Caring for Geriatric Patients in the Emergency Department Setting Part V: Pain Management Challenges Laurie A. Hanly, BA, BSN, RN, MS Emergency Department,

Caring for Geriatric Patients in the Emergency Department Setting

Part V: Pain Management ChallengesLaurie A. Hanly, BA, BSN, RN, MSEmergency Department, VA Medical Center, Portland, OR

Ula Hwang, MD, MPHGeriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NYDepartment of Emergency Medicine, Icahn School of Medicine at Mount Sinai, NY, NY

Timothy F. Platts-Mills, MD, MScDepartment of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC

February 2014

VETERANS HEALTH ADMINISTRATION 2

Discussion today

1. Introduction (Hwang)2. Assessment (Hanly)3. Pharmacological treatment options (Platts-Mills)4. Non-pharmacological treatment options (Platts-Mills)5. General challenges and recommendations (Hanly)


Part I. Introduction - Pain in the ED

• Pain as 5th vital sign• Identified as an area for quality improvement

• Pain is common ED cc– 70% of ED conditions – 34% of all medications used in ED for pain

• Inconsistent & inadequate analgesia (oligoanalgesia)


Disparities in Analgesia

• Differences in prescribing patterns found in cancer pain, fracture treatment, and postoperative pain patients across gender, AGE , and race/ethnicity

• In the ED setting, blacks or Latinos (vs. whites) received less analgesia for long bone fractures

Awareness of disparities may allow for targeting to reduce


Pain and Outcomes

• Under treated and untreated pain associated with increased risk of developing delirium

• Patients with higher pain scores at rest with longer hospital LOS, delays in functional recovery, and risk of long-term functional impairment


Pain in Older Adults

• High prevalence of pain in older adults– Self-doubt, reluctant, and reticent to complain

• 50% ED MDs uncomfortable giving analgesics to elderly

• Co-morbidities, drug-drug interactions, age-related drug metabolism changes, and fear of adverse reactions makes giving analgesia a challenge


Polypharmacy

• 90% older adults on 1 medications• 40% on >5 medications• 30-50% receive new prescription at ED discharge• Risk adverse drug reaction with– Multiple meds– Severity of illness– Multiple comorbidities– Changes in physiologic reserve


Physiologic Reserve LossLower body mass, total body water, hepatic and

renal function, increased fatty tissue…– Pharmacodynamics

(how drugs act at receptor sites and affect the body)

– Pharmacokinetics (drug distribution/elimination)

Caution and awareness in analgesia choice and dosing (do no harm…start low and go slow…)


Geriatric ED Pain Care

• Frequent assessments• Do no harm• (Start low and go slow) Start low and REASSESS


Beers Criteria

• Consensus based pharmacologic guidelines for older adults

• Defines “inappropriate use of medications”• List of medications to avoid • Most recent update in 2012


Geriatric ED Pain Care Quality Indicators

Quality indicators describe minimum level of care

– Pain assessed <1 hour arrival– F/U assessment <6 hours– F/U prior to discharge if received pain med– Pain med if mod-sev pain– Avoid meperidine– Bowel regimen if discharged with opioid Rx

(Terrell KM, et.al. Quality indicators for geriatric emergency care. Acad Emerg Med. 2009)


Part II. Pain Assessment - Laurie Hanly



The first step toward improving patient comfort is recognizing pain

66% of geriatric nursing home residents have chronic pain but 34% had pain that went undetected by their physician

Basic pain rating assessment tools: 1. Verbal

Numerical rating scale Verbal rating scale Functionally descriptive

2. Non-verbal Pictorial Behavioral

(Kay AD, Baluch A, Scott J. Pain Management in the Elderly Population: A Review. Ochsner Journal. 2010)


Verbal Pain Scales

1. Numerical pain rating scale: Rate your pain from 0 – 10

2. Verbal rating scale: Choose the phrase that best describes your pain

No -- mild -- moderate -- severe -- unbearable pain pain pain pain pain

VETERANS HEALTH ADMINISTRATION

Verbal Pain Scales continued

3. Functional Pain Scale:0 No Pain (pain free)

12 Functional:3 pain is present but does not get in the way of my daily activities or quality of life

4

5 Uncomfortable:6 hard to move, cannot concentrate, impacts ability to function and enjoyment of life

7

8 Severe: Not able to leave home, unable to do anything, spends time in bed

9 high effect on daily activities and quality of life

10 Unbearable: pain out of control, overwhelmed, can not tolerate, seeks immediate care

(Evans CM, Chronic Pain is a Chronic Condition, Not Just a Symptom. Permanente Journal. 2005) 15


Non-verbal Pain Scales

1. Wong Baker Pain Faces Scale:

2. Visual Analog Scale: 10 cm in length

No pain Worst pain imaginable


Other Non-verbal Pain Scales

3. Behavioral Scale:

Facial Expressions Vocalizations Body Movements Social Interactions

Clenched teeth

Wrinkled forehead

Biting lips

Scowling

Closes eyes tightly

Widely opened eyes or mouth

Crying

Moaning

Grasping

Groaning

Grunting

Restlessness

Protective body movement

Muscle tension

Immobility

Rhythmic movements

Silence

Withdrawal

Reduced attention

Focus on pain relief measures


Assessing Pain “O” to “T”

• O: origin (when, what was the patient doing)

• P: provocation and palliation

• Q: quality (sharp, achy, throbbing, tingly, burning, dull, etc….)

• R: region, radiation

• S: severity

• T: treatment (What do you take or do for your pain?)

Remember to use open-ended questions.


Tim Platts-Mills



Part III. Selecting Pharmacologic Therapies for Pain

• Acetaminophen• NSAIDs• Opioids• Other Medications• Shared Decision Making


Acetaminophen

• Safe except in patients with liver disease, chronic alcohol use• First-line therapy for outpatient treatment of pain in older adults• Dose in older adults: 500 mg every 4 hours • Max dose: 3 gm in 24 hours• Increase dosing interval if renal impairment:

– CrCl 10-50 mL/min = q 6 hours– CrCl < 10 mL/min = q 8 hours)

• Adjust dosing in patients taking combination opioid + acetaminophen


NSAIDs - Risks

• More effective for pain than acetaminophen• But due to risks, prescribed on a case-by-case basis• Risks: cardiovascular events, upper GI bleeding, acute renal failure,

CHF exacerbations• Most common cause of severe adverse drug reactions leading to

hospitalization• Considered inappropriate for long-term treatment of pain in older

adults by most experts

(Onder G, et.al. Adverse drug reactions as a cause of hospital admissions: results from the Italian group of pharmacoepidemiology in the elderly. JAGS. 2002)

TPM


NSAIDs - Risks

• Even short-term use (i.e. <48 hours) of NSAIDs unsafe in high risk patients

• Avoid NSAIDs (including Ketorolac/Toradol) in high risk patients:– Renal failure– CHF– History of upper GI bleed– Taking ACE Is, ARBs, of metformin

(Platts-Mills TF, et al. Life-threatening hyperkalemia after 2 days of ibuprofen. Am J Emerg Med. 2012)

TPM


NSAIDs – which one?

• In low risk patients, consider NSAIDs for short-term or intermittent pain management.

• Naproxen (Aleve)– lowest cardiovascular risk– similar GI bleeding risk to ibuprofen.

• COX-2’s (e.g. Celebrex)– lowest risks of upper GI bleeding– use of proton pump inhibitor further reduces risk of GI bleeding

(Bhala, N et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials." Lancet. 2013)

TPM


IV Opioids

• IV Opioids are appropriate for acute severe pain• Typical agents are morphine or dilaudid• Use lower doses (i.e. 2-4 mg morphine) for frail, small individuals

who are opioid naïve and those with respiratory conditions• Reassess and give more as needed frequently (q 20 minutes): “start

low but reassess often”• Use continuous cardiac and oxygen saturation monitor• Pre-treat for anticipated pain (e.g. during movements for x-rays)


Oral Opioids, Short-Term Use

• Use oral opioids for moderate or severe pain in patients who can tolerate oral medications and for outpatient treatment of pain

• Prescribed as supplement to scheduled acetaminophen• Side effects among older adults in first week of opioid treatment:

– Tiredness (30%)– Constipation (20%)– Nausea (20%)– Dizziness (17%)

(Hunold KM et al. Side effects from oral opioids in older adults during the first week of treatment for acute musculoskeletal pain. Acad Emerg Med. 2013)


Oral Opioids, Short-Term Use

• Prevent constipation. Tell your patients to:– Drink plenty of water– Eat at least 30 grams of fiber a day– Stay physical active (especially walking)– Senna 17 mg / day (increases bowel motility)– If history of constipation, Senna plus stool softener

• Polyethylene glycol (e.g. Miralax)• Docusate (e.g. Colace).


Oral Opioids, Long-Term Use

• Safety concerns – all are increased compared to NSAID therapy: – cardiovascular events– fractures– hospitalizations

• Best if managed by a single provider to – Ensure consistent dosing– Reduce risk of inappropriate use, overdose

(Solomon DH et al. The comparative safety of analgesics in older adults with arthritis. Arch Intern Med. 2010)


Questions to Consider When Deciding on Long-Term Opioid Treatment for Older Adults

1. What is usual practice for this type of pain?2. Are there safer, effective alternatives?3. Does this patient have increased risk of opioid-related adverse effects?4. Can patient take opioids responsibly?5. Are patient’s medical, behavioral, or social circumstances so complex as to

warrant referral to a pain medicine specialist?


Opioids – which one?

Safest Most Dangerous

All Cause Mortality: Tramadol/Hydrocodone Oxycodone

Fractures: Tramadol Hydrocodone/Oxycodone

GI events: No Difference

CV Events: Tramadol/Hydrocodone Oxycodone

(Solomon DH et al. The comparative safety of opioids for nonmalignant pain in older adults. Arch Intern Med. 2010)


Other Medications to Treat Pain

• SNRIs (duloxetine, venlafaxine) – neuropathic pain. Side effects: nausea, dizziness.

• Gabapentin –neuropathic pain, may be safer than SNRIs• Muscle relaxants – baclofen or benzodiazepines favored• Calcitonin –inhibits osteoclast activity – effective in reducing bone pain

from fractures, metastases. Side effect: nausea.• Topical Treatments

– Topical NSAIDs –not demonstrated to be better than placebo after first 2 weeks (BMJ 2004 systematic review)

– Lidoderm patch 5% – good for post-herpetic neuralgia


Femoral Nerve Block

• Use in patients with hip fractures, particularly those without good and long-lasting relief from an initial dose of opioids

• Technique:– Use ultrasound to identify femoral nerve or find nerve 1 cm lateral to femoral artery

pulse (see next slide)

– Bupivicaine 0.5% 20 mL • Provides pain relief in first 12-24 and reduces need for opioids• Side effect – short-term quadriceps muscle weakness/falls

(Fletcher AK et al. Three-in-one femoral nerve block as analgesia for fracture neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2010)

33

(Fletcher AK et al. Three-in-one femoral nerve block as analgesia for fracture neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2010)


Selecting Medications for Outpatient Treatment of Pain – Shared Decision Making

• Choosing the best pain medication is difficult: – acetaminophen often insufficient– NSAIDs and opioids significant risks

• Patients often know what works for them• Or, they have preferences regarding balance between pain relief and risks• Provide patients with information and working with them to reach decision

– fewer side effects– better pain relief.

• Shared decision making takes time, but the extra time is likely to help your patient.

(Isaacs CG et al. Shared decision making in the selection of outpatient analgesics in older adults. JAGS. 2013)


Part IV: Non-Pharmacologic Treatments for Pain

Generally more appropriate for chronic pain, but emergency providers should be aware of these issues.• Conceptual Basis• Cognitive Behavioral Therapy / Pain Coping Skills Training• Treatment of Depression• Other Non-pharmacologic Therapies


Conceptual Basis

• Biopsychosocial model – pain is a complex experience that is influenced by biological, psychological, and social context

• Evidence for the biopsychosocial model of pain in older adults:– Pain often not correlated with tissue injury– Treatments that correct tissue injury often fail to relieve pain– Psychological and social factors strongly associated with pain

• If we accept this model, it makes sense to consider treatment the psychological and social factors

(Keefe FJ et al. Psychosocial interventions for managing pain in older adults: outcomes and clinical implications. Br J Anesth. 2013)


Cognitive Behavioral Therapy / Pain Coping Skills Training

• Goal: Alter pain-related thoughts, emotions, and behaviors so that patients experience less pain.

• Best approach in older adults is pain coping skills training, including:– Muscle relaxation– Imagery– Identifying and challenging negative thoughts– Problem solving

• Benefit shown for osteoarthritis and cancer pain• Active learning better than didactic• More benefit if you include a spouse / significant other

(Keefe FJ et al. Effects of spouse-assisted coping skills training and exercise training in patients osteoarthritic knee pain: a randomized controlled study. Pain. 2004)


Treatment of Depression

• Two question screen for depression:– In past month, have you been bothered by feeling down, depressed,

or hopeless?– In past month, have you been bothered by little interest or pleasure in

doing things?• Antidepressant medication + psychotherapy focused on problem

solving• Results:

– Less pain– Improved function

(Lin EH et al. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. JAMA. 2003)


Other Non-Pharmacologic Therapies

• Physical Therapy – mostly studied for low back pain; no benefit or small benefit over usual care

• Spinal Manipulation – mostly studied for low back pain; no benefit or small benefit over usual care

• Electrical nerve stimulation – some evidence of benefit for knee osteoarthritis

(Cherkin DC et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. NEJM. 1998)

(Osiri M et al. Transcutaneous electrical nerve stimulation for knee osteoarthritis (Review). The Cochrane Library. 2009)


Part IV. General Challenges and Recommendations - Laurie Hanly



Pain Management Challenges in Geriatric Patients

Major Challenge Areas

• Generational differences

• Assessment of Pain

• Psychosocial issues

• Lack of pain related education in physician and nursing programs

• Disconnect between knowledge and practice

• Nurse-Physician Communication

(Kay, A.D., Baluch, A., Scott, J.: Pain Management in the Elderly Population: A Review. Ochsner Journal 2010)


Generational Pain Management Challenges

• Differences in acceptance of pain

• Pain generally accepted as an inevitable part of aging

• Under-reported by patients out of fear of potential diagnosis

• WWII population stoic, therefore less likely to admit to pain or request pain medication

• Increased incidence of dementia with aging

• Narrower view of how pain is defined


The Psychosocial Components of Pain Management

• Subtherapeutic and/or compliance of home pain management

• Support systems– Family relationships (particularly spousal support)– Caregiver involvement– Faith or faith-based association– Other Social supports

• Mood-- depression-- suicidality

• Potential of/for abuse

(Koizumy Y et al. Association between social support and depression status in the elderly: results of a 1-year community-based prospective cohort study in Japan. Psychiatry Clin Neurosci. 2005)

(Martire LM et al. Older Spouses’ Perceptions of Partners’ Chronic Arthritis Pain: Implications for Spousal Responses, Support Provision, and Caregiving Experiences. Psychology and Aging, 2006)


Physician/Nurse Education Related Challenges

• Many physician and nursing programs devote minimal, if any, time to pain management.

• Lack of knowledge specific for geriatric care: Recent study showed 50% of geriatric patients got pain medication administered IM

• Inability to assess pain in patients with dementia

(Titler MG et al. Acute pain Treatment for Older Adults Hospitalized with Hip Fracture: Current Nursing Practices and Perceived Barriers. Applied Nursing Research. 2003)


Disconnect Between Knowledge and Practice

• Medications contraindicated or those needing to be dose adjusted for geriatric patients

• Around the clock medication administration

• Routes of medication administration



Barriers to Effective Pain Management in Geriatrics

• Communication between nurses and physicians

• Lack of communication between nurses and patients

• Difficulty separating the elderly and the younger patient who may or may not look old but is physiologically old

• Fear of side effects


Pain Related Orders Can Facilitate Effective Pain Management

• Scheduledexample: 2mg Morphine IV q30 minutes PRN to a maximum of 8mg

• PRNexample: 4mg Zofran IV for nausea and/or vomiting

• Parametersexample: 0.25mg Hydromorphone IV q20minutes to maximum of 1mg, hold if respiratory rate drops below 10 or O2 < 94%

The comfort of a prescribing provider for any of these types of orders is of course dependent upon the trust one has in the nursing staff.


Changing Practice to Improve Care

Studies have shown that continuing education alone leads to only minimal changes in practice in physicians or nurses.

Reinforcing strategies such as the following have been shown to be helpful in changing practice. automated reminders integrated into orders

change championsaudits and/or peer feedback



Pain Improvement Programs currently in place at Portland VA MC

1. ED Pain Reassessment

2. Pain Resource Nurse Program (PR-RN)

If you would like more information on the ongoing Pain Resource Nurse Program or Pain Reassessment Study at PVAMC

feel free to contact me at [email protected]

mailto:[email protected]


Older patients are likely to continue to be untreated or undertreated for pain until we adopt in practice

what we know from research…

Thank you for joining us today!

Documents

Caring for Geriatric Patients in the Emergency Department Setting Part V: Pain Management Challenges Laurie A. Hanly, BA, BSN, RN, MS Emergency Department,