AMDA Clinical Practice AMDA Clinical Practice GuidelineGuideline

(CPG) for Pain (CPG) for Pain ManagementManagement

For Medical Directors and For Medical Directors and Attending PhysiciansAttending Physicians

Introduction to Pain Pain is common in the long-term care setting. Unrelieved chronic pain is not an inevitable

consequence of aging Aging does not increase pain tolerance or

decrease sensitivity to pain Most chronic pain in the long-term care

setting is related to arthritis and musculoskeletal problems

Pain may be associated with mood disturbances (for example, depression, anxiety, and sleep disorders)

Introduction to Pain The use of pain scales Acute vs. chronic pain Long-term care interventions

Pain in the Elderly

Definition of Pain—An individual’s unpleasant sensory or emotional experience Acute pain is abrupt usually abrupt in

onset and may escalate Chronic pain is pain that is persistent or

recurrent

Pain in the Elderly

The most common reason for unrelieved pain in the U.S. is failure of staff to routinely assess for pain

Therefore, JCAHO has incorporated assessment of pain into its practice standards

“The fifth vital sign”

Pain in the ElderlySources of pain in the nursing homeSource: Stein et al, Clinics in Geriatric Medicine: 1996

Condition causing painCondition causing pain Frequency (%)Frequency (%)

Low back painLow back pain 4040

ArthritisArthritis 3737

Previous fracturesPrevious fractures 1414

NeuropathiesNeuropathies 1111

Leg crampsLeg cramps 99

ClaudicationClaudication 88

HeadacheHeadache 66

Generalized painGeneralized pain 33

Neoplasm:Neoplasm: 33

Pain in the Elderly

Degenerative joint disease

Gastrointestinal causes

Fibromyalgia Peripheral vascular

disease

Rheumatoid arthritis Post-stroke

syndromes Low back disorders Improper positioning

Conditions Associated with the Development of Pain in the Elderly

Pain in the ElderlyPain in the Elderly

Crystal-induced arthropathies

Renal conditions Gastrointestinal

disorders Osteoporosis Immobility,

contracture

Neuropathies Pressure ulcers Headaches Amputations Oral or dental

Pathology

Conditions Associated with the Development of Pain in the Elderly

Pain in the Elderly

Different response to pain

Staff training Cognitive or

sensory impairments

Practitioner limitations

Social or Cultural barriers

System barriers Co-existing illness

and multiple medications

Barriers to the Recognition of Pain in the LTC setting:

Pain in the Elderly: Myths To acknowledge pain is a sign of personal

weakness Chronic pain is an inevitable part of aging Pain is a punishment for past actions Chronic pain means death is near Chronic pain always indicates the presence

of a serious disease Acknowledging pain will mean undergoing

intrusive and possible painful tests.

Pain in the Elderly: Myths

Acknowledging pain will lead to loss of independence

The elderly – especially cognitively impaired – have a higher pain tolerance

The elderly and cognitively impaired cannot be accurately assessed for pain

Patients in LTC say they are in pain to get attention

Elderly patients are likely to become addicted to pain medications

Pain in the Elderly

Consequences of untreated pain: Depression Suffering Sleep disturbance Behavioral disturbance Anorexia, weight loss Deconditioning, increased falls

Pain in the Elderly

Inferred Pain Pathophysiology Inferred Pain Pathophysiology 6]6]

Nociceptive pain – Explained by ongoing tissue injury

Neuropathic pain – Believed to be sustained by abnormal processing in the peripheral or central nervous system

Psychogenic pain – Believed to be sustained by psychological factors

Idiopathic pain – Unclear mechanisms

AMDA Pain Management CPG—Steps

1. Recognition

2. Assessment

3. Treatment

4. Monitoring

Pain in the Elderly-Recognition

Possible Indicators of Pain in MDS – Version 2.0

Restlessness, repetitive movements (B5) Sleep cycle (E1) Sad, apathetic, anxious appearance (E1) Change in mood (E3) Resisting care (E4) Change in behavior (E5) Functional limitation in range of motion (G4) Change in ADL function (G9)

Pain in the Elderly-Recognition

Possible Indicators of Pain in MDS – Version 2.0

Pain site (J3) Pain symptoms (J2) Restlessness, repetitive movements (B5) Sleep cycle (E1) Sad, apathetic, anxious appearance (E1) Change in mood (E3) Resisting care (E4)

Pain in the Elderly-Recognition

Possible Indicators of Pain in MDS – Version 2.0 Loss of sense of initiative or

involvement (F1) Any disease associated with pain (I1) Pain symptoms (J2) Pain site (J3) Mouth pain (K1) Weight loss (K3)

Pain in the Elderly-Recognition

Possible Indicators of Pain in MDS – Version 2.0

Oral status (L1) Skin Lesions (M1) Other skin problems (M4) Foot Problems (M6) ROM restorative care (P3)

Pain in the Elderly– Recognition

Non-specific signs and symptoms suggestive of pain:

Frowning, grimacing, fearful facial expressions, grinding of teeth

Bracing, guarding, rubbing Fidgeting, increasing or recurring

restlessness Striking out, increasing or recurring agitation Eating or sleeping poorly

Pain in the Elderly– Recognition

Non-specific signs and symptoms suggestive of pain:

Sighing, groaning, crying, breathing heavily Decreasing activity levels Resisting certain movements during care Change in gait or behavior Loss of function

Pain Management CPG— Recognition Steps

Is pain present? Have characteristics and causes of

pain been adequately defined? Provide appropriate interim treatment

for pain.

Pain Management CPG— Recognition

Pain Intensity Scales for Use with Older Patients – Visual Pain Intensity Scales for Use with Older Patients – Visual Analogue Scale Analogue Scale

No pain Terrible painl______l_____l_____l______l_____l______l_____l______l______l

1 2 3 4 5 6 7 8 9 10

Ask the patient:“Please point to the number that best describes your pain”

Scale has worst possible pain at a # 10

Pain Management CPG— RecognitionDocumenting an Initial Pain Assessment

Pattern: Constant_________ Intermittent__________Duration: __________Location: __________Character: Lancinating____ Burning______ Stinging_____ Radiating______ Shooting_____ Tingling______

Other Descriptors:________________________________ Exacerbating Factors:______________________________Relieving Factors:_________________________________

Pain Intensity – (None, Moderate, Severe) 1 2 3 4 5 6 7 8 9 10Worst Pain in Last 24 Hours (None, Moderate, Severe) 1 2 3 4 5 6 7 8 9 10Mood: ________________________________________Depression Screening Score: ______________________Impaired Activities: ______________________________Sleep Quality: __________________________________Bowel Habits: __________________________________Other Assessments or Comments:______________________________________________________________________________________________________________Most Likely Causes Of Pain: _____________________________________________________________________Plans: ______________________________________________________________________________________

Pain Management– Assessment Steps

Perform a pertinent history and physical examination

Identify the causes of pain as far as possible Perform further diagnostic testing as

indicated Identify causes of pain Obtain assistance/consultations as

necessary Summarize characteristics and causes of the

patient’s pain and assess impact on function and quality of life

Pain Management– Assessment Steps

Pain History [7] – Important Elements to Include:

Known etiology and treatments – previous evaluation, pain diagnoses and treatments

Prior prescribed and non-prescribed treatments

Current therapies

Pain Management– Assessment StepsChronic Pain History

“PQRST” Provocative/palliative factors (e.g., position, activity, etc.) Quality (e.g., aching, throbbing, stabbing, burning) Region (e.g., focal, multifocal, generalized, deep,

superficial) Severity (e.g., average, least, worst, and current) Temporal features (e.g., onset, duration, course, daily

pattern)

Medical History Existing comorbidities Current medicationsSource: Valley, MA. Pain measurement. In: Raj PP. Pain Medicine. St. Louis MO. Mosby, Inc. 1996:36-46.

Pain Management– Treatment Steps

Adopt an interdisciplinary care plan Set goals for pain relief Implement the care plan

Pain Management– Treatment Steps

Provide a Comforting and Supportive Environment –

Reassuring words/touch Topical or low-risk analgesic Talk with patient/caregivers about pain Back rub, hot or cold compresses Whirlpool, shower Comforting music Chaplain services

Pain Management– Treatment StepsEthics and Pain The old ethic of under-prescribing

“just say no” “it hurts so good”

The new ethic trust: believing what patients say commitment: formalized mutual

agreement standardized care: guidelines on

assessment and treatment collaboration: working together

Source: Marino A. J Law, Med Ethics, 2001

Pain Management– Treatment

General Principles for Prescribing Analgesics in the Long-Term Care Setting

Evaluate patient’s overall medical condition and current medication regimen

Consider whether the medical literature contains evidence-based recommendations for specific regimens to treat identified causes For example, acetaminophen for

musculoskeletal pain; narcotics may not help fibromyalgia

In most cases, administer at least one medication regularly (not PRN)

Pain Management– Treatment

General Principles for Prescribing Analgesics in the Long-Term Care Setting

Use the least invasive route of administration first

For chronic pain – begin with a low dose and titrate until comfort is achieved

For acute pain – begin with a low or moderate dose as needed and titrate more rapidly

Reassess/adjust the dose to optimize pain relief while monitoring side effects

Pain Management– Treatment

Appropriateness of regular or PRN dosing: Intermittent/less severe pain –

Start with PRN then switch to regular if patient uses more than occasionally. Start with a lower regular dose and supplement with PRN for breakthrough pain. Adjust regular dose depending on frequency/severity of breakthrough pain.

Pain Management– Treatment

Appropriateness of regular or PRN dosing More severe pain

Standing order for more potent, longer-acting analgesic and supplement with a shorter acting analgesic PRN

Severe/recurrent acute or chronic pain

Regular, not PRN dosage of at least one medication

– Start with low to moderate dose, then titrate upwards

Pain Management– Treatment

Goal of treatment is to decrease pain, improve functioning, mood and sleep

Strength of dosage should be limited only by side effects or potential toxicity

Pain Management CPG– Treatment Non-Opioid Analgesics Used in the Long-Term Care Setting

Pain Management CPG– Treatment

Opioid Therapy: Prescribing Principles and Professional Obligations [9]

Drug Selection Dosing to optimize effects Treating side effects Managing the poorly responsive

patient

Pain Management CPG– Treatment

Opioid Analgesics Used in the Long-Term Care Setting (Oral and Transdermal)

Pain Management CPG– Treatment

* Duration of effect increases with repeated use due to cumulative effect of drug

Pain Management CPG– TreatmentOral Morphine to Transdermal Fentanyl

* NOTE : This table is designed to convert from morphine to transdermal fentanyl and is based on a conservative equianalgesic dose. Using this table to convert from transdermal fentanyl to morphine could lead to overestimation of dose.

TreatmentTopical Analgesics Counterirritants

(menthol, methyl salicylate)

Supplied as liniments, creams, ointments, sprays, gels or lotions

May be effective for arthritic pain (not multiple joint pain)

Capsaicin cream (0.025%) and (0.075%)

Derived from red peppers Depletes substance P,

desensitizes nerve fibers associated with pain

Main limitations are skin irritation and need for frequent application

Need to use routinely for optimal effectiveness

TreatmentAnalgesics of Particular Concern in the Long-Term Care Setting

Chronic use of the following drugs are not recommended:

Indomethacin Piroxicam Tolmetin Meclofenamate Propoxyphene

Meperidine Pentazocine,

butorphanol and other agonist-antagonist combinations

Treatment Treatment Non-Analgesic Drugs Sometimes Used Non-Analgesic Drugs Sometimes Used for Analgesiafor Analgesia

Neuropathic pain Neuropathic pain AntidepressantsAntidepressants AnticonvulsantsAnticonvulsants AntiarrhythmicsAntiarrhythmics BaclofenBaclofen

Inflammatory Inflammatory diseases diseases CorticosteroidsCorticosteroids

Osteoporotic Osteoporotic fractures fractures CalcitoninCalcitonin

Treatment Factors to evaluate when considering complementary therapies

Patient’s underlying diagnosis and co-existing conditions

Effectiveness of current treatment Preferences of the patient and family or

advocate Past patient experience with the therapy Availability of skilled experienced providers

Pain Management CPG– Monitoring Steps

Re-evaluate the patient’s pain Adjust treatment as necessary Repeat previous steps until pain is

controlled

Pain Management CPG– MonitoringOpioid Therapy: Monitoring Outcomes

Critical outcomes: The “Four A’s” Analgesia – Is pain relief meaningful? Adverse events – Are side effects

tolerable? Activities - Has functioning improved? Aberrant drug-related behavior

Pain Management CPG– Monitoring

When patient is unresponsive to clinical management consider referral to:

Geriatrician Neurologist Physiatrist Pain clinic Physician certified in palliative medicine Psychiatrist (if patient has co-existing mood

disorder)

Dilemmas in Pain Management

While addressing pain management, have strategies in mind for common problems Patient refusal of potentially beneficial

medication Patient and family pressure to prescribe

certain drugs Patient and family misconceptions about

illness Unrecognized or denied psychiatric

disturbances

Reviewing the Physician’s Role

Prevention strategies Communication with patients/families Documentation Participate in Quality Improvement Follow policies and procedures

Summary

Views about management of pain in the elderly have changed in recent years

It is an expectation that pain be managed Pain can be effectively treated in the long-

term care setting A culture of patient comfort should

permeate all aspects of facility operations