Pain: What You Need to Know to Advocate

Transcription

1 Pain: What You Need to Know to Advocate Amy M. Corcoran, MD Assistant Professor of Clinical Medicine Department of Medicine, Division of Geriatrics University of Pennsylvania Associate Medical Director Penn-Wissahickon Hospice and Caring Way

2 Objectives State 5 essential components of a pain assessment. Discuss pain assessment in a person with limited verbal capacity. Describe two key aspects of communicating a pain assessment to a provider (NP/PA/MD). Review survey regulations about pain.

3 Why is treating pain important? Under-treated or untreated pain has been recognized as a problem in LTC communities Many LTC residents with dementia may have their pain unrecognized due to their cognitive impairment Teno JAMA Reynolds JPSM 2008.

4 F-tags 272 Pain Assessment 279/280 Comprehensive Care Plans 309 Quality of Life 329 Unnecessary drugs/medications

5 Case Scenario 90 year-old nursing home resident with dementia. Her nursing aide is concerned that she is in pain. How do you proceed with assessment?

6 Pain Assessment: OLDCART O onset L location D duration C characteristics A aggravating factors R relieving factors T treatments tried

7 Acute vs. Chronic Pain Acute pain begins suddenly and is usually sharp in quality. Warning of disease or a threat to the body. Might be caused by many events or circumstances. Complete history and physical Consider imaging

8 Case Scenario (cont) What type of questions would you like to ask the nursing assistant?

9 Non-verbal Cues Grimacing Furrowed brow Repetitive vocalizations Rigidity Irritability Confusion Changes in eating or sleeping habits Kaasalainen et al Perspectives 1998; Herr and Garand Clinics in Geriatric Medicine 2000

10 Case Scenario (cont) She makes facial grimaces with personal care and any movement especially her legs. She is sometimes moaning and inconsolable. This has happened before, but is becoming more frequent.

11 Case Scenario (cont) Given her history of osteoarthritis and old films that show hip/knee disease, you decide to start by treating her for chronic pain due to osteoarthritis. What would be the best choice for her pain management?

12 WHO Analgesic Ladder

13 Overview of Nonopioid Analgesics: Appropriate for MILD Pain Acetaminophen NSAIDs COX-2 Tramadol

14 Given her age, what types of pharmacological concerns do you have when choosing your medications?

15 Review of Geriatric Pharmacotherapy Kidney Liver CNS Protein Binding Body Composition Drug-Drug Interactions

16 Case Scenario 78y/o in the hospital recently diagnosed with metastatic breast cancer and living in assisted living. Although naproxen has given her some relief with the pain, she continues to feel pain in her bones. She has normal renal and hepatic function.

17 Do you have any concerns about NSAIDS in older adults? Limited to 1-2weeks with repeat labs to evaluate for renal insuffiency Other potential problems: PUD, bleeding diatheses, and exacerbation of fluid retention in patients with cirrhosis or CHF

18 What are your options for treating bone pain?

19 Bone Pain Bone Mets NSAIDS (oral and topical) Bisphosphonates pamidronate, zalendronic acid Radiotherapy (XRT) strontium-89, samarium-153- lexidronan Steroids Acute Fracture Bisphosphonates Calcitonin Lidoderm patch Paget s Disease Bisphosphonates

20 Case Scenario (cont) Her health deteriorates and she transfers to the long-term care home unit of her CCRC. She is still experiencing 8/10 pain and you decide to start opioids

21 Opioid Naïve Frail Elder Opioid Morphine Oxycodone Hydrocodone Suggested starting dose 2mg PO or SL 2.5mg PO 2.5mg PO Hydromorphone 0.5mg PO or SL Adapted from AMDA Toolkit

22 Opioid Naïve Adult Patient Opioid Morphine Oxycodone Hydrocodone Hydromorphone Tramadol Suggested starting dose 5mg PO or SL 5mg PO or SL 5mg 1mg PO or SL 25mg PO Adapted from AMDA Toolkit

23 What type of preventive medications or measures should you always consider when prescribing opioids? Bowel regimen

24 What is alert charting? Notify practitioner for pain >5/10 (depending on scale used in your community) Notify practitioner if prn opioid used 2x/12hours or 3x/24hours

25 How about holding parameters? Hold opioid dose and notify practitioner if: RR<10/minute Pulse ox <92% on RA Acute change in mental status (more sedated, confused, etc.)

26 How about neuropathic pain? Gabapentin Nortriptyline Pregabalin Topical capsaicin TENS Nerve block or lysis

27 What are some non-pharmacological methods to treat pain? Hypnosis Hyperstimulation analgesia Ice massage Acupuncture TENS (transcutaneous electrical nerve stimulation) Dry heat Hydrotherapy Orthotic devices Trigger point injections with lidocaine or steroid

28 Common Mistakes in Older Adults Failure to use quantitative pain scale Failure to prescribe opioids for patients whose pain levels are moderate to severe Failure to provide aggressive bowel regimen Failure to discontinue medications that contribute to sedation Failure to schedule around the clock medications Failure to re-assess clinically for effectiveness of pain regimen

29 References AGS Clinical Practice Committee: Management of cancer pain in older patients. JAGS (45): AMDA Palliative Care in the Long-term Care Setting Toolkit Cafiero, Angela C. PharmD, CGP. Geriatric Pharmacotherapy. Geriatric Secrets. 3 rd Edition. Henly and Belfus, Inc. 2004; Chibnall, John T. PhD, Raymond C. Tait, PhD, Bonnie Harman, PhD,w and Rebecca A. Luebbert, MSN. Effect of Acetaminophen on Behavior, Well-Being, and Psychotropic Medication Use in Nursing Home Residents with Moderate-to-Severe Dementia. JAGS 53: , Feldt, Karen PhD RN. The Checklist of Nonverbal Pain Indicators (CNPI). Pain Management Nursing. March 2000; Hadjistavropoulus T., et al. An Interdisciplinary Expert Consensus Statement on Assessment of Pain in Older Persons. Clinical Journal of Pain. January 2007 Supplement. Volume 23 (1):S1-43. Kapo, Jennifer MD and Janet Abrahm, MD. Pain Management. Geriatric Secrets. 3 rd Edition. Henly and Belfus, Inc. 2004; Mercadante, S. and Fabio Fulfaro. Management of Painful Bone Metastases. Current Opinion in Oncology (19): Pavlakis N. et al. Bisphosphonates for Breast Cancer (review). Cochrane Review. John Wiley and Sons Upton et al. Population pharmacokinetic modelling of subcutaneous morphine in the elderly. Acute Pain (8);

30 Acknowledgements GACA-HRSA funding Jennifer Kapo, MD Mary Ersek, PhD Susan Lysaght, CRNP