Managing pain in the older person. Linda Nazarko. MSc, PgDip, PgCert, BSc(Hons), RN, NIP, OBE, FRCN Consultant Nurse West London Mental Health Trust

Transcription

1 Managing pain in the older person Linda Nazarko MSc, PgDip, PgCert, BSc(Hons), RN, NIP, OBE, FRCN Consultant Nurse West London Mental Health Trust Prescribing for Pain, Colmore Gate Conference Centre, Birmingham 3rd February 2016

2 Aims and objectives To be aware of: The prevalence of pain in older people Types of pain experienced How to determine treatment options How to assess pain in older people The effects of aging and comorbidities Drug interactions How to work with the older person to identify and manage side effects How to improve concordance

3 What is pain? An unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP, 1994)

4 Prevalence Increases with age Affects 53% older people Affects ability, mobility, mood, sleep, quality of life

5 Musculoskeletal Pain Pain perceived within a region of the body, and believed to arise from the muscles, ligaments, bones, or joints (IASP, 2009). Tender, aching, stiff, throbbing Causes include: Fibromyalgia, gout, osteoarthritis, rheumatoid arthritis, tendinitis

6 Neuropathic pain Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system either at peripheral or central level (Haanpää et al, 2011). Shooting and burning, tingling & numbness, stabbing, electric shock like. Alcoholism,amputation, back, leg, & hip problems, chemotherapy, diabetes, facial nerve problems,hiv infection or AIDS, Multiple sclerosis, shingles, spinal surgery

7 Visceral: Pain arising from internal organs True visceral pain arises as a diffuse and poorly defined sensation usually perceived in the midline of the body, at the lower sternum or upper abdomen ( Procacci et al, 1986). Poorly localised, nonspecific regional or whole-body motor responses, strong autonomic & affective responses. Appendicitis, bowel obstruction, cancer pain, dysmenorrhea, indigestion, irritable bowel syndrome, renal colic, urinary retention

8 Differentiating neuropathic & muscle pain (Nazarko, 2014)

9 Determining treatment options Be aware that not everyone likes to complain Be alert to non verbal signs Enquire about pain Detailed clinical assessment of causes, types Be alert to sensory & cognitive impairment

10 Eyesight 20% of people aged over 75 and 50% of people aged 90 and over have sight loss (Access Economics, 2009). Be as visible as possible Ensure lighting is good Some older people with impaired hearing lip read so ensure they can see your face and mouth Be receptive

11 Hearing More than 70% of over 70 year-olds and 40% of over 50 year-olds have some form of hearing loss (Action on Hearing Loss, 2011) Minimise noise, be visible, don t cover your mouth Speak clearly and slow down slightly Check that you have been understood

12 Dementia Be aware that the incidence of dementia rises with age and around 25% of 85 year olds and 50% of 90 year olds have dementia (Knapp & Prince, 2007). Ensure that you have picked a time when the person is receptive. Take account of any cognitive or sensory difficulties

13 The value of nursing "Nursing is rooted from the needs of humanity and is founded on the ideal of service. And that, the nurse is temporarily the consciousness of the unconscious, the love of life for the suicidal, the leg of the amputee, the eyes of the newly blind, a means of locomotion for the infant, knowledge and confidence for the mother and the mouthpiece for those too weak or withdrawn to speak

14 Only when I move syndrome Be aware of the need to check that even though the person doesn t have pain now they might have when they are active.

15 Ten syndrome This is when a person consistently rates pain at 10 even though staff observe that it seems to vary.

16 Mustn t grumble syndrome Be aware of those who don t like to complain or who fear side effects of analgesia

17 Use the right tools Pictures, body maps, Abbey pain scale Evaluate regularly

18 Age related chages Age related changes cause reduced ability to absorb and excrete drugs (Wooten, 2012: Miller, 2007: Miller, 2000: Nguyen & Goldfarb, 2012: Esposito et al, 2007: Mühlberg & Platt, 1999). >Gastrointestinal motility and >gastro-intestinal blood flow Changes in distribution of drugs due to > in muscle mass & < in fat > ability to metabolise drugs due to > hepatic blood flow & liver mass Reduced ability to excrete drugs due to decline in renal function Changes at molecular level that alter receptor binding and may < or > sensitivity to particular classes of drugs.

19 Comorbidities Cardiac failure % over 75s CKD -33% over 75s Gastro-intestinal disease, peptic ulcers, oesophageal varices, diverticular disease Asthma- 10% over 65s Dysphagia 11% upwards Dementia 25% at 85 and 50% at 90

20 How comorbidities affect treatment Cardiac failure -NSAIDs > oedema, worsen failure contraindicated Renal failure- NSAIDS nephrotoxic, opiates and codeine with great caution Dysphagia- soluble meds > Na, BP and stroke risk Dementia, tramadol, codeine, opiates, > falls risk Depression anti-depressants + tramadol = seratonin syndrome

21 Drug interactions Remember falls risk Sedatives, analgesics and antidepressants dangerous Opiods double risk injurious falls Non opiods can > risk by 15-75% Tramadol and anti-depressants High doses, small people, > metabolism

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23 Concordance 40% non concordant why? Side effects Worried addiction Difficulty swallowing Forgetting to take Unsure of then to take How many pills prepared to take

24 Identify and manage side effects Explain possible side effects Discuss, be partners and negotiate Work out if its worth managing side effects or changing tack Have a dialogue

25 Treating pain 1. By mouth": 2. By the Clock 3. Around the clock 4. "By the Ladder": 5. For the individual

26 Treating pain Step one Paracetamol one gram QDS - people weighing 45kg or less may require reduced doses NSAIDS - beware of cardiovascular risks- Naproxen safest. Beware of renal, cardiac, asthma and other contraindications Step two Codeine - beware of renal impairement, be alert to side effects, constipation, nausea and those unable to metabolise Neurophatic pain options gabapentin and pregabalin Tramadol - be aware of multiple contraindications in older people Step three Opiates- be aware of side effects and falls risk

27 Codeine metabolism CYP2D6 responsible codeine metabolism Genetic differences, slow and fast metabolisers Ineffective in slow metabolisers Fast metabolisers at risk of toxicity Be alert to differences and use clinical judgement to guide treatment.

28 Prevalence rates of CYP2D6 polymorphisms by ethnicity Ethnicity Slow metabolisers Ultra-fast metabolisers Western European 8 10% 1 4% Southern European 7 10% African 0 20% 5 30% Eastern Asian 0 1% Arabian Up to 20%

29 Tramadol Tramadol centrally acting synthetic analgesic compound (EMC, 2014). Tramadol 100 mg = paracetamol & codeine (1000 mg/60 mg) (Kaye, 2004). Risk factor post operative delirium (Künig et al, 2006) Increases falls risk X10 )Costa-Dias et al,2014) Increased risk falls, #, mortality (Gogol et al, 2014) Use tramadol with extreme caution in older people.

30 NSAIDS 17 million NSAID prescriptions are issued in the UK each year Can improve quality of life but treatment can be risky Co-prescription of NSAIDs, diuretics and ACE inhibitors = > renal perfusion< renal dysfunction

31 NSAIDS (2) Worsen heart failure contraindicated severe failure Contraindicated asthma Increased risk heart attack, heart failure Nephrotoxic Naproxen lower cardiac risk, higher bleeding risk Use NSAIDS only after careful evaluation of individual risk

32 Opiates Hazardous in older people Increased risk toxicity due to renal and hepatic changes Start at doses 25-50% lower than in younger adults Monitor with great care

33 Last words Assess to work out what the problems are and how to treat Its not a pill for every ill Therapy and non drug options Sometimes a poodle is better than a pain killer

34 Thank you for listening Any questions?