Assessment and Treatment of Pain in Older Adults Daniel Pound, MD - - PowerPoint PPT Presentation

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

NSAID Acetaminophen Mild opioid

Strong opioid

A D J U N C T

Shirley’s Pain Ladder

Acetaminophen Mild opioid

Strong opioid

A D J U N C 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?

1.

Malignant hyperthermia

2.

Neuroleptic malignant syndrome

3.

Serotonin syndrome

4.

Intracranial hemorrhage

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

 Opioids  Benzodiazepines  Other sleeping pills  Antipsychotics  Antidepressants  Antiemetics  Antihistamines  Muscle relaxers

 Orthostatic hypotension

 Antihypertensives  Nitrates  Antiparkinsonian  Antipsychotics  Tricyclics  Trazodone  Anticholinergics

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

 Antidepressants  Antipsychotics  Antiemetics  Antihistamines  Opioids  Benzodiazepines  Other sleeping pills  Muscle relaxers

 Anticholinergic

 Tricyclics  Antipsychotics  Antiemetics  H1 antihistamines

(Benadryl)

 H2 antihistamines

(Cimetidine)

 Oxybutynin (Ditropan)  Loperamide (Imodium)  Dicyclomine (Bentyl)

Avoid Anticholinergic Drugs

 Anticholinergic

 Diphenhydramine

(Benadryl)

 Cimetidine (Tagamet)  Amitriptyline (Elavil)  Loperamide (Imodium)  Promethazine

(Phenergan)

 Not Anticholinergic

 Zolpidem (Ambien)

Fluticasone (Flonase)

 Omeprazole (Prilosec)  Citalopram (Celexa)  Kaopectate (bismuth)  Odansetron (Zofran) $

What Went Wrong

 Using different pain scales each shift  Pain should be assessed with movement

• r 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

Jones K. J Rehab Res Dev 2007;44(2):305-314.

M I L D M O D E R A T E S E V E R E

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.

Eileen Moore

 75 year old woman with spinal stenosis  PMH CKD (Cr 1.8), depression, irritable

bowel, COPD

 Mild dementia MMSE 24 / 30 (HS grad)  Divorced, lives alone  Daughter helps with IADLs (shop, clean,

mediset)

Current Medicines

 Bupropion (Wellbutrin) 75mg bid  Nortriptyline 25mg for sleep  Loperamide (Imodium) prn  Sulfa allergy

Spinal Stenosis Pain

 Aching, burning, numb pain in legs with

walking, 6 / 10 severity

 Hard to comprehend verbal NRS (“1-10”)  Verbal descriptive scale (“mild-moderate-

severe”) may be easier

 Broad based stiff gait  Poor candidate for spinal surgery due to

COPD

Her Request

 Asks for celecoxib and muscle relaxers  You prescribe celecoxib 100mg ***  Which muscle relaxer should you

prescribe?

Celecoxib FDA approved for OA, RA, ankylosing spondylitis

Skeletal Muscle Relaxers

 Carisprodol (SOMA) or cyclobenzaprine

(Flexeril) cause excess sedation or memory impairment in elderly with little benefit for pain

 Avoid muscle relaxers in elderly

Bad News

 A week later she walks in complaining of

rash and edema

 Creatinine is 2.3  What could be going on?

Celecoxib Reactions

 Celecoxib (Celebrex) contains sulfa  Cross-reactivity of antibiotic with non-

antibiotic sulfa drugs is disputed

 Incidence of rash in sulfa-allergic patients

same with celecoxib or placebo

 Celecoxib impairs renal function (just like

NSAIDs)

Patterson R. Clin Ther. 1999;21(12):2065.

Celecoxib Versus NSAID Risks

 Renal: celecoxib = NSAID  MI: ibuprofen > celecoxib > naproxen  Attenuation of aspirin benefit for CAD:

ibuprofen > naproxen (0 for celecoxib?)

 GI bleed: NSAID = celecoxib + ASA 81 >

celecoxib alone > placebo

CNT Collaboration. Lancet. 2013;382(9894):769. Catella-Lawson F. N Engl J Med. 2001;345(25):1809. Capone ML. J Am Coll Cardiol. 2005;45(8):1295. Silverstein FE. JAMA. 2000;284(10):1247. Kearney PM. BMJ 2006:332:1302-1308.

Plan B: Gabapentin

 Gabapentin (Neurontin) 100 TID increased

up to 600mg TID (1800/day) over 3 weeks

 Gabapentin *** and pregabalin (Lyrica) ***

have few drug interactions

 Pregabalin has quicker titration but is 3x

as expensive and is schedule V controlled

Gabapentin FDA approved for seizures, postherpetic neuralgia Pregabalin also FDA approved for seizures, postherpetic neuralgia, fibromyalgia, diabetic neuropathy, spinal cord injury pain

More Bad News

 Two weeks later her daughter brings her

due to drowsiness, unsteadiness, time disorientation, perseveration

 She has been taking loperamide for

diarrhea

 What is going on?

Gabapentin Side Effects

 Gabapentin (Neurontin) max daily dose:

 CrCl >= 60 3600mg  CrCl 30-59 1400mg  CrCl 15-29 700mg  CrCl 2.5-15 50 – 300mg proportional to CrCl

 Side effects (sedation, dizziness, ataxia,

confusion, tremor, edema) occur at lower doses in patients with renal insufficiency

Confusion

 Reduce or stop gabapentin  Stop loperamide (anticholinergic,

contributes to confusion)

 Continue bupropion + nortriptyline*** since

she still has depression + neuropathic pain

 Beware: nortriptyline (anticholinergic) is

risk for ongoing confusion!

Nortriptyline FDA approved for depression

Plan C: Tramadol

 Tramadol helps her neuropathic pain  But she develops side effect nausea  Rx prochlorperazine (Compazine)  She forgets she already took tramadol pills

and takes more when she feels pain

 Some days she may inadvertently use up

to 4 times what you prescribed

911 Call

 She passes out while sitting at the

breakfast table and her daughter calls 911

 By the time paramedics arrive, she is

starting to wake up but seems more confused than usual

 Is this related to her medicines?  She is taking tramadol, prochlorperazine,

nortriptyline, and bupropion

Tramadol Increases Seizure Risk

 Tramadol combined with most

antidepressants (including SSRI or tricyclic) can rarely cause seizures

 Bupropion (Wellbutrin) caused seizures in

anorexic / bulemic patients

 Phenothiazines (prochlorperazine /

Compazine) lower seizure threshold

 Tramadol + SSRI?? Weigh risk / benefit

Plan D: Duloxetine

 Taper off nortriptyline and bupropion  Duloxetine for depression and pain  FDA indications:

 Depression, anxiety  Diabetic neuropathy  Fibromyalgia  Chronic musculoskeletal pain

Adriano Gonzales

 81 year old Filipino man hospitalized due

to altered mental status

 PMH: moderate dementia (MMSE 15 / 30)  Current medicines: none  Lives in residential board and care home  Widowed, no children  Sister lives out of state

HD #1: Altered Mental Status

 Care home reports lethargy, severe

fatigue, no vomiting

 Quiet, does not initiate conversation  Denies pain but admits “ache” right flank  Urinalysis: + WBC + epithelial cells

(contaminated clean catch specimen)

 Admitted for UTI

Pain Assessment in Dementia

 Mild to moderately impaired can self report  MMSE >18 predicts able to use NRS  MMSE <13 predicts unable to use NRS  Verbal descriptor scale (mild-mod-severe)

most successful in moderate dementia

 Dementia patients may either underreport

pain or perseverate on prior pain

Weiner D. Clin J Pain 1999;15:92-101.

HD #2: A Familiar Caregiver

 Patient rarely admits pain, cannot describe

quality of pain

 Regular caregiver visits, brings his hearing

aid, notes he is withdrawn

 How do you assess pain in this patient?  Is he delirious (hypoactive)?

Inouye SK. Arch Int Med 2001;161:2467-73.

Pain Behaviors in Dementia

 Facial expressions (grimacing)  Vocalizations (moaning, asking for help)  Body movements (fidgeting, pacing, guarding)  Interpersonal interactions (aggressiveness,

withdrawal, not eating, not participating)

 Changes in activity patterns (resisting care)  Mental status changes (confusion, irritability)

AGS Management of persistent pain in older persons. JAGS 2002;50:S205-S224.

Observational Pain Scales

 Short scales appealing but insensitive  Longer scales (60 item) more sensitive, less

specific, impractical clinically

 Comparison values based on surrogate

assessment

 Scales rarely evaluated in other cultures  No single scale obviously best  Regular caregiver may recognize pain  http://prc.coh.org/elderly.asp (pain scales)

HD #3: Zoster Rash

 Urine culture 1,000 genital flora  Dermatomal vesicular rash on right flank  Rx acyclovir and oxycodone / APAP

HD #4: Sister Arrives

 “He looks ok, just tired”  Afraid he could become addicted  Asks you to stop giving him narcotics  Can you rely on his sister’s assessment of

him?

 Surrogate reporting valuable only if

familiar with daily routine

Lidocaine Patch for PHN

 Can’t start until sores heal  Avoids cognitive effects seen with:

 Opioids  Gabapentin  Tricyclic antidepressants

Topical analgesics / NSAIDs

 Expensive $20 / day  Insurance coverage may be limited to FDA

indications:

 Lidoderm (lidocaine) patch:

 Postherpetic neuralgia

 Voltaren (diclofenac) gel:

 Osteoarthritis (not including hip, shoulder, or back)

 Flector (diclofenac) patch:

 Acute pain from strain, sprain, or contusion

Jocelyn Walker

 86 year old African American SNF resident

with dementia and new agitation

 PMH: osteoarthritis, severe dementia

(MMSE 7 / 30)

 For last three days stays in bed,

combative, resists bathing, denies pain

Agitation in Dementia

 Satisfy hunger, thirst  Treat constipation, bladder retention  Address overstimulation, understimulation  Assume presence of pain based on

pathology (ie, if you would sense pain)

 Empiric analgesic trial (less risky than

antipsychotic)

J Amer Geriatr Soc 2002;50:S205-S240

Further Questioning

 Fell three days ago  Appetite unchanged  Daily bowel movement unchanged  Urine frequency unchanged  Unable to comprehend Faces Pain Scale-R

(scale preferred by African Americans with mild-mod dementia)

Taylor L. Pain Manage Nurs 2003; 4(2):87-95. Ware L. Pain Manage Nurs 2006: 7(3):117-125. www.iasp-pain.org/FPSR

Physical Exam

 Screams unpredictably with minimal touch

• r when BP checked (disinhibited)

 Point tenderness L spine, no skin breaks  Grimaces with movement  Denies pain after movement ceases  Xray new spinal fracture  Nasal calcitonin for vertebral fracture pain

Lyritis GP. Acta Orthop Scand Suppl. 1997;275:112.

Pain Assessment Spectrum

No Dementia Mild – Mod Dementia Severe Dementia

 Self-Report  Elicited Self-Report  Behavioral

Observation

Empiric Rx for Agitation***

 Acetaminophen 3000mg/day x 4 weeks 

agitation unchanged but more engaged

 Oxycontin 10mg bid + senna x 4 weeks 

less agitation

 Step rx x 8 weeks  ADL / cognition same

less agitation / aggression / pain

(acetaminophen 3000mg/day, morphine 20mg/day, buprenorphine patch 10mcg/hr, pregabalin 300mg)

Chibnall J. JAGS 2005; 53:1921-1929. Manfredi P. Int J Ger Psych 2003: 18:700-705. Husebo BS. BMJ 2011;343:d4065.

Summary

 Opioids are often preferable to NSAIDs in

elderly but impaired gait or memory may require closer supervision

 Consider self-report (in mild – mod

dementia) or behavior patterns (in severe)

 Consider bias and reliability when using

surrogate pain reports from family

 Treat pain empirically in postop delirium or

agitated dementia

References

 An interdisciplinary expert consensus

statement on assessment of pain in older

• persons. Hadjistavropoulos T. Clin J Pain

2007;23:S1-S43

 Improving the clinical usefulness of a

behavioural pain scale for older people with

• dementia. Zwakhalen SMG. J Adv Nurs

2007; 58(5): 493-502

 Pain in persons with dementia: complex,

common, and challenging. Shega J. J Pain 2007; 8(5):373-378

Assessment and Treatment of Pain in Older Adults

daniel.pound@ucsf.edu

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