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2 Geriatric Pain ManagementLong Term Care/Nursing 65511/ Geriatric Pain Management Mark V. Boswell, MD, PhD, MBA Professor and Chair, Department of Anesthesiology University of Louisville School of Medicine Louisville, Kentucky
3 Geriatric Pain ManagementLong Term Care/Nursing 65511/ Geriatric Pain Management Parampal Singh Bhullar, MD Assistant Professor, Internal Medicine Texas Tech University Health Sciences Center Lubbock, Texas
4 Long Term Care/Nursing65511/ Objectives Recognize definitions, demographics, and physiologic changes.
5 Long Term Care/Nursing65511/ Objectives Indicate diagnosis, therapy, and general health status.
6 Long Term Care/Nursing65511/ Objectives Identify equianalgesic prescribing and opioid management.
7 Lecture Outline Definitions and demographics Physiologic changes with age Diagnosis and therapy
8 Lecture Outline Functionality and competence General health status
9 Definitions and Demographics
10 Definitions Young elderly: age 65 years or older Older elderly: 75 years Chronic pain: >3 months duration
11 Demographics 6% of total world population in 1994 12.5% of population in USA (33.2 million) Large percentage of pain practice
12 Physiologic Changes with Age
13 Experimental Pain Detection Threshold in the ElderlyInconsistent findings presbyalgos: loss of pain sensibilities with age
14 nociceptor sensitivity (threshold)cutaneous electrical current: no change heat: increased mechanical pressure: increased
15 Pain Tolerance ThresholdCutaneous electrical current: decreased Cold pressor test: decreased Mechanical pressure: decreased
16 Pain Tolerance ThresholdHeat tolerance: unclear
17 Central Nervous System (CNS) ChangesFrontal and temporal lobes Neuronal plasticity may persist into the 70s Volume and number of neurons lost less than previously thought
18 CNS Changes in the Disabled Elderly90%: CNS dysfunction 48%: neurological disease 20%: movement disorders
19 CNS Changes in the Disabled Elderly16%: dementia 16%: strokes or transient ischemic attacks (TIAs)
20 Neurotransmitter ChangesCholinergic decline: dementias (anticholinergics cause confusion) Serotonin system: depression
21 Neurotransmitter ChangesDopaminergic system: movement disorders
22 Neurotransmitter ChangesNorepinephrine system reduced sympathetic tone orthostasis susceptibility to sympathetic blockers (tricyclic antidepressants)
23 Acetylcholine Synthesized in interneurons and long projection neurons (monoamines not synthesized in interneurons, except dopamine in the retina)
24 Hepatic System Liver size and blood flow decrease after age 50 First pass metabolism reduced
25 Hepatic System Demethylation decreased (e.g., diazepam clearance reduced by 50%)
26 Renal System 1% per year decline in creatinine clearance after age 40 Kidney size decreased by 20% (glomerular sclerosis)
27 Renal System Fewer renal tubules Renal vascular changes
28 Renal System Creatinine alone not good predictor of glomerular filtration rate Reduced drug clearance
29 Pharmacokinetic ChangesMost drugs show some decrease in clearance volume of distribution lean body mass decreases increased lipid content
30 Pharmacodynamic ChangesIncreased sensitivity to opioids and benzodiazepines: effect not due only to pharmacokinetic changes
31 Diagnosis and Therapy
32 Short-Form McGill Pain Questionnaire
33 Functional Pain Scale
34 Katz IADL (Instrumental Activities of Daily Living) Scale
35 Interventional ProceduresReduced compliance on polypharmacy
36 Interventional ProceduresEpidural steroid injections transforaminal caudal Facet nerve radiofrequency neurolysis Sacroiliac injections
37 Hospice and Palliative CareUnderutilized in United States
38 Specific Drugs
39 NSAIDS (Nonsteroidal Antiinflammatory Drugs)COX II selective vs. nonselective
40 NSAIDS (Nonsteroidal Antiinflammatory Drugs)Gastrointestinal (GI) safety of COX II selective agents for patients taking daily aspirin unclear
41 NSAIDS (Nonsteroidal Antiinflammatory Drugs)celecoxib: 50% reduction in bleeding compared to nonselective NSAIDs Cochrane Study: aspirin offsets safety
42 NSAIDS (Nonsteroidal Antiinflammatory Drugs)Renal effects with both agents selective and nonselective
43 Problems with NSAIDS Fluid retention or congestive heart failure Other problems history of GI bleeding risk of thrombotic events
44 Celecoxib Indications: osteoarthritis and rheumatoid arthritis; acute pain in adults
45 Celecoxib Must worry about decreased clearance and warnings regarding post coronary artery bypass graft, thrombosis, and stroke
46 American Geriatric Society RecommendationsAcetaminophen is drug of choice for musculoskeletal pain
47 Benzodiazepines Cognitive impairment age >65 alcohol use high lipid solubility agents
48 Benzodiazepines Cognitive impairment prolonged cognitive effects after benzodiazepine sedation
49 Antidepressants Tricyclic antidepressants (TCAs) – best evidence for treatment of neuropathic pain (many side effects)
50 Opioids
51 Morphine Morphine metabolites (M6G) active and accumulate with renal insufficiency Conclusion: use smaller doses in elderly
52 Oxycodone Oxycodone does not require dosage reduction in elderly Note: reduce dose when creatinine clearance <60 ml/min
53 Meperidine Generally poor choice for elderly patients
54 Functionality and Competence
55 Polypharmacy common in geriatrics – can affect cognitive function (dementias)
56 General Health Status
57 Clinical Pain in the ElderlySome evidence that migraine, tension headache, and low back pain less prevalent than in middle age
58 Clinical Pain in the ElderlySpinal stenosis higher in older population
59 Causes of Death Heart disease Malignancies Cerebrovascular disease Pulmonary diseases
60 Rheumatoid Arthritis 3% of population Male:female = 1:3 Inflammation of synovial joints; osteoporosis Majority of patients have cervical spine involvement
61 Polymyalgia RheumaticaAffects patients aged >55 Almost exclusively Caucasians Twice as common in females as males
62 Polymyalgia RheumaticaProximal muscles: aching pain in shoulders and hips Generalized malaise Elevated sedimentation rate (ESR) usually elevated (>50)
63 Temporal Arteritis Giant cell temporal arteritis incidence: cases per 100,000 associated with polymyalgia headache is leading symptom
64 Temporal Arteritis Oral steroids to prevent blindness (prednisone: 50 mg/day) Biopsy to prove diagnosis
65 Herpes Zoster Everyone >60 should get the vaccine
66 Postherpetic NeuralgiaPain that persists after rash has healed
67 Atherosclerotic Peripheral Vascular DiseaseVascular claudication
68 Degenerative DiseasesOsteoarthritis: joint pain Spine disorders spondylosis spinal stenosis spondylolisthesis
69 Alzheimer’s Disease and DementiaImpact ability to provide a pain regimen that patient can understand
70 Depression Serotonin dysfunction Confounding problem with pain management
71 Chemical Classes of Opioids
72 Phenanthrenes morphine codeine hydromorphone hydrocodone oxycodone oxymorphone
73 Diphenylheptane derivativesmethadone propoxyphene Phenylpiperidine derivatives fentanyl meperidine
74 Misconceptions About OpioidsRespiratory depression Addiction Rapid tolerance Narrow effective dose range Ineffective by mouth Nausea/euphoria
75 Equianalgesic Dosing Opioid Agonist PO (oral) IV (intravenously)Morphine/ Hydrocodone 30 10 Oxycodone 20 - Hydromorphone 7.5 1.5 Fentanyl mcg Fentanyl patch 25 mcg/hour ~ 50 mg/24 hours of PO morphine every 72 hours
76 Effective dose at home = Lortab® 2 tablets = 10 mg hydrocodone = 10 mg morphine equivalentReduce dose by 25-50% for reduced cross-tolerance = mg morphine
77 Convert to IV morphine: divide by 3 = 1. 6-2Convert to IV morphine: divide by 3 = mg IV morphine (give ~2 mg IV morphine)
78 Opioid Receptors Limited cross-tolerance – a patient receiving treatment with an opioid may experience more effective analgesia from a lower than equivalent dose of another opioid
79 Opioid Receptors It is recommended that after calculating the appropriate conversion dose, it be reduced by 25-50% to assure patient safety
80 How to Start a Regimen 24 hours of PRN (as needed) medications vs. PCA (patient-controlled analgesia)
81 How to Start a Regimen low dose (5 mg PO morphine) of immediate release product and monitor response after 1 hour – if IV, monitor response after 15 minutes
82 How to Start a Regimen once what works for the patient is discovered, write every 4 hours PRN and additional dose for breakthrough pain
83 How to Start a Regimen frail elderly: begin with % of usual adult dose
84 Titration Increments for Opioid DosingNo ceiling effect Breakthrough analgesia should be one sixth of the total regular daily dose of oral morphine. Each day assess the pain control, degree of side effects and total amount of morphine required, including breakthrough doses, in the previous 24 hours. Divide the total amount required in the previous 24 hours by six. Prescribe this dose every four hours and alter the breakthrough analgesia dose accordingly (this is the same as the four hourly dose) ie. one sixth of the total daily regular morphine dose.
85 Titration Increments for Opioid DosingKnow half-life of formulations/peak effect frequency PO: 1 hour Breakthrough analgesia should be one sixth of the total regular daily dose of oral morphine. Each day assess the pain control, degree of side effects and total amount of morphine required, including breakthrough doses, in the previous 24 hours. Divide the total amount required in the previous 24 hours by six. Prescribe this dose every four hours and alter the breakthrough analgesia dose accordingly (this is the same as the four hourly dose) ie. one sixth of the total daily regular morphine dose.
86 Titration Increments for Opioid DosingKnow half-life of formulations/peak effect frequency subcutaneous: minutes Breakthrough analgesia should be one sixth of the total regular daily dose of oral morphine. Each day assess the pain control, degree of side effects and total amount of morphine required, including breakthrough doses, in the previous 24 hours. Divide the total amount required in the previous 24 hours by six. Prescribe this dose every four hours and alter the breakthrough analgesia dose accordingly (this is the same as the four hourly dose) ie. one sixth of the total daily regular morphine dose.
87 Titration Increments for Opioid DosingKnow half-life of formulations/peak effect frequency subcutaneous: minutes IV max: 6-15 minutes Breakthrough analgesia should be one sixth of the total regular daily dose of oral morphine. Each day assess the pain control, degree of side effects and total amount of morphine required, including breakthrough doses, in the previous 24 hours. Divide the total amount required in the previous 24 hours by six. Prescribe this dose every four hours and alter the breakthrough analgesia dose accordingly (this is the same as the four hourly dose) ie. one sixth of the total daily regular morphine dose.
88 Titration Increments for Opioid DosingBreakthrough pain should be treated with 10-20% of the daily maintenance dose Breakthrough analgesia should be one sixth of the total regular daily dose of oral morphine. Each day assess the pain control, degree of side effects and total amount of morphine required, including breakthrough doses, in the previous 24 hours. Divide the total amount required in the previous 24 hours by six. Prescribe this dose every four hours and alter the breakthrough analgesia dose accordingly (this is the same as the four hourly dose) ie. one sixth of the total daily regular morphine dose.
89 Titration Increments for Opioid DosingIncrease daily maintenance by: 0-25% for mild pain 25-50% for moderate pain 50-100% for severe pain
90 Titration Increments for Opioid DosingIncrease daily maintenance if patient requires 3 or more breakthrough doses over 24 hours
91 Titration Increments for Opioid DosingContinuing reassessment: poor response – adjuvant drugs; nonphysical pain
92 PCA Dosing Acute pain management reevaluate in 15 minutes monitor respiratory rate: >8 okay Start lowest effective dose
93 PCA Dosing Use continuous dosing with patient previously on chronic opioids – calculate based on 24-hour dosing
94 PCA Dosing Breakthrough dose every minutes – usually 50% of hourly dose
95 Drugs to Avoid in ElderlyMeperidine (renal, central nervous system toxicity) Propoxyphene (central nervous system, cardiac, renal toxicity)
96 Opioid Neurotoxicity Triad of: delirium, hallucinations myoclonic jerks, seizures hyperalgesia, allodynia
97 Opioid Neurotoxicity Treatment change opioids IV hydration
98 Opioid Overdose/ToxicityRare; suspected when level of consciousness and respiratory rate decrease concomitantly to <6/minute; constricted pupils
99 Opioid Overdose/ToxicityReversal: dilute 1 ampoule (0.4 mg) of naloxone in 10 ml of saline and give 1 ml of this diluted mixture (0.04 mg) IV every 5 minutes
100 Pain and the Elderly – MythsPain is a normal, expected part of aging No complaint of pain means no pain Pain is a normal, expected part of aging. Pain is common--but not normal Pain sensitivity and perception decreases with age. Disease presentation may be altered in the elderly, such as painless myocardial infarction or perforated viscus, and disease states, such as diabetes, may diminish sensory acuity. However, in the absence of disease, aging does not alter pain sensitivity and threshold. Patient self-report of pain is unreliable. Self-report is accurate for 99% of patients, even those with mild to moderate dementia. However, a recent report by Caring editorial board member Jiska Cohen-Mansfield, PhD, and colleagues demonstrated that even expert geriatricians have difficulty with accurately evaluating pain in non-communicative patients with advanced dementia (Pain in cognitively impaired nursing home residents: How well are physicians diagnosing it? J Am Geriatr Soc. 2002; 50:1039). Research on pain assessment in advanced dementia is a "work in progress," according to Mary Cadogan RN, DrPH (Assessing pain in cognitively impaired nursing home residents: The state of the science and the state we're in. JAMDA. 2003; 4: 50-51). Premature administration of analgesics will obscure the diagnosis. This lore arose from a few isolated case reports most cases encountered in practice. No complaint of pain means no pain. Clinicians will fail to detect pain unless they ask and listen attentively. This is especially true of the current generation of elders, who are culturally conditioned to suffer silently.
101 Basic Rules By the mouth Around-the-clock for chronic pain By the ladder Start lowest effective dose Reassess and adjust
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108 316111 Nursing Conflicts of Interest:Mark V. Boswell, MD, PhD, MBA and Parampal Singh Bhullar, MD have disclosed that no financial interests, arrangements or affiliations with organization/s that could be perceived as a real or apparent conflict of interest in employment, leadership positions, research funding, paid consultants or member of an advisory board or review panel, speaker’s bureau, major stock or investment holder, or other remuneration. Commercial Support: There is no commercial support and/or relevant financial relationships related to this educational activity. Commercial support is defined as financial (or in-kind) contributions given by a commercial interest, which is used to pay all or part of the costs of a CNE activity. Relevant financial relationships are defined as financial relationships of any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner that could create a conflict of interest.
109 316111 Nursing Non-endorsement of Products:Mark V. Boswell, MD, PhD, MBA and Parampal Singh Bhullar, MD have disclosed that no significant relationships with commercial companies whose products or services are discussed in educational presentations. For speakers, significant relationships include receiving from a commercial company research grants, consultancies, honoraria and travel, or other benefits or having a self-managed equity interest in a company. Disclosure of a relationship is not intended to suggest or condone bias in any presentation, but is made to provide participants with information that might be of potential importance to their evaluation of a presentation. Off-label Use: Mark V. Boswell, MD, PhD, MBA and Parampal Singh Bhullar, MD have has disclosed that no products with off-label or unapproved uses are discussed within this activity.
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