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CASE #1
Case #2
Pain Management in the Elderly
Lee A. Jennings, MD MSHSAssistant Professor, UCLA Division of Geriatrics
Slides adapted from: Daniel P. Alford, MD, MPHBoston University School of Medicine
ObjectivesObjectives• Pain assessment in older adults• Pharmacotherapy considerations in older adults• Stepwise approach to pain management• Specific pain medications and use in older adults
– Topical preparations– NSAIDs and Acetaminophen– Adjuvant agents– Opioids
Chronic Pain is More CommonChronic Pain is More Common
• 20% U.S. population
• 25-‐50% community dwelling elderly
• 45-‐80% nursing home elderly
Jakobsson U et al. J Pain Symptom Manage 2003
N = 4,093Aged 75-‐105
Poorer Pain ControlPoorer Pain Control• Literature shows older post-‐operative patients…• Are asked about pain less often• Receive analgesia less frequently• More post-‐op painàmore post-‐op complications
• Cognitive impairment is an independent predictor of failure to receive analgesia despite presence of daily recorded pain in the nursing home
• Why?• Fear of side effects from pain medications• Older adults tend to under-‐report pain symptoms• May assume pain is okay if patient can’t ask for treatment
Catananti C, Gambassi G. Surgical Oncology 2010 (Bernabei R. JAMA 1998)
Consequences of Unrelieved PainConsequences of Unrelieved Pain
• Depression, anxiety• Social isolation• Sleep disturbance• Impaired ambulation→ deconditioning →↑ fall risk
• Decreased mobility• Anorexia and malnutrition• Subtle decrements in cognitive function• Agitation or delirium in cognitively impaired• Increased health care utilization and cost
Pain Assessment in the Older AdultPain Assessment in the Older Adult
• Under-‐reporting of symptoms•Expect pain with aging•Do not want to bother their physician•Stoicism•Do not think their pain can be alleviated•Fear addiction
• Cognitive impairment– Pain may present as change in behavior– Consider scheduled dosing
Dawson et al., 2005; Herr 2002; Jones et al., 2004
Pain Assessment in the Older AdultPain Assessment in the Older Adult
• Focus on how pain impacts function– Assess mobility and gait– Ask about impact on daily activities
• Assess psychosocial factors that may impact pain and treatment options (mood, fear-‐avoidance behaviors, caregiver support, social isolation, financial constraints)
• Drug-‐drug and drug-‐disease interactionsmay complicate pain medication choice
• Imaging—degenerative pathology common in older adults with and without pain
Dawson et al., 2005; Herr 2002; Jones et al., 2004
Chronic Pain Management Goal Setting (Five As)
Chronic Pain Management Goal Setting (Five As)
Improve• Analgesia (pain control)• ADLs (function)
– 30% reduction in pain and significant improvement in function
• Affective state (treat comorbid depression)
• Adaptive behaviors (consider CBT, set treatment expectations, assess social support/isolation)
Avoid• Adverse effects
PharmacotherapyAge-‐related Considerations
PharmacotherapyAge-‐related Considerations
• More narrow therapeutic window
• Age-‐related predisposition to adverse drug effects• 2-‐3 times higher
• Longer duration of drug activity• Increased GI transit timeàgreater absorption• Distribution
• Increased body fat with ageà longer drug half-‐life if drug deposits in fat• Less binding of drug to proteinà more drug available to act on ligands
• Decreased hepatic drug metabolism• Decrease in GFRà decreased drug elimination
PharmacotherapyGeneral Principles
PharmacotherapyGeneral Principles
• Start low and go slow…
– But go (and monitor frequently)
– Gradual increase also improves tolerability
• Rational polypharmacy
– Choose agents that work on different points for synergy
– Combine medications so doses can be decreased minimizing side effects
Gilron I et al NEJM 2005
Exploit SynergismRational PolypharmacyExploit SynergismRational Polypharmacy
Mechanism-‐Specific Pain ManagementMechanism-‐Specific Pain Management
Spinalcord
Brain
Peripheral sensitization(Na+ channels)
Central sensitization(Ca++ channels, NMDA receptor)
Descending inhibition(NE, 5HT)
TCASSRISNRI
TramadolOpioids
NSAIDsOpioidsTCA
LidocaineWoolf CJ Ann Intern Med 2004
Changes in Pain Perception with AgeChanges in Pain Perception with Age
• Changes in transmission along pain fibers– Elderly rely mostly on C-‐fiber input (slow, dull, achy)
• Unclear if nociception changes with aging– Visceral hypoalgesia (silent MI, silent surgical abdomen)
– No evidence of peripheral hypoalgesia
• Nociceptive vs. neuropathic pain
Chakour MC et al. Pain 1996
Stepwise Approach to Chronic Pain
6: Surgery
5: Systemic oral analgesics
4: Local and more invasive Rx (spine
injections)3: Local and minimally invasive Rx (trigger point/ knee/hip/shoulder
injections)
2: Topical preparations (lidocaine, NSAIDS)
1: Nonpharmacologic approaches
Oral Analgesics-‐Acetaminophen-‐Weak Opioids-‐Strong Opioids-‐SNRIs (duloxetine)
NIH module: http://palladianpartners.com/edna/
Nonpharm ApproachesAssistive device, PT, exercise, weight loss, hot/cold, yoga, acupuncture, massage, CBT, education, TENS
Acetaminophen and NSAIDsAcetaminophen and NSAIDs
– Ceiling analgesic effect – No known analgesic tolerance– Additive role– Usually ineffective for neuropathic pain– Adverse effects common at high doses– NSAIDs increased risk with age: Exacerbate HTN, CHF, LE edema, renal disease, GI ulceration (use with PPI)—not recommended for long-‐term use
– Topical NSAIDs (↓ systemic levels) are safer– Acetaminophen: caution with liver disease, ETOH
Adjuvant Analgesics and OthersAdjuvant Analgesics and Others• Antidepressants
SNRIs: duloxetine, venlafaxine, milnacipran
TCAs: nortriptyline, desipramine; anticholinergic SEs limit use
• Anticonvulsants: gabapentin, pregabalin (sedating)
• Antispasmotics/Muscle relaxants
– Avoid or limit use, 7 day max, BEERS list med, very sedatingà fall risk
• Topical anesthetics (i.e., lidocaine patch)
OpioidsOpioids• Okay to start with opioids when pain is moderate to severe. • Opioid responsiveness varies.
– Varies among individualsàpatient’s prior experience•Mu polymorphisms; differences in metabolism
– Varies by type of pain• Acute ~100% > Chronic ~50%• Nociceptive > Neuropathic
• Dosing– 25% decrease in starting dose for a 60 yo– 50% decrease in starting dose for an 80 yo– Same intervals
Managing Opioid Side EffectsManaging Opioid Side Effects• For all SEs, can try switching opioids• Nauseaà Usually resolves in few days; antiemetic prior to dose
• Sedation, mental cloudingàDecrease dose• Constipationà Bowel stimulants, start bowel regimen with opioid
• Pruritisà Antihistamines (but side effects common, beware of prescribing cascade)
• Urinary retentionà Treat constipation• Balance impairmentà Fall risk assessment, assistive device
Opioid SafetyOpioid Safety• Allergies are rare, side effects are common• Organ toxicities are rare
• Suppression of hypothalamic-‐pituitary-‐gonadal axis
• Addiction• 3-‐19% when treating chronic pain• Extremely low (<1%) when treating acute pain
• Overdose at high doses and combined with other sedatives
Saunders KW et al. J Gen Med 2010 Dunn KM et al. Ann Intern Med 2010Li X et al. Brain Res Mol Brain Res 2001 Doverty M et al. Pain 2001 Angst MS, Clark JD. Anesthesiology 2006
Opioid ChoiceOpioid Choice
Immediate-‐releaseWeak• Codeine• HydrocodoneDual Mechanism Opioids• Tramadol• TapentadolStrong• Morphine• Oxycodone• Hydromorphone
Extended-‐release• ER morphine• ER oxycodone• Fentanyl transdermal• Buprenorphine transdermal
Acute PainWhat Route?Acute PainWhat Route?
• GI tract, swallowing difficulties? – Level of consciousness?– IV and SL options
• How rapidly you need to get pain under control§ Maximum plasma concentration
• po ~ 1 hour• sc ~ 30 minutes• IV ~ 5-‐10 minutes• transdermal ~18 hours
PRN
Patient Need (Pain)Call Nurse
Nurse Responds
Injection Given
Absorption
Relief(Analgesia)
+/- Sedation
Assessment
Sign out Medication
Prepare Injection
Acute Pain How to Dose?“as needed” versus “scheduled - hold for sedationAcute Pain How to Dose?
“as needed” versus “scheduled - hold for sedation”
Reassessing
• How is patient using the medication?• Changing the dose or the frequency?
– Did patient get adequate pain relief?– Did pain med wear off too soon?
• Any side effects?• Stepwise approach—Add nonpharmacologic intervention?
• Treatment expectations: 5 A’s of chronic pain management
ObjectivesObjectives• Pain assessment in older adults• Pharmacotherapy considerations in older adults• Stepwise approach to pain management• Specific pain medications and use in older adults
– Topical preparations– NSAIDs and Acetaminophen– Adjuvant agents– Opioids
Clinical Guidelines & Recommendations: Pharmacologic Management of Persistent Pain in Older Persons. American Geriatrics Society (2009). Free pocket cardhttp://www.americangeriatrics.org/search/?q=persistent%20pain
Pain BehaviorsCognitively Impaired Older Adults
Pain BehaviorsCognitively Impaired Older Adults
• Facial expressions• Verbalizations, vocalizations• Body movements• Changes in interpersonal interactions• Changes in activity patterns or routines• Mental status changes
Fine PG. Pain Medicine 2012
Pain Assessment ToolsCognitively Intact Adults
Pain Assessment ToolsCognitively Intact Adults
• Pain scales– Visual analog scale– Numeric rating scales– Pain thermometer– Facial pain scale
• Brief pain inventory– Assesses pain history, location, intensity, quality and interference with
activities– Translated and validated in many languages
• Geriatric pain measure– Multidimensional questionnaire– Validity and reliability in European and US older adults
Geriatric Pain Measure SF (GPM-‐12)Geriatric Pain Measure SF (GPM-‐12)Do you currently have pain with or have you stopped:1. moderate activities such as moving a heavy table, pushing a vacuum cleaner, bowling, or playing golf?2. climbing more than one flight of stairs?3. walking more than 200 yards?4. walking 200 yards or less?
Because of pain, have you:1. cut down the amount of time you spend on work or other activities?2. been accomplishing less than you would like to?3. limited the kind of work or other activities you do?
8. Does the work or activities you do require extra effort?9. Do you have trouble sleeping?10. Does pain prevent you from enjoying any other social or recreational activities?11. On a scale of 0-‐10, how severe is your pain today?12. In the last 7 days, how severe has your pain been on average?
Blozik et al., JAGS, 55, 2007
