Pain Management and Older Adults Module development: Lynne E. Kallenbach MD Asst. Professor of Medicine

Pain Management Pain Management and Older Adultsand Older Adults

Module development:Module development:

Lynne E. Kallenbach MDLynne E. Kallenbach MD

Asst. Professor of MedicineAsst. Professor of Medicine

ObjectivesObjectives

Demographics of pain in older Demographics of pain in older adultsadults

Overview of pain physiologyOverview of pain physiology Discussion of appropriate use of Discussion of appropriate use of

opioids in older adultsopioids in older adults Discussion of other pain treatment Discussion of other pain treatment

modalities for older adultsmodalities for older adults Overview of ACOVE indicators on Overview of ACOVE indicators on

pain managementpain management

Persistent Pain Persistent Pain

Painful experience continuing for Painful experience continuing for prolonged period of timeprolonged period of time

May or may not be associated with May or may not be associated with a recognizable disease processa recognizable disease process

Common in older adultsCommon in older adults- - 1 in 5 older Americans are taking analgesic 1 in 5 older Americans are taking analgesic meds regularlymeds regularly- 63% of them had taken prescription pain - 63% of them had taken prescription pain meds for >6 monthsmeds for >6 months

Persistent PainPersistent Pain

Degenerative joint diseaseDegenerative joint disease Chronic back painChronic back pain Myofascial pain syndromesMyofascial pain syndromes Peripheral vascular diseasePeripheral vascular disease Neuropathic painNeuropathic pain Post-stroke syndromesPost-stroke syndromes HeadacheHeadache Crystal arthropodiesCrystal arthropodies Osteoporosis with fractureOsteoporosis with fracture Oral pathologyOral pathology RLSRLS

Persistent PainPersistent Pain

Very little research focuses on Very little research focuses on pain syndromes in the elderlypain syndromes in the elderly

Multiple treatment options are Multiple treatment options are availableavailable

Opioid use can be safeOpioid use can be safe

ACOVE IndicatorsACOVE Indicators

Assessing Care of Vulnerable EldersAssessing Care of Vulnerable Elders Comprehensive set of quality Comprehensive set of quality

assessment tools for ill older adultsassessment tools for ill older adults- - Covering domains of prevention, diagnosis, Covering domains of prevention, diagnosis, treatment, and follow uptreatment, and follow up

- Both hospital based and ambulatory based indicators- Both hospital based and ambulatory based indicators

Designed to evaluate health care at Designed to evaluate health care at system level rather than individual levelsystem level rather than individual level

ACOVE IndicatorACOVE Indicator

ALLALL vulnerable elders vulnerable elders should be screened during should be screened during the initial evaluation periodthe initial evaluation periodBECAUSE BECAUSE older people older people commonly have pain that commonly have pain that goes unrecognized by goes unrecognized by health care providershealth care providers

Annals of Internal MedicineOct. 16, 2001Vol. 135 No.8 pp 731-5


ALL ALL vulnerable elders vulnerable elders should be screened for should be screened for chronic pain every 2 yearschronic pain every 2 yearsBECAUSEBECAUSE older people older people commonly have pain that commonly have pain that goes unrecognized by goes unrecognized by health care providershealth care providers



IF IF a vulnerable elder has a newly a vulnerable elder has a newly reported chronic painful conditionreported chronic painful condition

THENTHEN treatment should be offered treatment should be offered

BECAUSEBECAUSE treatment may provide treatment may provide significant relief and improve significant relief and improve quality of life and health statusquality of life and health status


Persistent painPersistent pain

In general, pain is under-treated In general, pain is under-treated in older adultsin older adults

Untreated pain is associated withUntreated pain is associated with- decreased functiondecreased function- depression/ anxiety- depression/ anxiety- sleep disturbances- sleep disturbances

Being used as quality indicatorBeing used as quality indicator

Reasons for Reasons for UndertreatmentUndertreatment Both physician and patient based Both physician and patient based

concernsconcerns- regulatory- regulatory

- “ it’s just because I’m old”- “ it’s just because I’m old”

- concerns about cost, possible side - concerns about cost, possible side effectseffects

- addiction / tolerance concerns- addiction / tolerance concerns

- problems with assessment- problems with assessment


IFIF a vulnerable elder has a newly a vulnerable elder has a newly reported chronic painful conditionreported chronic painful conditionTHENTHEN a targeted history and a targeted history and physical examination should be physical examination should be initiated within 1 monthinitiated within 1 monthBECAUSEBECAUSE appropriate treatment appropriate treatment of the condition and pain of the condition and pain management require that the management require that the nature of the condition be nature of the condition be understoodunderstood


Pain AssessmentPain Assessment

HistoryHistory Can be difficult to assess in Can be difficult to assess in

demented patientsdemented patients Evaluate pain by self-report (tools Evaluate pain by self-report (tools

below), behavioral, or physiologic below), behavioral, or physiologic measuresmeasures

Most tools / graphs frequently Most tools / graphs frequently assess pain assess pain intensityintensity

Assessment ToolsAssessment Tools

Visual Analogue ScalesVisual Analogue Scales Facial Pain ScalesFacial Pain Scales Numeric Rating ScalesNumeric Rating Scales Verbal Rating ScalesVerbal Rating Scales Multidimensional toolsMultidimensional tools

McGillMcGillPain mapPain map

May be more of a global view, effect on May be more of a global view, effect on function function

Multiple others – at least 12 different Multiple others – at least 12 different behavioral based tools for patients with behavioral based tools for patients with dementia dementia

PainPain

Pain categorized asPain categorized as

- Nociceptive- Nociceptive

* somatic* somatic

* visceral* visceral

- Neuropathic- Neuropathic

Nociceptive PainNociceptive Pain

SomaticSomaticSomatic NSSomatic NSSkin, muscle, soft Skin, muscle, soft tissue, bonetissue, boneEasier to localizeEasier to localizeSharp, throbbing, Sharp, throbbing, constant, achingconstant, aching

VisceralVisceralAutonomic NSAutonomic NSMore stretch/ More stretch/ chemical receptorschemical receptorsHarder to describe Harder to describe and localize – may and localize – may be constant or come be constant or come in wavesin wavesCardiac, lung, GI, Cardiac, lung, GI, GU tractsGU tracts

Pain Pathways - UpPain Pathways - Up

Stimulation of peripheral nociceptorsStimulation of peripheral nociceptors Travel along small myelinated A and Travel along small myelinated A and

unmyelinated C fibers to DRGunmyelinated C fibers to DRG Signals travel from dorsal horn to thalamus Signals travel from dorsal horn to thalamus

along spinothalamic tractalong spinothalamic tract Then on to the primary and secondary Then on to the primary and secondary

somatosensory cortices, amygdalasomatosensory cortices, amygdala

http://www.perioperativepain.com/Neuroanatomy_of_Pain.htm

Pain PathwaysPain Pathways

Descending pathways can modulate Descending pathways can modulate activity in dorsal horn – “gating”activity in dorsal horn – “gating”

““Wind-up” phenomenon in DRGWind-up” phenomenon in DRGNMDA receptor fires in response to repeated pain stimulusNMDA receptor fires in response to repeated pain stimulus

Releases glutamate, activating other secondary pain Releases glutamate, activating other secondary pain receptors in spinal cordreceptors in spinal cord

Augmentation of pain stimulus in spinal cord going upAugmentation of pain stimulus in spinal cord going up

Arborization in DRGArborization in DRG

Pain Pain

Sensitization occurs with chronic Sensitization occurs with chronic painpainInjured/ chronically stimulated nerves fire w/o Injured/ chronically stimulated nerves fire w/o stimulus stimulus

Happens when pain inadequately treated Happens when pain inadequately treated over timeover time

Can explain why chronic pain may not seem Can explain why chronic pain may not seem to have direct cause clinicallyto have direct cause clinically

So what works where?So what works where?

Peripheral nociceptorsPeripheral nociceptorslocal anesthetics, anti-inflammatorieslocal anesthetics, anti-inflammatories

Dorsal hornDorsal hornlocal anesthetics, opioids, alpha2 antagonistslocal anesthetics, opioids, alpha2 antagonists

CentralCentralopiods, alpha 2 antagonistsopiods, alpha 2 antagonists

Modalities for RxModalities for Rx

Non- pharmacologic/ Non- systemic Non- pharmacologic/ Non- systemic Non-opioidNon-opioid

- acetominophen- acetominophen- NSAIDs/ COX-2 –I- NSAIDs/ COX-2 –I

may require caution in older adultsmay require caution in older adults- Steroids- Steroids

OpioidsOpioids Adjunctive (neuropathic)Adjunctive (neuropathic)

- Anti-convulsants- Anti-convulsants- Steroids- Steroids- TCAs- TCAs

Interventional modalitiesInterventional modalities

Non-pharmacologic/ Non-pharmacologic/ non-systemicnon-systemic Pain education programsPain education programs Behavioral modificationBehavioral modification Physical therapy- Physical therapy- massage, heat, ice, massage, heat, ice,

ultrasoundultrasound

Other exercise therapy Other exercise therapy Topical analgesicsTopical analgesics NeurostimulationNeurostimulation

General PrinciplesGeneral Principles

Chronic pain needs chronic medicineChronic pain needs chronic medicine Stepwise approachStepwise approach Nociceptive pain generally responds to Nociceptive pain generally responds to

acetominophen, opioids, anti-acetominophen, opioids, anti-inflammatoriesinflammatories

Neuropathic pain responds to neuropathic Neuropathic pain responds to neuropathic agents and, less well, to opioidsagents and, less well, to opioidsMechanism: Na+ channel blockade, upregulation of GABA in Mechanism: Na+ channel blockade, upregulation of GABA in spinal cord, upregulation of norepi/ serotonin in cord and cortex – spinal cord, upregulation of norepi/ serotonin in cord and cortex – all modulate transmission of pain signal on peripheral nerve or in all modulate transmission of pain signal on peripheral nerve or in CNSCNS

Adapted from WHO 1990


IFIF a vulnerable elder has been a vulnerable elder has been prescribed a nonselective non-steroidal prescribed a nonselective non-steroidal anti-inflammatory drug (NSAID) for the anti-inflammatory drug (NSAID) for the treatment of chronic pain treatment of chronic pain THENTHEN the medical record should the medical record should indicate whether he or she has a h/o of indicate whether he or she has a h/o of PUD and, if hx is present, justification of PUD and, if hx is present, justification of NSAID use should be documentedNSAID use should be documentedBECAUSEBECAUSE older patient with a hx of PUD older patient with a hx of PUD who receive NSAIDs are @ significant who receive NSAIDs are @ significant risk for recurrent disease and risk for recurrent disease and complicationscomplications


CaseCase

The patient is an 82 year old frail The patient is an 82 year old frail female, hospitalized for pain female, hospitalized for pain control after several acute control after several acute vertebral compression fractures. vertebral compression fractures. Outpatient pain management has Outpatient pain management has not been successful. She has lost not been successful. She has lost some weight and has early some weight and has early dementia. Where do you start?dementia. Where do you start?

Case, cont’dCase, cont’d

Pain assessmentPain assessment- - Including complete H&PIncluding complete H&P- Nature and severity of pain- Nature and severity of pain

Analgesia historyAnalgesia history Other considerations?Other considerations?

She is started on a continuous She is started on a continuous morphine IV infusion given morphine IV infusion given chronicity of the pain in the acute chronicity of the pain in the acute phase.phase.

A Brief Review…A Brief Review…

PharmacodynamicsPharmacodynamics- - Change with ageChange with age

* numbers of receptors* numbers of receptors* sensitivity of receptors* sensitivity of receptors* Counter regulatory mechanisms* Counter regulatory mechanisms

- Increase in receptor response is - Increase in receptor response is noted with opioidsnoted with opioids- Not as well understood as - Not as well understood as pharmacokineticspharmacokinetics

A Brief Review, cont’dA Brief Review, cont’d

PharmacokineticsPharmacokinetics- Absorption- Absorption

overall amt unchangedoverall amt unchanged

- Distribution- Distributionincreased Vd for lipophilic drugsincreased Vd for lipophilic drugs

- Metabolism- Metabolismgenerally prefer phase 2, less interaction and generally prefer phase 2, less interaction and

active metabolitesactive metabolites

- Elimination- Eliminationdecreased renal functiondecreased renal function

And now a little about And now a little about opioids…opioids… Bind to one or more of the opiate Bind to one or more of the opiate

receptors (mu, kappa, delta)receptors (mu, kappa, delta) Mu receptor is 7 transmembrance G Mu receptor is 7 transmembrance G

protein coupled receptorprotein coupled receptor- - binding stabilizes the membrane so neuron binding stabilizes the membrane so neuron doesn’t firedoesn’t fire

Where are the mu receptors?Where are the mu receptors?- periphery, dorsal root ganglia of spinal cord, - periphery, dorsal root ganglia of spinal cord, periaqueductal grey of brainstem, midbrain, gutperiaqueductal grey of brainstem, midbrain, gut

OpioidsOpioids

Metabolism mostly in liverMetabolism mostly in liver

- First pass may take away significant - First pass may take away significant amt of oral drugamt of oral drug

- But with advanced liver dz, 1st pass - But with advanced liver dz, 1st pass is bypassedis bypassed

OpioidsOpioids

““weak” opioidsweak” opioids- codeine- codeine- hydrocodone- hydrocodone- oxycodone- oxycodone

““strong” opioidsstrong” opioids- hydromorphone- hydromorphone- fentanyl- fentanylmorphine- morphine

OpioidsOpioids

DistributionDistribution- HydrophilicHydrophilic

* morphine, oxycodone, * morphine, oxycodone, hydromorphonehydromorphone

- LipophilicLipophilic

* fentanyl, methadone* fentanyl, methadone

OpioidsOpioids

IV- IV- morphine, hydromorphone, fentanylmorphine, hydromorphone, fentanyl PO- PO- morphine (LA & SA), oxycodone (LA & morphine (LA & SA), oxycodone (LA &

SA), hydromorphone, methadone, fentanyl, SA), hydromorphone, methadone, fentanyl, hydrocodonehydrocodone

Transdermal- Transdermal- fentanylfentanyl Initial decisions based on Initial decisions based on

- route of administration- route of administration- need for continuous vs. intermittent dosing- need for continuous vs. intermittent dosing- severity of pain- severity of pain

LA= long actingLA= long actingSA= short actingSA= short acting

Intravenous OpioidsIntravenous Opioids

MorphineMorphine- “gold standard”- “gold standard”

FentanylFentanyl - synthetic - synthetic

- 80-100 x potency of morphine- 80-100 x potency of morphine- no histamine release thus less - no histamine release thus less hemodynamic effecthemodynamic effect

HydromorphoneHydromorphone- semisynthetic morphine derivative- semisynthetic morphine derivative

Oral TherapyOral Therapy

Oxycodone and hydrocodone Oxycodone and hydrocodone combinations commoncombinations common

- dosing limited by acetominophen - dosing limited by acetominophen contentcontent

When titrating for relief, will need When titrating for relief, will need close follow-upclose follow-up- then can convert short acting needs to long - then can convert short acting needs to long acting needs if requiredacting needs if required

Opioids-PharmacologyOpioids-Pharmacology

All water soluble opioids behave similarly:All water soluble opioids behave similarly: Cmax is 60-90 minutes after PO doseCmax is 60-90 minutes after PO dose

30 minutes after SQ or IM30 minutes after SQ or IM

6-10 minutes after IV dose6-10 minutes after IV dose All are conjugated in liver and 90% All are conjugated in liver and 90%

excreted via the kidneyexcreted via the kidney With normal renal fx, all have ½ life of 3-4 With normal renal fx, all have ½ life of 3-4

hours, reach steady state in 4-5 ½ liveshours, reach steady state in 4-5 ½ lives


You are rounding on your patient You are rounding on your patient and note that she seems and note that she seems agitated. Her family has noted agitated. Her family has noted that she has been twitching. What that she has been twitching. What is your assessment? What can is your assessment? What can you do?you do?


IF IF a vulnerable elder is treated a vulnerable elder is treated for a chronic painful conditionfor a chronic painful conditionTHEN THEN s/he should be assessed for s/he should be assessed for a response within 6 monthsa response within 6 monthsBECAUSE BECAUSE initial treatment is often initial treatment is often incompletely successful, and incompletely successful, and reassessment may be needed to reassessment may be needed to achieve the most favorable achieve the most favorable outcome.outcome.


Special NotesSpecial Notes

MorphineMorphine

- low protein binding- low protein binding

- dialyzes off- dialyzes off

- active metabolite is morphine 6- - active metabolite is morphine 6- glucuronide (10%)glucuronide (10%)

* accumulates in renal failure and * accumulates in renal failure and causes neuroexcitationcauses neuroexcitation

* prolonged CNS effects* prolonged CNS effects


Your patient has mildly decreased Your patient has mildly decreased renal functionrenal function

The twitching is myoclonus The twitching is myoclonus related to the metabolites from related to the metabolites from the morphinethe morphine

You change her to a dilaudid You change her to a dilaudid infusion and ultimately to infusion and ultimately to sustained release oxycodonesustained release oxycodone


FentanylFentanyl

- little or no active metabolites- little or no active metabolites

- Not dialyzable- Not dialyzable

- Elderly more sensitive to effects - Elderly more sensitive to effects lipophilic so larger Vdlipophilic so larger Vd

- Unclear how TD route is affected by - Unclear how TD route is affected by low subcutaneous fatlow subcutaneous fat


HydromorphoneHydromorphone

- Generally considered to have inactive - Generally considered to have inactive metabolitesmetabolites

- Drug of choice with renal failure- Drug of choice with renal failure


OxycodoneOxycodone

- - Undergoes phase I metabolismUndergoes phase I metabolism

- 10% of the metabolites are - 10% of the metabolites are oxymorphone, which is 14x as strong oxymorphone, which is 14x as strong as oxycodoneas oxycodone


HydrocodoneHydrocodone

- Dosing limited by combination agent- Dosing limited by combination agent

- half life elimination ~ 4 hours- half life elimination ~ 4 hours

- onset of analgesia ~ 10-20 min- onset of analgesia ~ 10-20 min


MethadoneMethadone- binds mu and blocks NMDA receptorsbinds mu and blocks NMDA receptors- highly protein boundhighly protein bound

older adults may have more free/ active older adults may have more free/ active drug drug

- highly variable and prolonged half lifehighly variable and prolonged half life- Phase I metabolism and may prolong the Phase I metabolism and may prolong the

QT intervalQT interval- caution when changing from another caution when changing from another

opioid to methadoneopioid to methadonenon-linear conversionnon-linear conversion

Potential opioid side Potential opioid side effectseffects NauseaNausea CNS depression/ sedationCNS depression/ sedation PruritisPruritis ConstipationConstipation DeliriumDelirium Endocrine dysfunction with long Endocrine dysfunction with long

term useterm use

ACOVE IndicatorsACOVE Indicators

IF IF a vulnerable elder with chronic pain is a vulnerable elder with chronic pain is treated with opioidstreated with opioidsTHENTHEN s/he should be offered a bowel regimen s/he should be offered a bowel regimen or the medical record should document with or the medical record should document with potential for constipation or explain why potential for constipation or explain why bowel treatment is not neededbowel treatment is not neededBECAUSEBECAUSE opiate analgesics produce opiate analgesics produce constipation that may cause severe constipation that may cause severe discomfort and may contribute to inadequate discomfort and may contribute to inadequate pain treatment because patients may then pain treatment because patients may then minimize analgesic useminimize analgesic use


Other NotesOther Notes

Certain opioids generally avoided in Certain opioids generally avoided in the elderlythe elderly- propoxyphene- propoxyphene

not any more effective, more cognitive side effectsnot any more effective, more cognitive side effects

- meperidine- meperidinemetabolite with long T ½ and no analgesic metabolite with long T ½ and no analgesic

qualities, “stacking” phenom >>> lower seizure qualities, “stacking” phenom >>> lower seizure thresholdthreshold

- tramadol- tramadollowers seizure threshold, increases risk for lowers seizure threshold, increases risk for

interaction >>> serotonin syndromeinteraction >>> serotonin syndrome

Opioids and Older Opioids and Older AdultsAdults Appropriate for persistent pain, Appropriate for persistent pain,

both malignant and non-both malignant and non-malignantmalignant

Generally utilized for non-Generally utilized for non-malignant pain after other options malignant pain after other options have failedhave failed

Opioids and Older Opioids and Older AdultsAdults Should always be accompanied by Should always be accompanied by

a bowel regimena bowel regimen May need to clarify with patients May need to clarify with patients

and facilities about extended and facilities about extended release formulationsrelease formulations

Do not crush! Long acting preps available for Do not crush! Long acting preps available for PEG tubesPEG tubes

If utilizing long acting preparations, If utilizing long acting preparations, may still need breakthrough dosesmay still need breakthrough doses

Pain Management and Pain Management and Older AdultsOlder Adults Prescribing decisions based onPrescribing decisions based on

- chronicity of pain- chronicity of pain- severity of pain- severity of pain- type of pain- type of pain- other p-dynamic and p-kinetic - other p-dynamic and p-kinetic concernsconcerns- side effect profiles- side effect profiles

And the geriatrician’s mantraAnd the geriatrician’s mantra- START LOW AND GO SLOW- START LOW AND GO SLOW

Pain Management and Pain Management and Older AdultsOlder Adults Need frequent re-assessmentNeed frequent re-assessment

- effectiveness of analgesia- effectiveness of analgesia- ADLs/ functional status- ADLs/ functional status- adverse effects- adverse effects

constipationconstipation

- ? unusual behaviors- ? unusual behaviorsmay be a sign of an adverse drug effectmay be a sign of an adverse drug effect

““If we know that pain and suffering can be If we know that pain and suffering can be alleviated, and we do nothing about it, alleviated, and we do nothing about it, then we ourselves become the then we ourselves become the tormentors.” tormentors.” Primo Levi Primo Levi

“I must die. But must I die groaning?”“I must die. But must I die groaning?”Epictetus, 135 ADEpictetus, 135 AD

Acknowledgements/ Acknowledgements/ ReferencesReferences AGS Panel on Persistent Pain in Older Persons, “The Management of Persistent AGS Panel on Persistent Pain in Older Persons, “The Management of Persistent

Pain in Older Persons, Pain in Older Persons, JAGSJAGS, 50:S205-224, 2002., 50:S205-224, 2002. Dr. Karin Porter-Williamson, Medical Director of Palliative Care Consultation Team Dr. Karin Porter-Williamson, Medical Director of Palliative Care Consultation Team

at KUMCat KUMC Ballantyne and Mao, Opioid Therapy for Chronic Pain, Ballantyne and Mao, Opioid Therapy for Chronic Pain, NEJMNEJM, 349:20, Nov. 2003., 349:20, Nov. 2003. Burris J, “Pharmacologic Approaches to Geriatric Pain Management,” Burris J, “Pharmacologic Approaches to Geriatric Pain Management,” Arch Phys Arch Phys

Med RehabilMed Rehabil Vol 85, Suppl. 3, July 2004. Vol 85, Suppl. 3, July 2004. Chodosh J et al,” Quality Indicators for Pain Management in Vulnerable Elders,” Chodosh J et al,” Quality Indicators for Pain Management in Vulnerable Elders,”

Annals of Internal MedicineAnnals of Internal Medicine, Vol. 135 No.8, Oct. 16, 2001., Vol. 135 No.8, Oct. 16, 2001. Dworkin et al, “Pharmacologic Treatment of Chronic Pain in Elderly”, Dworkin et al, “Pharmacologic Treatment of Chronic Pain in Elderly”, Annals of Annals of

Long-Term CareLong-Term Care, 12(6):S1-S10, 2004., 12(6):S1-S10, 2004. Fick et al, Upadating the Beers Criteria for Potentially Inappropriate Medications in Fick et al, Upadating the Beers Criteria for Potentially Inappropriate Medications in

Older Adults, Older Adults, Archives of Internal MedicineArchives of Internal Medicine, Vol. 163, Dec. 2003., Vol. 163, Dec. 2003. Fine P., “Pharmacological Management of Persistent Pain in Older Adults,”Fine P., “Pharmacological Management of Persistent Pain in Older Adults,” Clin J Clin J

Pain,Pain, Vol 20 No.4, July/August 2004. Vol 20 No.4, July/August 2004. Journal of the American Geriatrics Society 50:S205-S224, 2002Journal of the American Geriatrics Society 50:S205-S224, 2002 Podichetty et al, Chronic non-malignant musculoskeletal pain in older adults: Podichetty et al, Chronic non-malignant musculoskeletal pain in older adults:

clinical issues and opioid intervention, clinical issues and opioid intervention, Postgraduate Medicine, Postgraduate Medicine, 2003.2003. Schneider J, Chronic pain management in older adults, Schneider J, Chronic pain management in older adults, GeriatricsGeriatrics, 60:5, May 2005., 60:5, May 2005. Zwakhalen S et al, “Pain in elderly people with severe dementia: A systematic Zwakhalen S et al, “Pain in elderly people with severe dementia: A systematic

review of behavioural pain assessment tools,” review of behavioural pain assessment tools,” BMC GeriatricsBMC Geriatrics, Vol6, No.3, Jan. , Vol6, No.3, Jan. 2006.2006.

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Pain Management and Older Adults Module development: Lynne E. Kallenbach MD Asst. Professor of Medicine