SN 402 Gerontological Nursing

Care for older people with pain

Justina Liu
PhD RN

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 Intended Learning Outcomes
After the completion of this lecture, students should be able to
- Define various pain types and explain the related physiologies
- Identify the scope of pain-related problems which include
barriers to effective pain assessment and management in
older adults
- Examine and dispel commonly held myths and beliefs about
pain is a normal ageing process in older people
- Identify the treatment options
- Describe principles of analgesic medication use in older
people

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 What is pain?

1. Multidimensional in nature
• Sensory-discriminative aspect
• Location, Intensity, Duration, etc.

• Motivational-affective aspect
• Past experience, Attention, Anxiety, etc.

• A personal and subjective experience,

involves both an emotional quality and a
physiologic sensation.
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 What is pain?

 A subjective feeling
– “Pain is whatever the experiencing person says it is,
existing, whenever he / she says it does” (McCaffery.
1968, p 8)

 Pain is defined by the International Association for the

Study of Pain (1994) as “ an unpleasant sensory and
emotional experience associated with actual or
potential tissue damage, or described in terms of such
damage.”

 Pain (intensity) should be treated as the 5th vital sign

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 Types of pain
• Acute pain vs. Chronic / Persistent pain
• Nociceptive pain :
– related to the transmission of pain signals between the
central nervous and peripheral nervous systems
– Body’s defense mechanism
– Four stages: Transduction Transmission 
Perception Modulation
• Neuropathic pain
• Cancer pain – complex and includes all the above-
mentioned types of pain

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 Nociceptive pain
• Caused by damaging somatic or visceral structures
– Somatic pain – well localized arises from bone, joint,
muscle or skin tissues
usually described as aching, deep, dull, sharp,
stabbing, etc.
e.g. wound pain, burn
– Visceral pain – originated from visceral organs
 may be hard to localize and radiate to other parts of
the body
 Usually described as cramping squeezing, shooting,
etc.
e.g. abdominal pain or cramping, colicky pain caused by
kidney stones 6
4 Stages of Nociception
Transduction – conversion of pain
sensation into nerve impulses by
nociceptors / pain receptors [i.e.
Myelinated A-delta (A fibers) & un-
myelinated axons (C fiber) ]

•Sensitizing substances, (such as Serotonin,

Bradykinin, Histamine, Prostaglandins) will
be released by the nociceptors due to cell
damages.
•Those substance can trigger changes in
the neuron cell membrane that permit an
influx of sodium ions transfers.
•The resulting change in electrical charge
generates an action potential (nerve
impulses)

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 4 Stages of Nociception
Transmission – impulses traveling
towards the spinal cord and the brain

1st phase: Impulses generate at the

damaged site and then travels to the end
of the damaged nociceptors in the spinal
cord. They travel across the synaptic cleft
between the nociceptors and the dorsal
horn neurons of the spinal cord through
the release of neurotransmitters.

2nd phase: impulses continue through the

spinal cord and up to the brain
From the dorsal horn, spinothalamic
tract and ascend to the brain stem and
the thalamus

-3rd phase: processing signal of pain at 8

cerebral cortex
4 Stages of Nociception

Perception – pain becomes a

conscious experience
• Physiological / Sensory
(sensory-discriminative aspect):
controlled by somatosensory
cortex
• Psychological / Emotional
(motivational-affective aspect):
controlled by limbic system
• Autonomic response:
controlled by reticular system

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 4 Stages of Nociception

Modulation - body’s responses to

pain (reducing painful stimuli)

- Substances ( such as endogenous,

serotonin and norepinephrine)
which can inhibit the transmission
of noxious impulses will be
released from the * descending
tracts resulting in analgesic

*The descending tracts from the brain to

the periphery follow the same route
down the spinal cord to the dorsal horn

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 Acute vs. Persistent Pain

Besides the duration, major differences of

persistent pain:
• Multifactorial in origin
• Can be affected by personal factors
• Cannot be explained by objective clinical
measures alone
• May be idiopathic and influenced by patients’
psychological makeup

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 Neuropathic pain

• Originates from an abnormal processing of sensory

stimulations by the central or peripheral nervous system.
– Centrally generated pain is caused by injury /
dysregulation of major nervous systems (e.g. phantom
pain ) or autonomic nervous system (e.g. burning pain
below the level of a spinal cord lesion)
– Peripherally generated pain is either caused by pain
along a known peripheral nerve pathway (mono-
neuropathy) (e.g. trigeminal neuralgia) or along the
distribution of many peripheral nerves (poly-neuropathy)
(e.g. diabetic neuropathy)

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 Is pain common among older people?

• 80% - 85% of people aged > 65 have a

significant health problem is associated with
pain
(Miller, 2015)
• 25% - 50% of community-dwelling older
adults had significant pain problems
(Planton & Edlund, 2010)
• Pain was reported by 50% - 75% nursing
home residents
(Dumas & Ramadurai, 2009)
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 Local figures of pain

• Telephone interviewed around 5000 local people

in which around 18% aged > 60, about 37.1% of
them had chronic pain (Wong & Fielding 2011)

• Follow up about 4000 older people, back pain

was most prevalent (48%), followed by knee
(31%), neck (22.5%) and hip (8.9%) pain (Woo, et
al., 2009)

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 Pain in Older People

• Most health conditions associated with ageing carry a

substantial burden of pain
– Examples of chronic pain conditions common in adults
of advanced age: OA, LBP, RA, Chronic leg cramps,
cancer, post-stroke pain, neuropathic pain.
• Pain is the most frequently reported symptom by older
people
• Most older people have more then one chronic condition
so the chances of persistent pain increase with the
advancement of age

(International Association for the Study of Pain, IASP, 2006)

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 “Pain relief” enough for older people?
Despite the presence of pain, many residents are not
prescribed with any scheduled analgesics:
•23 % of residents had no scheduled analgesics prescribed
(Lapane, et al.,2012)
• 46.9% of all analgesics were given on a regular basis
(Cadogan et al., 2004; Won et al., 2004)
•45% of residents with dementia received with no pain
medication (Plooij et al, 2012)
•Local figures: only 17.2% and 35% of nursing home
residents with dementia, with at least one painful condition
had pain medication or non-pharmacological pain treatments,
respectively. (Liu et al., 2016)

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Under-treated/ Untreated pain in older people

• Older people received fewer pain medications than

younger adults

• The discrepancy between the prescribed doses and the

actual administered doses widened as cognitive
impaired levels increased (Closs et al., 2004).

• Cognitive impaired older people are prescribed less pain

medications by their doctors and given less pain
medications by nurses

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Common barriers to pain management in older people

• Age-related changes in the pharmacokinetics and

pharmacodynamics of analgesics
 Affect absorption, distribution, metabolism and
elimination of analgesics in older people  prone to
develop adverse effects health professionals may
reluctant to prescribe or give analgesic to older
people
• Altered responses to pain (atypical presentation)
e.g. Silent MI, Silent Abdominal Catastrophe
 Pain may manifest as mental changes, restlessness,
aggression, fatigue or agitation  misdiagnosis or
delay in treatment

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Common barriers to pain management in older people

• A higher incidence of coexistent diseases

• Difficulties with assessment of pain
• Incorrect perceptions of pain by both older people
and health care providers

BUT there is NO strong scientific evidence supports

pain perception would be changed with the
advancement of age

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Common barriers to pain management in older people

Misconceptions from older people:

•Pain is a normal part of the ageing process
•Pain is equated with worsening disease
•Pain causes loss of independence
•Fear of being labelled as a “problem maker”
•There is not much doctors or nurses can do for relieving
chronic pain
•Pain medications are harmful, use them as seldom as
possible
•Decreasing activity levels can relieve pain
•Belief that pain is an atonement for past actions that must be
endured

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Common barriers to pain management in older people

Misconceptions from health care providers:

•Sensitivity to pain and pain perception decrease with age
•Belief that patients with dementia do not experience any pain
•Elderly patients will tell you when they are in pain
•Pain medications is harmful, use them as little as possible
•Inadequate knowledge about pain and how best to manage it
•Cannot see pain : HK nurses (86.3%, N=585) believed that
10% of patients have exaggerated their severity of pain
– US nurses pointed out that 22 % have exaggerated their
severity of pain

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Possible solutions of overcoming the barriers

(Miller, 2012)
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 Through explanations to overcome the
misconceptions on pain medications

Tolerance Refers to a decrease in one or more therapeutic

effects of the medication or its side effects due to
chronic drug administration
Dependence Refers to the development of withdrawal symptoms
on sudden discontinuation of the medication
(Physical dependence does not indicate the
presence of addiction)
Addiction Refers to psychological dependence on the
medication
•Compulsive use of the drug
•Loss of control over the use of the drug
•Use of the drug in spite of harm
The incidence of addiction as a result of taking an
opioid for therapeutic reasons is rare and about <
0.19 % (Jackson, 2009, Fishbain et al., 2008)
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 Consequences of persistent untreated pain
(Negative functional consequences)

• Pain correlated with psychosocial abnormalities :

Depression, Anxiety, Decreased socialization, etc
• Decreased optimal levels of functioning :
Sleep disturbance, Impaired ambulation, loss of
independence, etc
• Greater risk of disability
• Increased health services utilization :
increased financial burden
• Persistent pain – increased drug interactions

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 Wellness-focused pain management programme

1st step: Assessment

Pain Assessment
Algorithm

(Royal College of Physicians, 2007)

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 Assessment of pain

Pain history using “OLDCARTS”

• Onset
• Location
• Duration
• Characteristic
• Aggravating factors
• Radiation / Relieving Factor
• Treatment
• Severity
Pain intensity assessment

Pain management made incredibly easy, 2003 26

Assessment of pain

Numerical Pain Scale

Pain management made incredibly easy, 2003

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Pain Assessment

How pain has interfered

with your
- General activity
- Mood
- ADL
- Walking ability
- Working
performance
- Relationship with
other people
- Sleep

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 Pain assessment methods
for older people with cognitively impaired

1. Attempt to collect self-reported pain with a simple ‘yes-no’

question
2. Look for clues to the potential causes of pain
3. Observe the patient’s pain-related behaviours
– Facial expressions
– Body movements
– Physiological changes
– Vocalizations and Verbalizations
– Mood changes
– Changing patterns of ADL (AGS, 2002)
4. Obtain patient information about pain and behaviors from
family members or caregivers
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Pain-related behaviour Indicators

Facial
Expressions
• Frowning
• Grimacing • (Australian
Pain Society,
• Wrinkled 2005)
forehead
• Closed or
tightened
eyes • (Australian Pain
• Any distorted Society, 2005)
expression
• Rapid
blinking
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 Pain-related behaviour Indicators
Physiological Verbalization / Body
Change Vocalization Movements
• Perspiring, • Sighing, • Rigid, tense
flushing or moaning, body posture
pallor groaning • Guarding
• Noisy labored • Grunting, • Fidgeting
breathing calling out • Increased
• Change of vital • Asking for help pacing
signs • Verbally • Rocking
abusive • Restricted
movement
• Gait or
mobility
changes
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Pain-related behaviour Indicators

Changes in
Changes in activity Mental status
interpersonal
patters changes
interactions
• Aggressive • Refusing food • Crying or tears
• Resisting care • Increase in rest • Increased
• Decreased social periods confusion
interactions • Sleep, rest • Irritability or
• Socially pattern changes distress
inappropriate • Sudden cessation
• Disruptive of common
• Withdrawn routines
• Increased
wandering

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 Pain Assessment in Advanced Dementia (PAINAD) Scale
(Warden et al., 2003)
Items 0 1 2 Score
Breathing Normal Occasional labored Noisy labored
Independent breathing. breathing.
of Short period of Long period of
vocalisation hyperventilation hyperventilation
Cheyne-Stokes
respirations
Negative None Occasional moan or Repeated troubled
Vocalisation groan. Low level calling out loud
speech with a negative moaning or groaning.
or disapproving quality Crying

Facial Smiling, or Sad. Frightened. Facial grimacing

Expression inexpressive Frown
Body Relaxed Tense. Rigid. Fists clenched.
Language Distressed pacing. Knees pulled up.
Fidgeting Pulling or pushing
away. Striking out.
Consolability No need to Distracted or Unable to console,
console reassured by voice or distract or reassure.
touch
Total Score (1-10) 33
 General Principles of pain assessment for
older people

• Subjective data – Believe in your patients

– Self-reporting is the most reliable and common method
• Beware older people may expect pain with ageing
and be reluctant to report
• Sensitive to other signs that may indicate pain
– decreased functional capacity
– decreased quality of life
– depressed mood
– withdrawal from life activities
• Endorse skills in assessing pain of cognitive &
language impaired elderly people 34
 Wellness-focused pain management programme

2st step: Plan for pain

management

Pain Management
Flowchart

(Royal College of Physicians, 2007)

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Goals of wellness-focused pain management

• Relief from pain

• Address adverse effects of analgesics with
particular attention to maintaining bowel function
• Control of chronic disease condition causing
pain
• Maintenance of mobility and functional status
• Promotion of self-care and maximum
independence
• Improved qualify of life

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 Pain Management
Pharmacological management

(Briggs, 2003)

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 Non- opioid Analgesic Agents:

Paracetamol (Acetaminophen)
•Inhibiting the prostaglandin synthesis from
arachidonic acid can:
- Block the pain impulses peripherally
- Antipyretic action (lowering body temp when
fever occur)
•Does not possess anti-inflammatory properties

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 Paracetamol/ Acetaminophen
(Katzung, Masters & Trevor, 2012).

• Daily dosage • No > 4, 000 mg • Avoid use of

for healthy per day alcohol
adults: 500mg • Hepatotoxicity •  Liver
– 1000mg per damage
4 hours

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 Non- opioid Analgesic Agents:
(Black & Hawks, 2009).
(Non-Steroid Anti-inflammatory Drugs)
Cyclooxygenase
Mast cells (An enzyme convert
Arachidonic
acid Arachidonic acid to
Synthesize prostaglandin

COX-1 COX-2
Mechanism
Found in Stomach, Produce
intestine & kidney prostaglandin to
produce induce
prostaglandin to inflammatory
protect mucous response
membrane (macrophage)

NSAIDs Peptic Ulcer Stop inflammation

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Generic Diclofenac Diclofenac Sodium Ibuprofen
Name Potassium [Voltaren] [Advil]
[Brand Name] [Cataflam]

Generic Indomethacin Mefenamic Acid Naproxen

Name [Indocid] [Ponstan] [Naprosyn]
[Brane Name] 41
  Headache (Karch, 2012)
Central  Dizziness
Nervous  Insomnia
System  Tinnitus

 Nausea & Vomiting

Gastro-  Gastric Ulcers
intestinal  Constipation
 Duodenal Ulcers

 Dysuria
Kidney  Renal Impairment

Hemato-  Bleeding tendency

logic  Bone marrow depression

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Similar to NSAID, but specifically
acting on COX-2 enzyme, while no X
effects on COX-1 enzyme COX-1 COX-2

Inhibit the release of COX-2

enzyme
Found in Stomach, Produce
stop the pain caused by intestine & kidney prostaglandin to
produce induce
inflammation response prostaglandin to inflammatory
protect mucous response
*Reduce the side effects of NSAID membrane (macrophage)

such as GI upset, platelet inhibition Peptic Ulcer Stop inflammation

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(Black & Hawks, 2009).
 Celecoxib [Celebrex]
 Etoricoxib
 Meloxicam
 Valdecoxib

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  Headache
Central  Dizziness
Nervous  Somnolence
System  Insomnia

 Renal impairment
Adverse  Renal failure
renal
effects

Cardio-  Stroke
vascular  Myocardial infarction

 Rash on skin
Other  Bleeding
 Anaphylactic shock
(Karch, 2012)
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Act on the Opioid
receptors
Inhibit the release of
nociceptive excitatory
neurotransmitters from
the sensory neuron
X
Block the pain message
transmission

(Katzung, Masters & Trevor, 2012).

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 Tramadol Hydrochloride [Tramadol]
 Morphine
 Fentanyl
 Codeine Phosphate
 Dextropropoxyphene [Doloxene]

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  Light-headache
 Dizziness
CNS  Hallucination
 Sedation
 Nausea and Vomiting
GIS  Dry Mouth
 Constipation

 Respiratory depression
Resp.
pruritus

 Ureteral spasm
Kidney  Urinary retention
 Oliguria

 Arrhythmia
CVS  Hypotension (Karch, 2012)
 Syncope
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 Special Precautions for Older people
Paracetamol:
• First line treatment for musculoskeletal pain but
less effective for chronic inflammatory pain
• Max. recommended does: 4000 mg/ day
• Special precautions for older people with liver or
metabolic complications
• Hepatic / Renal impairment: reduce 50% to 75% of
max. recommended does
• Level of drug must be monitored carefully
(American Geriatrics Society Clinical Guideline,2002)

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 Special Precautions for Older people
NSAID
• Given with proton pump inhibitor can reduced GIB, however it
may cause competitive effect  reduce analgesic effect
• Excessive use of NSAID can result in renal insufficiency,
decreased platelet aggregations in older people
• NSAID should be avoided in older people who required long-
term daily analgesic therapy. The COX-2 selective agents
are preferred to older people.
(American Geriatrics Society Clinical Guideline,2002)

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 Special Precautions for Older People
Opioid:
•EP may required 3 to 4 times less opioid analgesics
•Preferred opioids with short half-lives
•Preferred route for giving opioids is trans-dermal
•Meperidine,(Pethidine): can cause renal impairment and
seizures in older people
•Management of side effects with long term use of opioids,
such as constipation
- What are the recommendations for maintaining bowel function in older people taking opioid? (hint,
miller 2012, page 571 box28-4)

-Therapy should be initiated with low does, and titration should

proceed slowly with systematic assessment of OP’s response

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 Non-pharmacological pain management
Therapy indication Contraindication

Heat Resolution of swelling Inflammation

Chronic pain Neuropathy
Muscle spasm Impaired circulation
Peripheral vascular
diseases
Cold/Cryotherapy Acute pain/ chronic Impaired circulation
pain Peripheral vascular
Acute inflammation diseases
Acute swelling Neuropathy
Transcutaneous electrical Most types of localized cardiac pacemakers
nerve stimulation(TENS) pain bleeding disorders
Cancer pain Allergies to adhesive

Physiotherapy Pain No specified

Decreased ROM contraindication
Stiffness of joint
Acupuncture Complementary Bleeding tendency
therapy of different infection
types of pain
Prentice, Quillen & Underwood et al (2011)
 Highlight of today’s lecture

• Definition, characteristics & types of pain

• Major barriers of effective pain assessment &
management in older adults
- Examine and dispel commonly held myths and beliefs
about pain is a normal ageing process in older people
- Identify the treatment options
- Describe principles of analgesic medication use in older
people

53
 References
• American Geriatric Society (2002). The management of persistent pain in older people. Journal of
American Geriatrics Society, 50(6, Suppl) S205-224.
• Black, J. M. & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for positive
outcomes (Vol. 8). WB Saunders Co.
• Briggs, E (2003) The nursing management of pain in older people. Nursing Standard, 17(18), 47-54.
• Closs SJ, Barr B, & Briggs M. (2004). Cognitive status and analgesic provision in nursing home
residents. Br J Gen Pract., 54(509): 919-921
• Duma LG & Ramadurai M (2009). Pain management in the nursing home. Nurse Clinicians of North
America, 44, 197-208.
• Jackson, K.C. (2009). Opioid pharmacological. In H. S, Smith (Ed.) : Current therapy in pain (pp. 78-84).
Philadelphia: Saunders Elsevier.
• Karch, A. M. (Ed.). (2012). 2013 Lippincott's Nursing Drug Guide. Lippincott Williams & Wilkins.
• Katzung, B.G., Masters, S.B.& Trevor, A.J. (2012). Basic & clinical pharmacology(12th ed). New York:
McGraw-Hill Medical.
• Lapane KL et al. (2012). Pharmacologic management of non-cancer pain among nursing home
residents. The journal of pain and symptoms management, DOI:
http://dx.doi.org/10.1016/j.jpainsymman.2011.12.285
• Liu JYW et al. (2016 In press). Pain treatments for nursing home residents with advanced dementia
and substantial impaired communication: cross sectional analyses at baseline of a cluster randomized
controlled trial. Pain Medicine.
• McCaffery,M.(1968). Nursing practice theories related to cognition, bodily pain, and man-environment
interactions. Los Angeles: University of California, Los Angeles.

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 References
• Miller, C. A. (2012). Nursing for Wellness in Older Adults (6th ed.). Philadelphia: Lippincott. - Chapter 26
• Plooij B, et al. (2012). Pain medication and global cognitive functioning in dementia patients with painful
conditions. Drugs Aging, 29(5), 377-384.
• Planton J & Edlund BJ (2010). Regulatory components for treating persistent pain in long-term care.
Journal of Gerontological Nursing, 36(4), 49-56.
• Warden, V., Hurley, A.C., Volicer, L. (2003). Development and psychometric evaluation of the Pain
Assessment in Advanced Dementia (PAINAD) Scale. Journal of the American Medical Directors,
Jan/Feb, 9-15.
• Wong WS & Fielding R. ( 2011). Prevalence and characteristics of chronic pain in the general population
of Hong Kong. The Journal of Pain, 12(2), 236-245.
• Woo J, Leung J, & Lau E (2009). Prevalence and correlates of musculoskeletal pain in Chinese elderly
and the impact on 4-year physical function and quality of life. Public Health, 123, 549-556.

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