Pragnesh Patel, M.D. Assistant Professor

Pragnesh Patel MDAssistant Professor

Board certified in Internal Medicine HospicePalliative Medicine and

GeriatricsDivision of Geriatrics

Wayne State UniversityDetroit Michigan

Pain Management inElderly Patients

ObjectiveUnderstand how to define and classify painLearn social and environmental factors

affecting the perception of pain and its treatment

Know the scales available to assess painLearn medical and non-medical treatments

available for pain

DemographicsUS population 306 milliongt 65 years represents about 36 million by 2020

54millionFastest growing segment of the population is gt 85

years Currently 5 million 20 million by 20501900rsquos - 3 million elderly (1 in 25 Americans) by 2020

54 million (1 in 6 Americans)2011 - first baby boomers will reach 65

US Census BureauCDCgov

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In 2000 42 of population gt65 and over reported long lasting disability

What is PainPain is an unpleasant sensory and emotional

experienceThe International Association for the Study of Pain

(IASP) defines pain in terms of both actual or potential tissue damage and the emotional experiences associated with pain

Acute Pain is often limited warns of tissue damage Often with signs of autonomic nervous system

activation Intensity of pain indicates severity of injury or diseaseChronic persistent ( gt 3 months) - pain no longer

signals tissue damage Autonomic signs are often absent IASP website

Hix MD Pain Management in elderly patients Journal of pharmacy Practice 2049-63 2007

Mechanism of pain based on PathophysiologyNociceptive pain Results from stimulation of pain

receptors Somatic damage to body tissue well localized Visceral from viscera poorly localized may have

nauseaNeuropathic pain Results from dysfunctions or

lesions in either the central or peripheral nervous systems

Mixed pain syndromes multiple or unknown mechanisms (eg headaches vasculitic syndromes)

Psychogenic Pain somatoform disorders conversion reactions

NeurobiologyMyelinated A-delta and Unmyelinated C fibers

respond to thermal mechanical electrical or chemical stimuli

Release of excitatory neurotransmitter glutamate and substance P

Information transmitted to thalamus by spinothalamic tract

Pain modulation frontal cortex hypothalamus descending pathway endogenous analgesia by releases of beta-endorphin enkephalins opioid peptides

Age related changesReduction in number and function of peripheral

nociceptive neuronsSensory threshold for thermal and vibratory stimuli

increase with agePain receptors 50 decrease in Pacinis

corpuscles10-30 decrease in MeissnersMerkles disks

Diminished endogenous analgesic response (endorphins)

in the older patients

Geriatric medicine An evidence based approach 4th edition 2003

Age related changesPeripheral nerves Myelinated nerves Decreased density Increase abnormaldegenerating fibers Slower conduction velocity Unmyelinated nerves Decreased number of large fibers (12-16 mm No change in small fibers (04 mm) Substance P content decreased

Geriatric medicine An evidence based approach 4th edition 2003

Age related changesCentral nervous system Loss in dorsal horn neurons Altered endogenous inhibition hyperalgesia Loss of neurons in cortex midbrain brainstem 18 loss in thalamus Altered cerebral evoked responses Decreased catacholamines acetylcholine

GABA serotonin Endogenous opioids mixed changes Neuropeptides no change

Geriatric medicine An evidence based approach 4 th edition 2003

Prevalence of pain in Elderly 1 in 5 elderly have pain 18 above 65 are taking pain medications regularlyOne-fifth of adults 65 years and older said they had

experienced pain in the past month that persisted for more than 24 hours

Almost three-fifths of adults 65 and older with pain said it had lasted for one year or more

Women report severely painful joints more often than men (10 percent versus 7 percent)

CDCprimes National Center for Health Statistics 2006

Prevalence of Pain in Elderly1 Community-dwelling older adults 25ndash562 Nursing home residents 45ndash80 3 Greater than 50 patients dying of a variety

of illnesses including cancer COPD CAD4 31 of women amp 19 of men gt 75 yrs report

pain in 3 or more sites

AGS panel on persistent pain in older persons JAGS 50s205-s224 2002Ferrell B A Pain evaluation and management in the nursing homes Ann Intern Med

123(9)681-6871992 Minner D M etal Evidence based assessment and treatment of persistent pain in the community dwelling elderly receiving home

health services A pathway Home health care management and practice 17294-3012005

Factors affecting perception of painPain affects quality of life far beyond the local

region of injuryFeeling of loneliness is predictor of

psychological distressLack of intimate relationships dependency

and loss increase lonelinessLoneliness has been shown to lower pain

threshold Loneliness is a risk factor for depression Deane G etal Overview of pain management in older persons Clin Geriatr Med 24185-

2012008

Factors affecting the perception of pain Depression lack of energy avoidance of

diversional activities decreased engagement in treatment

Anxiety may inhibit participation in rehab efforts

Sleep disturbance pain is best predictor of sleep disturbance

Increased health care needs Isolation and reduced independence

Involvement with family and friends can provide pleasurable experience

Factors affecting perception of painFocusing ones attention on pain makes the

pain worsePatients who have low levels of pain remember

it as being worse than they originally reportedPain can be a learned response rather than a

purely physical problemPsychosocial issues like patientrsquos belief about

their pain their coping skills their involvement in the ldquosick rolerdquo all have an impact on how much pain patients feel and how it affects them

Challenges of pain assessment in older patientsMyths that having pain is ldquonaturalrdquo with agingFears about addiction to pain medicationsSensory and cognitive impairmentsUnder-reporting Co-morbidities complicating the clinical picture and

caregivers beliefs and the reliability of patients painLack of congruence between patients and caregivers

perceptions of painCaregiver may misinterpret pain perception Stein WM Pain in the nursing home Clinics in Geriatric Medicine 17 575-942001

Stewart K et al Assessment approaches for older people receiving social care content and coverage International Journal of Geriatric Psychiatry 14 147-561999Horgas AL et al Pain in nursing home residents Comparison of residents self-report and nursing assistants perceptions Journal of Gerontological Nursing 27 44-53 2001Weiner D et al Chronic pain associated behaviours in the nursing home resident versus caregiver perceptions Pain 80 577-881999

Pain Assessment Unidimensional Scales A single item that

usually relates to pain intensity aloneAdvantages Easy to administer and require

little time or training to produce reasonably valid and reliable results

Disadvantages Some require vision hearing and attention pencil and paper

No pain

Slight pain

Mild pain

Severe pain

Moderate pain

Extreme pain

Pain as bad as it could be

(Herr and Mobily 1993)

Pain AssessmentObtain history of painAsk about onset pattern duration location

intensity and characteristics of the pain Find out aggravating or palliating factors

and the impact on the patientEvaluate psychological state of patientScreen for depressionAnxietyAssess social networks and family

involvement

Pain Assessment ScalesMultidimensional scales evaluate pain in

multiple domains ( McGill Pain Questionnaire)

Advantage looks at pain in terms of intensity affect sensation location and several other domains that are not evaluable with a single question

Disadvantage long time consuming and difficult to administer

Pain Assessment in DementiaPatientsrsquo self report are still reliableReports from caregiversfamily members are

also reliable if they are familiar with patientBehaviors exhibited may indicate painFacial pain scale Do not use pain scales and ask to recall

information from past

Pain assessment in advanced dementiaThe Pain Assessment in Advanced Dementia

(PAINAD) scaleAssess breathing independent of vocalizationNegative vocalizationFacial expressionBody languageConsolabilityEach behavior is scored 0 to 2higher the score

more severe the pain

Pain assessment in nonverbal patientsChecklist of Nonverbal Pain Indicators (CNPI)Nonverbal vocal complaints (sighs gasps moans

groans cries)Facial grimacingBracing (clutching or holding onto furniture

equipment)Rubbing (massaging affected area)RestlessnessVerbal vocal complaints such as ldquoouchrdquo or ldquostoprdquo

Feldt K S Pain Manag Nurs 1(1)13-212000

Barriers to Effective Pain Management Study of 805 chronic pain sufferers gt50

changed physicians due to lack of physicianrsquos1)Willingness to treat the pain aggressively 2)Failure to take the pain seriously 3)Lack of knowledge about pain management

Chronic pain in America roadblocks to relief Survey conducted for the American Pain Society The America Academy of Pain Medicine and Janssen Pharmaceutica Hanson NY Roper Starch Worldwide 2000

Health care system barriers Lack of a neighborhood pharmacy Lack of transportation to the physician or

pharmacy an absence of high doses of opioids at the pharmacy

Lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment

Patient related barriers to effective pain management Communication Patients with communication

problems with physician had worse pain control

Psychological Anxiety distress depression anger and dementia all of which can complicate assessment by masking symptoms

Attitudinal issues Fear of addiction tolerance and side effects belief that pain was inevitable

TreatmentAge-Related Physiologic ChangesDecreased renal function Decreased volume of distribution because of

decreased lean body weight Decreased liver mass and hepatic blood flow Decreased activity of some drug-metabolizing

enzymes Decreased serum protein concentrations Decreased pulmonary function

TreatmentNonopioid Analgesics for Older AdultsAcetaminophen 1)Treatment of choice for Osteoarthritis2)Exhibits an analgesic ceiling beyond which

higher doses do not provide greater pain relief

3) Maximum dose 4 gmday

TreatmentNonselective NSAIDs Inhibit prostaglandin synthesis Appropriate for short term useAll have ceiling effect Risk of gastrointestinal bleed renal

impairment platelet dysfunctionSelective COX-2 inhibitors (celecoxib is only

one currently available in US) Reduced gastrointestinal side-effects and

platelet inhibition

Treatment with OpioidsStimulates mu opioid receptorUsed for moderate to severe painUsed for both nociceptive and neuropathic painOpioid drugs have no ceiling to their analgesic

effects and have been shown to relieve all types of pain

Elderly people compared to younger people may be more sensitive to the analgesic properties

Advanced age is associated with a prolonged half-life and prolonged pharmacokinetics of opioid drugs

OpioidsMorphine Hepatic metabolism and renally excreted not

dialyzable Oral bioavailability 30-40 M6G is active metabolite with analgesic activity M3G is another metabolite causes neurotoxicity Morphine is available in oral (liquid and pill)

topical sublingual parenteral intrathecal epidural and rectal routes

High doses can lead to myoclonus and hyperalgesia

OpioidsOxycodone Only available in oral form More potent than morphine Available as single agent and in combination with NSAIDs

and acetamenophen Available in long-tacting slow release form ndash OxyContin)

Methandone Blocks NMDA receptors inexpensive lacks active

metabolite Used for neuropathic pain Variable(long) half-life high tissue distribution Converting from any opioid to methadone takes several

days

OpioidsHydrocodone (Vicodin Lortab Norco others) Only available in combination with

acetamenophen or NSAIDHydromorphone (Dilaudid) 5 times more potent than morphine Not available in long acting preparation Propoxyphene (darvocet) very weak analgesic effect can cause ataxia

and neurotoxicity twofold higher risk of hip fractures

OpioidsAll oral opioids (except methadone) have a

duration of action of 3-4 hours with normal metabolism

OpioidsMeperidine (Demerol) Metabolized to active metabolite

normeperidine Lowers seizure threshold risk for falls

confusion sedation Should be AVOIDED as analgesic

OpioidsFentanyl Patch

100 times more potent than morphineAbsorption altered by temperatureDepot of drug in excess adipose tissue

TramadolSynthetic mu (opioid) agonist and inhibition of serotonin and norepinephrine reuptake

15th as potent as morphine Lowers threshold for seizure and multiple

drug-grug interactions

OpioidsCan cause drowsiness nausea respiratory

depressionTolerance diminished effect of a drug associated

with constant exposure to the drug over timeTolerance develops to CNS side effectsTolerance does not develop to constipation (Prophylax with increasing fluid intake osmotic

laxatives or stimulant laxatives)Dependency uncomfortable side effects when the

drug is withheld abruptly Drug dependence requires constant exposure to

the drug for at least several days

Opioid AddictionAddiction drug use despite negative

physical and social consequences (harm to self and others) and the craving for effects other than pain relief

Pseudo-addiction inadequately treated and un-relieved pain leading to persistent or worsening pain complaints frequent office visits requests for dose escalations