Pain / Palliation of Older Adults

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Objectives

• Identify the incidence of pain in older adults

• Assess pain using client self-report and / or validated pain instrument

• Discuss barriers to pain relief in the older adult

• Identify problems and strategies in assessing pain in cognitively impaired older adults

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Objectives

• Describe adverse consequences associated with pain in older adults

• Identify considerations and specific strategies in treating pain in older adults

• Plan care for assessing and managing pain in an older adult, combining traditional and alternative pain treatment strategies

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Objectives

• Explain the dimensions of palliative care

• Identify the dimensions of quality of life

• Describe assessment parameters important in palliative care

• Describe the nurse’s role in supporting a multidisciplinary team approach to palliative and end-of-life care and identify the rationale for the team approach to care management

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Pain defined……

• Pain – unpleasant sensory emotional suffering experience

• “Whatever the experiencing person says it is, existing whenever he says it does? (McCaffery)

• Acute v. chronic pain

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Incidence• Prevalence of chronic pain

increases with age; increases 3X between 18 – 80 years of age

• 50% of community dwelling older adults; 70% - 80% of nursing home residents

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Incidence

• Associated with chronic and degenerative conditions with adverse consequences – osteoarthritis, degenerative musculoskeletal processes, cardiovascular system, fractures, neuropathy, bone and joint disorders, back problems, and phantom limb pain

• Pain is undertreated

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Assessment

• Most accurate evidence: client’s description and self-report

• ASK at regular and frequent intervals

• Reluctance to report pain – fear of tests or medication side effects; metaphor for death, atonement for past actions

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Assessment

• Intensity, quality, onset, duration, expression, aggravating factors, relief factors

• Examples of Assessment Instruments

– Try This Assessment Series• Assessing Pain in Older Adults• Assessing Pain in Persons with Dementia

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Assessment Instruments

Visual Analog Scale

Verbal Descriptor Scale

Visual Analog Scale (VAS)No Unbearabledistress distress|___________________________________________________________|| |

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Assessment Instruments

Wong-Baker FACES Scale

FACES Pain Scale - Revised

Figure 1. From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong’s Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p.1301. Copyrighted by Mosby, Inc. Reprinted by permission.

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Assessment Instruments

• Numerical Scale0-10 Numeric Pain Distress Scale

No Distressing Unbearablepain pain pain|_____|_____|_____|_____|_____|_____|_____|_____|_____|_____|| | | | | | | | | | |0 1 2 3 4 5 6 7 8 9 10

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Barriers to Assessment and Pain Relief• Older patients experience less pain

• Older patients cannot tolerate opioids.

• Failure to apply standardized assessment instruments.

• Cognitively impaired older adult cannot be assessed for pain.

• Misinterpretation of behavior as being unrelated to pain.

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Assessment of Cognitively Impaired Older Adult• Non-verbal pain behavior

• Recent changes in function and vocalization

• Moaning, crying, withdrawal or agitation

• Use objective pain assessment instruments:

• Accommodate for sensory losses, fatigue, slower processing, timing

• Present pain vs. recalled pain; evaluate analgesic use

• Caregiver Reports

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Adverse Consequences

• Decreased quality of life

• Depression

• Decreased socialization

• Sleep disturbances

• Impaired ambulation

• Suicidal ideation

• Decreased appetite and food intake

• Increased health care utilization and cost

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Considerations

• Physiologic changes influence pharmacodynamics and pharmacokinetics

• Assess every older adult for evidence of chronic pain

• Continue to treat until patient is comfortable

• Underlying conditions must be treated

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Considerations

• Pain Log or Diary

• Reassess regularly for improvement, deterioration, or complications

• Know and recognize physiological, psychological, and emotional responses to pain

• Oral medications are best for long-term management

• Be prepared to treat the side effects

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Pharmacologic Treatment

• Least invasive route – careful titration, frequent assessment, adjustments, monitoring and managing side effects

• WHO Ladder: non-opioid, low-potency opioids, high-potency opioids

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Pharmacologic Treatment

• SHORT TERM: fast-onset, short-acting analgesic

• MILD-TO-MODERATE pain: Acetaminophen

• EPISODIC or CHRONIC PAIN: opioid analgesics

• Monitor patients using NSAIDs – contraindicated with abnormal renal function, peptic ulcer, bleeding

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Pharmacologic Treatment

Precautionary measures:

• Encourage extra fluid

• Exercise

• Combination stool softener and non-bulk-forming laxative

• Patient safety concerns

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Nonpharmacologic Strategies

• Education program• Cognitive program: imagery,

relaxation, biofeedback, hypnosis• Behavioral program• Exercise• Acupuncture• Physical methods: heat, cold, massage• Chiropractic• Spiritual healing

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Assessing and Managing Pain• Based on Nursing Diagnosis:

Alteration in Comfort

• Determine tolerable level of pain, activity, sedation

• Integrate pharmacological and nonpharmacological strategies

• Ongoing evaluation

• Teach nursing assistants to use scales to assess and identify pain

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WHO definition….

…….the active total care of patients .the active total care of patients whose disease is not responsive whose disease is not responsive to curative treatment.to curative treatment.

• Enhance maximum comfort and function

• Open and active communication among patient, family and other disciplines

• Holistic intervention

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Goal of Palliative Care

……to prevent and relieve to prevent and relieve suffering and to support the suffering and to support the best possible quality of life for best possible quality of life for patients and their families, patients and their families, regardless of the stage of the regardless of the stage of the disease or the need for other disease or the need for other therapies.therapies.

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Dimensions of Quality of Life• Physical

• Function

• Interpersonal

• Well-being

• Transcendent

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Assessment Parameters

• Physical, psychosocial, and spiritual problems

• Accomplishment of developmental tasks of life

• Family dynamics / relationship issues / opportunities

• Grief / loss / bereavement issues• Functional status / environmental

status

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Nurse’s role• Identifies patient and family needs

• Recruits health care team members

• Coordinate interdisciplinary pain program and manage chronic coexisting problems

• Identify patient appropriateness for Hospice services

• Encourage family to participate in goals, processes and evaluation of care

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Summary

• Incidence of pain in older adults

• Pain assessment – instruments and scales

• Barriers to pain relief

• Problems and strategies in assessing pain in patients with cognitive impairment

• Adverse consequences

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Summary

• Considerations and treatment strategies: pharmacologic and nonpharmacologic

• Dimension of palliative care and quality of life

• Assessment parameters in palliative care

• Nurse’s role: interdisciplinary coordination