PAIN MANAGEMENT IN ELDERLY PERSONS

UCLA Multicampus Program of Geriatrics and Gerontology

Physicians Have a Moral Obligation to Provide Comfort and Pain Management

Especialy for those near the end of life!

Pain is the most feared complication of illness Pain is the second leading complaint in physicians offices Often under-diagnosed and under-treated Effects on mood, functional status, and quality of life Associated with increased health service use

18% of Elderly Persons Take Analgesic Medications Regularly

(daily or more than 3 times a week)

71 % take prescription analgesics

63% for more than 6 months

72% take OTC analgesics

Median duration more than 5 years

26% report side-effects

10% were hospitalized 41% take medications for side-effects

ELDERLY PATIENTS TAKING PAIN MEDICATIONS FOR CHRONIC PAIN WHO HAD SEEN A DOCTOR IN THE PAST YEAR

79% had seen a primary care physician 17% had seen a orthopedist 9% had seen a rheumatologist 6% had seen a neurologist 5% had seen a pain specialist 5% had seen a chiropractor 20% had seen more than 5 doctors

Common Causes of Pain In Elderly Persons

Osteoarthritis
back, knee, hip

Night-time leg cramps Claudication Neuropathies

idiopathic, traumatic, diabetic, herpetic

Cancer

MISCONCEPTIONS ABOUT PAIN

Myth: Pain is expected with aging.

Fact: Pain is not normal with aging.

PAIN THRESHOLD WITH AGING

Author Shumacher, 1940 Birren, 1950 Sherman, 1964 Collins, 1968 Harkins, 1977 Tucker, 1989 Stimulus Thermal Thermal Electric/Tooth Electric/Skin Electric/Tooth Electric/Skin Threshold No Change No Change Higher Lower No Change Higher

Age Related Differences in Sensory Receptor Function

Encapsulated end organs 50% reduction in Pacinis 10-30% reduction Meissners/Merkels Disks Free nerve endings no age change

Age Related Differences in Peripheral Nerve Function

Myelinated nerves Reduction in density (all sizes including small) Increase in abnormal/degenerating fibres Decrease in action potential/slower conduction velocity Unmyelinated nerves Reduction in number (1.2-1.6un) not (.4un) Substance P, CGRP content decreased Neurogenic inflammation reduced

Age Related Differences in Central Nervous System Function

Loss of dorsal horn spinal neurons Altered endogenous inhibition, hyperalgesia. Loss of neurons in cortex, midbrain, brain stem (18% reduction in thalamus, no change cingulum cortex) Altered cerebral evoked responses (increased latency, reduced amplitude) Reduced catecholamines, acetylcholine, GABA, 5HT, not neuropeptides

MISCONCEPTIONS ABOUT PAIN

Myth: If they dont complain, they dont have pain
Fact: There are many reasons patients may be reluctant to complain, despite pain that significantly effects their functional status and mood.

REASONS PATIENTS MAY NOT REPORT PAIN

Fear of diagnostic tests Fear of medications Fear meaning of pain Perceive physicians and nurses too busy Complaining may effect quality of care Believe nothing can or will be done

The most reliable indicator of the existence pain and its intensity is the patients description.

There is a lot we can do to relieve pain!

Analgesic drugs Non-drug strategies Specialized pain treatment centers Patient and caregiver education and support

Analgesic Drugs
Acetaminophen NSAIDs

Non-selective COX inhibitors Selective COX-2 inhibitors

Opioids Others

Antidepressants Anticonvulsants Substance P inhibitors NMDA inhibitors Others

CAUTION
Meperidine (Demerol) Butorphanol (Stadol) Pentazocine (Talwin) Propoxiphene (Darvon) Methadone (Dolophine) Transderm Fentanyl (Duragesic)

Do Not Use Placebos!

Unethical in clinical practice They dont work Not helpful in diagnosis Effect is short lived Destroys trust

Non-Drug Strategies

Exercise
PT, OT, stretching, strengthening general conditioning

Physical methods
ice, heat, massage

Chiropracty Acupuncture TENS Alternative therapies

relaxation, imagery herbals

Cognitivebehavioral therapy

PATIENT AND CAREGIVER EDUCATION

Diagnosis, prognosis, natural history of underlying disease Communication and assessment of pain Explanation of drug strategies Management of potential side-effects Explanation of non-drug strategies