects Worse than the Pain Kill the Patient or Make Them Very Sick Because they are more sensitive to drugs Drug-drug interactions Drug-disease interactions Reality Addiction versus Physical Dependence Tolerance Delirium and Side Effects can be controlled through Starting Low and Going Slow, anticipating and proactively treating side effects, and good caregiver advocacy A knowledgeable geriatrician and/or pain specialist, especially in collaboration with a pharmacist and good caregiver advocacy can avoid drug interactions Dementia Pain Facts Pain thresholds are not altered, but pain tolerance is significantly increased Conclusion: demented individuals experience the same pain sensations as non-demented individuals, but fail to interpret such sensations as painful Huffman, J. C. & Kunik, M. E. (2000). Assessment and understanding of pain in patients with dementia. Gerontologist, 40, 574 – 581. Persons with Dementia are at High Risk for Under-Diagnosis of Pain Self-report capacity is at least diminished Memory, Language, & Abstract Thought Deficits Typically manifest pain through behaviors - but wide overlap with behaviors due to other etiologies (e.g., agitation, boredom, depression) 5 of 8 NH residents on psychotropics to control “difficult” behavior were successfully removed from the medications when placed on scheduled acetaminophen (Douzijan et al., 1998). Dementia Patients are at High Risk for UnderTreatment of Pain Patients hospitalized for hip fractures with advanced dementia received three times less the amount of opioid analgesics administered to cognitively intact patients (Morrison & Siu, 2000). Several studies report that less than 25% of the demented individuals identified as in pain were receiving analgesics . What is Pain? Pain is “… an unpleasant sensory and emotional experience which we primarily associate with tissue damage, or, describe in terms of such damage, or both.” (International Association for the Study of Pain) Source: C. Kovach, U. Wis. Milwaukee What is Pain? McCaffery (Pasero, Paice, & McCaffery, 1999) says, "Pain is whatever the experiencing person says it is, existing whenever he says it does". But what if they can’t tell you? Distress Behaviors Distress Expressions Noises and words (“ow”, “ouch”, “that hurts”, “stop”, crying, moaning/groaning) Facial expressions (grimacing) Distress Movements (restlessness, guarding, bracing) Other Distress Behaviors Agitation, Aggression, Resisting care Negative Affect (Depressed, Blue, Sad, Apathy) Sleep and appetite disturbances Change in activity level Distress Behaviors are: Communications of Pain by Persons with Dementia Distress Expressions Noises and words (“ow”, “ouch”, “that hurts”, “stop”, crying, moaning/groaning) Facial expressions (grimacing) Distress Movements (restlessness, guarding, bracing) Other Distress Behaviors Agitation, Aggression, Resisting care Negative Affect (Depressed, Blue, Sad, Apathy) Sleep and appetite disturbances Change in activity level Distress Behaviors are: Communication of Other Unmet Needs by Persons with Dementia Distress Expressions Noises and words (“ow”, “ouch”, “that hurts”, “stop”, crying, moaning/groaning) Facial expressions (grimacing) Distress Movements (restlessness, guarding, bracing) Other Distress Behaviors Agitation, Aggression, Resisting care Negative Affect (Depressed, Blue, Sad, Apathy) Sleep and appetite disturbances Change in activity level CONCEPTUALIZATION: Number One Question: WHY IS THIS HAPPENING? What is causing the behavior? CAUSATION THEORIES: Unmet Needs Model The behavior of persons with dementia represents efforts of the person with dementia to get unmet needs addressed Algase, DL, Beck C, Kolanowski A, Whall A, et al. Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. Am J Alz Dis. 1996;11:12–19. Needs of All People With Dementia Physical Needs: Hunger, Thirst, Restroom, Pain/Discomfort, Rest Feel Safe and Secure Meaningful Positive Human Contact Meaningful Activity Feel That Are Contributing Have Success Experiences CAUSATION THEORIES: Learning/Behavioral Models Problem behaviors have been inadvertently reinforced in the environment, or positive behaviors have not been reinforced. ABC Model: Antecedent->Behavior->Consequence CAUSATION THEORIES: Environmental Vulnerability /Reduced Stress Threshold Model Dementia causes a lowered ability to cope with stimulation from the environment.a Behaviors are due to person being overstressed/overstimulated. Corollary: Under-stimulation is also problematic.b aLawton MP, Nahemo L. An ecological theory of adaptive behavior and aging. In: Eiserdorfer C, Lawton MP, eds. The Psychoogy of Adult Development and Aging. Washington, DC: American Psychological Assocation; 1973:657-667. bKovach CR, Taneli Y, Dohearty P, et al. Effect of the BACE Intervention on Agitation of People With Dementia. Gerontologist. 2004;44:797-806. CAUSATION THEORIES: Biological Models Neuropathology leads to neurotransmitter imbalances which lead to neuropsychiatric symptoms or disturbances in drives which lead to Behaviors. Cause Models are Complementary and not Mutually Exclusive Implication: Nonpharmacologic interventions can be developed to address these causes, even for behaviors caused in large part by biological problems Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia: a review, summary, and critique. AJGP. 2001;9:361-381. Decisional Models A good decisional model is the cornerstone of developing effective nonpharmacologic treatment plans A decisional model provides a map to follow to decide how to approach treatment Serial Trials Protocol IDENTIFY the problem ASSESS for all possible causes Unmet physical/functional needs Understimulation/Overstimulation Whose problem is it? Behavior/Learning Causes ADDRESS possible physical causes ADDRESS possible environmental causes ADDRESS possible behavior/learning causes Still a problem? REASSESS READDRESS Still a problem? REFER AND CONSULT (Geropsychiatry, Pain, etc.) DON’T GIVE UP…SERIAL trials…SERIAL!!! There Empirical Evidence that Persistence is Key to Success 15Kovach CR, Logan BR, Noonan PE, Schlidt AM, Smerz J, Simpson M, Wells T. Effects of the Serial Trial Intervention on discomfort and behavior of nursing home residents with dementia. Am J Alzheimers Dis Other Demen. 2006; 21:147-55. You can never know that you have achieved an accurate pain assessment by observation alone...you can only develop a hypothesis based on the collected data...that hypothesis must then be tested through intervention trials and re-assessment Use of analgesics for assessment Commonly done for other disease entities (such as Nitroglycerine for chest pain) Christine Kovach RN PhD has conducted an RCT of this approach in Wisconsin, and shown it to be effective. Their nursing home state regulators know about her work and have approved of this use of pain meds. Usually the drug Kovach’s group starts with is acetaminophen extra strength BID. Common Pain Beliefs I am familiar with the patient so I know if they are in pain or not…anyone not familiar with the patient will not know what their behaviors mean… There will be behavior change if pain is present If a person is on routine pain medications, they can’t be in pain The behavior is just part of dementia The resident just does that for attention Staff conceptualization/assessment of discomfort is different for verbal patients…their verbal reports are given more weight Treating Pain Non-pharmacologic Treatment Basic Non-pharmacologic Pain Management Repositioning, hot packs, cold packs, cushions and pillows Psychology Relaxation, Biofeedback, Cognitive retraining, Distraction/reinterpretation Techniques, Sleep hygiene, caregiver training Physical Therapy Reconditioning, Stretching, Exercise, Massage Occupational Therapy Pacing skills, work simplification, body mechanics Recreation Therapy Meaningful and Pleasant Activities Particularly for Persons with Dementia: Sensory Activities (touch, music, 1:1 attention) Be Particularly Aware of Basic comfort needs Use of Analgesics for Geriatric Pain Source: C. Kovach, U. Wis. Milwauk WHO 3-Step Analgesic Ladder Step 3 Severe Pain Step 2 Moderate Pain Step 1 Mild Pain ASA, Tylenol, NSAIDS+/Adjuvants Weak opioids ± non-opioids (e.g. A/Codeine, A/Hydrocodone, A/Oxycodone, Tramadol) Potent opioids ± nonopioids (e.g. morphine, Oxycodone, Hydromorphone, Methadone, Fentanyl) 2 Pitfalls: Over-aggressive Treatment Treatment That’s Not Aggressive Enough Treatment Considerations: Geriatric Physiological Changes Near EOL, loss of muscle mass and body fat Altered volume of distribution for lipid-soluble drugs leading to prolonged half-lives (benzodiazepines, methodone, psychotropics) In Older Adults, Renal clearance decreases Drugs like meperidine that rely on renal excretion become problematic In Older Adults, Altered hepatic metabolism Elimination by Cytochrome oxidation affected Elimination by conjugation not affected (morphine) Dementia = Sensitivity to anticholinergic effects antihistamines, tranquilizers, antiemetics Ferrell, Annals of LTC, 2004, vol 12 Acetaminophen “Drug of choice for most elderly persons with mild-to-moderate musculoskeletal pain” Preferred in pts with gastric, renal, or hematologic disease (Marcus) “A common mistake is not giving enough..6501000mg q6hrs or qid” Caution patients about acetaminophen in other prescription and OTC drugs, which might add up to a problematic dose Ferrell, Annals of LTC, 2004, vol 12 Source: C. Kovach, U. Wis. Milwaukee When is Tylenol Inappropriate? If a person is already on something stronger than tylenol, yet continues to have pain If they have an allergy or sensitivity to tylenol If someone has a high or chronic alcohol intake or has impaired liver function Opioids “Opioids are effective for elderly patients with most pain types, and are probably underutilized in this population, and may be safer than NSAIDS or other drug strategies used in older persons” Ferrell, Annals of LTC, 2004, vol 12 Why We Are Reluctant to Give Opioids: Opioid Side Effects Constipation (lactulose and senna) Nausea Somnolence and psychomotor retardation…tolerance usually develops in a few days of reaching steady-state drug levels Respiratory Depression…”for most patients opioid medications should never be held in the presence of severe pain and usually should not be held unless patients are poorly arousable and have a respiratory rate of less than 6 to 8 breaths per minute” Ferrell, Annals of LTC, 20004, vol 12 Marcus DA. 2003. Clinical Geriatrics. Vol 11 (11); Caracci G. 2003. Clinical Geriatrics. Vol 11(11). Opioid Side Effects Older adults have 10-25% higher risk of developing adverse drug reactions vs pts<30yrs old “Drug induced cognitive impairment accts for 1130% of delirium in hospitalized pts and in 2-12% of those evaluated for suspected dementia” Patients with dementia are at higher risk of developing increased confusion with opioids THESE ARE NOT REASONS TO AVOID OPIOIDS…these are issues to monitor and to prepare patients and family for Caracci G. 2003. Clinical Geriatrics. Vol 11(11). Opioids Avoid for chronic pain Propoxyphene Long half-life and metabolite norpropoxyphene is toxic Meperidine Its neurotoxic metabolite, normeperidine, causes tremor, irritability, cognitive changes, seizures agonist-antagonist opioids (e.g., pentazocine, nalbuphin) High incidence of delirium Opioids Caracci G. 2003. Clinical Geriatrics. Vol 11(11 Ferrell, Annals of LTC, 2004, vol 12 Morphine has most predictable metabolism Hydromorphone is a good alternative to morphine – more potent and better tolerated (Caracci) Oxycodone has fewer metabolites and side effects than codeine (Caracci) Methadone can be helpful, but should be prescribed by clinicians with expertise with its use or in closely monitored settings because of unpredictable pharmokinetics in older persons Fentanyl can be difficult to titrate…don’t start with it…don’t use in opioid-naïve pts Caracci G. 2003. Clinical Geriatrics. Vol 11(11). Opioid dosing “Most studies on dosages of opioids in geriatric populations indicate an inverse relation between dosage used and age independent of other factors….[but]…focus on attempting to adapt the dose to the pt’s needs, rather than treating pain with fixed doses. This process calls for carefully monitored titration depending on the pt’s response and the emergence of side effects.” Marcus DA. 2003. Clinical Geriatrics. Vol 11 (11 Rules of Thumb Start low and go slow Start pt on low doses of short-acting opioids (oxycodone, morphine) Educate caregiver on side effects to watch for so if they appear they won’t become severe before you are alerted Once daily dose requirement established, switch to sustained-release formulation at scheduled intervals, with prn for rescue doses Review prn admin regularly…if rescue doses used regularly, the scheduled dose needs to change Source: C. Kovach, U. Wis. Milwaukee Dose Escalation Done in percentages based upon the patient’s pain rating or prevalence/severity of behavioral symptoms. A guideline is: • Pain mild (or rated at 1 to 3/10), dose escalation is 25% of current dose • Pain moderate (or rated as 4 to 6/10), dose escalation in 25% 50% of current dose • Pain severe (or rated as 7 to 10/10), dose escalation is 50% to 100% of current dose to To Appropriately Make Analgesic Dosage Decisions you Need to Know… What Quality Of Life Looks Like In… The geriatric patient with serious chronic illness and disability The patient with mild dementia The patient with moderate dementia The patient with severe dementia