Pain Management Pain Management in Geriatric in Geriatric Medicine Medicine Smith, Howard. Clinics in Geriatric Medicine, May 2008; Smith, Howard. Clinics in Geriatric Medicine, May 2008; Vol 24, No.2; 1549 - 1556 Vol 24, No.2; 1549 - 1556 Zachary Lapaquette Zachary Lapaquette PharmD Candidate PharmD Candidate University of Georgia University of Georgia
Pain Management in Geriatric Medicine. Smith, Howard. Clinics in Geriatric Medicine, May 2008; Vol 24, No.2; 1549 - 1556. Zachary Lapaquette PharmD Candidate University of Georgia. Background. In 2000, 65-and-older population comprised 35 million people, 12.4% of U.S. population - PowerPoint PPT Presentation
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Pain Management in Pain Management in Geriatric MedicineGeriatric Medicine
Smith, Howard. Clinics in Geriatric Medicine, May 2008; Vol 24, Smith, Howard. Clinics in Geriatric Medicine, May 2008; Vol 24, No.2; 1549 - 1556No.2; 1549 - 1556
❖ Loss of ability to communicate can occur with several states:
❖ Dementias
❖ Delirium
❖ State of unconsciousness
❖ Severe depression
❖ Psychosis
❖ Mental disability
Pain Assessment
❖ 5 key principles of pain assessment in nonverbal populations:
1. Obtain self-report
2. Investigate possible pathologies
3. Observe behavior
4. Solicit surrogate report
5. Use analgesic trial
1. Self-Report
❖ Even “yes”/ “no” response is helpful
❖ Simple test to assess reliability:
❖ Patient provides number from 0 to 3 and a word to describe pain. After 1 minute of distracting conversation, patient is asked to provide same number and word.
2. Pathologies
❖ Concept that pain can be assumed and treated due to certain disease states
❖ Musculoskeletal, neurologic disorders, etc.
❖ Pain should be prophylactically treated before undergoing any procedure
3. Pain-Associated Behaviors
❖ Inherently subjective, it relies on observed behaviors
❖ Changes in vital signs are not reliable as indicators of pain
❖ Observations of behaviors should occur during movement or activity that is likely to elicit a pain response if pain is present
❖ Serial observations should be performed under similar circumstances to ensure objectivity
Body movementsTense body posture, guarding, fidgeting,
increased pacing, rocking, gait or mobility changes
Interpersonal interactions
Aggressive, combative, decreased social interactions, socially inappropriate
Activity patternsRefusing food, appetite changes, sleep, sudden cessation of common routines
Mental status changes
Crying, increased confusion, irritability or distress
4. Surrogate Reporters
❖ Family and care-givers (e.g. nurses’s assistant) of patient are more sensitive to patient behaviors
❖ Training of care-givers is important to safeguard reliability of behavioral observation
❖ Raters should compare observations with each other
5. Analgesia Trial
❖ Trial of patients with dementia receiving 3g/day of acetaminophen showed greater social activity v. placebo
❖ 2.6g/day trial unsuccessful
❖ Analgesic trial method has not been appropriately studied, but is promising approach
Dementia and Pain
❖ Alzheimer’s disease and vascular dementia patients experience language disturbance and mutism in late stages of disease
❖ Frontotemporal dementia and primary progressive aphasia show earlier onset
❖ It’s been determined that patients with dementia experience greater incidence of pain
Dementia and Pain
❖ Subtype of dementia impacts pain response:
❖ In frontotemporal dementia, a decrease in affective pain response has been documented
❖ In vascular dementia and AD, an increase in affective response is reported
Delirium and Pain
❖ Delirium is a transient cognitive impairment characterized by fluctuating awareness and change in cognition or perceptual disturbance, in the presence of underlying illness
❖ Considerable overlap between delirium and pain-associated behaviors
❖ Consider analgesic trial
Critical Illness
❖ Patients tend to experience constant baseline aching pain with intermittent sharp, stinging pain due to procedures
❖ Identification of pain in ICU is complex
❖ Sixty-two percent of older patients in ICU experience delirium