GUIDELINE FOR DOCTORS:

MANAGEMENT OF PAIN IN ADULT&

GERIATRIC PATIENTS

DR THAN YUN
PAKAR PERUBATAN KECEMASAN
HOSPITAL TAWAU
15/01/2024
 WhatSlide 4you?
is PAIN to
PAIN PAIN

PAIN PAIN

PAIN PAIN

PAIN PAIN
WHAT IS PAIN TO YOU ?

ⓘ Start presenting to display the poll results on this slide.

 Slide
PAIN 4
PAIN PAIN

Pain is "an unpleasant sensory and emotional

experience associated with actual or potential
PAINtissue damage, or described in terms of such
PAIN
damage”.

Merskey and Bogduk, International Association for the Study of Pain (IASP)
PAIN 1994.
PAIN

PAIN PAIN
 CASE
1
A 40-year old man, known CKD,
-presents with a one day history of acute lower
abdominal pain
-associated with nausea and vomiting.
-No other associated complaints.

• Abdomen: Tender and guarded in RIF

• Vital signs:
BP 145/90, PR 110/min, RR 18/min, GCS 15/15
O2 sat 99% on air, Temp 39C, PS 8/10
APPROAC
H? R-A-T
• R = Recognise
• A = Assess
• T = Treat
A 40-year old man, known CKD, RECOGNISE
-presents with a one day history
of acute lower abdominal pain
-associated with nausea and 1. Does the patient have pain?
vomiting. a. Ask
-No other associated b. Look (frowning, moving easily or not, sweating?)
complaints.

Abdomen: Tender and guarded

in RIF 2. Do other people know the patient has pain?
a. Other healthcare workers
Vital signs: b. Patient's family

BP 145/90, PR 110/min, RR
18/min, GCS 15/15, O2 sat 99%
on air, Temp 39C, PS 8/10
 ASSESS
Measure the severity
a. What is the pain score?
i. At rest
ii. With movement
b. How is the pain affecting the
patient?
i. Can the patient move, cough?
ii. Can the patient work?
Make a pain diagnosis
a. Acute or chronic/ acute on
chronic?
b. Cancer or non-cancer?
Does the patient's disease
explain the pain?
c. Nociceptive or neuropathic?
Are there other factors?
a. Physical factors (other
illnesses)
b. Psychological and social factors
i. Anger, anxiety, depression
ii. Lack of social support
9
 ASSESS

Measure the severity PainMake

diagnosis
a painexamples:
diagnosis Are there other factors?
a. What is the pain score? a. Acute non-cancer nociceptive
a. Acute or chronic/ acute onpain a. Physical factors (other
i. At rest b. Chronic cancer neuropathic pain
chronic? illnesses)
ii. With movement
b. Cancer or non-cancer?
b. How is the pain affecting the Does the patient's disease b. Psychological and social factors
patient? explain the pain?
i. Can the patient move, cough? i. Anger, anxiety, depression
ii. Can the patient work? c. Nociceptive or neuropathic? ii. Lack of social support

10
How do you treat your pain?
 Non pharmacological TREAT Pharmacological

Physical Nociceptive Pain

i. RICE (Rest, immobilization, cold - use the Analgesic ladder
compression, elevation)
ii. Nursing Care
iii. Physiotherapy, Occupational therapy, Neuropathic Pain
acupuncture, massage i. Traditional analgesic medications
iv. Surgery and/ or nerve blocks may be ii. Use other drugs (antineuropathic
required agents or adjuvants) -
Amitriptyline, Carbamazepine,
Psychological Gabapentin
i. Explanation and reassurance
ii. Input from social workers or religious
leader
iii. Family support
 WEAK
OPIODS STRONG
NON OPIODS
OPIODS
CASE 1 SCENARIO

• Oral PCM or
• IV/SC Tramal 50-
• IV Morphine Pain 100mg 6-8 hourly
And PCM
Protocol or
• IV PCM 1G
• IV Fentanyl 25- • Max 4g/24h
50mcg Moderate pain

Pain score 8/10

SEDATION <2 ( OCCASIONALLY DROWSY,
EASY TO AROUSE AND ABLE
TO STAY AWAKE ONCE
AWAKEN)
RR >8

BP APRROPRIATE TO AGE

AGE <60 YEARS OLD

Respiratory depression warrants intervention when
- The respiratory rate is <8/minute AND sedation score* = 2 (difficult to
arouse) or
-Sedation score is 3 (unarousable)

WHAT TO DO ?
Management:
1. STOP all opioids and sedative medications.
2. Administer oxygen via (face mask or nasal prongs)
3. Stimulate the patient and tell him/her to breathe

4. Dilute Naloxone 0.4mg/ml in 4 mls of water or normal saline. Administer Naloxone in aliquots
of 0.1 mg up to 0.4 mg every 1-2 minutes till patient wakes up or respiratory rate >10/minutes.

5. Monitor respiratory rate, sedation score hourly for next 4 hours.

6. Repeat another dose of naloxone if respiratory depression recurs.

7. Refer the patient to the ICU / HDU for close monitoring +/- naloxone infusion in severe or
recurrent respiratory depression.
If I give my patient analgesia for abdominal
pain, it will change the physical examination
findings, making diagnosis difficult.

MYT OR FACT
H
 MYTH OR FACT
The presence of peritoneal signs did not change in the group that
received morphine and the accuracy of diagnosis did not differ.
In fact, there was also a trend that the examination may be more
reliable after treatment with morphine.
Pace S, Burke TF. Intravenous morphine for early pain relief in patients with
acute abdominal pain. Acad. Emerg. Med. 1996;3:1086–1092

Morphine effectively reduces the intensity of pain and does not seem to
impede the diagnosis of appendicitis.
Green R. et al. Early analgesia for children with acute abdominal pain. Pediatrics.
2005;116:978-983.
GOAL :
• REDUCE PAIN to manageable levels, thereby making the patient more
cooperative and possibly improving the accuracy of the abdominal
examination by minimizing voluntary guarding.

• The goal is not to eliminate all pain and make the patient somnolent.
•In case of AAA, giving opiods
will cause hypotension.

MYT OR FACT
H
Opioid in small titrated doses, are the analgesics recommended by
experts in AAA pain relief.

Hypotension is much less likely to occur with fentanyl since this agent
does not cause the histamine release often associated with morphine.
 CASE
3
A 50 year old man with comorbid DM, HPT

Presented with typical angina chest pain 8am

today.
Diaphoresis
Pain score 9/10

Vital signs:
BP 135/80, PR 120/min, RR 14/min, SPO2 on
air 98%, GCS 15/15, PS 9/10
• Management and Analgesia Technique:
Aspirin 300mg oral initial dose and Glyceryl trinitrate (GTN) sublingual
spray 400 micrograms

or
Reperfusion therapy:
• Sublingual tablet 0.5 mg

Thrombolysis / PCI
• Repeat every 5 minutes as needed and if tolerated (monitor for hypotension) to
a maximum of 3 doses
with or without
• IV Morphine pain Protocol

• If morphine is contraindicated, consider

• Fentanyl at 25 to 50 micrograms IV as initial equivalent dose.
 CASE
4
A 30-year old woman
-involved in a motor vehicle crash.
-She sustained open # of Left tibia & closed #
fibula

Vital signs:
BP 135/80, PR 120/min, RR 14/min, SPO2 on
air 98%, GCS 15/15, PS 9/10
SEVERE PAIN FOR MODERATE PAIN USE: • NON PHARMACOLOGICAL

IV Morphine Pain Paracetamol 1g orally 4 hourly/ prn • Immobilisation, (RICE)

(to a maximum dose of 4g per 24 hour
Protocol period)
If morphine is
• And/ Or
contraindicated, consider
Fentanyl at 25 to 50 • NSAIDs or COX-2 inhibitor
micrograms IV as initial • If the oral and rectal routes are
equivalent dose. contraindicated,

• Paracetamol can be given IV 1g 6

And/ Or hourly

Paracetamol IV/ Oral 1g 6

hourly

And/ Or

NSAIDs or COX-2
If I give my patient narcotics, they
will not be competent enough to
consent for procedures later.

MYTH OR FACT
 MYTH OR FACT
Concern about rendering patient incompetent is unfounded.
Withholding analgesia can be looked upon as a form of “coercion” to sign
consent for procedures.

Gabbay DS, Dickenson ET. Refusal of base station physicians to authorize

narcotic analgesia. Prehosp Emerg Care. 2001;3(5):293-5.
 CASE
5
A 20-year old man presented with headache

- Throbbing in nature
- Aggravated by movement
- Unilateral
- Associated with aura sensation

Vital signs
BP 110/60, RR 28/min, PR 124/min, GCS
15/15, SPO2 on air 98%, pain score 5/10
What are the red flags for headache?
Red flags for headache include:

Sudden onset of severe headache especially if associated with confusion,

drowsiness, vomiting or neurological signs (e.g. consider subarachnoid,
intracerebral haemorrhage, dissection)

Recent onset with fever, confusion or drowsiness (e.g. consider meningitis,

encephalitis)

Age > 50 years (increased rate of tumours, temporal arteritis, glaucoma,

subdural haemorrhage and herpes zoster)

Trauma.
SEVERE PAIN FOR MODERATE PAIN USE:

IV Morphine Pain Paracetamol

Protocol
If morphine is And/ Or
contraindicated, consider • If this fails / has failed

Fentanyl at 25 to 50 • NSAIDs or COX-2 inhibitor

• OR for severe pain
micrograms IV as initial
• or If a Pain Score ≥4 triage
equivalent dose. patient to yellow/Red zone
• And/or
• Manage according to
And/ Or moderate and severe pain
protocol
Paracetamol IV/ Oral 1g 6 IV metoclopramide
hourly

And/ Or

NSAIDs or COX-2
 CASE
6
A 20-year old man, known IVDU, involves in a
MVC

• Sustained closed fracture left tibia and femur

and multiple rib fractures
• PS 10/10
• He is asking for Morphine injection
If I give my patient opiods,
they will abuse opiods.

MYTH OR FACT
 MYTH OR FACT
Because a few patients malinger and drug-seek is no reason to withhold
from legitimate pain patients.

Addicts need analgesia on occasion too.

 GUIDELINES FOR PAIN MANAGEMENT
IN ELDERLY

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

 IS PAIN UNDER TREATED IN OLDER
PERSONS?
Case example:

79 year old lady, presented with fall at home and sustained intertrochanteric fracture of right
hip

• She has Alzheimer’s disease, diagnosed since 3 years ago. Doesn’t recognize family
members anymore.
• Basic ADL dependent, managed by daughter.
• Some behaviour issues – wandering at night, occasionally aggressive, sleeps during
daytime, alert at night
• Constipation and anxiety are daily concerns

At day 2 of admission;
Surgical intervention for the fracture was performed
In the ward, nurse report:
Interrupted sleep at night
Incomprehensible sounds, waved her hands at staff
Given Paracetamol and Tramadol

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

 MANIFESTATION OF PAIN IN OLDER
PERSONS WITH COGNITIVE
IMPAIRMENT
Facial expression Verbalization

Body movement Change in interaction

Change in activity or Change in mental

routine status

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

 COMMON MISCONCEPTIONS AMONG
OLDER PERSONS AND NURSES
TO OLDER PERSON TO NURSES
PAIN IN UNAVOIDABLE OLDER PERSONS HAVE DECREASED
SENSSATION OF PAIN
PAIN IN PUNISHMENT OLDER PERSONS WHO ARE COGNITIVELY
IMPAIRED DON’T FEEL PAIN
ASKING FOR PAIN MEDICATION IS TOO A SLEEPING PATIENT IS NOT IN PAIN
DEMANDING AND MEANS I’M NOT A GOOD
PATIENT
PAIN MEDICATIONS ARE ADDICTIVE OLDER PATIENTS COMPLAIN MORE ABOUT
PAIN AS THEY AGE
TAKING PAIN MEDICATIONS MEANS I’LL LOSE NARCOTICS WILL HASTEN DEATH
MY INDEPENDENCE AND MENTAL CLARITY
PAIN IS NOT HARMFUL POTENT ANALGESICS ARE ADDICTIVE
NURSES DON’T HAVE TIME TO GIVE EXTRA POTENT PAIN MEDICATIONS WILL CAUSE
MEDICATIONS RESPIRATORY DEPRESSION

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

 FACTORS AFFECTING PAIN MANAGEMENT
IN OLDER PERSONS
▪ Older persons are more reluctant to report painful
stimuli & healthcare providers should understand their
patients as they have their own beliefs, attitude and
personality changes

▪ Healthcare providers are NOT managing pain

adequately as they perceived that elderly people are
expected to have pain and therefore is considered a
normal ageing process

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

 FACTORS AFFECTING PAIN MANAGEMENT
IN OLDER PERSONS
▪ Cognitive, hearing and visual impairment affect pain
assessment

▪ Physiological changes, co-morbidities, polypharmacy,

susceptibility to side effects affect pharmacotherapy of
older persons

▪ Older persons can become acutely confused due to pain

itself or from treatment (side effects of analgesia)

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

 COMPREHENSIVE GERIATRIC PAIN
ASSESSMENT
▪ Meas ur ement of pain - using standardized pain assessment

▪ I mpac t of pain on daily function - ability to perform instrumental

tools

and activities of daily living, social functioning, appetite and

▪ Comorbidities and drugs - regular review on the impact of the

sleep

▪ Attitudes and beliefs about pain, treatment goals and

comorbidities on pain and vice versa

expectations
▪ Assistance and Resources - a holistic approach in identifying
help from family members, caregivers and faith communities for
maximal support

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

 TYPES OF
ASSESSMENT
▪ UNIDIMENSIONAL
▪ MULTIDIMENSIONAL

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

 MULTIDIMENSIONAL
ASSESSMENT
PAINAD
Pain Assessment In
Advanced Dementia
• simple, valid and sensitive tool for detecting
pain in people with advanced dementia and
non-communicative patients
• useful to assess whether pain management
strategies have been successful

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

 MULTIMODAL APPROACH TO PAIN
MANAGEMENT

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

PRINCIPLES OF ANALGESIC PRESCRIPTION
IN OLDER PERSONS
▪ Timing of medication administration
o Severe, episodic pain – requires rapid onset and short duration
o Continuous pain – regular analgesia, modified release formulations

▪ Start low, go slow

o One drug initiated at a time, low dose followed by incremental dose
titration
o low dose followed by incremental dose titration
o Allow adequate intervals between introducing drugs to allow
assessment of effect

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

 PRINCIPLES OF ANALGESIC PRESCRIPTION
IN OLDER PERSONS
▪ Consideration to choose analgesia:
o Comorbidities
o Contraindications
o Possibilities of drug-disease and drug-drug interactions

▪ Treatment should be monitored regularly and adjusted if

required to improve efficacy and limit adverse events

▪ Consider the use of non-pharmacological strategies –

physiotherapy, cognitive behavioural approaches, acupuncture
etc

PAIN FREE PROGRAMME I KEMENTERIAN KESIHATAN MALAYSIA I UNIT AUDIT KLINIKAL

 Take Home Message
 Listen and belief the patient when they say they are in pain. Pain is prevalent among older
persons
 Pain management in older persons is fundamentally complex due to complexity of ageing

 It is mandatory to adequately assess pain in comprehensive manner and intervention should

be multimodal in approach based on geriatric principles

 Use objective pain measures

 Acute pain & chronic pain are not the same .Acute pain is a symptom. Chronic pain is a disease.

 Know your drugs very well ( onset, duration of action and how to treat the side effect)

 AIM TO ACHIEVE REASONABLE PAIN RELIEF WITH ACCEPTABLE SIDE EFFECT.

 Words To Ponder

Our primary duty is to

COMFORT, MANAGE AND REDUCE
the suffering of patient.

And yet the management of pain is often regarded as least

important compared to arriving at diagnosis and treatment