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Question #1
What is the analgesic of choice for mild to
moderate knee pain due to osteoarthritis in a 78
year old female patient?
A. Acetaminophen
B. Aspirin
C. Celocoxib
D. Propoxyphene
E. Tramadol
Question #2
You are in the ED treating a 78 year old female patient with a
history of breast cancer treated 7 years prior with surgery,
chemotherapy, and radiation. She complains of severe, unrelenting
pain in her low back without radicular symptoms or bowel or
bladder dysfunction. The pain has been present for 3 months as a
nagging ache, but, for the past 3 days, it has been unbearable. Her
BP is 150/100, pulse 105, RR 18, Temp 98.8, pulse ox 96% on
room air. What is the appropriate intravenous dose of morphine in
mgs per kilogram of body weight to treat her pain?
A.
B.
C.
D.
E.
0.01 mg/kg
0.05 mg/kg
0.10 mg/kg
1.00 mg/kg
2.50 mg/kg
Question #3
Which of the following classifications best describes
pain in the elderly resulting from inflammation,
musculoskeletal, or ischemic disorders?
A. Limbic system mediated
B. Nocioceptive
C. Neuropathic
D. Parasympathetic mediated
E. Sympathetic mediated
Acute And Chronic Pain
Management In The Elderly
Henry R. Schuitema, D.O., FACOEP
Medical Director
Department of Emergency Medicine
Kennedy Health Systems
Stratford Campus
Acute And Chronic Pain Management In The Elderly
This Care of the Aging Medical Patient in
the Emergency Room (CAMPER)
presentation is offered by the Department of
Emergency Medicine in coordination with the
New Jersey Institute for Successful Aging.
This lecture series is supported by an educational grant from the
Donald W. Reynolds Foundation Aging and Quality of Life
program.
Learning Objectives
• Perform a comprehensive, multi-dimensional assessment
of the elderly patient presenting to the ED with acute or
chronic pain
• Evaluate for untreated pain as the causative factor of
agitation or delirium in older patients
• Increase awareness of untreated pain and use of nonverbal cues in agitated elderly patients with impairments
in hearing, speech and cognitive function
• Identify both rapidly and accurately the patient’s goals of
care and develop an appropriate, patient-centered plan of
treatment for pain control
Learning Objectives, Cont.
• Discuss safety measures for the prevention of
common ED iatrogenic pain complications from
indwelling Foley catheters, central line placement,
and endotracheal intubation
• Prescribe and appropriately dose medications for
the treatment of acute or chronic pain
• Exercise caution when prescribing analgesic
medications that increase morbidity in older
patients
• Manage opioid related side effects
Case 1
• 79 year old woman presents with newly
diagnosed recurrent metastatic breast cancer to
bone and liver with underlying COPD. Her
COPD has progressed over recent years leaving
her oxygen and steroid dependent.
• Her recent pathologic hip fracture results in
daily pain and her dyspnea is difficult to control.
• She is weakened by chronic anemia from PUD.
• Constipation and anxiety are daily concerns.
Aging In The United States
• 1900 – 3.1 million elderly
• 2000 – 35 million elderly
• 2020 – 54 million elderly
**Incidence of pain increases as we age
What Is Pain
• An unpleasant sensory and emotional experience
associated with actual or potential tissue damage
• Pain is whatever the person experiencing it says
it is
• “Discomfort Management”
Oligoanalgesia
• The failure to recognize/treat pain
• Risk factors
– Advanced Age
– Minorities
• Failure to detect
• Joint Commission – “5th Vital Sign”
Reason For Oligoanalgesia
• Lack of training
• Inappropriate pain assessment
• Reluctance to prescribe opioids
Consequences Of Untreated Pain
•
•
•
•
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Negatively impact on quality of life
Depression and anxiety
Social isolation
Cognitive impairment
Sleep disturbances
Pain Management
Provider Responsibilities
• Pain relief is a moral and ethical professional
responsibility
• Providers must help patients make their own
decisions and determine their own actions
• Assessment focused on individual as a whole
person and their response to pain
Pain Assessment Tools
• The Brief Pain Inventory
– Measures severity of pain
– Degree to which it interferes with life
Pain Severity
• Worst Pain
• Least Pain
• Average Pain
• Pain Now
Interference
• Relations with others
• Enjoyment of life
• Mood
• Sleep
• Walking
• General Activity
• Working
Pain Assessment
• The Short Form McGill Pain Questionnaire
– Descriptor of pain graded on a scale 0,1,2,3
– Present Pain Intensity on scale 0-5
Pain Assessment
•
•
•
•
Assessment in the ED must be rapid
Report of pain intensity and other descriptors
Past pain history and medication history
Ongoing monitoring of pain intensity, duration,
response
• Comprehensive assessment should be delayed
Obstacles To Pain Assessment
• Older patients fail to report pain (they view it as
part of aging, don’t want more testing and
medications)
• Accept as punishment for past actions
• Frequently deny pain – use terms like aching or
sore
• Communication and cognitive status
Classification Of Pain
• Nociceptive
• Neuropathic
• Combination
Nociceptive Pain
• Visceral or Somatic
• Stimulation of pain receptors
• Inflammation, musculoskeletal, ischemic
disorders
• Typically respond to both opioid and nonopioid therapy (and other non-pharmacologic
treatment)
Neuropathic Pain
• Pathophysiologic disturbance of peripheral and
central nervous system
• Examples: Post-herpetic neuralgia and diabetic
neuropathy
• Respond better to anticonvulsants and
antidepressants
• Pain of mixed origins – combination therapy
Management Of Acute Pain
• Combination of opioid/non-opioid analgesics
• Addition of adjunct medications
• Non-pharmacologic interventions
Pharmacologic Management
Of Pain In Elderly
•
•
•
•
Principal treatment modality for pain
Significant adverse drug reactions
Drug/drug and drug/disease interactions
Typically requires trials of various agents
Pharmacologic Management
General Principles
•
•
•
•
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Non-opioid mild pain
Opioids for severe pain
Select the agent that targets the issue
Neuropathic – anticonvulsants
Start Low and GO Slow
Non-Opioid Analgesics
• Mild to moderate musculoskeletal pain
• Acetaminophen
–
–
–
–
no effect platelet aggregation
no anti-inflammatory properties
well tolerated if no renal/hepatic failure
do not exceed 2 gm/day
Non-Opioid Analgesia
• NSAIDS
• Significant Risk in Elderly
– GI Bleeding
– Platelet dysfunction
– Impaired coagulation
• Prolonged use in elderly should be avoided
Opioid Analgesia
Cornerstone of acute pain management
–
–
–
–
–
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Proper drug selection
Route of administration
Initial dose
Frequency of administration
Adjunct agent
Side effects
Opioid Potency
•
•
•
•
Fentanyl
Hydromorphone
Morphine
Oxycodone
Route Of Administration
•
•
•
•
•
Intravenous preferred route
Intramuscular should be avoided
Inhaled very effective
Oral mainstay in ambulatory ED setting
Transdermal great outpatient
Dose And Frequency
• Start low and go slow!!!
• Elderly at risk oligoanalgesia and pharmacocomplications
• Many elderly opioid naïve
Adjunct Agents/Side Effects
•
•
•
•
•
Anticipate, prevent, manage
Nausea and itching
Over-sedation
Prophylactic bowel regimens
Avoid chewing/crushing sustained release
products
Specific Painful Conditions
•
•
•
•
•
Head Injuries
Migraines
Chest Pain
Abdominal Pain
Fracture/Dislocations
Painful Procedures
•
•
•
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Foley Catheters
Central Venous Access
Endotracheal Intubation
Cardioversion
Chronic Pain
• Painful condition lasting longer than 3 months
• 4 types
–
–
–
–
Pain persisting beyond normal healing time
Pain relating to chronic degenerative disease
Cancer related pain
Pain without identifiable cause
Chronic Pain
Goals Of Therapy
• Pain reduction
• Return to functional status
Epidemiology Of Chronic Pain
• 1/3 of population affected
• Caused by chronic pathologic process to organ
system
• Caused by prolonged dysfunction of
peripheral/central nervous system
• Frequently psychiatric issues in play
Psychological Characteristics
Of Chronic Pain Patients
• Misuse of narcotics
• Tendency to “Doctor shop”
• Bodily impairment related to physical/emotional
factors
• Inability to work
• Feeling of helplessness
• Over-dramatization
• Despair and negative attitudes
Objective Findings Of Chronic Pain
• Muscle atrophy
• Skin temperature changes
• Trigger points
Chronic Pain And Treatment
• Management is controversial
• Opioids should only be used if they enhance
function
• Single practitioner should be sole prescriber
• Narcotics are effective and recommended for
cancer pain
• NSAIDS helpful but problematic in elderly
Chronic Pain And Anti-Depressants
• Very effective
• Lower doses needed compared to depression
• TCA enhance endogenous pain inhibitory
mechanisms
• Used in conjunction with private physician
Chronic Pain And Anticonvulsants
•
•
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•
Effective Neuropathic Pain
Prevent burst of action potentials
Helps lancinating pain
Carbamazepine, valproic acid frequently used
Chronic Pain
• Muscle relaxants
• Anxiolytics
• Tramadol
Special Pain Presentations
Post Herpetic Neuralgia
•
•
•
•
Follow acute course herpes zoster
Characterized by shooting, lancinating pain
Frequently have hyperesthesia
Narcotics, antidepressants
Special Pain Presentations
Fibromyalgia
•
•
•
•
11 of 18 specific tender points
Muscle stiffness, generalized aching pain
Sleeplessness
Narcotics, short course NSAIDS,
antidepressants, exercise
Special Pain Presentation
Neurogenic Back Pain
• Very common with advanced age
• Frequently associated with neuropathy
• Narcotics, tapered steroids, muscle relaxants
Treating Cancer Pain
•
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Pain is cancer's most disturbing symptom
Aggressive pain management can relieve >90%
Pain management remains poor
Long acting narcotics scheduled with bursts for
breakthrough pain
Drug Seeking Behavior in Elderly
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Not well studied
Prescription drug abuse increasing
It knows no boundaries
Substance abuse by “family members”
Most Common Abuse Presentations
•
•
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•
Back Pain
Headache
Extremity Pain
Dental Pain
Case 1
• 79 year old woman presents with newly
diagnosed recurrent metastatic breast cancer to
bone and liver with underlying COPD. Her
COPD has progressed over recent years leaving
her oxygen and steroid dependent.
• Her recent pathologic hip fracture results in
daily pain and her dyspnea is difficult to control.
• She is weakened by chronic anemia from PUD.
• Constipation and anxiety are daily concerns.
References
1.
2.
3.
4.
5.
6.
7.
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Cavalieri TA. Pain management in the elderly. J Am Osteopath Assoc
2002;102(9):481-485.
Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am
Geriatr Soc 1990;38(4):409-414.
Gibson SJ, Helme RD. Age-related differences in pain perception and
report. Clin Geriatr Med 2001;17(3):433-456, v-v1.
Lawton MP, Brody EM. Assessment of older people: Self-maintaining and
instrumental activities of daily living. Gerontologist.1969;9(3):179-186.
Miller J, Neelon V, Dalton J, et al. The assessment of discomfort in elderly
confused patients: A preliminary study. J Neurosci Nurs 1996;28(3):175-182.
Parmelee PA. Pain in cognitively impaired older persons. Clin Geriatr Med
1996;12(3):473-478.