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PERSISTENT PAIN
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OBJECTIVES
• List the 3 major types of pain syndromes
• Identify components of a thorough pain assessment
• Recognize common pain behaviors in cognitively
impaired older people
• Gain an initial understanding of the principles
underlying nonpharmacologic and pharmacologic
treatment of persistent pain
• Describe how to manage the adverse effects of
opioids
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TO P I C S C O V E R E D
• Assessment
• Assessing and Treating Pain in Cognitively
Impaired People
• Treatment
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Fundamental Approaches
Barriers to Using Opioids in Older People
Adverse Effects of Opioids
Nonopioid Medication to Treat Persistent Pain
Medications to Avoid in Older People
PREVALENCE OF
PERSISTENT PAIN IN OLDER PEOPLE
Substantial pain is experienced by:
25% to 50%
of community-dwelling older adults
45% to 80%
of nursing-home residents
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PAIN IS COMMONLY UNDERTREATED
• Patients may:
 Minimize their symptoms
 Not report pain
 Be unable to report pain because of limited
English proficiency or cognitive impairment
• Clinicians may:
 Inadequately assess pain
 Undertreat pain with ineffective therapies
 Encounter intolerable adverse effects with
otherwise effective therapies
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INITIAL ASSESSMENT
• Take a complete history of the pain
 Character
 Course of its onset
 Duration
 Location
• Carefully evaluate patient’s baseline functional status
( before initiating any therapy and compare to post
treatment functional status)
• Evaluate patient’s cognitive state, participation in
social activities, mood, and quality of life
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PAIN INTENSITY SCALES
• Unidimensional scales:
 Numeric Rating Scale—0 is no pain, 10 is worst pain
imaginable
 Faces Pain Scale—patient chooses a facial expression
that corresponds to the pain
 Verbal Descriptor Scale—“no pain” to “pain as bad as it
could be”
• Multidimensional scales:
 McGill Pain Questionnaire
 Pain Disability Scale
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PAIN MAP
• Ask patient to indicate the locations of their pain on a
drawing of a human figure
• Consider referral to a mental health specialist (to
evaluate for affective disorder contributing to the
discomfort) if the patient’s pain pattern:
 Is erratic
 Is diffuse
 Does not conform to an anatomic distribution
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PHYSICAL EXAMINATION
• Carefully examine the reported site of pain and
locations that may be a source of referred pain
• Perform complete musculoskeletal exam
 Fibromyalgia, osteoarthritis, or myofascial pain is
commonly either the primary source of pain or an
exacerbating process
 Accurate diagnosis is critical to formulating the
correct therapeutic plan
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3 TYPES OF PAIN SYNDROMES
• Nociceptive—pain due to activation of nociceptive
sensory receptors; often adequately treated with
common analgesics
 Somatic—well localized in skin, soft tissue, bone
 Visceral—due to cardiac, GI, or lung injury
• Neuropathic—from irritation of components of the CNS
or peripheral nervous system; may respond well to
nonopioid therapies; responds unpredictably to opioids
• Mixed or unspecified—has characteristics of both
nociceptive and neuropathic pain; common in older
adults
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NOCICEPTIVE PAIN
Examples
Source of
pain
Table 15.1
Typical description
Effective drug classes
and nonpharmacologic
treatments
Nociceptive: somatic
Arthritis, bone
metastases
Tissue injury
Well localized, constant;
(eg, bones, soft aching, stabbing,
tissue, joints,
gnawing, throbbing
muscles)
Acetaminophen, opioids
Physical and cognitivebehavioral therapies
Nociceptive: visceral
Renal colic,
constipation
Viscera
Diffuse, poorly localized,
referred to other sites,
intermittent, paroxysmal;
dull, colicky, squeezing,
deep, cramping; often
accompanied by nausea,
vomiting, diaphoresis
Treatment of underlying
cause
Physical and cognitivebehavioral therapies
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NEUROPATHIC PAIN
Examples
Table
Source of
15.1 pain
Cervical or lumbar
radiculopathy,
post-herpetic
neuralgia,
trigeminal
neuralgia, diabetic
neuropathy, poststroke syndrome,
herniated
intervertebral disc
Peripheral
or central
nervous
system
Typical description
Prolonged, usually
constant, but can have
paroxysms; sharp, burning,
pricking, tingling,
squeezing; associated with
other sensory disturbances
(eg, paresthesias and
dysesthesias); allodynia,
hyperalgesia, impaired
motor function, atrophy, or
abnormal deep tendon
reflexes
Effective drug classes
and nonpharmacologic
treatments
Tricyclic antidepressants,
anticonvulsants, serotoninnorepinephrine reuptake
inhibitor antidepressants,
opioids, topical
anesthetics
Physical and cognitivebehavioral therapies
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UNDETERMINED PAIN
Examples
Table
15.1
Myofascial pain
syndrome,
somatoform
pain disorders
Source of
pain
Poorly
understood
Typical description
No identifiable
pathologic processes
or symptoms out of
proportion to
identifiable organic
pathology; widespread
musculoskeletal pain,
stiffness, and
weakness
Effective drug classes
and nonpharmacologic
treatments
Antidepressants,
antianxiety agents
Physical, cognitivebehavioral and
psychological therapies
PAIN IN COGNITIVELY
IMPAIRED PEOPLE
• Observe for possible pain-related behaviors (see next
slides) and ask caregivers for their observations
 Consider trial of analgesia for patients exhibiting
pain-related behaviors
• Validated scales (eg, Hurley Discomfort Scale,
Checklist of Nonverbal Pain Indicators) require training
 Provide empiric analgesia during procedures and
conditions known to be painful
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COMMON PAIN BEHAVIORS IN
COGNITIVELY IMPAIRED OLDER ADULTS (1 of 2)
Behavior
Examples
Facial expressions
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Slight frown; sad, frightened face
Grimacing, wrinkled forehead, closed/tightened eyes
Any distorted expression
Rapid blinking
Verbalizations, vocalizations
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Sighing, moaning, groaning
Grunting, chanting, calling out
Noisy breathing
Asking for help
Verbal abusiveness
Body movements
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Rigid, tense body posture, guarding
Fidgeting
Increased pacing, rocking
Restricted movement
Gait or mobility changes
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COMMON PAIN BEHAVIORS IN
COGNITIVELY IMPAIRED OLDER ADULTS (2 of 2)
Behavior
Examples
Changes in interpersonal interactions
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Aggressive, combative, resists care
Decreased social interactions
Socially inappropriate, disruptive
Withdrawn
Changes in activity patterns or routines
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Refusing food, appetite change
Increase in rest periods
Sleep, rest pattern changes
Sudden cessation of common routines
Increased wandering
Mental status changes
• Crying or tears
• Increased confusion
• Irritability or distress
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NONPHARMACOLOGIC THERAPIES
• Patient education and involvement in decisions
 Teach patients to take medications properly and how to use
assessment instruments
 Give partner-guided pain management training to caregivers
• Cognitive-behavioral therapy
• Regular physical activity
 Or supervised rehabilitation for frail patients, or regular
repositioning and gentle massage for bed-bound patients
• Referral to an interdisciplinary pain clinic
PRINCIPLES OF
PHARMACOLOGIC THERAPY
• Besides pain relief, the goals are improved function
and enhanced adherence with rehabilitation
• Individualize the initial dose and rate of titration
• In general, start opioids at lowest dose and titrate
slowly, but if patient is in pain crisis, do not withhold
medications
• Try nonsystemic or nonpharmacologic therapies first
if appropriate
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TREATING MILD TO MODERATE PAIN:
ACETAMINOPHEN
• Particularly for musculoskeletal pain
• No more than 4 g every 24 hours
• Lower the dose by 50%, or avoid, in patients at risk of
liver dysfunction, especially with history of heavy
alcohol intake
• Know all medications the patient is taking, as
acetaminophen is a common ingredient in prescription
and OTC drugs
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TREATING MILD TO MODERATE PAIN:
NSAIDs
• Many significant adverse effects
• Use selective COX-2 inhibitor with extreme caution, if
at all, in older people. Only celecoxib is available
currently ( 2013).
• Use judiciously, if at all, only after acetaminophen has
been tried and only in highly select individuals
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TREATING MODERATE TO SEVERE PAIN
• To estimate opioid requirements, conduct a trial of a
short-acting opioid ( start low and go slow)
• Treat continuous pain with 24-hour opioids in longacting or sustained-release formulations
 To cover breakthrough pain, combine with fast-onset
medications that have short half-lives
 Breakthrough pain typically requires 5%–15% of the
daily dose, offered q2 to q4h orally
• In general, different opioids are similarly efficaciouschoice of opioid is based on side effect profile.
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USING OPIOIDS IN RENAL FAILURE
• Avoid morphine, as its metabolites accumulate; if it
must be used, increase the dosing interval and
reduce the dose
• Safety of oxycodone in older adults has not be
studied well but clinical practice shows that it is safer
than morphine in patients with renal dysfunction.
• Hydromorphone is an acceptable choice for older
adults, but start slow and go slow as there are no
sustained-release formulations currently ( 2013)
• Low-dose methadone is reasonable as metabolized
in the liver and excreted thru feces
COMBATTING FEAR OF TOLERANCE
AND ADDICTION TO OPIOIDS
• Avoid withdrawal symptoms by tapering carefully over
days to weeks
• If rapid upward titration is required to reduce pain,
evaluate the cause of pain:
 Search for new pathologies, exacerbation of known sources
 Consider nonphysical causes of pain
• There is partial cross-tolerance between opioids
 When from one opioid to another, reduce the dose of the
new drug by 50%–65% of the equianalgesic dose
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MANAGING THE ADVERSE
EFFECTS OF OPIOIDS (1 of 2)
• Constipation
 Educate patient about probable need for long-term
laxative treatment
 In most cases, start with a stimulant laxative
 Encourage exercise and hydration
 Consider methylnaltrexone for patients with severe
opioid-induced constipation despite maximal laxative
therapy
• Nausea and vomiting—evaluate for reversible causes
such as constipation; short-acting opioids are more likely
to cause nausea
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MANAGING THE ADVERSE
EFFECTS OF OPIOIDS (2 of 2)
• Sedation, fatigue, mild cognitive impairment
 Educate the patient and caregiver that these changes
generally subside days to weeks after dose adjustment
 Warn against driving or operating heavy equipment
when medication is initiated
 Warn of the risk of falls
 Severe sedation or fatigue: try a stimulant such as lowdose methylphenidate or rotation to a different opioid
• Respiratory depression—use naloxone sparingly, at
the lowest dose, and titrate carefully
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NONOPIOID MEDICATION (1 of 2)
• Tricyclic antidepressants (off-label) are the best-studied
drugs for neuropathic pain
 Avoid amitriptyline in older adults
 Use imipramine, desipramine, or nortryptamine
• Optimal analgesia requires treatment of depression
 SSRIs are less well studied than TCAs as
analgesics, but they are better tolerated in
antidepressant doses
 Duloxetine is approved as both an antidepressant
and for treatment of pain from diabetic neuropathy
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NONOPIOID MEDICATION (2 of 2)
• Antiepileptics such as gabapentin and pregabalin are
commonly used for neuropathic pain
• Corticosteroids are useful adjuvants for neuropathic
pain and pain associated with swelling, inflammation,
and tissue infiltration
PAIN MEDICATIONS TO
AVOID IN OLDER PEOPLE
• Meperidine
• Mixed agonist-antagonists such as nalbuphine
and butorphanol
• COX-2 inhibitors
• Other NSAIDs ― use rarely, if ever
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S U M M A RY ( 1 o f 2 )
• Pain requires a thorough assessment to determine its
source, severity, and impact on the patient’s well-being
• Cognitively impaired patients who cannot communicate
about pain should receive empiric analgesia during
procedures and conditions known to be painful
• A stepped approach to pain treatment is advised,
starting with local and nonpharmacologic approaches
• Systemic analgesics should not be withheld if needed
initially
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S U M M A RY ( 2 o f 2 )
• In general, different opioids have similar efficacy and
limited cross-tolerance
• Patients being treated with opioids usually develop
tolerance to the respiratory depression, fatigue, and
sedation, but not to the constipating effect
• Optimal analgesia requires treatment of any
associated clinical depression
• COX-2 inhibitors should be avoided in older patients,
and nonselective NSAIDs should be used cautiously
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CASE 1 (1 of 3)
• A patient who lives in a nursing home is evaluated
because his family is concerned that he has
inadequately treated pain.
• The patient has moderate dementia.
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CASE 1 (2 of 3)
How does pain assessment for patients with dementia
differ from assessment for cognitively intact patients?
A. Patients with dementia are less likely to report pain
after activity.
B. Patients with dementia are more likely to demonstrate
pain behaviors, such as guarding or grimacing.
C. Patients with dementia are more likely to express
degree of pain by using a visual analogue pain scale.
D. Patients with dementia are less likely to experience
pain.
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CASE 1 (3 of 3)
How does pain assessment for patients with dementia
differ from assessment for cognitively intact patients?
A. Patients with dementia are less likely to report pain
after activity.
B. Patients with dementia are more likely to demonstrate
pain behaviors, such as guarding or grimacing.
C. Patients with dementia are more likely to express
degree of pain by using a visual analogue pain scale.
D. Patients with dementia are less likely to experience
pain.
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CASE 2 (1 of 4)
• A 72-year-old woman comes to the office because for
the past 6 months she has had severe burning pain
in her feet that is worse at night.
• She recently tried gabapentin but discontinued it
because it caused gait disturbance.
• History includes uncontrolled DM, chronic
constipation, and mild cognitive impairment.
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CASE 2 (2 of 4)
• Medications include insulin glargine 20 units at night,
lisinopril 20 mg/day, docusate sodium 100 mg q12h,
metformin 1,000 mg q12h, and acetaminophen 1,000
mg q8h.
• Her fingerstick glucose levels have been between
180 and 200 in the morning and in the mid-200s at
night.
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CASE 2 (3 of 4)
Which of the following is the most appropriate next step
for improving pain control?
A. Increase insulin dosage.
B. Refer for sympathectomy.
C. Start lamotrigine.
D. Start pregabalin.
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CASE 2 (4 of 4)
Which of the following is the most appropriate next step
for improving pain control?
A. Increase insulin dosage.
B. Refer for sympathectomy.
C. Start lamotrigine.
D. Start pregabalin.
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CASE 3 (1 of 3)
• A 71-year-old woman comes to the office because
she has pain from an osteoporotic vertebral fracture.
• She is now receiving recommended therapy for
osteoporosis.
• The pain from the fracture prevents her from
gardening.
• Conservative measures—such as acetaminophen,
physical therapy, and NSAIDs—have not provided
adequate relief.
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CASE 2 (2 of 3)
Which of the following is the most appropriate
recommendation for her pain?
A. Vertebroplasty
B. Oxycodone 2.5 mg orally q6h as needed
C. Acetaminophen/hydrocodone 500/5 mg, 1 tablet
orally q4h as needed
D. Methadone 10 mg orally q8h
E. Reiki therapy
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CASE 2 (3 of 3)
Which of the following is the most appropriate
recommendation for her pain?
A. Vertebroplasty
B. Oxycodone 2.5 mg orally q6h as needed
C. Acetaminophen/hydrocodone 500/5 mg, 1 tablet
orally q4h as needed
D. Methadone 10 mg orally q8h
E. Reiki therapy
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GNRS4 Teaching Slides Editor:
Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF
GNRS4 Teaching Slides modified from GRS8 Teaching Slides
based on chapter by VJ Periyakoil, MD
and questions by Rachelle Bernancki, MD, MS
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2014 American Geriatrics Society
SlideSlide
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