Question #1What is the analgesic of choice for mild to moderate knee pain due to osteoarthritis in a 78 year old female patient?

A. AcetaminophenB. AspirinC. Celocoxib D. PropoxypheneE. Tramadol

Question #2You are in the ED treating a 78 year old female patient with a history of breast cancer treated 7 years prior with surgery, chemotherapy, and radiation. She complains of severe, unrelenting pain in her low back without radicular symptoms or bowel or bladder dysfunction. The pain has been present for 3 months as a nagging ache, but, for the past 3 days, it has been unbearable. Her BP is 150/100, pulse 105, RR 18, Temp 98.8, pulse ox 96% on room air. What is the appropriate intravenous dose of morphine in mgs per kilogram of body weight to treat her pain?A. 0.01 mg/kgB. 0.05 mg/kgC. 0.10 mg/kgD. 1.00 mg/kgE. 2.50 mg/kg

Question #3Which of the following classifications best describes pain in the elderly resulting from inflammation, musculoskeletal, or ischemic disorders?

A. Limbic system mediatedB. NocioceptiveC. NeuropathicD. Parasympathetic mediatedE. Sympathetic mediated

Acute And Chronic Pain Management In The

ElderlyHenry R. Schuitema, D.O., FACOEP

Medical DirectorDepartment of Emergency Medicine

Kennedy Health SystemsStratford Campus

Acute And Chronic Pain Management In The Elderly

This Care of the Aging Medical Patient in the Emergency Room (CAMPER) presentation is offered by the Department of Emergency Medicine in coordination with the

New Jersey Institute for Successful Aging.This lecture series is supported by an educational

grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

Learning Objectives• Perform a comprehensive, multi-dimensional

assessment of the elderly patient presenting to the ED with acute or chronic pain

• Evaluate for untreated pain as the causative factor of agitation or delirium in older patients

• Increase awareness of untreated pain and use of non-verbal cues in agitated elderly patients with impairments in hearing, speech and cognitive function

• Identify both rapidly and accurately the patient’s goals of care and develop an appropriate, patient-centered plan of treatment for pain control

Learning Objectives, Cont.• Discuss safety measures for the prevention of

common ED iatrogenic pain complications from indwelling Foley catheters, central line placement, and endotracheal intubation

• Prescribe and appropriately dose medications for the treatment of acute or chronic pain

• Exercise caution when prescribing analgesic medications that increase morbidity in older patients

• Manage opioid related side effects

Case 1• 79 year old woman presents with newly

diagnosed recurrent metastatic breast cancer to bone and liver with underlying COPD. Her COPD has progressed over recent years leaving her oxygen and steroid dependent.

• Her recent pathologic hip fracture results in daily pain and her dyspnea is difficult to control.

• She is weakened by chronic anemia from PUD. • Constipation and anxiety are daily concerns.

Aging In The United States

• 1900 – 3.1 million elderly• 2000 – 35 million elderly• 2020 – 54 million elderly**Incidence of pain increases as we age

What Is Pain

• An unpleasant sensory and emotional experience associated with actual or potential tissue damage

• Pain is whatever the person experiencing it says it is

• “Discomfort Management”

Oligoanalgesia

• The failure to recognize/treat pain• Risk factors

– Advanced Age– Minorities

• Failure to detect• Joint Commission – “5th Vital Sign”

Reason For Oligoanalgesia

• Lack of training• Inappropriate pain assessment• Reluctance to prescribe opioids

Consequences Of Untreated Pain

• Negatively impact on quality of life• Depression and anxiety• Social isolation• Cognitive impairment• Sleep disturbances

Pain ManagementProvider Responsibilities

• Pain relief is a moral and ethical professional responsibility

• Providers must help patients make their own decisions and determine their own actions

• Assessment focused on individual as a whole person and their response to pain

Pain Assessment Tools

• The Brief Pain Inventory– Measures severity of pain– Degree to which it interferes with life

Pain Severity• Worst Pain• Least Pain• Average Pain• Pain Now

Interference• Relations with

others• Enjoyment of life• Mood• Sleep• Walking• General Activity• Working

Pain Assessment

• The Short Form McGill Pain Questionnaire– Descriptor of pain graded on a scale

0,1,2,3– Present Pain Intensity on scale 0-5

Pain Assessment

• Assessment in the ED must be rapid• Report of pain intensity and other

descriptors• Past pain history and medication

history• Ongoing monitoring of pain

intensity, duration, response• Comprehensive assessment should

be delayed

Obstacles To Pain Assessment

• Older patients fail to report pain (they view it as part of aging, don’t want more testing and medications)

• Accept as punishment for past actions

• Frequently deny pain – use terms like aching or sore

• Communication and cognitive status

Classification Of Pain

• Nociceptive• Neuropathic• Combination

Nociceptive Pain

• Visceral or Somatic• Stimulation of pain receptors• Inflammation, musculoskeletal,

ischemic disorders• Typically respond to both opioid and

non-opioid therapy (and other non-pharmacologic treatment)

Neuropathic Pain

• Pathophysiologic disturbance of peripheral and central nervous system

• Examples: Post-herpetic neuralgia and diabetic neuropathy

• Respond better to anticonvulsants and antidepressants

• Pain of mixed origins – combination therapy

Management Of Acute Pain

• Combination of opioid/non-opioid analgesics

• Addition of adjunct medications• Non-pharmacologic interventions

Pharmacologic Management Of Pain In Elderly

• Principal treatment modality for pain• Significant adverse drug reactions• Drug/drug and drug/disease

interactions• Typically requires trials of various

agents

Pharmacologic ManagementGeneral Principles

• Non-opioid mild pain• Opioids for severe pain• Select the agent that targets the

issue• Neuropathic – anticonvulsants• Start Low and GO Slow

Non-Opioid Analgesics

• Mild to moderate musculoskeletal pain

• Acetaminophen– no effect platelet aggregation– no anti-inflammatory properties– well tolerated if no renal/hepatic failure– do not exceed 2 gm/day

Non-Opioid Analgesia

• NSAIDS• Significant Risk in Elderly

– GI Bleeding– Platelet dysfunction– Impaired coagulation

• Prolonged use in elderly should be avoided

Opioid Analgesia

Cornerstone of acute pain management

– Proper drug selection– Route of administration– Initial dose– Frequency of administration– Adjunct agent– Side effects

Opioid Potency

• Fentanyl• Hydromorphone• Morphine• Oxycodone

Route Of Administration

• Intravenous preferred route• Intramuscular should be avoided• Inhaled very effective• Oral mainstay in ambulatory ED

setting• Transdermal great outpatient

Dose And Frequency

• Start low and go slow!!!• Elderly at risk oligoanalgesia and

pharmaco-complications• Many elderly opioid naïve

Adjunct Agents/Side Effects

• Anticipate, prevent, manage• Nausea and itching• Over-sedation• Prophylactic bowel regimens• Avoid chewing/crushing sustained

release products

Specific Painful Conditions

• Head Injuries• Migraines• Chest Pain• Abdominal Pain• Fracture/Dislocations

Painful Procedures

• Foley Catheters• Central Venous Access• Endotracheal Intubation• Cardioversion

Chronic Pain

• Painful condition lasting longer than 3 months

• 4 types– Pain persisting beyond normal healing

time– Pain relating to chronic degenerative

disease– Cancer related pain– Pain without identifiable cause

Chronic PainGoals Of Therapy

• Pain reduction• Return to functional status

Epidemiology Of Chronic Pain

• 1/3 of population affected• Caused by chronic pathologic

process to organ system• Caused by prolonged dysfunction of

peripheral/central nervous system• Frequently psychiatric issues in play

Psychological CharacteristicsOf Chronic Pain Patients

• Misuse of narcotics• Tendency to “Doctor shop”• Bodily impairment related to

physical/emotional factors• Inability to work• Feeling of helplessness• Over-dramatization• Despair and negative attitudes

Objective Findings Of Chronic Pain

• Muscle atrophy• Skin temperature changes• Trigger points

Chronic Pain And Treatment

• Management is controversial• Opioids should only be used if they

enhance function• Single practitioner should be sole

prescriber• Narcotics are effective and

recommended for cancer pain• NSAIDS helpful but problematic in

elderly

Chronic Pain And Anti-Depressants

• Very effective• Lower doses needed compared to

depression• TCA enhance endogenous pain

inhibitory mechanisms• Used in conjunction with private

physician

Chronic Pain And Anticonvulsants

• Effective Neuropathic Pain• Prevent burst of action potentials• Helps lancinating pain• Carbamazepine, valproic acid

frequently used

Chronic Pain

• Muscle relaxants• Anxiolytics• Tramadol

Special Pain PresentationsPost Herpetic Neuralgia

• Follow acute course herpes zoster• Characterized by shooting,

lancinating pain• Frequently have hyperesthesia• Narcotics, antidepressants

Special Pain PresentationsFibromyalgia

• 11 of 18 specific tender points• Muscle stiffness, generalized aching

pain• Sleeplessness• Narcotics, short course NSAIDS,

antidepressants, exercise

Special Pain PresentationNeurogenic Back Pain

• Very common with advanced age• Frequently associated with

neuropathy• Narcotics, tapered steroids, muscle

relaxants

Treating Cancer Pain

• Pain is cancer's most disturbing symptom

• Aggressive pain management can relieve >90%

• Pain management remains poor• Long acting narcotics scheduled

with bursts for breakthrough pain

Drug Seeking Behavior in Elderly

• Not well studied• Prescription drug abuse increasing• It knows no boundaries• Substance abuse by “family

members”

Most Common Abuse Presentations

• Back Pain • Headache• Extremity Pain• Dental Pain

Case 1• 79 year old woman presents with newly

diagnosed recurrent metastatic breast cancer to bone and liver with underlying COPD. Her COPD has progressed over recent years leaving her oxygen and steroid dependent.

• Her recent pathologic hip fracture results in daily pain and her dyspnea is difficult to control.

• She is weakened by chronic anemia from PUD. • Constipation and anxiety are daily concerns.

References1. Cavalieri TA. Managing pain in geriatric patients. J Am Osteopath

Assoc 2007;107(suppl 4):ES10-ES16.2. Cavalieri TA. Pain management in the elderly. J Am Osteopath Assoc

2002;102(9):481-485.3. Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am

Geriatr Soc 1990;38(4):409-414.4. Gibson SJ, Helme RD. Age-related differences in pain perception and

report. Clin Geriatr Med 2001;17(3):433-456, v-v1.5. Lawton MP, Brody EM. Assessment of older people: Self-maintaining

and instrumental activities of daily living. Gerontologist.1969;9(3):179-186.

6. Miller J, Neelon V, Dalton J, et al. The assessment of discomfort in elderly confused patients: A preliminary study. J Neurosci Nurs 1996;28(3):175-182.

7. Parmelee PA. Pain in cognitively impaired older persons. Clin Geriatr Med 1996;12(3):473-478.