Geriatric Population. Pain and Palliative Care for the Older (Geriatric) Adult

LET’S DISCUSS

Pain assessment

Pain management

Palliative care

PAIN IS…

Physiologic

Psychologic

Behavioral

Social

Cultural

Religious

A Multifaceted Experience

Pain in the Elderly

Ability to cope may change

LossesSignificant other, friends, pets

Finances

Transportation

Driving

Multiple chronic illnesses

Unwanted relocation

Elderly Pain Barriers

Myth that pain is normal aging

Underestimation by clinicians

Overestimation of addiction rate

Overestimation of depressed

respiration

Lack of clinician education

Elderly Pain Barriers

Hearing, visual deficits

Cognitive impairment, depression

Financial constraints, accessibility

Underused pharmaceutical agentsFears of addiction

What other’s might think

Adverse side effects

Acute Pain

Unpleasant sensory or emotion

Whatever they say it is

Acute Pain identified with:

An event

A beginning and end

“Looks sick”

May present with changes in vitals, symptoms

Chronic Pain

Often exhausting experience

Physically, functionally,

psychologically

Pain becomes focus of treatment

Underlying condition chronic,

rarely resolved

Somatic Pain

Identified with:

Direct stimulation, receptors, muscles, bones

Usually localized

Soft tissue, bone pain:

Sharp, throbbing, aching

Muscle pain:

Cramping, gripping, clenching

Visceral Pain

Identified with:

Direct stimulation of

intact receptors in

deep visceral organs

like heart and lungs

Difficult to localize

Deep aching, cramping,

pressure or colicky

Neuropathic Pain

Identified with: Disordered function, Direct

damage to nerves, Difficult to treat

effectively

Peripheral Pain: Burning, Shooting

Spinal Cord Pain: Constant, Dull aching with

neurologic deficits

Central Nervous System Pain: Changes in vital

signs, nausea, vomiting, increased

intracranial pressure

Pain Assessment

Location, Onset, Duration Quality, Intensity Relationship to Activity &

Position Precipitating & Alleviating Associated Findings Life-style Factors: Function,

Appetite, Sleep, Socialization

Assessment of Pain

Standardized Pain

Assessment

Subjective Report

Severity, Intensity

Desired Outcome

Instruments: Numerical or

Verbal Descriptor, Visual Analog,

Vertical or Horizontal,

Pictorial Facial Expressions

Pain Management

Goals:Prevention of acute painControl of chronic painOptimizing functionImproving quality of lifeInterdisciplinary team

Effective Management

Requires the health care providers to be aware of personal biases surrounding pain and its

management

Non Pharmacological

Consider prior to pharmacological

Enhances management

Physical or Occupational Therapy

Transcutaneous electrical nerve stim

Biofeedback

Visual imagery

Non Pharmacological

Relaxation Yoga

Counter Irritation

Hydrotherapy

Psychotherapy

Magnetic Therapy

Nerve Blocks

Prayer

Meditation

Music

Activities

Heat

Cold

Massage

Pharmacological

World Health Organization

Stepwise Analgesic Ladder

Focus on

Proper selection, dosing, titration, and

administration of analgesics

Five concepts: by mouth, by the clock, by

the ladder, for the individual, with attention

to detail

Step 1

Mild pain 1 - 3 on a 10 point scale

Analgesics include:

Aspirin

Acetaminophen (Tylenol)

Nonsteroidal anti-inflammatory

drugs (Elderly need to be cautious)

Coanalgesics

Step 2

Moderate pain 4 - 6 on 10 point scale

Analgesics include:

Codeine

Hydrocodone

Oxycodone

Nonopioid analgesic

Coanalgesics

Step 3

Severe Pain 7 - 10 on a 10 point scale

Analgesics include:

Morphine

Oxycodone

Hydromorphone

Fentanyl

Nonopioid analgesics

Coanalgesics

The relief you need when you are experiencing serious medical illness

PALLIATIVE CARE

Patient

&

Family

Centered Care

Patient Population

Comprehensive Care

Inter-disciplinary

Team

Attention to relief of suffering

TimingQuality

Improve-ment

Communi-cation

Continuity of care across

settings

Equitable Access

Addressing regulatory

barriers

Palliative Components

Palliative Care Team

Clinical Team:

Physician

Nurse Practitioner

Physician Assistant

Nurse

Therapists, Dietician

Pharmacist

Psychosocial Team:

Social Worker

Case Manager

Psychologist

Chaplain

Grief Counselor

Child Life Specialist

Who Uses Palliative Care

People of all ages…

Life threatening

illness

Limiting injuries

from accidents or

other trauma

Congenital injuries

Dependent on life-sustaining treatments

Serious, life-threatening illness

Progressive chronic conditions

Palliative Care Indications

Uncontrolled

symptoms

Goals of care

Cardiac arrest

Advanced cancer

Multi-organ failure

Ventilation support

Hospice eligibility

Prolonged

hospitalization

Multiple

hospitalizations

Family distress

Reduce physical, emotional symptoms

Improve function and reduce disability

Integrating complimentary therapies

Coordinate with specialists, resources

Assist in making informed decisions

Palliation of suffering along with continued

treatment (no requirement to stop care)

Palliative Care Goals

Pain and symptom control

Avoid inappropriate prolongation of the

dying process

Achieve a sense of control

Relieve burdens on family

Strengthen relationships with loved ones

Singer, et al. (1999).

The Patient’s PerspectiveWhat Do Palliative Care

patients want?

ReferencesBrown, J. B.; Bedford, N. K.; White, S. J. (1999).

Gerontological Protocols for Nurse Practitioners.

Bruera, E. & Ahmed E. (2008). The MD Anderson

Supportive and Palliative Care Handbook.

End of Life Palliative/ Education Resource center:

www.eperc.mcw.edu/EPERC

www.hartfordign.org

www.ConsultGeriRN.org

Singer, et al. JAMA 1999;281(2):163-168.