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Michael DiMarco, Jr. Psy.D.

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Caring for Geriatric Patients in the Emergency Department Setting Part 6: Caring for Older Patients with Pain who are High Utilizers of the ED. Michael DiMarco, Jr. Psy.D. Emergency Department Consult Psychologist Clement J. Zablocki VA Medical Center - PowerPoint PPT Presentation
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Caring for Geriatric Patients in the Emergency Department Setting Part 6: Caring for Older Patients with Pain who are High Utilizers of the ED Michael DiMarco, Jr. Psy.D. Emergency Department Consult Psychologist Clement J. Zablocki VA Medical Center Assistant Professor, Psychiatry & Behavioral Medicine Medical College of Wisconsin
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Page 1: Michael DiMarco, Jr. Psy.D.

Caring for Geriatric Patients in the Emergency Department Setting

Part 6: Caring for Older Patients with Pain who are High Utilizers of the ED

Michael DiMarco, Jr. Psy.D. Emergency Department Consult Psychologist Clement J. Zablocki VA Medical Center Assistant Professor, Psychiatry & Behavioral MedicineMedical College of Wisconsin

Page 2: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 2

Disclosures

• Michael DiMarco, Jr. Psy.D. – No disclosures. – No conflicts of interest to report.

Page 3: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 3

A Common ED Dilemma

• Patient comes to ED with complaint of low back pain, longstanding, but recent increase has been unbearable.

• There is an opiate agreement in the EHR.

• Patient has a PCP who prescribes pain medication, including opiates.

• What do you do?

Page 4: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 4

Managing the Dilemma

1. Believe the patient’s report of pain

2. Assess pain using numerical, visual, or other standard pain scale

3. Determine diagnosis

– Acute pain issue – Exacerbation of a chronic non-cancer condition– Disease progression

Page 5: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 5

Managing the Dilemma

4. Review the opiate agreement in the EHR

5. Make a decision

– Administer Rx the ED i.e. injection– Write a prescription to be filled – Provide non-opiate medication

6. Discuss the benefits of follow up with the PCP/PS

Page 6: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 6

Staff Reactions to Pain Patients

• Empathy• Mistrustful • Frustration• Confrontation• Anger • Lecturing • Investigation • Delay treatment • Rush treatment – aka “treat & street”

Page 7: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 7

“Frequent Flyers”

• Common terminology used in the ED

• Terminology may have pejorative connotations

• The terminology may negatively impact pain care.

• Consider the impact of the term.

• Consider replacing the term with “Reoccurring”

“Mr. Matthews is a 69 year old man reoccurring to the emergency department due to persistent lower extremity neuropathic pain.”

Page 8: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 8

“Frequent Flyers” Reasons Patients Come to the ED for Pain Control

• Lack health insurance

• No established primary care provider (PCP) or pain specialist (PS)

• Disagreement with PCP/PS regarding the pain management plan

• Abrupt pain increase that may be exacerbated by a recent physical activity

• Pain increase due to rapid disease progression

• Fear/catastrophizing beliefs about pain

Page 9: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 9

“Frequent Flyers” Reasons Patients Come to the ED for Pain Control

• Regimen is not effective – Developed a physical tolerance to the RX – Under medicated in the first place

• Running out of RX before time of refill –Rx overuse

• Poor planning of routine prescription refills

• Addiction (personal use, self-medicating of MH condition)

• Criminal behavior -intent to sell Rx (diversion)

• Victim of abuse (patient’s Rx is being taken from them)

Page 10: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 10

Screening for Abuse(Screen the Patient Alone)

• “Who helps you organize your pain medications?”

• “Where do you keep your pain medications?”

• “Have you ever had to hide your medications from anyone?” If so, “Tell me about that.”

• “Has anyone ever offered you any money for some of your medications.” If so, “For which medications?”

• “Has anyone ever offered you food or other kind of help in exchange for some of your medications?”

• “Has anyone ever taken your medication from you?”

Page 11: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 11

Aberrant Medication Taking Behavior: “To abuse or not to abuse…is the question!”

• Addiction– Escalating Rx use with no therapeutic benefit on reducing pain

• Tolerance– The need for increase doses of Rx to maintain the same level of pain relief

• Pseudo-addiction – Patient appears drug-seeking but not due to addiction. Drug seeking is in the

context of being under medicated in the first place.– Drug seeking behavior diminishes once appropriate analgesia is achieved

Page 12: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 12

Consequences of Untreated Pain in Elderly

• Further physical limitations• Loss of independence• Decreased socialization• Depression• Impaired sleep• Cognitive impairment • Increase risk for falls and other injuries• Increased healthcare utilization/cost

• Lacas & Rockwood, 2012

Page 13: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 13

Myths About Treating Pain in the Elderly

• Analgesics are too dangerous.

• Analgesics will cause more cognitive dysfunction.

• Older people cannot accurately report pain –they’re just demented.

• Older people don’t understand pain rating scales.

Page 14: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 14

Assessment Issues

• ED culture –fast paced and not “geriatric-friendly.”

• Assessment biases based on gender, race, age

• Differences in how younger vs older patients experience pain psychologically

• Cognitive Impairment

Page 15: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 15

Biases in Pain Treatment

• Patients who are members of racial or ethnic minorities are under evaluated and undertreated for painful conditions in the emergency department.

• Some literature suggests females may receive more analgesia in the ED than males

• Some literature suggests that elderly patients receive less analgesia compared to their younger counterparts.

• Reference: Motov & Khan, 2009

Page 16: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 16

Age Bias

• Jones et al. (1996) found that out of a sample of 231 hospital patients, 66% of elderly patients received less analgesia compared to 80% of their younger counterparts.

• The study also found that elderly patients had a prolonged wait time for administration of pain Rx, significant under dosing of pain Rx, and received less opiate analgesics.

Page 17: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 17

Age Bias

• Lee et al. (2006) did not find any association between advanced age, gender, ethnicity in pain management including delays in administration of analgesic agents among the elderly presenting with abdominal pain to an emergency department.

• The study was unique in that it looked at the interaction of gender, race, and age. The original hypothesis was that female, non-Caucasian, an advanced age would expect delays in the administration of analgesia in comparison to their younger counterparts.

Page 18: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 18

Differences in Pain-Related Fear: Older vs. Younger

• Younger people have more generalized pain-related fears – global catastrophizing.

• Older people are more fearful of re-injury and further loss of autonomy and control that comes with aging.

• Gagliese, L. (2009)

Page 19: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 19

Pain Assessment in the Elderly

Cognitively Intact

Cognitively Impaired

Page 20: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 20

General Considerations for Pain Assessment in Elderly

• Ask about pain.

• Be aware that older patients may deny pain but endorse other descriptions such as aching, soreness, stiffness.

• Be aware that a decrease in physical activity may be the only indicator of pain because geriatric patients may not verbalize pain.

Page 21: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 21

Vertical Pain Scales

• Use assessment approaches that include both self-report and observational measures when possible.

• Involve the family in the assessment of pain.

Page 22: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 22

General Considerations for Pain Assessment

• Be aware that pain recall may pose some challenges– pain yesterday versus pain today.

• Be aware that deficits in language skills may pose challenges in the report of pain and explanation of pain – i.e. stroke.

• Be aware that facial expression associated with pain may be reduced/masked in the elderly.

• Be aware that impairments in executive function pose problems in noticing the early emergence of lower level pain intensity.

Page 23: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 23

Strategies for Cognitively Impaired Patients

• Don’t write these patients off.

• Reassess pain frequently.

• Minimize distractions when making a pain assessment.

Page 24: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 24

Strategies for Cognitively Impaired Patients

• Account for both visual and auditory deficits if possible.

• Use a nonverbal rating scale.

• Pain assessment during a movement (activity during transferring, bathing, dressing, and ambulating) is more likely to identify an underlying persistent pain problem than observation at rest.

Page 25: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 25

Pain Assessment in Advanced Dementia (PAINAD)

Pain Assessment IN Advanced Dementia- PAINAD (Warden, Hurley, Volicer, 2003) ITEMS

0

1

2

SCORE

Breathing Independent of vocalization

Normal

Occasional labored breathing. Short period of hyperventilation

Noisy labored breathing. Long period of hyperventilation. Cheyne-stokes respirations.

Negative vocalization

None

Occasional moan or groan. Low- level of speech with a negative or disapproving quality

Repeated troubled calling out. Loud moaning or groaning. Crying

Facial expression Smiling or inexpressive

Sad, frightened, frown

Facial grimacing

Body language

Relaxed Tense. Distressed pacing. Fidgeting

Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out

Consolability

No need to console

Distracted or reassured by voice or touch

Unable to console, distract or reassure

TOTAL*

* Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score indicating more severe pain (0=”no pain” to 10=”severe pain”).

Page 26: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 26

Coordinated Care

• View alert – PCP– PC-SW– PC-psychologist

• Referral to the PC Home-Based Program

Page 27: Michael DiMarco, Jr. Psy.D.

Management & Follow-up Care Coordination for Older Patients with Pain in the ED

Jelili A. Apalara, MD, MPH, FACP, CPE, FACHE.Assistant Clinical Professor of Medicine,University of California, San Francisco

Medical Director – Emergency Dept.VA Central California Healthcare System

MARCH 2014

Page 28: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 28

Disclosure

No Conflict of Interest!

Page 29: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 29

ObjectivesBy the End of this Presentation, participants will be able to:

• acquaint themselves with the consequences of inadequate pain treatment in the Elderly.

• familiarize themselves with the legal position on pain management.

• describe different modalities for pain management in the Elderly.

• recognize their roles in subsequent follow-up and management of the patients.

Page 30: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 30

Recommendation GradingEvidence Quality

High 1

Moderate 2

Low 3

Strength of Recommendation

Strong A

Weak B

Insufficient I

Page 31: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 31

Introduction

• In 2009, the Elderly population, persons 65 years and older, represents only one out of every eight Americans.

• This denoted 12.9% of the US population., or 39.6 million people in that year.

Page 32: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 32

Introduction

(Based on online data from the U.S. Census Bureau’s 1) Population Estimates and Projections; 2) Table 1. Projected Population by Single Year of Age (0-99, 100+), Sex, Race, and Hispanic Origin for the United States: July 1, 2012 to July 1, 2060, Release Date: 2012; and 3) Table 5. Population by Age and Sex for the United States: 1900 to 2000, Part A. Hobbs, Frank and Nicole Stoops, Census 2000 Special Reports, Series CENSR-4, Demographic Trends in the 20th Century.)

Page 33: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION

Realities and Challenges

• One major challenge faced by the elderly people is physical disability.

• Physical disability in this group often worsens with age.

• Majority have at least one chronic medical problem, and many have multiple chronic conditions.

• Arthritis and degenerative joint disease top the list, and often associated with Pain.

Page 34: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 34

Types of Pain

Page 35: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 35

Pain should be Evaluated and Treated in the

Elderly.

Page 36: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 36

Treating Pain is Both a MORAL and an

ETHICAL responsibility for

Healthcare Providers.

Page 37: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 37

The mission of DEA's Office of Diversion Control is to prevent, detect, and

investigate the diversion of controlled pharmaceuticals and listed chemicals

from legitimate sources while ensuring an adequate and uninterrupted supply

for legitimate medical, commercial, and scientific needs.

Page 38: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 38

Consequences of Untreated Pain

Functional Impairment. Depression.

Increased Suicide Risk.

Increased Mortality.

Page 39: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 39

Treatment Modalities

TREATMENT MODALITIES

Pharmacologic

Interventional

Surgical ProcedureBehavioral Medicine

Physical Therapy

Neuromodulation

Page 40: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 40

Treatment Modalities

NSAIDs

Opioids

Antidepressants

NMDA-ra

Anti-epileptics

α2 adrenergic agonists

Muscle Relaxants

Tramadol

Topical Agents

Page 41: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 41

Pharmacological Treatment

WHO’s Pain Relief Ladder

WHO 1980.

Page 42: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 42

Pharmacological Treatment• WHO recommends a progressive increment in doses and

types of analgesic to ensure effective pain management.

• Modality of treatment is not static, it changes with the characteristics of the pain.

• Mild pain should be treated with acetaminophen, aspirin or other Non-steroidal Anti-inflammatory Drugs (NSAIDs).

• Moderately persistent or worsening pain requires addition of opioid such as codeine or hydrocodone.

Page 43: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 43

Pharmacological Treatment• Opioids with fixed dose acetaminophen provides additive

analgesia.

• If pain worsens, and higher doses of opioid are necessary, separate dosage of opioid and non-opioid analgesic.

• This ensures maximally recommended doses of acetaminophen or NSAIDs are not surpassed.

• Severe pain requires more potent opioids, such as morphine, hydromorphone, methadone or fentanyl.

Page 44: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 44

Pharmacological Treatment

• Patients with persistent cancer-related pain should be on around-the-clock schedule, with additional “PRN" doses.

• Patients who have moderate to severe pain when first seen by the clinician should be started at the second or third step of the ladder.

• Adjuvant drugs should be used at any step as necessary to enhance analgesic efficacy and treat concurrent symptoms exacerbating pain.

Page 45: Michael DiMarco, Jr. Psy.D.

45

Page 46: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 46

Page 47: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 47

Geriatrics Pain Management

Page 48: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 48

Physician’s Role

PHYSICIAN&

PATIENTInterventional

Social Work

Behavioral Medicine

Physical Therapy

Physicians and Other Healthcare Providers are central to ensuring effective interdisciplinary pain management.

Page 49: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 49

Interdisciplinary Pain ManagementGOALS• Pain Reduction.

• Increased activity levels.

• Increased functionalilty.

• Early return to work or vocation.

• Reduced opioids use or more appropriate dosing.

• Reduced depression and anxiety.

• Improved coping skills.

• Reduced use of medical resources

Page 51: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 51

Key Points

Key Points

Acetaminophen should be considered as initial and ongoing pharmacotherapy in the treatment of persistent pain, particularly musculoskeletal pain, owing to its demonstrated effectiveness and good safety profile (1-A).

Most patients with moderate to severe pain, pain-related functional impairment, or diminished quality of life due to pain should be considered for opioid therapy (3-A).

Most patients with neuropathic pain are candidates for adjuvant analgesics (1-A).

Most patients with localized neuropathic pain are candidates for topical lidocaine (2-A) or capsaicin.

Pharmacological Management of Persistent Pain in Older Persons. JAGS. 2009.

Page 52: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 52

Key PointsPatients should not take more than one nonselective NSAID or COX-2 selective inhibitor for pain control (3-A).

Clinicians should anticipate, assess for, and identify potential opioid-associated adverse effects (2-A).

Only clinicians well-versed in the use and risks of methadone should initiate it. Methadone must be titrated cautiously (2-A).

Long-term systemic corticosteroids should be reserved for patients with pain-associated inflammatory disorders or metastatic bone pain. Osteoarthritis should not be considered an inflammatory disorder (2-A).

Therapy should begin with the lowest possible dose and increase slowly based on response and side effects, with the caveat that some agents have a delayed onset of action and therapeutic benefits are slow to develop. For example, gabapentin may require 2 to 3 weeks for onset of efficacy (2-A).

Pharmacological Management of Persistent Pain in Older Persons. JAGS. 2009.

Page 53: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 53

Conclusion

Optimal Pain Control improves elderly patient’s

quality of life!

Pharmacological Approach should not be the only

focus of management!! Interdisciplinary and Collaborative Approach

provide better management outcomes in

Elderly patients.

Page 54: Michael DiMarco, Jr. Psy.D.

VETERANS HEALTH ADMINISTRATION 54

Questions?

??

?


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