CEBU TECHNOLOGICAL UNIVERSITY

In consortium with
CEBU CITY MEDICAL CENTER – COLLEGE OF NURSING
N. Bacalso Ave. cor Panganiban St., 6000 Cebu City, Cebu Philippines
Tel. Nos. (032)316-5128 / (032)4186105
Email address: ctuccmc_cn@ymail.com
Jimnah Rhodrick M. Bontilao 1181398 Section B

Course: Care of the Elderly NCM 3115

Module No.: 5
Module Title: Common Physiologic Stressor of the Elderly
Clinical Instructor In-Charge: Mrs. Rowena L. Madrid

Learning Activities:

1. Give examples of Illicit drugs. ( at least 5 pictures with the name, uses, and side
effects).

Cocaine
Uses:
- Can be used as an excellent topical anesthetic
- Can be used as a vasoconstricting agent
- Can shrink the mucosa or mucous membranes
- Can block the reuptake of the neurotransmitters serotonin and norepinephrine
Side Effects:
- intense depression, edginess and a craving for more of the drug
- Permanent damage to blood vessels of heart and brain
- High blood pressure, leading to heart attacks, strokes, and death
- Liver, kidney and lung damage
 - Destruction of tissues in nose if sniffed
- Respiratory failure if smoked
- Infectious diseases and abscesses if injected
- Malnutrition, weight loss
- Severe tooth decay
- Irritability and mood disturbances
- Increased frequency of risky behavior
- Delirium or psychosis
- Severe depression

Ecstasy
Uses:
Studies have shown that ecstasy are notably important in treating these conditions
- PTSD
- Anxiety
- Depression
- Alcohol Addiction
Other research has found that ecstasy has robust anticancer properties, particularly for
leukemia, lymphoma and myeloma
Side Effects:
- nausea
- muscle cramping
- involuntary teeth clenching
- blurred vision
- chills
- sweating
- irritability
- impulsiveness and aggression
- depression
- sleep problems
- anxiety
- memory and attention problems
- decreased appetite
 - decreased interest in and pleasure from sex

Heroin
Uses:
- A study showed that heroin can help people with painkiller addiction
- Heroin is also commonly used in hospitalized pain management, particularly in
palliative care
Side Effects:
- dry mouth
- warm flushing of the skin
- heavy feeling in the arms and legs
- nausea and vomiting
- severe itching
- clouded mental functioning
- going "on the nod," a back-and-forth state of being conscious and semiconscious
- insomnia
- collapsed veins for people who inject the drug
- damaged tissue inside the nose for people who sniff or snort it
- infection of the heart lining and valves
- abscesses (swollen tissue filled with pus)
- constipation and stomach cramping
- liver and kidney disease
- lung complications, including pneumonia
- mental disorders such as depression and antisocial personality disorder
- sexual dysfunction for men
- irregular menstrual cycles for women
Ketamine
Uses:
- Ketamine can provide pain relief and short-term memory loss (for example, amnesia
of a medical procedure).
- In surgery, it is used an induction and maintenance agent for sedation and to provide
general anesthesia.
- It has also been used for pain control in burn therapy, battlefield injuries, and in
children who cannot use other anesthetics due to side effects or allergies.
- Ketamine, through blocking at the N-methyl-D-aspartate (NMDA) site, has rapid
action in controlling symptoms of depression and acute suicidal ideation.
- At normal doses, it is often preferred as an anesthetic in patients at risk of
bronchospasm and respiratory depression.
Side Effects:
- Feelings of calmness and relaxation; relief from pain
- Depressed mental state
- Dizziness
- Detached feelings from body
- Slurred speech
- Diminished reflexes
- Hallucinations
- Nystagmus
Marijuana
Uses:
Studies have showed that marijuana can help treat these conditions namely:
- Alzheimer's disease
- Appetite loss
- Cancer
- Crohn's disease
- Diseases effecting the immune system like HIV/AIDS or Multiple Sclerosis (MS)
- Eating disorders such as anorexia
- Epilepsy
- Glaucoma
- Mental health conditions like schizophrenia and posttraumatic stress disorder (PTSD)
- Multiple sclerosis
- Muscle spasms
- Nausea
- Pain
- Seizures
- Wasting syndrome (cachexia)
Side Effects:
- Short-term memory problems
- Severe anxiety, including fear that one is being watched or followed
(paranoia)
- Very strange behavior, seeing, hearing or smelling things that aren’t there, not
being able to tell imagination from reality (psychosis)
- Panic
- Hallucinations
- Loss of sense of personal identity
- Lowered reaction time
- Increased heart rate (risk of heart attack)
- Increased risk of stroke
- Problems with coordination (impairing safe driving or playing sports)
- Sexual problems (for males)
2. Give at least 5 management of Alcohol abuse and dependence of Elderly.

 Assess the patient for psychological dependence

 Assess the patient for physiological dependence
 Assess need for medical detoxification
 Refer patient and family to addictions or mental health nurse practitioner or physician
 Evaluate patient and family capacity to implement referral

3. Provide an article about the pain management of elderly.

Managing Pain in Geriatric Patients

Thomas A. Cavalieri, DO

Abstract

The elderly are often untreated or undertreated for pain. Barriers to effective management
include challenges to proper assessment of pain; underreporting by patients; atypical
manifestations of pain in the elderly; a need for increased appreciation of the
pharmacokinetic and pharmacodynamic changes of aging; and misconceptions about
tolerance and addiction to opioids. Physicians can provide appropriate analgesia in geriatric
patients by understanding different types of pain (nociceptive and neuropathic), and correctly
using nonopioid, opioid, and adjuvant medications.

Opioids have become more widely accepted for treating older adults who have persistent
pain, but such use requires physicians have an understanding of prevention and
management of side effects, opioid titration and withdrawal, and careful monitoring. Placebo
use is unwarranted and unethical. Nonpharmacologic approaches to pain management are
essential and include osteopathic manipulative treatment, cognitive behavioral therapy,
exercise, and spiritual interventions. The holistic and interdisciplinary approach of
osteopathic medicine offers an approach that can optimize effective pain management in
older adults.

Pain is a common complaint of the elderly. As the number of individuals older than 65 years
continues to rise, frailty and chronic diseases associated with pain will likely increase.
Therefore, primary care physicians will face a significant challenge in pain management in
older adults. The elderly are more likely to have arthritis, bone and joint disorders, cancer,
and other chronic disorders associated with pain. 1 Between 25% and 50% of community-
dwelling elderly have important pain problems. 2 Geriatric nursing home residents have an
even higher prevalence of pain, which is estimated to be between 45% and 80%. 3
The elderly are often either untreated or undertreated for pain. Consequences of
undertreatment for pain can have a negative impact on the health and quality of life of the
elderly, resulting in depression, anxiety, social isolation, cognitive impairment, immobility,
and sleep disturbances.4 Reasons that physicians often cite for inadequate pain control
include lack of training, inappropriate pain assessment, and reluctance to prescribe
opioids.2
As with other age groups, the elderly have pain that can be classified pathophysiologically as
either nociceptive or neuropathic in origin. Alternatively, pain may be mixed, that is, having
origins that are both nociceptive and neuropathic. Nociceptive pain may be either visceral or
somatic and is due to stimulation of pain receptors. In the elderly, this stimulation may be the
result of inflammation or musculoskeletal or ischemic disorders. Patients with nociceptive
pain are treated pharmacologically with both opioid and nonopioid agents as well as
nonpharmacologic interventions.1,3 Neuropathic pain results from a pathophysiologic
disturbance of either the peripheral or the central nervous system. In the elderly, common
examples include postherpetic neuralgia and diabetic neuropathy. Patients with neuropathic
pain are less likely to respond to agents used to treat patients with nociceptive pain such as
pain due to bone metastasis, and more likely to respond to adjuvant agents such as anti-
convulsants and antidepressants. Pain of mixed origins may respond to administration of
agents that treat for both nociceptive and neuropathic pain. 1,4
Because diseases often have an atypical presentation in the elderly, it has been speculated
that pain perception may be different in older adults. Although pain sensitivity and tolerance
across all ages varies,5 it is generally accepted that such differences probably do not have a
significant clinical impact.
As is the case in the use of any medications in the elderly, older adults are likely to have an
increased risk of adverse reactions from pharmacologic agents administered for analgesia.
This propensity is likely due to pharmacokinetic changes such as reduced renal excretion
and hepatic metabolism, as well as pharmacodynamic changes that occur with age, such as
an increased sensitivity to certain analgesics, particularly the opioids. 2,4 In addition,
polypharmacy is a contributing factor for the increased incidence of adverse drug reactions.

For pain management to be effective in the elderly, physicians need to be skillful in pain
assessment; capable of recognizing the importance of a holistic, interdisciplinary team
approach to care; and knowledgeable of both pharmacologic and nonpharmacologic
approaches to providing optimal analgesia.1,4

Assessment of Pain in the Elderly

Effective assessment of pain in the elderly can be challenging. It requires an appreciation
that such discomfort may present atypically, particularly in the cognitively impaired. Because
biologic markers are not available, self-reporting is viewed as the best evidence for the
presence of pain and the optimal way to assess pain intensity. 4 Pain has been described as
the “fifth vital sign,” and therefore, physicians should regularly inquire about the presence of
pain in their elderly patients. Pain can be assessed, even in those with dementia, using
simple questions and screening tools. 6
Assessing pain in the elderly is often associated with significant obstacles. Older adults
frequently fail to report pain because they may view that it is an expected part of old age or
because they are fearful that it may lead to more diagnostic testing or added
medication.1 Some patients may accept pain as punishment for past actions. 3 Rather than
admitting to the presence of pain, the elderly may use terms such as “aching” or
“hurting.”7 Communication and cognitive disturbances are additional barriers to such
assessment. Increased agitation, changes in functional status, altered gait, and social
isolation may be signs of pain in patients with dementia. 6
A comprehensive assessment should include a careful history and physical examination and
diagnostic studies aimed at identifying the precise etiology of pain. Characteristics such as
intensity, frequency, and location should be described. Standardized geriatric assessment
tools to assess function, gait, affect, and cognition should be used. 8 Intensity should be
assessed by using one of several pain scales that have been accepted for use in the elderly
(Figure 1).
A verbally administered 0-through-10 scale is an effective measurement of pain intensity in
most older adults. When using this scale, physicians can ask patients, “On a scale of zero to
10, with zero meaning no pain and 10 meaning the worst pain possible, how much pain do
you have now?” Some older adults, particularly those with dementia, may have difficulty
using this scale. Other tools such as a visual analog scale, numerical scale, pain
thermometer scale, and pain faces scale can be helpful. 1,4,9 Recently, evidence has
established the reliability and validity for the use of the faces pain scale with older adults. 10
When possible, use of an interdisciplinary team approach to assessment and management
of pain in the elderly is advantageous. These strategies need to be sensitive to cultural and
ethnic issues, as well as to values and beliefs of patients and their families. Once etiologic
factors are determined and therapy is initiated, a pain log or diary is appropriate to assess
effectiveness of treatment. Physicians should encourage patients to record such
documentation on a daily basis. Regular reassessment by use of previously administered
assessment scales is important and serves to modify therapy to assure an optimal response.
Reassessment should include an evaluation of compliance and the presence of adverse
drug effects11 (Figure 2).

Pharmacologic Management of Pain in the Elderly

Even though adverse drug reactions in the elderly are a significant risk, pharmacologic
intervention for pain management is the principal treatment modality for pain. Along with
considering age-associated changes of pharmacokinetics and pharmacodynamics,
physicians must consider the likelihood of drug-drug and drug-disease interactions. Despite
these challenges, pain in the elderly can be controlled but most likely will require trials of
various agents and careful titration of dosages. Because older patients may have increased
sensitivity to analgesic medications, lesser dosages may be effective as compared with
effective dosages in younger patients. 12 This difference is especially true when using opioid
analgesics.

Nonpharmacologic Pain Management in the Elderly

Although most elderly patients require pharmacologic intervention to manage pain,
nonpharmacologic approaches may have an added benefit and should be routinely
considered. This aspect is particularly important in older adults because procedures that
avoid drugs have a low frequency of adverse reactions compared with pharmacologic
approaches.

Although many nonpharmacologic methods lack rigorous, evidence-based studies to

document their efficacy, the body of knowledge to substantiate their use is increasing,
particularly when such methods are used in conjunction with drug therapy. 15,28,29

From: https://jaoa.org/article.aspx?articleid=2093506

4. Write a reaction paper about the article you choose.

Pain is a general term that describes uncomfortable sensations that we feel in our
bodies. Pain stems out from the activation of our nervous system, there are types of pains
and there are a tons of reasons to feel pain. Well, pain in the elderly base on this article is
different, and it sometimes challenge the caregivers and healthcare workers in providing the
perfect treatment or management. Pain in the elderly commonly arise from various
conditions and illnesses such as degenerative spine and arthritic conditions, neuropathic
pain, ischemic pain, cancer and it can also arise from having treatments. With this, it is a fact
that as the person gets old the incidence of having chronic pain is high especially if there is
an underlying disease that is felt.

Pain management in the elderly is seen as a challenge. The elderly are often
untreated or undertreated in terms of pain this is because of the present barriers that hinders
the proper pain assessment of the elderly. Assessment as we all know is a very important
part of giving care, it does not only let us know what's the problem but it also gives us the
power as health care provider to do what's best for our patient, it is a crucial part in the
management. But with the elderly as patients it became a problem. Several reasons are
identified why pain in elderly is undertreated, first elderly patients usually do not report the
felt pain due to the anxiety and fear that it may lead to a further diagnostic testing or added
medication, also they view it as a punishment for the bad deeds they had done in the past,
and another point is that other elderly cannot report the pain due to disabilities. Pain
management in the elderly has a lot of ways, there is what we call as the pharmacologic
management where a variety of drugs are used to treat pain. This way poses several risks in
elderly, there might be drug reactions in the elderly that cannot be controlled and also there
are known drug to drug actions of mixed drugs. Well despite these known risks pain in the
elderly can be treated but most likely require several trials. Pharmacologic management
include these kinds of drugs, nonopiod analgesics, opiod analgesics and adjuvant
medications. On the other hand, there is also nom pharmacologic approach in pain
management, although this kind or approach is not that beneficial in treating pain but it
should be also considered. This approach should be considered because of the reason that
it has a low frequency of adverse reactions and it has a low incidence of posing risks to
elderly. This approach includes, patient and caregiver education, cognitive - behavioral
therapy, osteopathic manipulative treatment, and spirituality.

With this information, it will broaden the knowledge of the readers about how
complicated pain management in elderly is. But despite of it being seen as a difficult job it
also inspired me as a future nurse to really devote myself in helping my clients to deal with
their conditions and illnesses. This article has helped me a lot in understanding the pain
management in elderly and its various challenges.