Geriatric Grand Rounds

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Willis Bond
5 years ago
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1 Geriatric Grand Rounds Tuesday, February 12, :00 noon Dr. Bill Black Auditorium Glenrose Rehabilitation Hospital To receive the poster, and handouts via , subscribe to our ing list at our web site Analgesia without poisoning Helpful hints for in the management of pain in elderly people Saifee Rashiq Director, Multidisciplinary Pain Centre Associate Professor Department of Anesthesiology & Pain Medicine University of Alberta No conflict of interest I gave a very similar lecture to this at the End of Life conference at the Glenrose Hospital on Nov 22, 2007 I have no association with any commercial entity that might result in an actual or perceived conflict of interest with respect to this session, but I wish I had. 1

2 Arthur A 77 years old Widower Lives in a seniors home Pain everywhere X Rays : OA Multiple medical problems Bad delirium 2006: pneumonia The usual suspects ruled out NSAIDS: Gastropathy,, bleeding Opioids: constipation, confusion TCAs: : Constipation, retention, glaucoma Anticonvulsants: drowsiness, niche drugs Physio: : no access, no interest Objective To describe a selection of effective, evidence-based pain treatments that might be applicable in the pre-frail and frail elderly You will need One white flag One orange flag One purple flag 2

3 This speaker seems to be I work mostly Suave Charming Over-rated rated In hospital In long term care In office/clinic In my experience, the pain management given to patients like Albert is Good Mediocre Heinous Impediments to pain management in elderly people Don t t complain Can t t complain Nobody listening No time No money Fear of adverse effects Inadequate CME 3

Multidisciplinary programs Neuromodulation

4 Treatments for chronic pain Nothing Lifestyle Physical treatments Drugs Surgery Psychology Multidisciplinary programs Neuromodulation Nothing Will daily exercise help Albert s s pain Yes No Maybe 4

5 Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain J. A. Hayden, M. W. van Tulder, and G. Tomlinson Ann Intern Med 142 (9): , Exercise : worth doing BEST: A combination of stretching exercises with other exercises or relaxation GOOD: Strengthening exercise alone GOOD: Advice to stay active Education. Will manipulation help pain? Yes No Maybe 5

6 Manipulation : not indicated Q-tip 6

FIG 1 - Tape being applied with force to pull patella into medial

7 Can Albert s s pain be treated with a Q-tip? Yes No Maybe Can Albert s s pain be treated with elastoplast? FIG 1 - Tape being applied with force to pull patella into medial position Yes No Maybe Cushnaghan, J et al. BMJ 1994;308: Copyright 1994 BMJ Publishing Group Ltd. 7

8 Other physical treatments Effective in short term Acupuncture, LILT, Massage, TENS, Mindfulness mediation Ineffective bed rest, Vax-D, U/S, passive heat/cold Unclear OT/PT Biopsychosocial model Social What lies beneath Behaviour Suffering Pain Nociception Biological Psychological 8

9 If Albert is depressed and in pain, I would.. Treat his pain first Sadness, anhedonia insomnia Treat depression first Treat both together Lin EHB et al JAMA 2003 IMPACT trial (1800 depressed elders) RCT of treatment vs usual care 1001 pts with arthritis Treating depression only Reduced pain Reduced pain related interference Treat depression as well as pain Sadness, anhedonia insomnia 9

10 Everything is contra-indicated most of the time! NSAIDS TCAs Opioids Cannabinoids Steroids 10

My first choice analgesic drug for Albert would be Tylenol #3 Plain Tylenol An NSAID Analgesic relative potencies: moderate to severe pain Acetaminophen 1000 mg Aspirin 650 Tylenol #3, 2 tablets

11 My first choice analgesic drug for Albert would be Tylenol #3 Plain Tylenol An NSAID Analgesic relative potencies: moderate to severe pain Acetaminophen 1000 mg Aspirin 650 Tylenol #3, 2 tablets Ibuprofen 200 Naproxen 375 Aspirin 1200 Ketorolac 30 iv Morphine 10 sq Demerol 100 sq Percocet 2 tabs Diclofenac 100 po/pr Morphine 15 sq Morphine 45 po Hydromorphone 3 sq Hydromorphone 5 po Oxycodone 20 po Works in 25% Works in 33% Works in >50% Tramadol Old drug, new to Canada Weak opioid, plus potentiates NA and 5HT Same potency as codeine or demerol Available as IR and LA forms Does not require triplicate prescription (?) Less constipation than other opioids Worthy of consideration 11

A Pain Clinic referral would : Likely be helpful Likely be useless Don t t know What UAH Pain Clinic does well Clinical assessment of complex pain Brings multidisciplinarity to the case Educates

12 A Pain Clinic referral would : Likely be helpful Likely be useless Don t t know What UAH Pain Clinic does well Clinical assessment of complex pain Brings multidisciplinarity to the case Educates patients and families Defend appropriate drug prescription Suggest newer approaches Bringing finality to diagnostic hunt Interventional procedures Research Objective To describe a selection of effective, evidence-based pain treatments that might be applicable in the pre-frail and frail elderly 12

13 More information The pharmacotherapy of chronic pain: A Review Lynch ME & Watson CPN. Pain Res Manage 2006;11:

Pain Control After Surgery. Patient Information

Pain Control After Surgery. Patient Information Pain Control After Surgery Patient Information What is Pain? Pain is an uncomfortable feeling that tells you something may be wrong in your body. Pain is your body s way of sending a warning to your brain.