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P i t t P i i Persistent Pain in the Elderlythe Elderly

PD St JohnP Daeninck P Daeninck Centre on Aging Spring Symposium

No Commercial InterestNo Commercial InterestNo Relevant Financial

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97 year old woman in Assisted Living 97 year old woman, in Assisted Living, daughter in cityPast History: Past History:

Dementia – mild functional limitation Heart disease – stableHeart disease stableFallsCompression Fracture 4 years ago with Compression Fracture 4 years ago, with chronic low back painOsteoarthritis

ER visit with failure to cope and more ER visit with failure to cope and more falls with no fractureHome with GPAT follow-upHome with GPAT follow upAdmitted

Disoriented in place, dateMMSE 13/30Fluctuating LOCP tt tiPoor attentionHallucinations – birds in her room – asking family to shoot themfamily to shoot themSelf-reports of severe pelvic painGDS 14/15

Thin pale looked unwell – 42kgThin, pale, looked unwell 42kgNeuro exam unremarkableGeneral exam OA most jointsGeneral exam – OA most jointsNo evidence neuropathy

MedicationsMedicationsKetaminePregabalinPregabalinHydromorphoneAlendronateAlendronateCa/Vit DCalcitonin

What to tell family?

Pain is under-treated, and with proper treatment, can be alleviated without side effectscan be alleviated without side-effects.

Pain is causing her delirium.Pain is causing her delirium.

Pain medications are contributing to her delirium.

We may need to balance treatment goalsLessen painImprove cognition

Too many elderly 'left in pain'

Not enough is being done to improve the management of pain in the elderly

Nursing home staff underestimate pain: study

The study says nursing home staff routinely underestimate pain in their clients It their clients. It estimated 40 per cent of seniors in nursing homes are living in pain everyday everyday. Nursing home staff should pay more attention to pain pmanagement

MYTH #1

Pain is due to ageingPain is due to ageing

Reality

Pain is due to injury/illness not ageingPain is due to injury/illness, not ageing.Pain is more common in the elderly.

Epidemiology of Pain in Elderly

PrevalencePrevalence25 – 62% in community

Canadian data using data from large surveys (Ipsos-Reid)

22% in 18 to 34 year olds 22% in 18 to 34 year olds, 29% in 35 to 54 year olds, 39% in 55 plus 39% in 55 plus

Age is a prognostic factor

P i i Pain is more persistent in the elderly elderly

MYTH #2

We know what we are doingWe know what we are doing

REALITY

Literature very limitedLiterature very limitedIssues

Less research in elderlyLess research in elderlySetting of research – less in community or long-term carelong term careConflict of interest

Complicated group Complicated group

Major Causes of Chronic PainMajor Causes of Chronic Pain

ArthritisArthritisLow Back PainDental problemspOld injuriesVascular DiseaseN iNerve painLeg Pain SyndromesCancer painCancer pain

Other Risk FactorsOther Risk Factors

DepressionPrevious psychological traumaPrevious psychological traumaSocial risk factorsPrevious beliefs around painPrevious beliefs around painPrevious experience with painN th i k f tNeuropathy risk factors

Pain and Depressive Symptoms

Strong association Strong association

Pain predicts depression and depression Pain predicts depression and depression predicts pain

Social Risk FactorsSocial Risk Factors

Inadequacy of income Lower social class Lower social class This association was more pronounced in women in women

Pain Model

Complicating factors

Older adults more likely to be Older adults more likely to be interruptedFamily influencesFamily influencesCognitive impairmentMakes assessment of pain difficultMakes assessment of pain difficultHigher delirium risk if pain is untreated, Higher delirium risk if pain is treated with Higher delirium risk if pain is treated with psychoactive medications

MYTH #3

Pain cannot be assessed in someone Pain cannot be assessed in someone with dementia

REALITY

Pain is often difficult to assess but it Pain is often difficult to assess, but it can be assessed

COMMON PAIN BEHAVIORS IN COGNITIVELY IMPAIRED ELDERLY PERSONS

Behavior Examples

Facial expressions Slight frown; sad frightened faceFacial expressions Slight frown; sad, frightened faceGrimacing, wrinkled forehead, closed/tightened eyesAny distorted expressionRapid blinkingRapid blinking

Verbalizations, vocalizations

Sighing, moaning, groaningGrunting, chanting, calling outNoisy breathingy gAsking for helpVerbal abusiveness

Body movements Rigid, tense body posture, guardingFid tiFidgetingIncreased pacing, rockingRestricted movementGait or mobility changes

B h i E lBehavior Examples

Changes in interpersonal interactions

Aggressive, combative, resists careDecreased social interactionsSocially inappropriate disruptiveSocially inappropriate, disruptiveWithdrawn

Changes in activity patterns or Refusing food appetite changeChanges in activity patterns or routines

Refusing food, appetite changeIncrease in rest periodsSleep, rest pattern changesSudden cessation of common routinesIncreased wanderingIncreased wandering

Mental status changes Crying or tearsIncreased conf sionIncreased confusionIrritability or distress

MYTH #4

Little old ladies are just older adultsLittle old ladies are just older adults

REALITY

We are different at 80 than we were at 40

Changes in body composition and organ function influence medications and medication adverse events

Differences between people increases as we grow old g

General Principles - American Geriatrics Society Guidelines

Pain management in older persons differs from Pain management in older persons differs from that for younger people

Pain is often complex and multifactorial in the older population

Older people may underreport pain

Concurrent illnesses and multiple problems make pain evaluation and treatment more difficult difficult

Older persons are more likely to Older persons are more likely to experience medication-related side effects and have a higher potential for effects and have a higher potential for complications and adverse events related to diagnostic and invasive

dprocedures

ld lOlder people constitute a heterogeneous population, making optimum dosage and common side optimum dosage and common side effects difficult to predict.

Least-invasive method of drug administration Least invasive method of drug administration should be used

Rapid-onset, short-acting analgesic drugs should be used for severe episodic pain

Scheduled administration before anticipated ( i id ) i i d (or incident) pain episodes

C ti i di ti h ld b Continuous pain, medications should be provided around the clock

PAIN RATING SCALES

Reliable valid scales and assessment Reliable valid scales and assessment tools (including in cognitively impaired patients)patients)

Reliable valid questionnaires Reliable, valid questionnaires

P i iPain mapping

Categorize Pain

InjuryInjuryInflammationSoft tissueSoft tissueCancerNerve Pain

Associated features

Assess cognition

Assess functional status

Assess social situation

Assess mood

Assess attitudes to pain

Treatment strategies

Weigh treatment options Weigh treatment options

Assess urgencyAssess urgency

Set goals of treatment

Treatment optionsAcetaminophen

Recent dose change recommendation by FDAg y

NSAIDS / COX-2 inhibitors

Opiates

Other GabapentinPregabalinPregabalinTCAKetamine

The WHO Analgesic Ladder

OPIATE USE – Historical Perspective

Combat at Guangzhou (Canton) during the Second Opium War

Ancient use (4200 BC - 800 AD)

The first known cultivation of opium The first known cultivation of opium poppies was in Mesopotamia approximately 3400 B.C - Hul Gilapproximately 3400 B.C Hul GilSeventeen finds of Papaver somniferumfrom Neolithic settlements in Europefrom Neolithic settlements in EuropeEgypt - "stop a crying child"

was generally restricted to priests was generally restricted to priests, magicians, and warriors

Islamic Societies (600-1500 A.D.)

Arab traders introduced opium to China Arab traders introduced opium to China Fi ma-yahdara al-tabib (In the Absence of a Physician): use for anesthetic and of a Physician): use for anesthetic and melancholy Religious prohibition variously appliedReligious prohibition variously applied

Western Medicine

Initially stigmatized as foreignLa da O i i d ith Laudanum: Opium mixed with alcohol -pain, sleeplessness, and diarrhea d a eaSydenham: “Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium “efficacious as opium.US Civil War: > 3 million doses of God’s Own Medicine

MYTH #5

Old people don’t get addicted to Old people don t get addicted to narcotics

REALITY

Opiates are addictive at all agesOpiates are addictive at all agesThe risk is, however, lowIn many settings the risk is worth itIn many settings, the risk is worth it

OPIATE USE HAS INCREASED

OPIATE MISUSE HAS INCREASED

Woodcock, J. N engl j med 361;22

Opiate Use Depends on Where You Livep p

Neuropathic pain

Often more difficult to treat and Often more difficult to treat and characterizeDifferent treatment Different treatment

NEUROPATHIC PAIN

Gabapentin works but has side-effects Gabapentin works, but has side effects Tricyclic antidepressants work just as well but have side-effectswell, but have side effectsOpiates work, but have side-effects

APS-AAPM Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

Opioids are associated with increased short-Opioids are associated with increased shortterm adverse events compared to placebo.

The most frequent adverse events are nausea, constipation, sedation, vomiting,

l d di i somnolence, and dizziness.

Adverse events frequently lead to Adverse events frequently lead to discontinuation of opioids

APS-AAPM Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

There is insufficient evidence that any long-y gacting opioid is more beneficial or less harmful than others.

No clear differences in benefits or harms between sustained- and immediate-release opioids.opioids.

DO OPIATES CAUSE DELIRIUM?

Both pain and narcotics have been reported as causes of delirium as causes of delirium.

It is often felt that clinicians under treat pain It is often felt that clinicians under treat pain in elderly patients, possibly due to the concern of causing delirium via the use of opioid analgesics in a vulnerable population opioid analgesics in a vulnerable population.

We conducted a systematic review to We conducted a systematic review to determine if delirium is associated with opiate use independent of the effect of pain.

Few studies with good measures of Few studies with good measures of delirium and pain.

There were no studies from the chronic care literature.

The palliative care literature showed that pain and opioids were equally strong risk p p q y gfactors for developing delirium.

The surgical literature had mixed resultsThe surgical literature had mixed results.

Back to the case…

Several conversations with daughterSeveral conversations with daughter.Established goals of care

Reduce not eliminate painReduce, not eliminate painImprove mobilityImprove cognitionImprove cognitionNo work-up for cause of pain or anaemia

Added plain regular acetaminophen 650 Added plain regular acetaminophen 650 mg po tid with breakthrough doses

Added prn hydromorphone as a prn for painful activities p

Tapered off of pregabalinp p g

Tapered off of ketamineTapered off of ketamine

Stopped calcitoninStopped calcitonin

d h b hRemained with pain, but this improved.

Cognition returned to baseline.

Functional status returned to u ct o a status etu ed tobaseline slowly.

Acknowledgements Acknowledgements Riverview Health Centre Foundation

Further ReadingPharmacological Management of Persistent Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society Panel on the Pharmacological y gManagement of Persistent Pain in JAGS, 57:1331–1346, 2009.

Harper lauds press freedom in speech, doesn't take questions from reporters doesn t take questions from reporters

The Canadian Press

Fig 2 Treatment efficacy of traditional anticonvulsants versus placebo

Wong, M.-c. et al. BMJ 2007;335:87

Fig 3 Withdrawals related to adverse events for traditional anticonvulsants versus placebo

Wong, M.-c. et al. BMJ 2007;335:87

Fig 4 Treatment efficacy of newer generation anticonvulsants versus placebo

Wong, M.-c. et al. BMJ 2007;335:87

Fig 5 Withdrawals related to adverse events for newer generation anticonvulsants versus placeboplacebo

Wong, M.-c. et al. BMJ 2007;335:87

Fig 6 Treatment efficacy of tricyclic antidepressants (TCA) versus placebo

Wong, M.-c. et al. BMJ 2007;335:87

Fig 7 Withdrawals related to adverse events for tricyclic antidepressants (TCA) versus placebo

Wong, M.-c. et al. BMJ 2007;335:87

Fig 14 Treatment efficacy of opioids versus placebo

Wong, M.-c. et al. BMJ 2007;335:87

Fig 16 Proposed treatment algorithm for painful diabetic neuropathy

Wong, M.-c. et al. BMJ 2007;335:87

Optimal pharmacological treatment of pain in patients with cognitive impairments should be based on the following cognitive impairments should be based on the following guiding principles:

(1) When pain is detected, institute treatment rapidly; (2) Use scheduled rather than “as needed” dosing (also (2) Use scheduled rather than as needed dosing (also

referred to as prn [pro re nata]) for chronic or predictably recurrent (e.g., postoperative) pain;

(3) Titrate medication to pain level and assess verbal, b h i l d f ti l t di ti behavioral, and functional response to medication;

(4) Choose a regimen that will mitigate common side effects of pain medication in elderly persons

Last-Observation Carried Forward Primary Depression and Pain Outcomes

Copyright restrictions may apply.

Kroenke, K. et al. JAMA 2009;301:2099-2110.

Community dwelling Swedish population

Westerbotn et al. Aging Clin Exp Res 20; 40-46

Assessing pain in cognitively impaired individuals..

Clear guidelines for standard ways of assessing pain;(Guidelines of the Agency for Healthcare Research (Guidelines of the Agency for Healthcare Research

and Quality, the American Pain Society, and The Joint Commission)a formalized approach to pain management a formalized approach to pain management, assessment, and frequent reassessment/ monitoring; organizational standards for collaborative and organizational standards for collaborative and interdisciplinary approaches; both pharmacological and non pharmacological strategies to alleviate pain; strategies to alleviate pain; individualized pain-control plans

Do the elderly perceive pain differently to younger adults?

Age-related increases in pain report may be more apparent Age related increases in pain report may be more apparent when stimuli are very intense and/or persist for longer periodsThe efferent actions of the nociceptive system in older people require a greater level of stimulus to achieve a people require a greater level of stimulus to achieve a maximum response, but the size of this response is comparable with that observed in younger peopleOlder subjects demonstrate a much longer period of

d h l i d it bl l l f secondary hyperalgesia despite comparable levels of spontaneous pain, thermal hyperalgesia, and flare -tenderness after injury appears to be prolonged with advancing ageThe threshold for pain is more likely to be increased in older people when stimuli are briefer, of lesser spatial extent, and at peripheral cutaneous or visceral sites –therefore placing older people at increased risk of harm p g p pfrom certain noxious stimuli

Assessment of Pain

Assess painAssess painCharacter

Course of its onsetCourse of its onset

Duration

Location Location

Previous Pain History

Previous treatments

Acuity

ChronicChronicChronic with exacerbationAcute Acute Chronic with new pain

Attitudes to painAttitudes to painAttitudes to sensation of sedationFunctional statusFunctional statusHigh fall risk

AGS Guidelines

Persistent pain or its inadequate treatment is associated with a number of adverse outcomes associated with a number of adverse outcomes in older people, including functional impairment, falls, slow rehabilitation, mood changes (depression and anxiety), decreased changes (depression and anxiety), decreased socialization, sleep and appetite disturbance, and greater healthcare use and costs. Although appropriate treatment can reduce these pp padverse events, the treatments themselves may incur their own risks and morbidities. Persistent pain can also be as distressing for th i f th ti t C i the caregiver as for the patient. Caregiver strain and negative caregiver attitudes can substantially affect the patient's experience of pain and should be evaluated and discussed pain and should be evaluated and discussed during the clinical encounter, if present.

Current evidence-based literature does Current evidence based literature does not serve as an adequate guide in many decision-making situations that many decision making situations that are routinely encountered in clinical practice. p

Variation in Opiate Use in Manitoba

Sadowski C et al. Can J Clin Pharmacol Vol 16 (2) 2009:322-e330;

Zerzan,Med Care 2006;44: 1005–1010

Gabapentin for Neuropathic Pain

TCA for Neuropathic Pain

Gabapentin versus TCAs for neuropathic pain

Side effect profile of gabapentin versus TCAs

Opioids for neuropathic pain

Opioids and delirium

Delirium is a common medical problem, especially in older patients in institutionalized and hospitalized settings.

It causes substantial morbidity, functional deterioration, prolonged cognitive impairment and an increased risk of mortality.

Delirium increases mortality during a hospital stay by almost twofold, increases length of stay on average by 8 days and results in worse physical and cognitive days and results in worse physical and cognitive recovery at 6 and 12 months with increased time in institutional care.

There is good evidence to indicate that in up to one third of patients, delirium persists for months and that this is a poor prognostic signmonths and that this is a poor prognostic sign.

Medications often contribute to delirium and are the only identifiable cause in 12%-39% of cases.

The most common drugs associated with delirium are psychoactive agents such as b di i i id l i d d benzodiazepines, opioid analgesics and drugs with anticholinergic effects.

Young J, Inouye SK. Delirium in older people. BMJ 2007;334;842-846Pisani MA et al. Crit Care Med. 2009 Jan;37(1):177-83

Gaudreau et al. Psychosomatics 2005;46:4,302-316

Data sources: A medical librarian Data sources: A medical librarian searched Medline and the Cochrane Database from 1966 to January 1st, Database from 1966 to January 1st, 2008.

Study selection: Retrieved studies were reviewed independently by two were reviewed independently by two reviewers.

Studies included randomized controlled Studies included randomized controlled trials as well as observational studies (cohort and case control).

REGULAR, NOT AS NEEDED

Fig 15 Withdrawals related to adverse events of opioids versus placebo

Wong, M.-c. et al. BMJ 2007;335:87

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