PD St John. Centre on Aging Spring Symposium

Transcription

1 Persistent t Pain in the Elderly PD St John P Daeninck Centre on Aging Spring Symposium

2 No Commercial Interest No Relevant Financial Relationships

3 Mrs C 97 year old woman, in Assisted Living, daughter in city Past History: Dementia mild functional limitation Heart disease stable Falls Compression Fracture 4 years ago, with chronic low back pain Osteoarthritis

4 ER visit with failure to cope and more falls with no fracture Home with GPAT follow-up Admitted

5 Disoriented in place, date MMSE 13/30 Fluctuating LOC Poor attention ti Hallucinations birds in her room asking family to shoot them Self-reports of severe pelvic pain GDS 14/15

6 Thin, pale, looked unwell 42kg Neuro exam unremarkable General exam OA most joints No evidence neuropathy

7 Medications Ketamine Pregabalin Hydromorphone Alendronate Ca/Vit D Calcitonin

8 What to tell family? Pain is under-treated, and with proper treatment, can be alleviated without side-effects. effects Pain is causing her delirium. Pain medications are contributing to her delirium. We may need to balance treatment goals Lessen pain Improve cognition

9 Too many elderly 'left in pain' Not enough is being done to improve the management of pain in the elderly

10 Nursing home staff underestimate pain: study The study says nursing home staff routinely underestimate pain in their clients. It estimated 40 per cent of seniors in nursing homes are living in pain everyday. Nursing home staff should pay more attention to pain management

11 MYTH #1 Pain is due to ageing

12 Reality Pain is due to injury/illness, not ageing. Pain is more common in the elderly.

13 Epidemiology of Pain in Elderly Prevalence 25 62% in community Canadian data using data from large surveys (Ipsos-Reid) 22% in 18 to 34 year olds, 29% in 35 to 54 year olds, 39% in 55 plus

14

15 Age is a prognostic factor Pain is more persistent in the elderly

16 MYTH #2 We know what we are doing

17 REALITY Literature very limited Issues Less research in elderly Setting of research less in community or long-term care Conflict of interest Complicated group

18 Major Causes of Chronic Pain Arthritis Low Back Pain Dental problems Old injuries Vascular Disease Nerve pain Leg Pain Syndromes Cancer pain

19 Other Risk Factors Depression Previous psychological trauma Social risk factors Previous beliefs around pain Previous experience with pain Neuropathy risk factors

20 Pain and Depressive Symptoms Strong association Pain predicts depression and depression Pain predicts depression and depression predicts pain

21 Social Risk Factors Inadequacy of income Lower social class This association was more pronounced in women

22 Pain Model

23 Complicating factors Older adults more likely to be interrupted Family influences Cognitive impairment Makes assessment of pain difficult Higher delirium risk if pain is untreated, Higher delirium risk if pain is treated with Higher delirium risk if pain is treated with psychoactive medications

24 MYTH #3 Pain cannot be assessed in someone Pain cannot be assessed in someone with dementia

25 REALITY Pain is often difficult to assess but it Pain is often difficult to assess, but it can be assessed

26 COMMON PAIN BEHAVIORS IN COGNITIVELY IMPAIRED ELDERLY PERSONS Behavior Examples Facial expressions Slight frown; sad, frightened face Grimacing, wrinkled forehead, closed/tightened eyes Any distorted expression Rapid blinking Verbalizations, vocalizations Sighing, moaning, groaning Grunting, chanting, calling out Noisy breathing Asking for help Verbal abusiveness Body movements Rigid, tense body posture, guarding Fidgeting Increased pacing, rocking Restricted movement Gait or mobility changes

27 Behavior Examples Changes in interpersonal interactions Aggressive, combative, resists care Decreased social interactions Socially inappropriate, disruptive Withdrawn Changes in activity patterns or Refusing food, appetite change routines Increase in rest periods Sleep, rest pattern changes Sudden cessation of common routines Increased wandering Mental status changes Crying or tears Increased confusion Irritability or distress

28 MYTH #4 Little old ladies are just older adults

29 REALITY We are different at 80 than we were at 40 Changes in body composition and organ function influence medications and medication adverse events Differences between people increases as we grow old

30 General Principles - American Geriatrics Society Guidelines Pain management in older persons differs from that for younger people Pain is often complex and multifactorial in the older population Older people may underreport pain Concurrent illnesses and multiple problems make pain evaluation and treatment more difficult

31 Older persons are more likely to experience medication-related side effects and have a higher potential for complications and adverse events related to diagnostic and invasive procedures Older people constitute a heterogeneous population, making optimum dosage and common side effects difficult to predict.

32 Least-invasive method of drug administration should be used Rapid-onset, short-acting analgesic drugs should be used for severe episodic pain Scheduled administration before anticipated (or incident) id pain episodes C ti i di ti h ld b Continuous pain, medications should be provided around the clock

33 PAIN RATING SCALES Reliable valid scales and assessment tools (including in cognitively impaired patients) Reliable, valid questionnaires Pain mapping

34 Categorize Pain Injury Inflammation Soft tissue Cancer Nerve Pain

35 Associated features Assess cognition Assess functional status Assess social situation Assess mood Assess attitudes to pain

36 Treatment strategies Weigh treatment options Assess urgency Set goals of treatment

37

38 Treatment options Acetaminophen Recent dose change recommendation by FDA NSAIDS / COX-2 inhibitors Opiates Other Gabapentin Pregabalin TCA Ketamine

39 The WHO Analgesic Ladder

40 OPIATE USE Historical Perspective Combat at Guangzhou (Canton) during the Second Opium War

41 Ancient use (4200 BC AD) The first known cultivation of opium poppies was in Mesopotamia approximately 3400 B.C - Hul Gil Seventeen finds of Papaver somniferum from Neolithic settlements in Europe Egypt - "stop a crying child" was generally restricted to priests was generally restricted to priests, magicians, and warriors

42 Islamic Societies ( A.D.) Arab traders introduced opium to China Fi ma-yahdara al-tabib (In the Absence of a Physician): use for anesthetic and melancholy Religious prohibition variously applied

43 Western Medicine Initially stigmatized as foreign Laudanum: Opium mixed with alcohol -pain, sleeplessness, and diarrhea da Sydenham: Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium. US Civil War: > 3 million doses of God s Own Medicine

44 MYTH #5 Old people don t get addicted to Old people don t get addicted to narcotics

45 REALITY Opiates are addictive at all ages The risk is, however, low In many settings, the risk is worth it

46

47 OPIATE USE HAS INCREASED

48 OPIATE MISUSE HAS INCREASED Woodcock, J. N engl j med 361;22

49

50 Opiate Use Depends on Where You Live

51 Neuropathic pain Often more difficult to treat and characterize Different treatment

52 NEUROPATHIC PAIN Gabapentin works, but has side-effects effects Tricyclic antidepressants work just as well, but have side-effects effects Opiates work, but have side-effects

53 APS-AAPM Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain Opioids are associated with increased short- term adverse events compared to placebo. The most frequent adverse events are nausea, constipation, sedation, vomiting, somnolence, and dizziness. i Adverse events frequently lead to Adverse events frequently lead to discontinuation of opioids

54 APS-AAPM Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain There is insufficient evidence that any long- acting opioid is more beneficial or less harmful than others. No clear differences in benefits or harms between sustained- and immediate-release opioids.

55

56 DO OPIATES CAUSE DELIRIUM? Both pain and narcotics have been reported as causes of delirium. It is often felt that clinicians under treat pain in elderly patients, possibly due to the concern of causing delirium via the use of opioid analgesics in a vulnerable population. We conducted a systematic review to We conducted a systematic review to determine if delirium is associated with opiate use independent of the effect of pain.

57 Few studies with good measures of delirium and pain. There were no studies from the chronic care literature. The palliative care literature showed that pain and opioids were equally strong risk factors for developing delirium. The surgical literature had mixed results.

58

59 Back to the case Several conversations with daughter. Established goals of care Reduce, not eliminate pain Improve mobility Improve cognition No work-up for cause of pain or anaemia

60 Added plain regular acetaminophen 650 mg po tid with breakthrough doses Added prn hydromorphone as a prn for painful activities Tapered off of pregabalin Tapered off of ketamine Stopped calcitonin

61 Remained with pain, but this improved. Cognition returned to baseline. Functional status returned to u ct o a status etu ed to baseline slowly.

62 Acknowledgements Riverview Health Centre Foundation Further Reading Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in JAGS, 57: , 2009.

63 Harper lauds press freedom in speech, doesn't take questions from reporters The Canadian Press

64

65

66

67

68

69

70

71 Fig 2 Treatment efficacy of traditional anticonvulsants versus placebo Wong, M.-c. et al. BMJ 2007;335:87 Copyright 2007 BMJ Publishing Group Ltd.

72 Fig 3 Withdrawals related to adverse events for traditional anticonvulsants versus placebo Wong, M.-c. et al. BMJ 2007;335:87 Copyright 2007 BMJ Publishing Group Ltd.

73 Fig 4 Treatment efficacy of newer generation anticonvulsants versus placebo Wong, M.-c. et al. BMJ 2007;335:87 Copyright 2007 BMJ Publishing Group Ltd.

74 Fig 5 Withdrawals related to adverse events for newer generation anticonvulsants versus placebo Wong, M.-c. et al. BMJ 2007;335:87 Copyright 2007 BMJ Publishing Group Ltd.

75 Fig 6 Treatment efficacy of tricyclic antidepressants (TCA) versus placebo Wong, M.-c. et al. BMJ 2007;335:87 Copyright 2007 BMJ Publishing Group Ltd.

76 Fig 7 Withdrawals related to adverse events for tricyclic antidepressants (TCA) versus placebo Wong, M.-c. et al. BMJ 2007;335:87 Copyright 2007 BMJ Publishing Group Ltd.

77 Fig 14 Treatment efficacy of opioids versus placebo Wong, M.-c. et al. BMJ 2007;335:87 Copyright 2007 BMJ Publishing Group Ltd.

78 Fig 16 Proposed treatment algorithm for painful diabetic neuropathy Wong, M.-c. et al. BMJ 2007;335:87 Copyright 2007 BMJ Publishing Group Ltd.

79

80 Optimal pharmacological treatment of pain in patients with cognitive impairments should be based on the following guiding principles: (1) When pain is detected, institute treatment rapidly; (2) Use scheduled rather than as needed dosing (also referred to as prn [pro re nata]) for chronic or predictably recurrent (e.g., postoperative) pain; (3) Titrate medication to pain level and assess verbal, behavioral, and functional response to medication; (4) Choose a regimen that will mitigate common side effects of pain medication in elderly persons

81 Last-Observation Carried Forward Primary Depression and Pain Outcomes Kroenke, K. et al. JAMA 2009;301: Copyright restrictions may apply.

82 Community dwelling Swedish population Westerbotn et al. Aging Clin Exp Res 20; 40-46

83 Assessing pain in cognitively impaired individuals.. Clear guidelines for standard ways of assessing pain; (Guidelines of the Agency for Healthcare Research and Quality, the American Pain Society, and The Joint Commission) a formalized approach to pain management, assessment, and frequent reassessment/ monitoring; organizational standards for collaborative and interdisciplinary approaches; both pharmacological and non pharmacological strategies to alleviate pain; individualized pain-control plans

84 Do the elderly perceive pain differently to younger adults? Age-related increases in pain report may be more apparent when stimuli are very intense and/or persist for longer periods The efferent actions of the nociceptive system in older people require a greater level of stimulus to achieve a maximum response, but the size of this response is comparable with that observed in younger people Older subjects demonstrate a much longer period of secondary hyperalgesia despite comparable levels l of spontaneous pain, thermal hyperalgesia, and flare - tenderness after injury appears to be prolonged with advancing age The threshold for pain is more likely to be increased in older people when stimuli are briefer, of lesser spatial extent, and at peripheral cutaneous or visceral sites therefore placing older people p at increased risk of harm from certain noxious stimuli

85 Assessment of Pain Assess pain Character Course of its onset Duration Location Previous Pain History Previous treatments

86 Acuity Chronic Chronic with exacerbation Acute Chronic with new pain

87 Attitudes to pain Attitudes to sensation of sedation Functional status High fall risk

88

89 AGS Guidelines Persistent pain or its inadequate treatment is associated with a number of adverse outcomes in older people, including functional impairment, falls, slow rehabilitation, mood changes (depression and anxiety), decreased socialization, sleep and appetite disturbance, and greater healthcare use and costs. Although appropriate p treatment can reduce these adverse events, the treatments themselves may incur their own risks and morbidities. Persistent pain can also be as distressing for the caregiver as for the patient. t Caregiver strain and negative caregiver attitudes can substantially affect the patient's experience of pain and should be evaluated and discussed during the clinical encounter, if present.

90 Current evidence-based literature does not serve as an adequate guide in many decision-making situations that are routinely encountered in clinical practice.

91 Variation in Opiate Use in Manitoba Sadowski C et al. Can J Clin Pharmacol Vol 16 (2) 2009:322-e330;

92 Zerzan,Med Care 2006;44:

93 Gabapentin for Neuropathic Pain

94 TCA for Neuropathic Pain

95

96 Gabapentin versus TCAs for neuropathic pain

97 Side effect profile of gabapentin versus TCAs

98 Opioids for neuropathic pain

99 Opioids and delirium Delirium is a common medical problem, especially in older patients in institutionalized and hospitalized settings. It causes substantial morbidity, functional deterioration, prolonged cognitive impairment and an increased risk of mortality. Delirium increases mortality during a hospital stay by almost twofold, increases length of stay on average by 8 days and results in worse physical and cognitive recovery at 6 and 12 months with increased time in institutional care.

100 There is good evidence to indicate that in up to one third of patients, delirium persists for months and that this is a poor prognostic sign. Medications often contribute to delirium and are the only identifiable cause in 12%-39% of cases. The most common drugs associated with delirium are psychoactive agents such as benzodiazepines, i opioid id analgesics and drugs with anticholinergic effects. Young J, Inouye SK. Delirium in older people. BMJ 2007;334; Pisani MA et al. Crit Care Med Jan;37(1): Gaudreau et al. Psychosomatics 2005;46:4,

101 Data sources: A medical librarian searched Medline and the Cochrane Database from 1966 to January 1st, Study selection: Retrieved studies were reviewed independently by two reviewers. Studies included randomized controlled trials as well as observational studies (cohort and case control).

102 REGULAR, NOT AS NEEDED

103

104 Fig 15 Withdrawals related to adverse events of opioids versus placebo Wong, M.-c. et al. BMJ 2007;335:87 Copyright 2007 BMJ Publishing Group Ltd.