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Pain Assessment & Management in Dementia
December 19, 2005
Tracy Marx, D.O.Assistant Professor, Geriatric
MedicineOUCOM
Definition of Pain
Pain is an “unpleasant sensory and emotional experience.”
Chronic pain is difficult to define but understood as persistent pain that is not amenable to routine pain control methods
Pain Statistics
75 million Americans live with “serious pain” 50 million suffer from chronic pain
Many have lived with this more than 5 years and experience pain almost 6 days/wk
American Pain Society http://www.ampainsoc.org/ce/npc/ Pain: Current Understanding of Assessment, Management and Treatments, 7/2004
Geriatric Statistics Chronic pain is common in older
adults Arthritis, bone & joint disorders, many
chronic conditions 25 – 50% community adults suffer with
chronic pain 45 – 80% in nursing home substantial
pain, undertreated 1 in 5 older Americans taking analgesic
medications regularly
Common Causes of Chronic Pain Back and neck pain Myofascial pain/fibromyalgia Headache Arthritis pain Neuropathic pain
From American Pain Society http://www.ampainsoc.org/ce/npc/ Pain: Current Understanding of Assessment, Management and Treatments, July 2004
Painful Conditions in the Elderly DJD Rheumatoid arthritis Fibromyalgia Low back disorders Arthropathies (gout) Osteoporosis Neuropathies Pressure Ulcers Amputations Immobility,
contractures
GI conditions (ulcers, ileus, gastritis)
Renal Conditions (kidney stones, bladder distension)
Headaches Oral/dental
pathology Peripheral vascular
disease Post-stroke
syndromes
Older People with Pain Experience Deconditioning Gait disturbances Falls Slow rehabilitation Multiple medication use Cognitive impairment Malnutrition
Ferrell, Ann Int. Med 1995; 123 (9): 681-687
Consequences of Chronic Pain Depression Decreased socialization Sleep disturbance Impaired ambulation Increased health care
utilization and costs
Lavsky-Shulan et al, JAGS 1985; 33(1): 23-28
Physician Barriers to Mgmt
Inadequate knowledge of pain management
Poor assessment of pain Concern about regulation of
controlled substances Fear of patient addiction or misuse Concern about side effects, tolerance According to U. S. Dept. of Health & Human Services, Agency for
Health Care Policy & Research
Patient Barriers to Mgmt.
Older adults often expect pain with age Use other words than “pain’ (aching,
hurting, throbbing, “a misery”) Fear need for diagnostic tests or
medications that have side effects For some, pain is a metaphor for
serious disease or death For others, pain and suffering
represent atonement for past actions
Barriers in LTC setting Different response (may not show
typical sx) Cognitive and communication barriers Cultural and social barriers Co-existing illnesses and multiple meds Staff training and access to
appropriate tools Practitioner limitations System barriers
Pain Assessment Failure to assess pain is critical
factor leading to under treatment Should occur initially Occur at regular intervals after
initiation of treatment At each new report of pain At suitable interval after
pharmacologic or nonpharmacologic intervention
Initial Assessment
Detailed history Physical examination Psychosocial assessment Diagnostic evaluation
Detailed History Goal is to characterize pain by
location, intensity, and etiology Listen to descriptive words about
quality, location, radiation Evaluate intensity or severity,
aggravating factors (have patient keep a log)
Impact on activity, mood, mentation, sleep, functioning in daily activities
Detailed History (cont’d)
Previous episodes, relation to physical or stress-related etiological factors
Previous diagnostics and findings Previous treatment and its effects Concurrent medical problems
(cardiac, respiratory, anxiety, depression)
Detailed History (cont’d)
What are the patient’s goals of pain control? Some merely want an accurate
diagnosis Others want total pain relief Most fall somewhere in the
middle
Categorize Type of Pain Bone/Soft Tissue (Somatic) Pain
“tender,” “deep,” “aching” arthritis, myofascial pain, bony mets
Neuropathic Pain “shooting,” “burning,” “stabbing,”
“scalding” trigeminal neuralgia, diabetic
neuropathy, post stroke, reflex sympathetic dystrophy
Visceral Pain “spasms,” “cramping” bowel obstruction, adhesions
Multiple Causes of Pain
Physical Emotional
Anxiety, depression Social
Isolation, abandonment, financial Spiritual
Search for meaning/purpose, being punished
Pain Assessment in Terminal Patients 40-50% of cancer patients report
moderate to severe pain (30% severe)
80% more than one type of pain At least 25% of all cancer patients
die without adequate pain relief due to under treatment
Need aggressive assessment, treatment, and reassessment
Pain Assessment in Cognitively Impaired
Can often verbalize how they feel at the moment
Pain can be just as severe – not able to communicate effectively
Often don’t receive adequate analgesics
Pain Signs in Cognitively Impaired
Facial expressions Verbalizations Body Movement Change in Interaction Change in Activity or Routine Mental Status Changes
Pain Assessment Tools completed by the patient flexible enough to be adapted simple enough to be used
consistently over time
No one scale works for all patients
Pain Assessment Tools Verbal description
No pain---slight---mild---moderate---severe---extreme---worst pain ever
Rating Scale 0-10 with 10 being worst pain ever
experienced 0-5 with 5 being worst pain
Faces Have patient point to most accurate
representation
Pain and Longterm Care “in order to assist long-term care
residents in improving their activities of daily living, decreasing pain is likely to yield the greatest overall improvements”
Cipher and Clifford, International Journal of Geriatric Psychiatry, 2004 Vol. 19: 741-748
Severe Dementia
Found that facial expressions and vocalizations are accurate means for assessing the presence of pain, but NOT its intensity
Manfredi, Journal of Pain and Symptom Management, 2003; 25: 48-52
Observation Assumptions Facial characteristics, body posture, and
movement patterns can indicate the presence of pain
Pain can interfere with ADLs such as dressing and eating
Caregivers can reliably observe and rate such behavior
Villanueva, JAMDA, J/F 2003; 4: 1-8
Pain Assessment for the Dementing Elderly (PADE) PADE Part I (selected items): Physical
“Is the resident frowning? Restless?” PADE Part II: Global Assessment
“Place a mark on the line that you feel best represents the resident’s level of pain at the time of observation”
PADE Part III (selected items): Functional “During the hours that the resident has been
awake, what percentage of time was the resident out of bed?”
Villanueva, JAMDA, J/F 2003; 4: 1-8
Assessment of Chronic Pain
Any persistent or recurrent pain that has significant effect on function or quality of life should be recognized as a significant problem.
For those with cognitive or language impairments, nonverbal pain behavior, recent changes in function, and vocalizations suggest pain as possible cause. Interview caregiver for more information.
Approach to Pain
Need accurate diagnosis Review patient goals Assess, treat, reassess, treat If unsuccessful, review type of
pain and history
Pathophysiology of Nociceptive Pain
Somatic (well localized) or visceral (often referred) -- most often derived from stimulation of pain receptors
May arise from tissue inflammation, mechanical deformation, ongoing injury or destruction.
Examples include inflammatory or traumatic arthritis, myofascial pain syndromes, ischemic disorders
responds well to traditional pain meds
Pathophysiology of Neuropathic Pain
involves central or peripheral nervous system
Often poorly localized, unusual Examples: trigeminal neuralgia, post-
herpetic neuralgia, phantom limb pain, reflex sympathetic dystrophy, poststroke
Poorly responsive to conventional analgesics; may respond to antidepressants, anticonvulsants, or antiarrhythmics
Pathophysiology of Mixed Chronic Pain
Mixed or unknown mechanisms Examples include recurrent
headaches, vasculitic pain syndromes
Treatment often unpredictable, requiring various trials
Pathophysiology of Psychogenic Pain
Psychological factors judged to have a major role in onset, severity, exacerbation, or persistence of pain
Examples include conversion reactions and somatoform disorders
Treatment consists of psychiatric referral and treatment
Pharmacologic Treatment: General Principles “Start low and go slow” Continuity of care
same physician if possible, utilize team approach (social worker, nurse, physical therapist)
Be proactive treat pain and symptoms as they
arise Re-evaluate frequently
Pharmacologic Treatment: General Principles
Regular dosing around the clock Establish good relationship
patient as active, responsible participant
consider use of an opioid contract Document, document, document
symptoms, signs, progression, side effects
consider second opinion
Pharmacologic Treatment: General Principles
Whenever you establish a pain control program, also set up a bowel regimen to prevent constipation!!
Analgesic drugs should supplement other medications directed at definitive treatment of underlying disease
WHO Ladder
1. Mild AspirinAPAPNSAIDs+/-
Adjuvants
2. ModerateCodeineHydrocodoneOxycodoneDihydroxycodon
eTramadol+/- Adjuvants
3. SevereMorphineHydromorpho
neMethadoneLevorphanolFentanylOxycodone+/- Adjuvants
Stepwise Approach to Pain (WHO) Treat “mild to moderate pain” initially
with acetaminophen or NSAIDs acetaminophen has ceiling dose (max
4g) NSAIDs often with GI side effects Consider salsalate (Disalcid) or
trisalicylate (Trilisate) as options to NSAIDs, with less GI effect
Stepwise Approach to Pain Then progress to a mixed agent
(acetaminophen or NSAID with codeine, oxycodone or hydrocodone) or oxycodone alone. acetaminophen/propoxyphene
(Darvocet) considered no more effective than acetaminophen
oxycodone SR (Oxycontin) long acting (12 hrs.) controlled release compound
oxycodone - short acting (4 hours)
WHO Step 3 - Severe morphine sulfate or a derivative
No ceiling dose Long acting morphine sulfate such as MS Contin,
Avinza, Kadian Short acting preparations are available in tablets
(MSIR), rectal suppositories or a highly concentrated sublingual from (Roxanol)
Fentanyl (Duragesic) is available in a transdermal prep that provides pain relief for 72 hours (takes 12 hours to reach a steady state)
AVOID meperidine (Demerol) and mixed agonist
Approach to Pain Fears of drug dependency and
addiction do not justify the failure to relieve pain.
Monitor the side effect of opioid therapy (sedation, hypoxia, myoclonus, pruritus).
Adjuvant Analgesics may decrease total opioid needed NSAIDs often used for musculoskeletal
pain soft tissue and bone involvement limited due to side effects
Tricyclic antidepressants and SSRIs useful in neuropathic pain, insomnia, and depression High doses of TCAs associated with side
effects but often low doses are effective
Adjuvant Analgesics Anticonvulsants effective in neuropathic
pain gabapentin (Neurontin), carbamazepine
(Tegretol) start low and dose upwards
Corticosteroids used in terminal patients to help with bony metastases, increased intracranial pressure, abdominal distention or inflammatory disease Use is limited due to long term side effects
Nonpharmacologic Treatments Alone or in combination with drugs Many modalities exist such as:
Osteopathic manipulation Physical therapy TENS Acupuncture Massage Exercise programs Psychological counseling
Nonpharmacologic Treatments
Biofeedback Hypnosis Relaxation therapy Religious practice Cognitive therapy Herbal medicine Homeopathy
Importance of patient education is paramount--giving patients knowledge gives them control.
Nonpharmacologic Tx Results Body has self regulatory and self
healing abilities Touch alone has been shown to reduce
anxiety and pain Postulated that retraining of nervous
system to reestablish more neural connections through use of exercise and psychologic treatment can effectively diminish chronic pain