Dr Tomiko Barrett Staff Specialist Geriatrician, Wyong Hospital.

Transcription

1 Dr Tomiko Barrett Staff Specialist Geriatrician, Wyong Hospital.

2 Doris Story: An Example of Elder Abuse

3 Outline of Talk Why is pain under treated? How to recognize and assess pain in elderly people Drugs The Pain Ladder Non-pharmacological management of pain Unusual drugs Pitfalls in pharmacological treatment What to do to get specialist help Time for questions

4 Why is Pain Undertreated - Patient Factors Stoicism, acceptance of the condition and low expectation of help Communication difficulties: e.g. comprehending on a scale of 1-10 Patients with dementia have difficulty describing, quantifying, localising the pain Pain manifests in different ways in elderly people, especially patients with dementia Angina or AMI in women Agitation, resistance or aggression in patients with severe dementia

5 Why is Pain Undertreated Health Professional Factors Pain not even considered possible There is no reason Richard would have pain Pain is not recognized because it s labelled as difficult behaviour, resisting care, grumpy Pain is poorly evaluated even when recognised Under prescribing due to fear of side effects of drugs Over reliance on all encompassing drugs No timely follow up to assess effectiveness of treatment

6 Simple Ways to Assess Pain Consider all the patient s health issues how would you feel with these? Ask with hearing aids, glasses, quiet place Ask in a variety of ways Watch body language Use a pain scale appropriate for cognition

7 PainAid

8 PainAid Page 2

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10 Pain Management Ladder Treat the cause Non-pharmacological analgesia Paracetamol- regularly if the cause cannot be fixed Non-narcotics e.g. Non-steroidal anti-inflammatory drugs Narcotics e.g. morphine, oxycodone Regular plus breakthrough Pro actively for incident pain Watch for side effects Adjuvant drugs Complimentary therapies

11 Non Drug Management of Pain Consider chair, mattress, shoes, clothing, teeth etc. Podiatry and Orthotics Physiotherapy : splints, US, Deep heat Better wound management Nerve stimulation : TENS, implantable stimulators Psychological support: explaining the cause, relaxation techniques, positive imagery Complimentary therapy e.g. Acupuncture

12 Adjuvant Drugs Bone Pain: NSAIDS, bisphosphonates, calcitonin Nerve compression or damage: anti-epileptics and antidepressants, Headache from raised intra-cranial pressure: Dexamethasone Liver distension from metastases: dexamethasone Colic: Hyoscine (Buscopan) Topical medications e.g. Bongela, Nitrate patches, NSAID gels Radiotherapy and Anaesthetic techniques

13 Pitfalls in Treating Pain No diagnosis or cause not sought Straight to narcotics Early use of long acting narcotics Early use of trans-dermal narcotics Combination of narcotics avoid other narcotics with buprenorphine (Norspan) Avoid Norspan in patients with dementia Side effects not anticipated or ignored No assessment of effectiveness

14 When You Need Specialist Help Who to Call Palliative Care , fax Geriatric Medicine Need a GP referral Gosford Wyong ASET Outreach No doctor s referral needed Pain Clinic What they will Ask The time course What precipitates and relieves the pain? What drugs have been tried? What was the response? How much did it relieve the pain and how long did it take to work? Try to differentiate breakthrough and incident pain.

15 Are there any questions?

16 Take home message Consider pain if your patient is distressed or agitated, or has a physical problem. Assess the pain using reproducible tools and best communication strategies. Be the patients advocate for obtaining diagnosis, referrals and appropriate drugs Anticipate side effects There is always something that can be done to relieve a person s pain.