22nd September 2015 pain in the older person
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Managing pain in the older person
Linda Nazarko Consultant Nurse London North West
Healthcare NHS Trust22nd September 2015
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
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)
Prevalence Increases with
age Affects 53% older
people Affects ability,
mobility, mood, sleep, quality of life
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
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
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
Differentiating neuropathic & muscle pain
(Nazarko, 2014)
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
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
HearingMore 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 mouthSpeak clearly and slow down slightlyCheck that you have been understood
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
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”
“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.
“Ten” syndrome This is when a person
consistently rates pain at 10 even though staff observe that it seems to vary.
“Mustn’t grumble” syndrome Be aware of those
who don’t like to complain or who fear side effects of analgesia
Use the right tools
Pictures, body maps, Abbey pain scale Evaluate regularly
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.
Comorbidities Cardiac failure- 12-13% 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
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
Drug interactions Remember falls risk “Sedatives, analgesics and anti-
depressants dangerous Opiods double risk injurious falls Non opiods can > risk by 15-75% Tramadol and anti-depressants High doses, small people, > metabolism
Concordance 40% non concordant
why? Side effects Worried addition Difficulty swallowing Forgetting to take Unsure of then to take How many pills
prepared to take
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
Treating pain
1. “By mouth":
2. “By the Clock”
3. “Around the clock
4. "By the Ladder":
5. For the individual
Treating pain
Codeine metabolism CYP2D6 responsible codeine
metabolism Genetic differences, slow and fast
metabolisers Ineffective in slow metabolisers Fast metabolisers at risk of toxicityBe alert to differences and use clinical
judgement to guide treatment.
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%
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.
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
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 factors, in the smallest possible dose for the shortest possible time and monitor carefully.
Opiates Hazardous in older people Increased risk toxicity due to renal and
hepatic changes Start at doses 25-50% lower than in
younger adultsMonitor with great care
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
Thank you for listening
Any questions?
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