PAIN MANAGEMENT IN ELDERLY PERSONS - PAIN MANAGEMENT

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					 PAIN MANAGEMENT
IN ELDERLY PERSONS




UCLA Multicampus Program of
  Geriatrics and Gerontology
    Physicians Have a Moral Obligation to
    Provide Comfort and Pain Management
          Especialy for those near the end of life!

   Pain is the most feared complication of illness
   Pain is the second leading complaint in
    physicians’ offices
   Often under-diagnosed and under-treated
   Effects on mood, functional status, and quality
    of life
   Associated with increased health service use
      18% of Elderly Persons
Take Analgesic Medications Regularly
          (daily or more than 3 times a week)

    71 % take prescription analgesics
     – 63% for more than 6 months
    72% take OTC analgesics
     – Median duration more than 5 years
    26% report side-effects
     – 10% were hospitalized
     – 41% take medications for side-effects
   ELDERLY PATIENTS TAKING PAIN
MEDICATIONS FOR CHRONIC PAIN WHO
HAD SEEN A DOCTOR IN THE PAST YEAR

     79% had seen a primary care physician
     17% had seen a orthopedist
     9% had seen a rheumatologist
     6% had seen a neurologist
     5% had seen a pain specialist
     5% had seen a chiropractor
     20% had seen more than 5 doctors
    Common Causes of Pain
      In Elderly Persons
   Osteoarthritis
    – back, knee, hip
 Night-time leg cramps
 Claudication
 Neuropathies
    – idiopathic, traumatic, diabetic, herpetic
   Cancer
MISCONCEPTIONS ABOUT PAIN
 Myth: Pain is expected with aging.

 Fact: Pain is not normal with aging.
 PAIN THRESHOLD WITH AGING
Author              Stimulus       Threshold
Shumacher, 1940     Thermal        No Change
Birren, 1950        Thermal        No Change
Sherman, 1964     Electric/Tooth    Higher
Collins, 1968     Electric/Skin     Lower
Harkins, 1977     Electric/Tooth   No Change
Tucker, 1989      Electric/Skin     Higher
        Age Related Differences in
        Sensory Receptor Function

   Encapsulated end organs
    – 50% reduction in Pacini’s
    – 10-30% reduction Meissner’s/Merkels Disks

   Free nerve endings
     – no age change
              Age Related Differences in
              Peripheral Nerve Function
   Myelinated nerves
     Reduction in density (all sizes including small)
     Increase in abnormal/degenerating fibres
     Decrease in action potential/slower conduction velocity
   Unmyelinated nerves
     Reduction in number (1.2-1.6un) not (.4un)
     Substance P, CGRP content decreased
     Neurogenic inflammation reduced
           Age Related Differences in
        Central Nervous System Function
   Loss of dorsal horn spinal neurons
     Altered endogenous inhibition, hyperalgesia.


   Loss of neurons in cortex, midbrain, brain stem
     (18% reduction in thalamus, no change cingulum
      cortex)
     Altered cerebral evoked responses (increased latency,
      reduced amplitude)
     Reduced catecholamines, acetylcholine, GABA, 5HT, not
      neuropeptides
   MISCONCEPTIONS ABOUT PAIN
Myth: If they don’t complain, they don’t have pain

Fact: There are many reasons patients may be
 reluctant to complain, despite pain that
 significantly effects their functional status and
 mood.
    REASONS PATIENTS MAY
      NOT REPORT PAIN
 Fear of diagnostic tests
 Fear of medications
 Fear meaning of pain
 Perceive physicians and nurses too busy
 Complaining may effect quality of care
 Believe nothing can or will be done
The most reliable indicator
of the existence pain and its
intensity is the patient’s
description.
      There is a lot we can do to
             relieve pain!
 Analgesic drugs
 Non-drug strategies
 Specialized pain
  treatment centers
 Patient and caregiver
  education and support
                Analgesic Drugs
 Acetaminophen
 NSAIDs
    – Non-selective COX inhibitors
    – Selective COX-2 inhibitors

 Opioids
 Others
    –   Antidepressants
    –   Anticonvulsants
    –   Substance P inhibitors
    –   NMDA inhibitors
    –   Others
 CAUTION

 Meperidine (Demerol)
 Butorphanol (Stadol)
 Pentazocine (Talwin)
 Propoxiphene (Darvon)
 Methadone (Dolophine)
 Transderm Fentanyl (Duragesic)
         Do Not Use Placebos!
 Unethical in clinical practice
 They don’t work
 Not helpful in diagnosis
 Effect is short lived
 Destroys trust
           Non-Drug Strategies
   Exercise                    Chiropracty
    – PT, OT, stretching,       Acupuncture
      strengthening
    – general conditioning      TENS
   Physical methods            Alternative therapies
    – ice, heat, massage         – relaxation, imagery
                                 – herbals
   Cognitive-
    behavioral therapy
    PATIENT AND CAREGIVER
          EDUCATION
 Diagnosis, prognosis, natural history of
  underlying disease
 Communication and assessment of pain
 Explanation of drug strategies
 Management of potential side-effects
 Explanation of non-drug strategies

				
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posted:5/8/2010
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