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Identification, Treatment and Management of Pain and Inflammation in the Aged

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Title: Identification, Treatment and Management of Pain and Inflammation in the Aged


1
Identification, Treatment and Management of Pain
and Inflammation in the Aged
  • Dr. Stephen de Graaff MBBS FAFRM
  • Medical Director
  • Cedar Court HealthSouth Rehabilitation Hospital

2
Definition of Pain
  • Pain is an unpleasant sensory and emotional
    experience associated with actual or potential
    tissue damage, or described in terms of such
    damage. Pain is always subjective.
  • (IASP) International Association for the
    Study of Pain

3
Acute Pain
  • Usually due to a definable acute injury or
    illness
  • Has a definite onset duration is limited
  • Is accompanied by anxiety clinical signs of
    sympathetic over-activity tachycardia,
    tachypnoea, hypertension, sweating etc
  • Treatment is directed at the illness or injury
    causing pain

4
Chronic Pain
  • Results from a chronic pathological process
  • Has a gradual or ill-defined onset, continues
    unabated and may become progressively more severe
  • Patient appears distressed withdrawn with
    usually no signs of sympathetic over-activity
  • May be associated with depressive symptoms
    lethargy, apathy, anorexia and insomnia
  • Personality changes may occur due to progressive
    alterations in lifestyle and functional ability
  • Treatment is directed at the underlying disease
    where possible, as well as psychological and
    social supportive care

5
Incident Pain
  • Occurs only in certain circumstances, such as
    pain after a particular movement.

6
Pathophysiological Classification
  • Neuropathic Pain
  • Peripheral or CNS injury
  • Pain occurs because the injured nerve reacts
    abnormally to stimuli or discharge spontaneously
  • Described as burning, stinging, shooting,
    lancinating

7
Pathophysiological Classification
  • Nociceptive Pain
  • Pain produced in response to a stimulus. Derived
    from Latin nocere meaning to hurt.
  • Somatic Pain
  • Pain from skin and superficial structures, well
    localised described as aching, sharp,
    throbbing.
  • Visceral Pain
  • Pain from organs, less well localised, described
    as deep aching or throbbing.

8
The Issue
  • Chronic pain leads to alterations in
  • receptors and transmitters in the spinal cord
  • and brain that may lead to perpetuation of
  • pain or reduced opioid sensitivity

9
Prevalence of pain in community-dwelling elderly
  • 25 - 50 (Ferrell BA, 1991)
  • 25 - 86 (Crook J et al, 1984 Brattberg G et
    al,1989
  • Herr KA Mobily PR, 1996)

10
Clinical Assessment
  • Detailed history of pain severity, site,
    duration, progression, frequency, radiation,
    precipitating relieving factors
  • A functional assessment
  • Ability to perform activities of daily living
  • Changes in lifestyle
  • Impact on the pain on home, work and
  • Social life
  • Impact on relationships

11
Inflammation Features
  • 2 Population- 7 women 60 years
  • 14-20 Attendants to Rheumatology Clinics
  • 80 Female
  • Severe Diffuse Chronic Pain- Trunk Girdles
  • Fatigue
  • Awaken stiff unrefreshed
  • Poor sleep hygiene

12
Inflammation Associations
  • Headaches (Tension Migraine)
  • Irritable Bowel Syndrome
  • Finger Cold Sensitivity
  • TMJ Syndrome
  • Depression Anxiety

13
Inflammation Examination Investigation
Findings
  • Examination
  • Tender Points
  • Normal Neurological Exam- Subjective weakness,
    normal sensation
  • Skin Hypersensitivity
  • ?Other conditions- OA, RhA
  • Investigations
  • Normal
  • No ? CRP, ESR
  • NCS/Muscle Biopsy Normal
  • Sleep Study
  • Other Conditions

14
Inflammation Assessment
  • Exclude other conditions eg. PMR, RhA, CTS, OSA,
    Myositis, Vitamin D Deficiency, Thyroid Disease,
    Depression
  • Investigate within reason
  • Diagnosis Explanation
  • Fibromyalgia
  • Regional myofascial syndrome
  • CFS
  • Overuse Syndromes

15
Red Flags
  • Most clues for red flag conditions are found in
    the patient history
  • Pre-test probabilities for major red flag
    conditions have been suggested
  • Cancer lt0.7
  • Infection lt0.01
  • Ankylosing spondylitis lt0.3

16
Yellow Flags
  • Fear-avoidance behaviour
  • Tendency to low mood and withdrawal from social
    interaction
  • Presence of a belief that the pain is harmful or
    potentially severely disabling
  • An expectation that passive treatments rather
    than active participation will help

17
Reasons for denial of pain in the elderly
  • Poor memory
  • Stoicism
  • Anxiety that pain could indicate disease
    progression
  • Belief that pain occurs naturally with age
  • Fear of abuse by nursing staff

Yates P
et al, 1995 Ferrell BA, 1996
Hickey T, 1988 Copp LA, 1990
18
Reporting of pain in people with dementia
  • Inability to report pain
  • Inaccurate reporting of pain
  • Infrequent re-evaluation by
  • nursing staff
  • Staff not believing pain is present
  • Behavioural changes

Therapeutic Guidelines
analgesic, 2002
19
Pain-related behavioural changes
  • Rubbing the affected body part
  • Agitation
  • Restlessness
  • Immobility
  • Screaming
  • Being unco-operative
  • Refusing food
  • Sleep disturbances
  • Signs of depression

Therapeutic Guidelines
analgesic, 2002
20
Pain prevalence in nursing homes
  • McClean WJ Higginbotham NH, 2002
  • - 28 reported pain at time of interview
  • - 22 of those - no record of analgesic
  • medication
  • -16 - no pain treatment ordered
  • - Predominantly musculoskeletal
  • Madjar I Higgins IJ, 1997
  • - 86 of residents in one nursing home
  • Overseas studies
  • - 27 to 83 of residents



21
Improving pain assessment
  • Encourage staff to ask regularly about pain
  • Become involved in the nursing care plan
  • Reassure that pain is not an inevitable outcome
    of old age
  • Encourage staff to keep concise records
  • Listen to relatives
  • Believe the patient
  • Utilise pain assessment scales

McClean WJ Higginbotham NH, 2002 McClean
WJ, 2003 Cohen-Mansfield J, 2002 Kamel HK et
al, 2001

22
Pain scales
  • Numerical pain scale
  • 0 1 2 3 4 5 6 7
    8 9 10
  • Visual analogue scale
  • No ______________________________ Worst
  • pain possible
    pain


Adapted from Therapeutic
Guidelines analgesic, 2002
23
Biopsychosocial assessment of pain
  • Effect of pain on behaviour, lifestyle and
    relationships
  • Degree of disability related to pain, e.g.
    depression
  • Manner of expressing pain
  • Understanding of pain
  • Coping and adaptive skills
  • Interpersonal and family support systems
  • Motivation
  • Sleep, appetite
  • Financial aspects
  • Other factors influencing pain e.g. past pain
    experience, loss of control,
    difficulties with the health system

Goucke CR, 2003 Ferrell BA, 1996 Therapeutic
Guidelines analgesic, 2002 McCaffery M Pasero
C, 1999
24
Managing chronic non-cancer pain
  • Diagnose and treat cause
  • Avoid unnecessary investigations
  • Treat exacerbating co-morbidities,
  • e.g. depression
  • Set realistic goals
  • Prevention
  • - seating, clothing, positioning

Therapeutic Guidelines analgesic, 2002
Goucke CR, 2003 McClean WJ, 2003

25
Managing chronic non-cancer pain (cont)
  • Start physical treatments and non-drug
    interventions early
  • - exercise, hydrotherapy
  • - cognitive behavioural therapy
  • - heat and massage
  • - TENS stimulation, acupuncture
  • - distraction, e.g. music
  • - prayer
  • - relaxation imagery, hypnosis
  • Nutritional therapies, e.g. glucosamine sulphate,
    chondroitin
  • Medication
  • - regular doses, not prn
  • Multidisciplinary pain clinic
  • Surgery

Therapeutic Guidelines analgesic, 2002
Goucke CR, 2003 McClean WJ, 2003

26
Consequences of persistent pain
  • Limitation of function/disability
  • Changes in mood and behaviour
  • Adverse psychosocial circumstance
  • Financial, employment and legal difficulties

Therapeutic Guidelines analgesic, 2002
27
Principles of Treatment
  • Thorough assessment
  • Good communication
  • Encourage patient participation
  • Set realistic goals
  • Regular review adjustment of goals

28
Non-Pharmacologic Treatments
  • Cognitive Behavioural Therapy
  • Occupational Therapy
  • Heat therapy
  • Cold therapy
  • TENS
  • Acupuncture
  • Massage
  • Physical Therapy

29
Patient Education
  • Known cause/s of pain hurt vs harm
  • Methods of pain assessment, measurement and
    evaluation
  • Goals of the treatment
  • Expectations of the treatment
  • Things the patient can do themselves
  • -self-management strategies
  • -pacing

30
Role of allied health professionals in
musculoskeletal pain management
  • Occupational therapist
  • - home assessment and modification, work
    simplification, devices
  • Physiotherapist
  • - exercises, splinting, pain management,
    hydrotherapy
  • Podiatrist
  • - assessment/treatment, orthotics
  • Social worker
  • - home/social assessment, community supports
  • Self help groups (e.g. arthritis foundations)
  • - education, social contact
  • Commonwealth Carelink Centre
  • - www.commcarelink.health.au


NHRMC, 1994
31
Exercise in the elderly with musculoskeletal
pain
  • Reverses age-related decline in muscle size and
    strength
  • Decreases bone loss
  • Improves dependency, disability
  • and pain
  • NB Avoid immobilisation where possible

Felson DT, 1990 Fiatarone M et al, 1990
NHMRC, 1994
32
Exercise programs for the elderly
  • Tailor exercise to
  • - functional status, fitness, difficulties with
    daily activities
  • Specific
  • - directed at certain joints
  • General
  • - at least 20 minutes, 3-4 times/week
  • - 60 of aerobic power
  • Warm up, warm down
  • - stretches muscles
  • - reduces risk of arrhythmias
  • Examples
  • - swimming, walking,
    - aquaerobics,
    tennis, golf, Tai Chi, yoga
  • NHMRC, 1994


33
Regular Assessment
  • To maximise functional wellbeing
  • To optimise pain management/relief
  • To minimise side effects (if drugs involved)
  • To engender the best quality of life for the
    patient

34
Pain Diary
  • Assessment of severity
  • Behaviour of pain over the day
  • Exacerbating or relieving factors
  • Sleeping patterns
  • Use of medication
  • Functional behaviour

35
Pain Management Programs
  • Functional Restoration
  • Chronic Pain Management
  • Individualised treatment programs
  • Fibromyalgia Program

36
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37
Pain Management Programs
  • Multidisciplinary team approach to management of
    chronic pain conditions.
  • Inpatient or Outpatient basis
  • Team members may include
  • - Medical Consultant.
  • - Physiotherapist.
  • - Occupational Therapist.
  • - Psychologist.
  • - Exercise Physiologist.
  • - Psychiatrist (primarily with inpatient
    programs)

38
Functional Restoration Program
  • Generally have short term goal of increasing
    capacity for return to work/preparation for job
    seeking and for daily/leisure activity.
  • Higher level physiotherapy/exercise physiologist
    program.
  • OT focus on work simulation/education on manual
    handling/liaison with stakeholders.
  • Psychology education and individual sessions
    pain framework, practical self management
    strategies to assist with return to work/function

39
Chronic Pain Management
  • Greater education on chronic pain condition.
  • More intensive psychology input aimed at
    stress/mood/sleep/pain management, medication and
    pain and cognition. Also emphasis on relaxation
    techniques.
  • Physiotherapy generally lower level exercise and
    physical conditioning.
  • OT body mechanics, pacing, activity diary and
    functional circuit aimed at ADL. Return to work
    longer term focus- not for all.

40
Fibromyalgia Program
  • 7 week cohort group.
  • Rheumatologist education session on What is
    Fibromyalgia.
  • Education sessions covering exercise, pacing,
    diet, stress management, depression, pain
    management, medication, wellness and choices
    for living.
  • Yoga based approach to exercise and relaxation

41
Individualised Programs
  • Where not appropriate for a group based program.
  • Significant psychological issues.
  • English as a second language.

42
Multidisciplinary pain clinics
  • Elderly underrepresented
  • Benefits similar to those in younger patients
  • Consider referral to a pain centre when
  • A trial of opioids fails to provide relief
  • The patient fails to improve in function
  • The patient has difficult-to-control neuropathic
    pain
  • A satisfactory diagnosis cannot be reached
  • There are complex psychosocial influences
  • Pain is accompanied by medication misuse


Gibson SJ et al, 1996 Goucke CR, 2003
43
Cognitive behavioural therapy
  • Level 1 evidence for efficacy (NHMRC)
  • Included in multidisciplinary pain management
    plan
  • Identifies dysfunctional attitudes, beliefs and
    fears
  • Education component
  • - basic anatomy, posture
  • - relationship between stress and tension
  • tension and pain
  • - physical, emotional and psychological factors
  • in chronic pain
  • - skills to control and decrease pain
  • relaxation training, activity pacing, distraction
  • techniques, cognitive restructuring, calming self
  • statements


Therapeutic Guidelines analgesic, 2002
Goucke CR, 2003 Keefe FJ et al, 1996
44
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45
Pharmacology of analgesics in the elderly
  • Decline in the therapeutic index
  • Poor compliance
  • Decline in the ratio of lean body mass to total
    body weight
  • Decreased hepatic metabolism
  • Decline in renal drug clearance
  • Drug-disease interactions
  • e.g. CCF causes diminished hepatic blood flow

Popp B Portenoy RK, 1996
46
Pharmacological Treatments
Adapted from Mashford. Therapeutic Guidelines
Analgesic 2002.
47
Choice of Analgesic Follow the WHO Analgesic
Ladder
  • Regular dosing ? supplements prn
  • Note Step 2 no longer used in a clinical
    setting for cancer pain

Step 3
  • Strong opioid
  • morphine
  • oxycodone
  • hydromorphone
  • methadone
  • ? non-opioid
  • ? adjuvant

Step 2
  • Weak opioid
  • codeine
  • oxycodone(combination low dose)
  • tramadol
  • ? non-opioid
  • ? adjuvant

Step 1
  • Non-opioid
  • NSAIDs
  • aspirin
  • paracetamol
  • ? adjuvant


Adapted from WHO,1986
48
Continuous assessment of analgesic efficacy
  • Monitor the pain behaviour of the individual
  • Re-evaluate frequently
  • Use pain assessment scales

49
Precautions with drugs in the elderly - NSAIDS
  • GI, renal effects, hypertension and fluid
    retention
  • ACE inhibitor diuretic NSAID
  • - risk of fatal drug-induced renal failure
  • - includes angiotensin II receptor
  • antagonists, COX-2 inhibitors
  • COX-2 inhibitors- CVS/CNS issues/ Drug
    Interactions

McClean WJ, 2003 Therapeutic Guidelines
analgesic, 2002
50
Analgesic medications
  • Steroid injections in non-inflammatory conditions
  • - rationale obscure
  • ACE inhibitor diuretic NSAID (or COX-2
    inhibitor)
  • - a dangerous combination
  • ACE inhibitor NSAID
  • - reduced effect ACE inhibitor
  • - increased risk hyperkalaemia and
  • acute renal failure
  • Aspirin COX-2 inhibitor
  • - continue aspirin in patients with
    cardiovascular
  • disease

Therapeutic Guidelines analgesic 2002 McColl
GJ, 2001 McClean WJ, 2003
51
Precautions with drugs in the elderly
  • Tricyclic antidepressants
  • Elderly more susceptible to anticholinergic
    adverse effects - confusion and delirium may
    occur in this age group
  • May cause impairment of cardiac conduction
  • Should be used with caution in patients with
    epilepsy

Therapeutic Guidelines analgesic,
2002
52
Pain Not Responsive to Non-opioid Analgesia
  • Randomised, double-blind active controlled
    two-period cross-over trial.
  • 47 patients with stable moderate to severe
    persistent back pain non-responsive to non-opioid
    analgesia received
  • Oxycodone CR (10mg bid)
  • Oxycodone IR (5mg qid)
  • Titration (from a minimum dose of 20mg/day to a
    maximum of 80mg/day) was continued until stable
    analgesia was achieved for 48 hours
  • Pain intensity reduced from moderate/severe to
    slight, despite the previous use of maximum doses
    of non-opioid analgesics with or without prn
    opioids
  • The reasons for improved pain control include
  • Use of a stronger opioid
  • Around the clock dosing
  • A more appropriate opioid dose

Hale ME et al. Clin J Pain 199915179-183.
53
Precautions with drugs in the elderly - Opioids
  • Higher plasma concentrations
  • Increased sensitivity to analgesic and
  • other effects
  • Tramadol
  • - confusion, hallucinations, convulsions,
    serotonin
  • syndrome, drug interactions
  • Pethidine
  • - toxic metabolite, avoid in chronic therapy
  • - tremulousness, dysphoria, myoclonus, seizures
  • - morphine generally safer, even for acute
    severe pain

Therapeutic Guidelines analgesic, 2002
Popp B Portenoy
RK, 1996 Adverse Drug Reactions Bulletin,
2003
54
Precautions with drugs in the elderly Opioids
(cont)
  • Transdermal fentanyl
  • - dangerous in opiate naïve people
  • Morphine
  • - nausea, vomiting, constipation
  • - respiratory depression
  • Oxycodone
  • - one and a half to two times as potent as
  • morphine orally
  • - adverse effects similar to those of morphine

Therapeutic Guidelines analgesic, 2002 Popp B
Portenoy RK, 1996 Ferrell BA, 1996

55
Paracetamol/Codeine vs Tramadol
  • Double-blind, randomised, multiple-dose
    cross-over study
  • 55 patients with persistent low back pain,
    received
  • 2 x 500mg APAP 30 mg codeine
  • 2 x 50mg tramadol
  • APAP/codeine was as efficacious as tramadol
  • APAP/codeine was better tolerated than tramadol
  • More patients preferred treatment with
    APAP/codeine

Muller FO et al. Drug Res 199848(1)675-679.
56
Dextropropoxyphene
  • Accumulation of metabolite
  • Cardiotoxicity
  • Physical and psychological dependence
  • Psychosis and convulsions
  • Central adverse effects in the elderly

Therapeutic Guidelines analgesic,
2002
57
Definitions
  • Physical dependence
  • - withdrawal symptoms
  • - related to tolerance
  • Tolerance
  • - increasing doses required to maintain effect
  • Addiction
  • - cyclical craving
  • - compulsive drug-seeking
  • - high tendency to recidivism

Therapeutic Guidelines analgesic,
2002
58
Starting opioid therapy in the elderly with
chronic pain
  • Titrate with short-acting opioid first
  • Start low, go slow
  • Stop other non-essential centrally active drugs

Therapeutic Guidelines analgesic,
2002
59
Guidelines for opioid therapy in chronic
non-cancer pain
  • Only one doctor prescribes and monitors
  • Patient and doctor agree on goals
  • Treatment trial (4-6 weeks) before
  • long-term use
  • Continuous treatment with long-acting opioid
  • Regular ongoing review mandatory

Graziotti PJ Goucke CR, 1997

60
Consent and opioid therapy
  • Treatment goals
  • Dependence vs addiction
  • Responsible security procedures
  • Adverse effects
  • - withdrawal symptoms
  • - cognitive effects
  • - constipation, laxatives
  • - drug interactions

Graziotti PJ Goucke CR, 1997

61
Informed consent
  • Define goals for treatment, and educate about
    dependence and addiction
  • Warn that withdrawal symptoms will occur if the
    treatment is stopped suddenly
  • Warn about potential interactions with other
    medications, indications for ceasing treatment
    and other adverse effects
  • Outline patients responsibilities regarding
    security and ensuring adequate supply


Graziotti PJ Goucke CR, 1997
62
Surgery
  • Virtually eliminates pain
  • Significantly increases mobility
  • Failure rate for hip and knee prostheses ? 5 at
    five years (major units)
  • Some patients continue to have pain on weight
    bearing
  • Few situations where this should not be
    considered
  • Spinal anaesthesia
  • Pre-operative assessment
  • - weight reduction and exercise program
  • can improve outcome


NHMRC, 1994
63
Unrelieved Pain
  • Related to patient
  • Failure to report pain
  • belief that pain is inevitable
  • belief that pain is untreatable
  • putting on a brave face
  • Failure to take medication
  • side effects
  • does not believe in medications
  • fear of tolerance, addiction
  • fear of having nothing in reserve

64
Barriers to effective pain management in the
community
  • Lack of knowledgeable carers
  • Assessment inadequate
  • Poor quality of life
  • - disability, depression
  • Lack of collaboration
  • Burden on the caregiver
  • Non-compliance
  • Ferrell BA, 1991 Blum RH et al, 1990 Walker
    JM et al, 1990 Haley WE Dolce JJ,
    1986 Williamson GM Schultz R, 1992 Ferrell BR
    et al, 1993b Ferrell BA Ferrell BR, 1991
    Austin C et al, 1986 Bachman R, 1987

65
Overcoming pain management barriers in the
community
  • Be aware of age-related bias in health care
    workers
  • Use standard assessment protocols
  • Individualise plan of care
  • - simplify treatments
  • - minimise night-time monitoring
  • Educational support
  • - address misbeliefs, e.g. fears of addiction,
    misperceptions about the pathophysiology of pain
  • - counsel patient and caregiver about medication
  • use and how to deal with side effects

Herr KA Mobily PR, 1996 Haynes RB et al, 1976
66
Overcoming pain management barriers in the
community (cont)
  • Use calendars and pill organisers
  • Use home-care nursing agencies
  • Recommend pain logs/diaries
  • Consider inpatient hospitalisation/respite care
  • Listen to family caregiver
  • Reinforce pain management principles
  • Communicate regularly with nurse and family
    caregiver

Morgan AE et al, 1994 Herr KA Mobily PR,
1996 Ferrell BR Dean GE, 1994
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