Assessment and Treatment of Pain in Older Adults Daniel Pound, MD Clinical Professor Family and Community Medicine, UCSF Medical Director, UCSF Center for Geriatric Care Doe wat je t’liefste doet
Learning Objectives Adapt pain assessment and treatment based on cognitive impairment and comorbid disease Recognize limitations of pain rating scales Understand relationships between pain, delirium, and analgesic treatment
What I’m Not Talking About Boring pharmacokinetics Impractical assessment scales Perfect patient scenarios All patient names and stories are fictitious Off-label uses for neuropathic pain or agitated dementia are indicated with ***
Shirley Lowe 72 year old woman with arthritis knee + hip Cognitively intact PMH atrial fib, htn, MI, CHF, depression Poorly controlled diabetes A1C 9.5 Cr 2.3 PSH mastectomy, cholecystectomy Widow, lives with daughter (helps IADLs) Obese, walks with cane Doesn’t want any more surgery
Current Medicines Warfarin 2mg Metoprolol 50mg bid Benazepril 20mg Furosemide 40mg Amiodarone 200mg Paroxetine 40mg Glipizide 10mg bid Cimetidine 400mg
History and Physical Aching pain 3 / 10 at rest, worse at night 6 / 10 pain with weight bearing Walks 4 blocks limited by pain Stopped attending church due to stairs Knee valgus, flexion contraction, crepitus Hip full internal rotation
Pain Signature Pain effects more important than # rating: ADLs, IADLs Hobbies, socialization, exercise Concentration, appetite, sleep Mood, energy, relationships Overall health Track function in addition to pain rating
Initial Plan Non-pharmacologic or topical interventions with least chance of side effects: Inject knee 40mg triamcinolone Physical therapy Weight loss (good luck)
What She Did Aleve (naproxen 220mg) OTC BP 172 / 96, 2+ edema on exam How is she in trouble from taking naproxen? What potential problems should you look for?
NSAID Risks GI bleeding – ulceration, platelet inhibition Renal failure – worse if volume depleted, hyperCa, kidney, heart, or liver disease CHF – 2 to 10-fold risk of hospitalization Hypertension – 3/2 point increase Cardiac – ibuprofen > naproxen risk Feenstra J. Arch Intern Med 2002;162:265. Page J. Arch Intern Med 2000;160:777. CNT Collaboration. Lancet. 2013;382(9894):769.
Shirley’s Risks GI bleed Combination warfarin + NSAID + SSRI Renal failure Diabetes, CHF, diuretic therapy Metoprolol, insulin deficiency raise K levels CHF exacerbation: NSAIDS blunt effect of Diuretic (furosemide) ACE inhibitor (benazepril)
The Moment of Truth Guaiac stool exam negative (no blood) STAT lab results: INR 2.9 Hemoglobin 13 Creatinine 2.9 Potassium 5.7 Good news: no bleeding Bad news: kidney function worse & potassium ↑
WHO Pain Ladder A Strong opioid D J Mild opioid U N NSAID C Acetaminophen T
Shirley’s Pain Ladder A Strong opioid D J Mild opioid U N C Acetaminophen T
Plan B: Acetaminophen Slow release acetaminophen 650mg TID Acetaminophen > 2 grams / day potentiates warfarin Pain remains 6 / 10 walking Unable to climb stairs
Plan C: Mild Opioids Prescribe Tylenol #3 codeine 1 q4hr Patient recalls it helped after cholecystectomy However, no benefit now from 6 / day Change to Tramadol 50mg q4h Insufficient pain relief Why are these not helping? Other medicines include paroxetine / amiodarone / cimetidine
Pro-drugs Converted by Liver Codeine and tramadol are pro-drugs Codeine has weak direct effect on mu receptors to relieve pain Most of codeine effect occurs because liver converts codeine into morphine Some people lack liver enzymes Paroxetine / amiodarone / cimetidine might block CYP2D6 conversion to active drug
ER Visit 18 hours after starting tramadol Restless, confused, nausea, diarrhea Diaphoresis, leg tremor, hyperreflexia, clonus, fever, dilated pupils Medicines: warfarin, metoprolol, benazepril, furosemide, amiodarone, paroxetine, glipizide, cimetidine, tramadol
What Are You Concerned About? Malignant hyperthermia 1. Neuroleptic malignant syndrome 2. Serotonin syndrome 3. Intracranial hemorrhage 4.
Serotonin Syndrome Excessive serotonin neurotransmitter activity from combination of tramadol + SSRI (paroxetine / Paxil) Severe cases cause rigidity, hyperpyrexia FYI: all cause fever, tachycardia MH: minutes after anesthesia SS: hours after drug, GI, hyperreflexia NMS: days after antipsychotic, hyporeflexia
Shirley Lowe: Chapter 2 Hospitalized for hip fracture 2 years later Total hip replacement, pathology benign Why did she fall?
Medicines That Cause Falls Sedation Orthostatic hypotension Opioids Antihypertensives Benzodiazepines Nitrates Other sleeping pills Antiparkinsonian Antipsychotics Antipsychotics Antidepressants Tricyclics Antiemetics Trazodone Antihistamines Anticholinergics Muscle relaxers
Shirley’s Risks for Falls Bradycardia – metoprolol, amiodarone Hypoglycemia – glipizide ↓ BP – metoprolol, benazepril, furosemide Sedation – opioids Mechanism unclear – SSRI
POD #1 Night nurse assessed 8 / 10 on Numeric Rating Scale when patient transferred into bed after returning from surgery Morning nurse assessed mild pain with Faces Pain Scale while patient lying still in bed next morning (POD#1)
POD #1 Pulls out IV and foley Insists she has to “go back to the hospital” Changes the subject unpredictably while you are trying to reassure her Gets distracted each time a monitor beeps What is happening now?
Delirium Happens frequently (50% older inpatients) Rarely written in chart as a diagnosis (4%) What history do you need now? Buffum MD. J Rehab Res Dev 2007;44(2):315-329. Confusion Assessment Method in Inouye SK. Ann Intern Med 1990;113:941-8.
Postoperative Delirium Alcohol history: None Med history: Tylenol / codeine #3 1 q4-6 hr prn mild pain Morphine 1-2mg IM q1-4 hr prn severe pain Metoprolol, benazepril, furosemide Enoxaparin, cimetidine Diphenhydramine (Benadryl) prn for sleep
Medicines That Cause Confusion Sedation Anticholinergic Antidepressants Tricyclics Antipsychotics Antipsychotics Antiemetics Antiemetics Antihistamines H1 antihistamines (Benadryl) Opioids H2 antihistamines Benzodiazepines (Cimetidine) Other sleeping pills Oxybutynin (Ditropan) Muscle relaxers Loperamide (Imodium) Dicyclomine (Bentyl)
Avoid Anticholinergic Drugs Anticholinergic Not Anticholinergic Diphenhydramine Zolpidem (Ambien) (Benadryl) Fluticasone (Flonase) Cimetidine (Tagamet) Omeprazole (Prilosec) Amitriptyline (Elavil) Citalopram (Celexa) Loperamide (Imodium) Kaopectate (bismuth) Promethazine Odansetron (Zofran) $ (Phenergan)
What Went Wrong Using different pain scales each shift Pain should be assessed with movement or weight bearing, not just at rest Faces Pain Scale may underestimate severe pain Jones K. J Rehab Res Dev 2007;44(2):305-314 .
Comparing Pain Scales Jones K. J Rehab Res Dev 2007;44(2):305-314.
Categories Overlap M I L D M O D E R A T E S E V E R E Jones K. J Rehab Res Dev 2007;44(2):305-314.
What Else Went Wrong IM route unpredictable (don’t use IM) PRN medicines rarely given postop Avoid range of times (q1hr, not q1-4hr) Given a choice, nurses usually pick: Weaker opioid Lower dose Longer interval
Postoperative Pain Morphine 4mg q3h ATC (hold for sedation) reduced risk of postop delirium (28% 7%) Prophylactic laxatives Poor pain control causes: Immobility and respiratory complications Depression, impaired concentration Functional & gait impairment Poor appetite, poor sleep Brain atrophy from chronic pain? Morrison FS. J Geront 2003; 58A(1):76-81. Bosley BN. J Am Geriatr Soc 52:247-251.
Shirley Lowe: Chapter 3 5 years later hospitalized with widely metastatic breast cancer 6 / 10 back pain unrelated to activity Start IV morphine or hydromorphone Morphine metabolites accumulate in CKD Myoclonus Hyperalgesia Dysphoria Respiratory depression
Death Approaches A Week Later She is sleeping much of the time Self reported pain scores vary 1 to 10, at times she does not respond Doctor made rounds while asleep, did not change doses Family insist she needs more pain medicine but want medicine that will not make her sleep What do you think is going on?
Death Approaches 50% of dying cancer patients lose ability to use pain rating scales (terminal delirium) Family may overestimate, doctors may underestimate pain Family may prioritize survival and avoiding side effects over pain relief to greater extent than they would for themselves Shannon MM. J Pain Symptom Manage 1995;10:274-8. Cohen-Mansfield J. J Pain Symptom Manage 2002;4:562-71. Bruera E. J Pain Symptom Manage 2003;26:818-826.
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