Pain in the Elderly (Dr. Ann Berger)

Pain Issues and the ElderlyPain Issues and the ElderlyPain Issues and the ElderlyPain Issues and the Elderly

Dr. Ann M. Berger, MSN, MD Dr. Ann M. Berger, MSN, MD Chief, Pain and Palliative Care Chief, Pain and Palliative Care

National Institutes of Health, Clinical CenterNational Institutes of Health, Clinical Center

Acute vs. Chronic Pain

Chronicvegetative

Sleep disturbances

anorexia

decreased libido

anhedonia

constipation

Somatic pre-occupation

Personality change

lethargy

Acutetime course-transient

features-fight or flight

pupillary dilatation

sweating

increased RR

increased HR

Increased shunting of

blood fromviscera to muscles

PathophysiologicMechanisms of Pain

Type

Somatic

Visceral

Neuropathic

Cause

Nociceptor activation

Nociceptor activation

Destruction of a nerve

Characteristics

Aching or gnawing,

localized

Aching, vaguely

localized, oftenreferred

Severe or dullshooting pain onbackground of burning, aching sensations

Pain In the ElderlyPain In the Elderly

• Prevalence in population based Prevalence in population based studies in those 65+ are from 55%-studies in those 65+ are from 55%-86%. 86%.

Step I:Step I: Mild PainMild Pain

• OTC, non-opioid, and adjuvant OTC, non-opioid, and adjuvant medicationsmedications

• Common medications:Common medications:– AspirinAspirin, , acetaminophenacetaminophen, , ibuprofenibuprofen, ,

naproxennaproxen, , TrilisateTrilisate, COX-2 anti-, COX-2 anti-inflammatoriesinflammatories

– ketorolac (ketorolac (ToradolToradol): IV or PO (): IV or PO (<< 5 days) 5 days)

Step I

Step II

Step III

*

Step II:Step II:ModerateModeratePainPain

• Opioid medication Opioid medication – With/without adjuvant analgesicsWith/without adjuvant analgesics– Common medications:Common medications:

•Hydrocodone, Hydrocodone, oxycodoneoxycodone, , tramadol (Ultram)tramadol (Ultram)

•Duration= 3-4 hour, (except may have Duration= 3-4 hour, (except may have longer relief with tramadol)longer relief with tramadol)

•Common combination drugs: Tylenol #3, Common combination drugs: Tylenol #3, PercocetPercocet, Roxicet, Oxycet, Vicodin, Lortab, , Roxicet, Oxycet, Vicodin, Lortab, Lorcet, Fioricet.Lorcet, Fioricet.

Step I

Step II

Step III

Step III:Step III: Severe Severe PainPain

• Short acting opioids:Short acting opioids:– For acute pain, rescue dosing, or titration of long For acute pain, rescue dosing, or titration of long

acting agentsacting agents– Common: Common: Dilaudid, morphine sulfate IR, Roxanol, Dilaudid, morphine sulfate IR, Roxanol,

ACTIQ, oxycodoneACTIQ, oxycodone

• Long acting:Long acting:– requires titration of short acting opioidsrequires titration of short acting opioids– Provides consistent 24 hr therapeutic blood levelsProvides consistent 24 hr therapeutic blood levels– 8-12 hrs: 8-12 hrs: OxycontinOxycontin, , MS ContinMS Contin, Oramorph, , Oramorph,

methadone methadone (long t(long t1/2 1/2 with shorter analgesic effect)with shorter analgesic effect) – 48-72 hrs duration: 48-72 hrs duration: DuragesicDuragesic

Step I

Step II

Step III

Opioids for Moderate to Severe Pain

Long Acting• Morphine (MS Contin, Oramorph SR, Kadian• Oxycodone (Oxycontin)• Fentanyl (Duragesic)• Methadone (Dolophine)• Levorphanol (Levo-Dromoran) Oxymorphone

Opioids for Moderate to Severe Pain

Short Acting • Morphine (Roxanol, MSIR)

• Oxycodone (Roxicodone, Oxy IR)

• Fentanyl (Actiq)

• Hydromorphone (Dilaudid)

Oxymorphone

• Constipation- prophylactic use of laxatives and stool softeners

• Nausea and vomiting- neuroleptics, metoclopramide, cisapride,

antivertigenous drugs

• Sedation- discontinue other CNS depressants- add psychostimulants

• Respiratory depression- monitor if not severe; carefully titrate naloxone

if severe

Management of Common Opioid Side effects

ToleranceTolerance: :

• pharmacological need to increase dose to pharmacological need to increase dose to achieve the same effect over time in the achieve the same effect over time in the absence of advancing disease. Tolerance absence of advancing disease. Tolerance is usually not problematic in chronic is usually not problematic in chronic analgesic use. analgesic use.

Physical dependence: Physical dependence: • class-specific, predictable psycho-class-specific, predictable psycho-

physiological reaction to sudden cessation physiological reaction to sudden cessation or blocking of a drug. A tapering regimen or blocking of a drug. A tapering regimen will mitigate or stop withdrawal. will mitigate or stop withdrawal.

AddictionAddiction • overwhelming preoccupation with acquisition overwhelming preoccupation with acquisition

• use of drug for non-medicinal purposesuse of drug for non-medicinal purposes

• results in reduced quality of life and continued results in reduced quality of life and continued use despite harm. use despite harm.

• Fewer than 0.1% of acute/chronic pain Fewer than 0.1% of acute/chronic pain medication users develop addiction behaviors medication users develop addiction behaviors (Jick, Portenoy).(Jick, Portenoy).

Pseudo-addictionPseudo-addiction• aberrant or illegal drug-seeking behavior similar aberrant or illegal drug-seeking behavior similar

to addiction that is due to unrelieved pain, which to addiction that is due to unrelieved pain, which stops when adequate pain relief is achieved.stops when adequate pain relief is achieved.

Neuropathic Pain-Neuropathic Pain-Adjuvant AnalgesicsAdjuvant AnalgesicsNeuropathic Pain-Neuropathic Pain-Adjuvant AnalgesicsAdjuvant Analgesics

• Tricyclic antidepressantsTricyclic antidepressants

• AnticonvulsantsAnticonvulsants

• ClonidineClonidine

• CorticosteroidsCorticosteroids

• Local anesthetics-MexiliteneLocal anesthetics-Mexilitene

• KetamineKetamine

• BaclofenBaclofen

Nature of PainNature of Pain

Total Pain

Pain

Suffering

Neuropathic Mechanism

Psychosocial Influences

Somatic,Visceral Nociception

Psychological State and Traits

Loss of Work

Spirituality

Social / Family Functioning

Fear of DeathPhysical Disability

Financial Concerns

Emotional Pain “ hurts all over”Emotional Pain “ hurts all over”

Most common palliative care symptoms Most common palliative care symptoms

AnxietyAnxiety; may present as sleeplessness, ; may present as sleeplessness, reluctant to be left alone or overt frightreluctant to be left alone or overt fright

Anticipatory AnxietyAnticipatory Anxiety; previous negative ; previous negative experience becomes overwhelmingexperience becomes overwhelming

Treatment: relaxation & imagery, Treatment: relaxation & imagery, acupressure, massage, music therapy, acupressure, massage, music therapy, hypnosis…. then maybe hypnosis…. then maybe pharmacotherapy such as lorazepam, pharmacotherapy such as lorazepam, haloperidolhaloperidol

Emotional Pain;Emotional Pain;Care Giver BurdenCare Giver Burden “ communication, “ communication,

communication, communication”communication, communication”

Spirit of cooperationSpirit of cooperation

Complex family dynamics emergeComplex family dynamics emerge

Support to work through accumulated Support to work through accumulated emotionsemotions

Can not take away all of the symptoms all the Can not take away all of the symptoms all the timetime

Imposing own expectations Imposing own expectations

Sense of presence is the very best medicineSense of presence is the very best medicine

SpiritualitySpirituality

The part of self where search for The part of self where search for meaning takes place.meaning takes place.

Distinction between religion and Distinction between religion and spiritualityspirituality

Intimate connection with life through Intimate connection with life through family, home, friends, leisure and workfamily, home, friends, leisure and work

Core Team• Comprehensive Assessment• Coordinate Interventions• Discharge Planning

Recreational Therapy• Relaxation• Stress Management• Pet, Music, & Art Therapy

Rehabilitation• Functional Interventions• Assistive Devices• Energy Conservation

Social Work• Socioeconomic Support• Community Resources• Coping Skills

Thanatology• Grief Counseling• Family Support, End-of-Life Issues• Community Transition

Complementary• Acupuncture/ Acupressure• Tai Chi• Trigger Point Release

SpiritualMinistry• Pastoral Presence• Prayer• Hope & Peace

Nutrition• Satiety, Dysphagia• Nausea• Intake Modification, TPN/Tube Feedings

Pharmacy• Pharmacological Counseling• Equianalgesia• Adjuvant Agents

Symptoms

It takes a nurturing interdisciplinary It takes a nurturing interdisciplinary team to practice the nature of palliative team to practice the nature of palliative carecare

It takes a nurturing interdisciplinary It takes a nurturing interdisciplinary team to practice the nature of palliative team to practice the nature of palliative carecare

Co-morbidityConcomitant

Disorder

Spirituality

Roles and Relationships

Isolation

EmotionalState

GriefEconomicBurden

Level ofFunction

PsychologicalPredisposition

DiseaseProcess

Treatment Regimen

Suffering

Individuals’Quality of Life

Clinical Trials

Protocol

MassageMassage

A simple form of therapy with the potential of restoring A simple form of therapy with the potential of restoring physical, emotional & spiritual well-beingphysical, emotional & spiritual well-being

• RelaxationRelaxation

• Eases muscular tension, Eases muscular tension, stiffness & painstiffness & pain

• Promotes communicationPromotes communication

• Lessens feeling of isolation, Lessens feeling of isolation, tactile stimulationtactile stimulation

• Replenishes energyReplenishes energy

• Improves plasma & Improves plasma & lymphatic circulationlymphatic circulation

• Strengthens & tones musclesStrengthens & tones muscles

• Stimulates or calms functions Stimulates or calms functions of the nervous systemof the nervous system

Electro Therapeutic Point Electro Therapeutic Point StimulatorStimulator

• Applies concentrated low frequency Applies concentrated low frequency stimulation to acutherapy points, stimulation to acutherapy points, biochemical response, contracted biochemical response, contracted motor & trigger pointsmotor & trigger points

• Used to provide immediate or chronic Used to provide immediate or chronic pain relief and decrease muscle pain relief and decrease muscle tonicity tonicity

Transcutaneous Electrical Transcutaneous Electrical Nerve Stimulation (TENS)Nerve Stimulation (TENS)

• Blocks pain by directing a stimulating Blocks pain by directing a stimulating current into local nervescurrent into local nerves

• Uses high-frequency signalsUses high-frequency signals

• At low frequencies, reduces pain by At low frequencies, reduces pain by stimulating acupuncture and trigger stimulating acupuncture and trigger points points

Methods of RelaxationMethods of Relaxation

Used to modify behavior, perception, Used to modify behavior, perception, feelings or internalfeelings or internal psychological statepsychological state

• CenteringCentering

• BreathingBreathing

• MeditationMeditation

• Guided imageryGuided imagery

• VisualizationVisualization

• Passive & Progressive Passive & Progressive Muscle RelaxationMuscle Relaxation

• Stretching/MovementStretching/Movement

• AffirmationsAffirmations

• DesensitizationDesensitization

YogaYoga

• Focuses on the physical & mental Focuses on the physical & mental practice of binding mind, body & spirit practice of binding mind, body & spirit with controlled movementwith controlled movement

• Used to ease muscle tension, improve Used to ease muscle tension, improve flexibility, strength, balance & flexibility, strength, balance & enduranceendurance

… …increasing body awarenessincreasing body awareness

Vibroacoustic ChairVibroacoustic Chair

• Delivers auditory & tactile vibrations Delivers auditory & tactile vibrations to the body to areas of greatest bone to the body to areas of greatest bone conductivityconductivity

• Used to relieve symptom burdenUsed to relieve symptom burden

BiofeedbackBiofeedback

• Provides guidance for the validation Provides guidance for the validation of & direct feedback to bodily of & direct feedback to bodily processes (peripheral body processes (peripheral body temperature, EMG, skin conduction)temperature, EMG, skin conduction)

• Used for relaxation and self-Used for relaxation and self-regulationregulation

HypnosisHypnosis

• Develops a purposeful altered state of Develops a purposeful altered state of consciousness through focused consciousness through focused attentionattention

(responsiveness to suggestion, ability to (responsiveness to suggestion, ability to dissociate through time & space)dissociate through time & space)

• Used to accomplish difficult Used to accomplish difficult psychophysical changespsychophysical changes

AcupunctureAcupuncture

• Therapeutic insertion of needles in Therapeutic insertion of needles in patterns at acupuncture points to patterns at acupuncture points to encourage the flow of energy (qi)encourage the flow of energy (qi)

• Manual or electrical stimulation used Manual or electrical stimulation used to elicit local & generalized effectsto elicit local & generalized effects

AcupressureAcupressure

• Ancient Chinese healing method that Ancient Chinese healing method that involves applying pressure to one or involves applying pressure to one or more of the 14 meridian points…areas more of the 14 meridian points…areas that carry energy throughout the bodythat carry energy throughout the body

• Meridians start at the finger tips, Meridians start at the finger tips, connect to the brain, then to the organ connect to the brain, then to the organ associated with the specific meridian associated with the specific meridian

ReikiReiki

• Utilizes a universal energy healing Utilizes a universal energy healing system that is applicable to all system that is applicable to all purposes, conditions or situationspurposes, conditions or situations

• Used for whole body energy Used for whole body energy balancing, healing, well-being & balancing, healing, well-being & maintaining immune system integrity maintaining immune system integrity

Finger LabyrinthFinger Labyrinth

• A replica of a walking Labyrinth, A replica of a walking Labyrinth, used as a spiritual tool for used as a spiritual tool for meditation with the aims of……meditation with the aims of……

1.1. Releasing:Releasing: as you enter, quiet the mind by as you enter, quiet the mind by focusing on your breathing & sensing your finger focusing on your breathing & sensing your finger on the pathon the path

2.2. Receiving:Receiving: pause in the center, reflect where pause in the center, reflect where you are in your life & ask for guidanceyou are in your life & ask for guidance

3.3. Renewal: Renewal: as you exit, reconnect with universal as you exit, reconnect with universal life & reflect on a positive quality you want to life & reflect on a positive quality you want to bring into your life, allowing the guidance to lead bring into your life, allowing the guidance to lead youyou

MandalaMandala

• An artistic design often used in meditation for An artistic design often used in meditation for centering, focusing & contemplation centering, focusing & contemplation

• A spiritual tool for creating symbolism, relating A spiritual tool for creating symbolism, relating to the relationship of one’s soul to the universeto the relationship of one’s soul to the universe

• A means that allows the patient to explore self-A means that allows the patient to explore self-understanding, as a path to healingunderstanding, as a path to healing

-- the center of the circle represents the most the center of the circle represents the most important thing in important thing in your lifeyour life

-- surround the center with concentric circles, using surround the center with concentric circles, using symbols for symbols for your life & symbols of that which threatens your life & symbols of that which threatens or protects youor protects you

-- the outer circle represents the absolute boundary the outer circle represents the absolute boundary of the of the universe as you know ituniverse as you know it

Animal –Assisted TherapyAnimal –Assisted Therapy

• Designed for goal-directed Designed for goal-directed interventions by companion animals interventions by companion animals from the National Capital Therapy Dogsfrom the National Capital Therapy Dogs

• Used to reduce the negative impact of Used to reduce the negative impact of a medical environment, improve tactile a medical environment, improve tactile stimulation, maintain/improve social stimulation, maintain/improve social skills & increase physical movementskills & increase physical movement

Art TherapyArt Therapy

A supportive venue of psychotherapy A supportive venue of psychotherapy thatthat

enables the patient to break the enables the patient to break the barriers ofbarriers of

inhibition, while promoting emotional inhibition, while promoting emotional

expression & healing through non-expression & healing through non-verbalverbal

means.means.

MusicMusic• Incorporates active & passive experiences Incorporates active & passive experiences

of listening, participation, life review, lyric of listening, participation, life review, lyric analysis, song writing and toning *.analysis, song writing and toning *.

** Toning is the elongation of a note/tone from the voice, Toning is the elongation of a note/tone from the voice, aimed at a specific area of the body. The body has a aimed at a specific area of the body. The body has a relaxation response when toning is applied to certain relaxation response when toning is applied to certain conditions such as localized pain, nausea or constipation. It conditions such as localized pain, nausea or constipation. It also has a soothing effect for emotional pain & suffering.also has a soothing effect for emotional pain & suffering.

• Used to achieve/maintain optimal physical, Used to achieve/maintain optimal physical, emotional, spiritual & social well-being, as emotional, spiritual & social well-being, as well as enhancing communicationwell as enhancing communication

Considerations in Considerations in Complementary TherapiesComplementary Therapies

• Initiate one modality at a timeInitiate one modality at a time• Re-evaluate for effectivenessRe-evaluate for effectiveness• Therapies may have interactions; Therapies may have interactions;

synergistic use of Reiki and Hypnosis synergistic use of Reiki and Hypnosis but not Reiki and Acupuncture but not Reiki and Acupuncture

• Complimentary therapies often Complimentary therapies often require a series of treatments, such require a series of treatments, such as 6 to 12 sessions of Acupunctureas 6 to 12 sessions of Acupuncture

Take Back to PracticeTake Back to PracticePalliative Intervention Palliative Intervention

EarlyEarlyAvailableAvailableIntegrativeIntegrativeReassurance Reassurance

To our patient-Heroes disguised as ordinary To our patient-Heroes disguised as ordinary people going on an extraordinary journey !people going on an extraordinary journey !

……and they lived at peace each day they and they lived at peace each day they had………had………