Management of Pain in Older Persons*

Transcription

1 Management of Pain in Older Persons* Dr. Ruth Dubin PhD, MD, CCFP, FCFP DAAPM, DCAPM ECHO Ontario (*Thanks to Dr Dave Ruggles and Dr. Ramesh Zacharias for some slides)

2 Faculty/Presenter Disclosure Faculty: Dr. Ruth Dubin Relationships with commercial interests: None

3 Learning Objectives By the end of this session, participants will be able to: Recognize the burden of chronic pain patients aged 65 years and over Tailor therapy to this population s common pain diagnoses and co-morbidities Demonstrate pain assessment and treatment skills in elderly patients with frailty and/or dementia

4 Epidemiology of Pain in Older Persons Slide by Dr. R. Zacharias Chronic pain affects 20% of Canadians and is > than 60% of those over 65. Chronic Pain in Canada: Prevalence, Treatment. Impact and Role of Opioid Analgesia, Moulin, D et al., Pain Research and Management, : Epidemiologic studies show a very high prevalence of persistent pain, often exceeding 50% of community dwelling older patients and up to 80% of nursing home residents. Gibson, SJ, Expert Review of Neurotherapeutics. 7(6): , 2007 June.

5 Continued Sample of retirement residents : 85% of the study participants reported pain in more than one location 74% reported pain in the lower extremities, 57% reported pain in the back, and 55% reported pain in the buttocks/hips Most popular treatments: acetaminophen (61%) regular exercise (58%) prayer (53%) heat or cold (48%) Kemp C. et al A descriptive study of older adults with persistent pain: Use and perceived effectiveness of pain management strategies. BMC Geriatrics. 5(12), 1-12 (slide by Dr. R. Zacharias)

6 Consequences of Unrelieved Pain: Acute and Chronic Behavioural changes Depression Isolation Impaired mobility Disrupted sleep Changes in Social Roles and relationships Increased length of hospital stay Increased risk of institutionalization Decrease in successful rehabilitation

7 Pain Prevalence in Older Adults and Gaps in Treatment Across Care Setting Slide by Dr. R. Zacharias Setting Prevalence of pain No Pain Treatment? Nursing Home (551 OA/6 NHs) (Reynolds et al., 2008) 51.4% intact 47.7% impaired 20% intact 44% impaired Hospital (367 OA/8 hosp) (Gianni et al., Arch Geront & Geriatrics, 2010) 67% pain present 51% no treatment or inadequate for intensity Emerg Dept (1454 >65 hip fx) (Herr & Titler, Emerg Nsg, 2009) Mean pain intensity=7 40% patients no analgesic ordered Home Care (2779 OA) (Maxwell et al., 2008) 48% daily pain 22%

8 Assessment of Pain in Older Persons Acute vs Persistent(Chronic) Pain Acute or acute on chronic pain requires an even more thorough medical assessment. The incidence of potentially serious causes of acute pain increases with age. Red Flags for serious back conditions Age > 50 years

9 Red Flags for Serious Back Conditions Age > 50 History of osteoporosis Previous cancer history Immunosuppression Corticosteroid use Unexplained weight loss hard to assess as most lose weight if progressive dementia

10 Nonspinal Causes of Back Pain Psoas abscess Retroperitonea l hematoma if on warfarin

11 Common Causes of Pain in the Older Patient Arthritis particularly OA Other degenerative musculoskeletal conditions Neuropathic pain Diabetic neuropathy, radiculopathy and post herpetic neuralgia, post surgical and postchemotherapy NP Osteoporosis fractures Peripheral vascular disease Immobility/contractures PAIN IN OLDER PEOPLE PCrome, CJ Main, F Lally eds. Oxford Pain Management Library

12 Video goes here

13 Barriers to Pain Assessment in Older Persons Reluctance to report Expect pain with aging Fear of tests/procedures, addiction to medication, and possible cause of pain Depression, anxiety, guilt Inability to report Cognitive and sensory impairment

14 Pharmocokinetic Considerations in the Elderly Higher fat to lean body mass ratio Reduced serum protein Reduced renal GFR, tubular reabsorption and creatinine clearance Reduced hepatic function Reduced first pass gut metabolism

15 Pharmacokinetic Implications Dosage reduction Slower dosage adjustment Higher likelihood of side effects Increased sensitivity to drugs acting on the central nervous system Greater potential for serious adverse events Drug interactions (polypharmacy)

16 Continued LTC residents: 45% to 80% live with chronic pain caregivers often unaware of pain due to communication barriers Daily pain: 24% to 38% of residents 16% received non-opioid medication, 26% received WHO Step- Ladder level 3 opioid medication, 26% received no analgesic medication Most commonly prescribed analgesics (US STUDY): Acetaminophen (37.2%), propoxyphene (18.2%), hydrocodone (6.8%), and tramadol (5.4%) Acetaminophen was usually prescribed on an as needed basis (65.6%) Hollenack K. et al. (2006). The Application of Evidence-Based Principles of Care in Older Persons (Issue 4): Pain Management. JAMDA. 5(7), Keeney C. et al. (2008). Initiating and sustaining a standardized pain management program in long-term care facilities. JAMDA. 10,

17 Consequences of Unrelieved Pain in LTC/Retirement Homes (Fraility) ACUTE: Delerium DVT Falls Nausea and Vomiting Respiratory Infections Increased Mortality

18 Pain Assessment in the Elderly with Dementia (Aubin, Can Pain Soc 2007) 2/3 in LTC also diagnosis of dementia 40-50% with severe limitations in ability to communicate Undiagnosed in 2/3 s of residents 15% had received medication (mostly Tylenol) in previous 24 hours <1/2 with daily pain had received medication in the previous 7 days with frequent inadequate prescribing Type and dosage of analgesics frequently inappropriate

19 PAIN Assessment TOOLS in LTC with Communication Barriers Assessed on basis of content/construct validity, reliability, and clinical use TOOLS GLOBAL SCORE PACSLAC Global Score 87 Abbey Scale * (my favorite) Global Score 73 DOLOPLUS Global Score 65 PADE Global Score 64 PAINAD Global Score 63

20 Facial Grimace Scale The scale has been developed to assess pain in adults who are cognitively impaired and are unable to communicate using the other tools Caregivers or clinicians can rate pain based on patient s facial expression Clients/patients who can understand this scale can use it also no pain mild discomforting distressing horrible excruciating Adapted with permission from Grey Bruce Palliative Care/Hospice Association Manual Guidelines for Developing a Pain Management Program. 2000; 2nd edition

21 PACSLAC: Checklist Permission Required: Thomas.Hadjistavropoulo

22 PAINAD Scale Available at:

23 ABBEY Pain Scale Australian in public domain Available online at: nline Look on page 72 My favourite: easiest to use: score based on vocalization, facial expression, body language, behavioural change, physiological change and physical changes

24 Pain Medications: New Who Ladder NOW INCLUDES Tramadol: (Mild opiate+snri) very safe in elderly, years of worldwide use, not caution with SSRI s (listed in Canada), increased seizure risk, Can t use if renal failure (Cr Clearance < 30 mls/min or severe renal failure) not covered on ODB, Also has indication for neuropathic pain Tramadol short acting, combined with acetaminophen Multiple long acting brands in Canada

25 NSAIDs- Relative Risk for Complicated PUD/Yr Use of NSAID (overall risk) 4 Past history PUD 17 Age over 60 years 3-13 COXIB (overall risk) 2 Low dose NSAID: high dose 2:8 Multiple NSAID use 9 Concurrent corticosteroids 10 Concurrent anticoagulants 13 Concurrent aspirin ( mg daily) 8 NSAIDs + SSRI** 12

26 NSAIDs and COXIBs Acute and chronic renal toxicity DeMaria AN. JPSM 2003 Double the risk of hospitalization for CHF Garcia-Rodriguez LA. Epidemiology 2003 Increased risk of hypertension Freis S. Hematology 2005 Forman JP. Arch Intern Med 2007

27 COXIBs No effect on platelets (good for post-op pain) (NOT post CABG surgery) (Stephens JM. Pharmacotherapy, 2004) ½ risk of complicated PUD (2%/yr) (VIGOR) Concurrent ASA reduces the GI protective effect Increased risk of CV events (MI & CVA) (CLASS)

28 Opioid Pointers Caution with morphine in elderly: more side effects: active metabolites, variability in metabolism, metabolite build-up in renal dysfunction Consider hydromorphone: inactive metabolites, less constipation, nausea and pruritis, LA Hydromorphone no LU code (Starts at 3 mg q 12h) START LOW, GO SLOW (can use hydromorphone oral suspension at to 0.5 mg q4h prn and titrate) Tramadol (caution egfr); but not covered Buprenorphine transdermal patch (5/10/20 ucg) q7days, safe in elderly, can be used in opiate naïve : not on ODB?antiemetic prn before first dose and stimulant laxative! Watch for sedation, risk of falls, and confusion in LTC patients

29 Don t Forget to Assess for Opioid Risk in BOOMERS, and their Families too!

30 Tricyclic Antidepressants Start low and go slow mg for sleep; mg for neuropathic pain Nortriptyline better tolerated, avoid amitriptyline Greater risk of adverse effects in elderly Tachyarrythmias, hypotension and urinary retention

31 Gabapentinoids Start low and go slow 25mg pregabalin and 100 mg gabapentin capsules Still potential for various side effects but few adverse events and drug interactions sedation, edema, vertigo I often have them open capsule and sprinkle 1/3 or less on applie sauce ****OFF LABEL ALERT*****

32 Other Co-Analgesics esp. if Neuropathic Pain Trazodone also useful if sleep/depression Topicals less toxic (Capsaicin, lidoderm 5% cream OTC, compounded) useful in neuropathic pain -$$$$$ Duloxetine SNRI with indication for neuropathic pain: egfr/serotonin syndrome, nausea (not it egfr < 30 CAN ALSO OPEN AND SPRINKLE - ***OFF LABEL ALERT!) Cannabinoids: nabilone as a liquid: tiny dose can be tolerated ( mg hs) and improve sleep and reduce agitation in advanced dementia (***OFF LABEL ALERT!)

33 Vertebroplasty/Kyphoplasty Vertebroplasty Kyphoplasty

34 Rehab Therapy: HOMECARE - CCAC Physiotherapy Passive physical modalities (massage, acupuncture)indicated to provide temporary pain relief and facilitate exercises initially but not as long term maintenance therapy. Occupational therapy: Pacing, ergonomics/positioning, ADL s, assistive devices Exercise, tai chi etc also reduces falls, improves mood Education and self management we have been running CPSMP in seniors residences in SELHIN

35 Strength and Aerobic Conditioning Exercise for OA Exercise moderately reduces pain and has a small effect on self reported disability in elderly patients with OA. Reduced fall risk Improved mood, socialization

36 Tai Chi Studies in older adults have shown improvements in balance, strength, functional mobility, flexibility, psychological wellbeing and disturbed sleep.

37 Recreation Therapy Senior s Associations YMCA s ARTHRITIS SOCIETY

38

39 Other References 1. Pharmacotherapeutic Management of Pain with a Focus Directed at the Geriatric Patient. Barkin et al. Rheum. Dis. Clin. N. Am. 33(2007): The Management of Persistent Pain in Older Persons. J. Amer. Ger. Soc. 50(6)June 2002:S205-S Observation Scales for Pain Assessment in Older Adults with Cognitive Impairments or Communication Difficulties. Nursing Research 56(1)Jan. 2007:34-43.