Dr. Ramesh Zacharias GEM Persistent Pain.pdf

GERAITRIC EMERGENCY MEDICINECONFERENCE 2010PERSISTENT PAIN IN OLDER PERSONSRamesh Zacharias MD FRCS DAAPM CMDMedical Director Village of Erin MeadowsAssistant Clinical Professor (Adjunct)Department of AnaesthesiaMcMaster Universityrzacharias@rogers.com

DISCLOSURES• Unrestricted education grant: Sanofi-Aventis• Speakers honoraria: Schering-Plough,Sanofi-Aventis, Pfizer• Consulting projects: Ontario MOHLTC,Atlantic Region Ministries of Healthand Education, CIDA Inc, Ministries ofHealth Malaysia and Kerala India

LEARNING OBJECTIVES• Discuss the current state of painmanagement in older persons• Address changes in brain morphology withaging and chronic pain• Describe the consequences of pain in olderpersons such as depression, loss ofindependence and reduced quality of life• Assess pain in older persons with cognitiveor communication impairment

THE PURPOSE OF HUMAN LIFE IS TOSERVE, TO SHOW COMPASSION, ANDTO HELP OTHERS.ALBERT SCHWEITZER

EPIDEMEOLOGY OF PAININ OLDER PERSONS• Pain is a common problem encountered amongelderly people in sub acute and long-term facilities.Pain is often underestimated and under treated inthese settings. Ferrell, BA. Clinics in GeriatricsMedicine. 16(4):853-74, 2000 November.• Pain management remains at the forefront of long-term care. Herr, Keela. Journal of GerontologicalNursing. 28(1):20-7 7 2002 Jan.• In the geriatric population, common causes of paininclude osteoarthritis, low back pain, diabetes andother neuropathies etc. Freedman, Gordon.Geriatrics. 57(5): 36-41; 2002, May, Mitchell, C.British Journal of Nursing. 10(5): 296-304, 2001March 8-21. 8

EPIDEMEOLOGY OF PAININ OLDER PERSONS• Chronic Pain is a complex problem with both clinicaland psychological implications• Chronic pain affects 20% of Canadians and jumpsto 60% of those over 65. Chronic Pain in Canada:Prevalence, Treatment. Impact and Role of OpioidAnalgesia, Moulin, D et al., Pain Research andManagement, 2002. 7:179-84.• Epidemiologic studies show a very high prevalenceof persistence pain, often exceeding 50% ofcommunity dwelling older patients and up to 80%of nursing home resident. Gibson, SJ, ExpertReview of Neurotherapeutics. 7(6): 627-35, 2007June.

EPIDEMEOLOGY OF PAININ OLDER PERSONS• Increased incidence of atypical presentations in theelderly due to diminished physiological reserves andinteracting co-morbidities. Gibson & Helme, 2001.• Older patients tend to under report pain.• Impaired quality of life secondary to pain may beexpressed by depression, anxiety, sleep disruption,appetite disturbance and weight loss, cognitiveimpairment, and limitation in the performance ofdaily activities. These burdens are expected toimprove with effective pain management (AGSPanel 2002).

EPIDEMEOLOGY OF PAININ OLDER PERSONS• Pain management in the older patient requires acomprehensive assessment, adapted to the patientscognitive functioning, using specific tools, andtaking into account the activities of daily living andautonomy. Perrot, S. Psychologie etNeuropsychiatrie du Viellissement 4(3): 163-70,2006 Sep. Cunningham C. Nursing Standard.20(46):54-8, 2006 Jul-Aug 1.• The impact of poorly managed chronic pain on thequality of life of elderly patients and the problemsrelated to its management are widelyacknowledged. Auret K et al. Drugs and Aging.22(8): 641-54, 2005.

PAIN IN OLDER PERSONS• MYTHS ABOUT PAIN• PAIN VERSUS SUFFERING• CONSEQUENCES OF UNTREATEDPAIN• RECOGNITION, ASSESSMENT,TREATMENT AND MONITORING

PAIN IN OLDER PERSONSMYTHS• Acknowledging pain will lead to loss ofindependence• The elderly – especially cognitively impaired– have a higher pain tolerance• The cognitively impaired cannot beaccurately assessed for pain• Patients in LTC say they are in pain to getattention• Elderly patients are likely to become addictedto pain medications

INADEQUATE PAIN TREATMENTIN OLDER PERSONS• Consequences of untreated pain– Depression/social isolation– Suffering– Sleep disturbance– Behavioral problems– Anorexia, weight loss– Deconditioning, increased falls

“Pain is something thathappens to a body…Suffering is something thathappens to a person.”

IMPACT OF PAIN ONWELLBEINGPain and SufferingNOCICEPTIONPAINEmotionsCognition (vigilance)EnvironmentSUFFERING

Potential InteractionsInfluencing Pain SensationHPA-AxisImmuneFunctionAGESexAutonomicFunctionPsycho-SocialGenetic

CHANGES WITHADVANCING AGE• Decreased efficacy of opiatesmediating antinociception (Crisp et al,.1994; Jourdan et al., 2002).• Decreased opiate receptors (Hess etal., 1981; Messing et al., 1980).• Reduction in myelinated andunmyelinated fibers in peripheralnerves (Ceballos et al, 1999).• Diminished expression of CGRP,substance P, somatostatin and nitricoxide (Ko et al., 1997).

CHANGES WITHADVANCING AGE• Modifications in the expressionand functional state of spinal glialcells (Watkins and Maier, 2003).• Decreased levels of 5-HT and NEin dorsal horn and increased c-fos (Iwata et al., 1995; 2002).

“Normal” Aging: Changesin Brain Morphology• Atrophy of prefrontal gray matter– Raz et al, Cerebral Cortex 1997; 7: 268• Atrophy of thalamus– Van Der Werf et al, Cog Brain Res 2001; 11: 377• Diminished frontal white matterintegrity– Pfefferbaum et al, NeuroImage 2005

IMPLICATION• Chronic non-malignant pain isassociated with alterations in brainmorphology in older adults, above andbeyond those associated with normalaging.

Older Adults with Disabling vs. NondisablingCLBP

Pain Duration and WMIntegrity

IMPLICATIONS• Reinforces that pain is associated withWM damage over and above thatassociated with aging.• Understanding what biologically drivessubjective pain-associated associated disabilitymay open the door to newly targetedtreatments.

WHY DEVELOP A PAINPROGRAM• “There is an urgent need for betterprofessional education programs,further dedicated research to helpguide clinical practice, and better painmanagement strategies thatspecifically target the special needs ofthe older persons in our community”Gibson 2006.

A Survey of Pain Curriculain Health Science Facultiesin Canada – CPS 2007Total Hours(mean)RangeDentistry 15 0 - 24Medicine 16 0-38Nursing 31 0-109OccupationalTherapy28 0-48Pharmacy 13 2-33Physical Therapy 41 18-69Veterinary 87 27-200200

Barriers for Physicians•Limited training in medical schools•Pain management not seen as apriority•Time consuming•Lack of consultation and treatmentresources•Biases and fears about use of opioidanalgesics

Chronic Pain is PoorlyManaged•Only 36% of patients felt their painwas very effectively treated•32% of MDs thought chronic pain waseffectively treated•45% of people with moderate tosevere chronic pain were not takingany prescription medicationMoulin DE, et al. Pain Res Manage 2002; 7(4):179-84.Morley-Forster PK, et al. Pain Res Manage 2003; 8(4):189-94.SES Canadian Pain Survey 2007.

AMDA PAIN MANGEMENTGUIDELINES 2009• Recognition• Assessment• Treatment• Monitoring

AMDA CPG:RECOGNITION• Is pain present• Has characteristics and causes of painbeen adequately defined• Has appropriate treatment for painbeen addressed

PAIN IN OLDER PERSONSRECOGNITIONNon-specific signs and symptomssuggestive of pain:• Frowning, grimacing, fearful facialexpressions, grinding of teeth• Bracing, guarding, rubbing• Fidgeting, increasing or recurringrestlessness• Striking out, increasing or recurringagitation• Eating or sleeping poorly

KEY COMPONENTS OFPAIN ASSESSMENT• Measurement of Pain:– Using standardized scales in a format that isaccessible to the individual.• Cause of Pain:– Examination and investigation to establishthe cause of pain.

Type of PainassessmentOlder people with nosignificantcognitive/communicationimpairmentandOlder people with mild tomoderatecognitive/communicationimpairmentPracticalSuggestions forScale SelectionNumeric graphic ratingscale.Verbal rating scale.Numerical rating scale (0-10)Comments andReferencesHigh validity and reliabilityin older people.Can be used inmild/moderate cognitiveimpairment.Vertical as opposed tohorizontal orientation mayhelp to avoidmisinterpretation in thepresence of visuo-spaticalspaticalneglect, e.g. in patients withstroke.

Type of PainassessmentOlder people with moderateto severecognitive/communicationimpairmentPracticalSuggestions forScale SelectionPain ThermometerColored Visual AnalogueScaleComments andReferencesEasy to useValidity has not been fullyevaluatedWell understood in earlyand mid-stage state ofAlzheimer’s s disease

Type of PainassessmentObservational painassessmentPracticalSuggestions forScale SelectionAbbey pain ScaleComments andReferencesShort and easy to applyscaleOlder people with severecognitive/communicationimpairment (no singlerecommendation currentlypossible)MultidimensionalassessmentOlder people with minimalcognitive impairmentRequires more detailedevaluation.Brief Pain Inventory 15- item scale assessing:severity, impact on dailyliving, impact on mood andenjoyment of life.

Observational ChangesAssociated with PainTypeAutonomic ChangesFacial ExpressionsBody MovementsDescriptionPallor, sweating, tachypnoea, alteredbreathing patterns, tachycardia,hypertension.Grimacing, wincing, frowning, rapidblinking, brow raising, brow lowering,cheek raising, eyelid tightening, nosewrinkling, lip corner pulling, chinraising, lip puckering.Altered gait, pacing, rocking, handwringing, repetitive movements,increased tone, guarding, *bracing*

Observed ChangesAssociated with Pain Cont’d:TypeVerbalisations/vocalisationsInterpersonal interactionsChanges in activity patternsMental status changesDescriptionSighing, grunting, groaning,moaning, screaming, calling out,aggressive/offensive speechAggression, withdrawal, resistingWandering, altered sleep, alteredrest patternsConfusion, crying, distress,irritability.

Use of the Abbey PainScale• The Abbey Pain Scale is the best used as part of an overall painmanagement plan.Objective:• The Pain Scale is an instrument designed to assist in theassessment of pain in residents who are unable to clearly articulatetheir needs.Ongoing Assessment:• The Scale does not differentiate between distress and pain, someasuring the effectiveness of pain-relieving interventions isessential.• Recent work by the Australian Pain Society recommends that theAbbey Pain Scale be used as a movement-based assessment. Thestaff recording the scale should therefore observe the residentwhile they are being moved, e.g. during pressure area care, whileshowering, etc.

Use of the Abbey PainScale cont’d:Ongoing assessment:• Complete the scale immediately following the procedure andrecord the results in the resident’s s notes. Include the time ofcompletion of the scale, the score, staff member’s s signatureand action (if any) taken in response to results of theassessment, e.g. pain medication or other therapies.• A second evaluation should be conducted one hour after anyintervention taken in response to the first assessment, todetermine the effectiveness of any pain-relieving intervention.

Use of the Abbey PainScaleLastly. . .If, at this assessment, the score on the pain scale is the same,or worse, consider further intervention and act as appropriate.Complete the pain scale hourly, until the resident appearscomfortable, then four-hourly for 24 hours, treating pain if itrecurs. Record all the pain relieving interventions undertaken.If pain/distress persists, undertake a comprehensiveassessment of all facets of resident’s s care and monitor closelyover a 24-hour period, including any further interventionundertaken. If there is no improvement during that time, notifythe medical practitioner of the pain scores and the action’s s taken.-Jenny Abbey April, 2007.

Pain Management Goals• Decrease pain• Improve function– Physical– Psychological– Social• Minimize risk– Patient– Physician– Society

IDEAL TREATMENT OFPERSISTENT PAINPhysical / Rehabilitative(CAM)PsychologicalMedicalPharmacologicalInterventional

AGS RECOMMENDATIONS2009• Acetaminophen as initial and ongoingpharmacotherapy particularlymusculoskeletal pain• NSAIDS AND Cox-2 2 selective inhibitorsmay be considered rarely and withextreme caution• Opioids for all patients with moderate-to-severe pain

Drug treatment of olderpersons with neuropathicpainFIRST LINE• Tricyclic antidepressants (Amitriptyline,nortriptyline)• Gabapentinoids (gabapentin,pregabalin)• Carbamazepine and oxycarbazepine in TNClin Interv Aging, 2008 March; Clair Haslamand Turo Nurmikko

Neuropathic Pain—ContCont’dSECOND LINE• Tramadol• Lamotrigine• SNRI’s s (Venlafaxine, duloxetine)

Neuropathic Pain Cont’dTHIRD LINE• Opioids (Morphine, oxycodone,methadone)• Cannabinoids• Citalopram and paroxetine• Capsaicin

Tricyclic Antidepressants(TCA)Ray et al: Clinical PharmacolTherapeutics;2004 Mar;75(3):234-4141• Slight increase in cardiac deaths onlywith TCA doses greater than100mg/day• Gabapentin or Pregabalin is a betteralternative

OPIOD TREATMENT INOLDER PERSONS• Significant differences in drugpharmacokinetics and drugsensitivities• With swallowing difficulties usecapsules that can be opened andsprinkled on food or flushed throughnasogastric or gastric tubes

OPIOD TREATMENT INOLDER PERSONS• Presence of renal insufficiency alsoinfluences choice of opioids• Oxycodone, morphine, propoxyphene, andmeperidine all have active metabolitesexcreted renally.• Dose adjustments are necessary for patientswith renal insufficiency• Hydromorphone a possible choice inpatients with renal impairment

OPIOID TREATMENT INOLDER PERSONS• Transdermal fentanyl patch is anotheroption for patients requiring around-thethe-clock pain control• 2005 FDA advisory: “should only be used inpatients who are already receiving opioidtherapy, who have demonstrated opioidtolerance and require a daily dose of atleast 25 mcg/hr”• Transdermal Butrans recently available inOntario—once once weekly for moderate pain

TOPICAL ANALGESICAGENTS• Topical agents, either alone or incombination with other oral agentsmay provide relief for patients withmusculoskeletal and neuropathic pain• When compared with oral NSAIDs,topical NSAIDs showed similar rates ortreatment success without the risk ofGI events

TOPICAL ANALGESICAGENTSLidocaine 5%, Amitriptyline 5%,Ketoprophen 7.5%, Ketamine 10%In PLO Gel or Lidoderm TID-QID

SUMMARY• Views about management of pain inthe elderly have changed in recentyears• It is an expectation that pain berecognized and managed appropriately• MOHLTC 2009: Pain management arequired program• Pain can be effectively treated in thecommunity and long-term care setting

SUMMARY• A combination of non-pharmacologicand pharmacologic interventions caneffectively reduce pain and its burden• Consider physiological characteristicsin older patients• Pharmacologic modalities can be usedsafely and effectively to treat pain inolder patients

REFERENCES• Hadjistavropoulos T, Herr K, Turk DC et al.An interdisciplinary expert consensusstatement on assessment of pain in olderpersons. Clin J Pain 2007; 23(Suppl 1):S1-43• Royal College of Physicians, BritishGeriatrics Society and British Pain Society.The assessment of pain in older people;national guidelines. Concise guidance togood practice series, No 8 RCP, London2007

REFERENCES• American Medical Directors Association2009. Pain Management in the Long TermCare Setting: Clinical Practice Guidelines.Available atwww.amda.com/tools/guidelines.cfm• AGS Panel on Pharmacological Managementof Persistent Pain in Older Persons. J AmGeriatr Soc 2009: 57(8): 1331-46

“DON’T T FOCUS ON THE PROBLEM.FOCUS ON THE SOLUTION”“OUR JOB IS IMPROVING THE QUALITYOF LIFE, NOT JUST DELAYINGDEATH”PATCH ADAMS