Pain in Older Patients.pptx

7/25/2019 Pain in Older Patients.pptx

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PAIN IN THEOLDER

PERSONDr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist


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A national telephone-based survey in US:

lder adultsreported si!ilar prevalence ratesof current pain as their younger counterparts

"ersistent pain:

ver age #$ people are twice as li%ely asyoungercounterparts

y '$( adults are three ti!es !ore li%ely tohave than those under )' years of age

Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist


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Aging alters functions(

Degeneration of peripheral neuronalstructure

Slows transduction &

trans!ission



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nce pain is established*

the lower density of descendinginhibitory circuitsand an i!pairedability to recover fro! hyperalgesicor allodynic states is attributed toaging



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+he decline in function of theendogenous

antinociceptive!echanis!s as well asthe capacity to reverse spinal andsupraspinal sensitization places olderpatients

at greater ris% for developingpersistent pain following an illness(surgery( or trau!a



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"revalence of pain !ay be as high as,. to $. in co!!unity-dwellingolder persons and /. to '$. in

nursing ho!e residents

Many physicians and patientsincorrectly

view pain as an e0pected part of aging



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1n presence of !ultiple co!orbidconditions(

and their !edical care ( 2ittle attention!ay be paid to the alleviation ofassociated sy!pto!s such as pain

"ain is unrecognizedandundertreated



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Signi3cant portion of those over age #do not receive analgesics:

over a 4uarterof older adults with cancer

pain(

/$. of elders with hip fracture in the5!ergency

Depart!ent/$. to '$. of elders living with pain in

the co!!unity



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Uncontrolled pain

6unctional status

"sychosocial well-being and 4uality of life

1!paired !obility

Decreased socialization

Depression

Sleep disturbances

1ncreased health use and costs(

7ait i!pair!ent ( falls("olyphar!acy

8ognitive dysfunction

Malnutrition



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1t is ti!e to

Replace unrealistic fearsand!ista%en beliefs

7reatest opportunity for i!prove!entis:

9altingthe practices of usingplacebos

9alting reco!!ending treat!entssuch as aceta!inophen alone forsevere pain



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8hange in "ain +hreshold and+olerance

5vidence supports an age-relatedincreasein thresholds to ther!al(pressure(

and electrical sti!ulation

1n advancing age( pain thresholdincreases while tolerance of paindecreases



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8linical "resentation ofAcute "ain

1n older

adults pain !ay be absent or atypicalin acute infectious( !etabolic( ortrau!atic disorders

5g: Up to ;$. of older adults with M1report an absence of acute

sy!pto!scult to score at the bedside

nidimensional instruments

+hese tools ta%e less ti!e to ad!inister

andare !ore practical for use in various

clinical settings



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"ain Assess!ent

in the 8ognitively1!paired



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1n patients with !ild to !oderatecognitive i!pair!ent the "ain

+her!o!eterand the ?DSaregenerally reco!!ended for use



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1n patients with severe cognitivei!pair!ent:

)-May be able to convey through @yesand @no answers to si!ple 4uestions

,-bservational indicatorsof pain



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6acial e0pressionis often the 3rstor!ost co!!onindication of pain( and1t !ay be the only one

+he !ost reliable behavior !ay relateto guardingduring e0a!ination orroutine activitiessuch as wal%ing(!orning care( and transfers



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An atypical behavior in a patient withsevere

de!entia should trigger assess!entfor pain

6a!ily !e!bers( caregivers( andothers

who %now the patient well !ay provideuseful 4ualitativeinfor!ation



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59A?1RA2 MA=165S+A+1=S 6"A1= 1= +95 87=1+1?52B 1M"A1R5D



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"9ARMA82718+R5A+M5=+

6 "A1= 1=

2D5R "5RS=SDr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist


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Cith the e0ception of the rectal route(the rate of !edication absorption is

typically not aected by aging

less total body water( and !ore body

fat is seen in older adults

1ncrease distribution and

accu!ulation of lipophilic fentanyl


S f " d t S l ti d U f


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Safe "roduct Selection and Use ofpioids

0ycodone and !orphine are probablythe best 3rst-line opioid agents for anopioid na1ve patient with acute pain

9ydrocodoneis another reasonable3rstline

option* it is available only in 30ed-doseco!binations with aceta!inophen



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+ra!adol is co!!only chosen( but ithas low potency and an associationwith seizures

1n 5urope( buprenorphineis e!ergingas a potential 3rst-line opioid

+he transder!al buprenorphine patchis ideally suited for older adults( butnot e0ist in US



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AD!"ANTS



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A!itriptylineis the best studiedadJuvant for pain( but it shouldbeavoided in the elderly due to its

cardiac( anticholinergic( and sedativeeects

=ortriptyline or desipra!ine are better

choices with a K. lower incidenceof side eects at co!parable doses



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Dulo0etine( has approved labeling forcertain pains and appears to be abetter tolerated antidepressant for

older adults



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Antie#ile#tic dru$s are 3rst-lineagents to treat neuro#athic #aininolder persons

7abapentinandpregabalin havelabeled

indications for speci3c neuropathicpain disorders

Dosing should be initiated as low as

)$$ !g at bedti!eDr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist


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8arba!azepine also has UFSF 6DAapproved labeling for trige!inalneuralgia( but li%e !any older

antiepileptic agents( drug-druginteraction( liver( and he!atologicto0icity

!a%e the! less than ideal in olderadults



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when pain is co!ple0 and refractory toinitial

treat!ent atte!pt:

Additional co!ple!entary andalternative !edicine

Multidisciplinary pain treat!ent

progra!s are li%ely the !ost bene3cialin opti!izing

the outco!es



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Pain in Older Patients.pptx