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Palliative Approach to Pain Management
in the Older Adult
Amy M Corcoran, MD CMD FAAHPM
Associate Professor
Geriatric and Palliative Medicine
Milton S Hershey Medical Center
College of Medicine, Penn State University
Disclosure
• Speaker has no conflict of interest, financial agreement, or working affiliation with any group or organization.
Objectives
• Define palliative approach• Describe pain assessment tools,
including those utilized for cognitively impaired and nonverbal patients
• Create case-based pain management plans for older adults
Palliative Care
• Holistic patient-centered care• Focus on symptom management –
physical, psychosocial, spiritual• Interprofessional team approach
http://www.who.int/cancer/palliative/definition/en/
Review Major Types of PainType Somatic Visceral Neuropathic
Characteristics -well-localized-dull or achy
-poorly-localized-deep, squeezing, pressure-like-associated with nausea, vomit, sweating
-severe-burning or vise-like-occasionally shooting
Patho-physiology
-arises from cutaneous or deep tissues (i.e. post-op pain or bone mets)
-arises from organ infiltration, compression, or stretching (i.e. MI, cholecystitis, bowel obstruction)
-arises from traumatic or ischemic injury to PNS or CNS or other nerve damage
Review Pain Assessment
• Requires repeat comprehensive assessments
• Older adults under-report pain”normal aging”
• How is it affecting function and daily life?• How do you pick what scale to utilize?
AGS Panel on Pharmacologic Management of Persistent Pain in Older Persons. JAGS 57:1331-1346, 2009
0 1 2 3 4 5 6 7 8 9 10
No pain
Worst pain
imaginable
Numerical Scale
0 Very happy, no
hurt
2 Hurts just a little
bit
4 Hurts a little
more
6 Hurts even more
8 Hurts a whole lot
10 Hurts as much as you can imagine (don't have to be crying to feel this
much pain)
Whaley L, Wong, D. Nursing Care of Infants and Children, ed 3, p. 1070. ©1987 by C.V. Mosby Company. Research reported in Wong D, Baker C. Pain in children: Comparison of assessment scales. Pediatric Nursing 14(1):9-17, 1988.
Other Components to Assess
• Spiritual• Psychosocial• Depression/anxiety• Misc
Scenario
90 year-old patient with advanced dementia. She is non-ambulatory, non-verbal, and requires assistance with all basic ADLS. Her nursing aide is concerned that she is in pain.
What types of questions would you ask her aide to assist with assessing her for pain?
Scenario
Her aide reports that she scores a 5/10 on the PAIN-AD. She makes facial grimaces with personal care and any movement. She is sometimes moaning and inconsolable.
Given her history of osteoarthritis, what would be the best choice for her pain management?
Overview of Nonopioid Analgesics:Appropriate for MILD Pain
• Acetaminophen• NSAIDs• COX-2• Tramadol
Given her age, what types of pharmacological concerns do you have when choosing your medications?
Review of Geriatric Pharmacotherapy
• Kidney• Liver• CNS• Protein Binding• Body Composition• Drug-drug Interactions
Scenario
78y/o in the hospital with recently diagnosed with metastatic breast cancer. Although NSAIDs have given her some relief with the pain, she feels pain “in her bones”. She is still experiencing 5-8/10 constant, sharp pain. She has normal renal and hepatic function.
Her primary physician gave her Percocet and she reports taking 4-6/day.
Do you have any concerns about NSAIDS in older adults?
She is still experiencing 5-8/10 constant, sharp pain. She has known bone metastases causing his pain.
What are your options for treating bone pain?
Bone Pain• Bone Mets
– NSAIDS– Bisphosphonates—pamidronate, zalendronic
acid– Radiotherapy (XRT)—strontium-89, samarium-
153-lexidronan– Steroids
• Acute Fracture– Bisphosphonates– Calcitonin
• Paget’s Disease– Bisphosphonates
Her cancer doctor gave her percocets and she reports taking 4-6/day. She is still experiencing 5-8/10.
How long does it take for opioids to take affect given the route of administration?
Review of the Opioid Basics
• Morphine• Hydromorphine• Oxycodone• Fentanyl transdermal• Methadone
What type of regimen would you start?
• Her cancer doctor gave her percocet (10/325) and she reports taking 4-6/day. Taking into account that his pain is moderate-severe (5-8/10) could increase dose by 50-100%.
• Approximately 50mg oxycodone/dayincrease by 50% to 75mg/day
• Oxycontin (long-acting) 40mg bid with oxycodone (short-acting) 10mg q3hours/prn
What type of preventive medications or measures should you always consider
when prescribing opioids?• Bowel regimen (senna at a minimum!)• Nausea prophylaxis?
She expresses concern about addiction or fear of tolerance
– now what do you do?
• What is addiction?• What is tolerance?• What is dependence?
She agrees to start the regimen and then develops diffuse itching after about 3 days
of the regimen….what do you do next?
What if there is a neuropathic pain component
or mixed-pain?
Neuropathic Pharm Review
• Tricyclic antidepressants (TCAs)
• Anticonvulsants• NSAIDs• Steroids
Scenario
70 year-old with stage IV lung cancer. He is comfortable on a continuous infusion of morphine at 6mg/hr IV on home hospice.
However, he is experiencing “jerking, shock-like movements” and “moderately severe” cramping pain.
What is happening? What are your management options?
What are some non-pharmacological methods to treat pain?
• Hypnosis• Hyperstimulation analgesia
– Ice massage– Acupuncture– TENS (transcutaneous electrical nerve stimulation)
• Dry heat• Hydrotherapy• Orthotic devices• Trigger point injections with lidocaine or steroid
Common Pitfalls in Older Adults
• Not using a quantitative pain scale• Not prescribing opioids for patients whose pain
levels are moderate to severe• Not providing aggressive bowel regimen• Not discontinuing medications that contribute to
sedation• Not scheduling around the clock medications• Not re-assessing clinically for effectiveness of
pain regimen• Not utilizing the interprofessional team
Which of the following are non-verbal pain indicators?
A. Facial grimace
B. Restlessness
C. Tachycardia
D. All of the above
Which of the following are common pitfalls in palliative pain management of the older adult?
A. Inconsistent use of a pain assessment tool
B. Forgetting to discontinue medications that could be contributing
C. Forgetting to order a bowel prophylaxis regimen
D. Not re-evaluating the effectiveness of the regimen
E. All of the above
Helpful References• AGS Panel on Pharmacologic Management of Persistent Pain in Older
Persons. JAGS 57:1331-1346, 2009• AGS Clinical Practice Committee: Management of cancer pain in older
patients. JAGS. 1997 (45): 1273-76.• Cafiero, Angela C. PharmD, CGP. Geriatric Pharmacotherapy. Geriatric
Secrets. 3rd Edition. Henly and Belfus, Inc. 2004; 29-35.• Feldt, Karen PhD RN. The Checklist of Nonverbal Pain Indicators (CNPI).
Pain Management Nursing. March 2000; 13-17.• Hadjistavropoulus T., et al. An Interdisciplinary Expert Consensus
Statement on Assessment of Pain in Older Persons. Clinical Journal of Pain. January 2007 Supplement. Volume 23 (1):S1-43.
• Kapo, Jennifer MD and Janet Abrahm, MD. Pain Management. Geriatric Secrets. 3rd Edition. Henly and Belfus, Inc. 2004; 87-94.
• Mercadante, S. and Fabio Fulfaro. Management of Painful Bone Metastases. Current Opinion in Oncology. 2007 (19):308-314.
• Pavlakis N. et al. Bisphosphonates for Breast Cancer (review). Cochrane Review. John Wiley and Sons. 2007.
• Upton et al. Population pharmacokinetic modelling of subcutaneous
morphine in the elderly. Acute Pain. 2006 (8);109-116.