22nd September 2015 pain in the older person

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?