Pain Issues and the Elderly

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Pain Issues and the Elderly

• Dr. Ann M. Berger, MSN, MD
• Chief, Pain and Palliative Care
• National Institutes of Health, Clinical
  Center

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Acute vs. Chronic Pain
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PathophysiologicMechanisms of Pain
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Pain In the Elderly

• Prevalence in population based studies in those
  65 are from 55-86.

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Step I Mild Pain
Step III
Step II
Step I

• OTC, non-opioid, and adjuvant medications
• Common medications
• Aspirin, acetaminophen, ibuprofen, naproxen,
  Trilisate, COX-2 anti-inflammatories
• ketorolac (Toradol) IV or PO (

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Step II Moderate Pain
Step III
Step II
Step I

• Opioid medication
• With/without adjuvant analgesics
• Common medications
• Hydrocodone, oxycodone, tramadol (Ultram)
• Duration 3-4 hour, (except may have longer
  relief with tramadol)
• Common combination drugs Tylenol 3, Percocet,
  Roxicet, Oxycet, Vicodin, Lortab, Lorcet,
  Fioricet.

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Step III Severe Pain
Step III
Step II
Step I

• Short acting opioids
• For acute pain, rescue dosing, or titration of
  long acting agents
• Common Dilaudid, morphine sulfate IR, Roxanol,
  ACTIQ, oxycodone
• Long acting
• requires titration of short acting opioids
• Provides consistent 24 hr therapeutic blood
  levels
• 8-12 hrs Oxycontin, MS Contin, Oramorph,
  methadone (long t1/2 with shorter analgesic
  effect)
• 48-72 hrs duration Duragesic

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Opioids for Moderate to Severe Pain
Long Acting Morphine (MS Contin, Oramorph SR,
Kadian Oxycodone (Oxycontin) Fentanyl
(Duragesic) Methadone (Dolophine) Levorphanol
(Levo-Dromoran) Oxymorphone
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Opioids for Moderate to Severe Pain
Short Acting Morphine (Roxanol, MSIR)
Oxycodone (Roxicodone, Oxy IR) Fentanyl
(Actiq) Hydromorphone (Dilaudid) Oxymorphone
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Management of Common Opioid Side effects
Constipation - prophylactic use of laxatives
and stool softeners Nausea and vomiting -
neuroleptics, metoclopramide, cisapride,
antivertigenous drugs Sedation - discontinue
other CNS depressants - add psychostimulants
Respiratory depression - monitor if not severe
carefully titrate naloxone if severe
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• Tolerance
• pharmacological need to increase dose to achieve
  the same effect over time in the absence of
  advancing disease. Tolerance is usually not
  problematic in chronic analgesic use.
• Physical dependence
• class-specific, predictable psycho-physiological
  reaction to sudden cessation or blocking of a
  drug. A tapering regimen will mitigate or stop
  withdrawal.

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• Addiction
• overwhelming preoccupation with acquisition
• use of drug for non-medicinal purposes
• results in reduced quality of life and continued
  use despite harm.
• Fewer than 0.1 of acute/chronic pain medication
  users develop addiction behaviors (Jick,
  Portenoy).
• Pseudo-addiction
• aberrant or illegal drug-seeking behavior similar
  to addiction that is due to unrelieved pain,
  which stops when adequate pain relief is achieved.

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Neuropathic Pain-Adjuvant Analgesics

• Tricyclic antidepressants
• Anticonvulsants
• Clonidine
• Corticosteroids
• Local anesthetics-Mexilitene
• Ketamine
• Baclofen

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Nature of Pain
Neuropathic Mechanism
Psychosocial Influences
Somatic,Visceral Nociception
Pain
Psychological State and Traits
Total Pain
Spirituality
Suffering
Loss of Work
Social / Family Functioning
Physical Disability
Financial Concerns
Fear of Death
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Emotional Pain hurts all over

• Most common palliative care symptoms
• Anxiety may present as sleeplessness, reluctant
  to be left alone or overt fright
• Anticipatory Anxiety previous negative
  experience becomes overwhelming
• Treatment relaxation imagery, acupressure,
  massage, music therapy, hypnosis. then maybe
  pharmacotherapy such as lorazepam, haloperidol

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Emotional Pain

• Care Giver Burden communication, communication,
  communication
• Spirit of cooperation
• Complex family dynamics emerge
• Support to work through accumulated emotions
• Can not take away all of the symptoms all the
  time
• Imposing own expectations
• Sense of presence is the very best medicine

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Spirituality

• The part of self where search for meaning takes
  place.
• Distinction between religion and spirituality
• Intimate connection with life through family,
  home, friends, leisure and work

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It takes a nurturing interdisciplinary team to
practice the nature of palliative care
Thanatology Grief Counseling Family
Support, End-of-Life Issues Community
Transition
Recreational Therapy Relaxation Stress
Management Pet, Music, Art Therapy
Core Team Comprehensive
Assessment Coordinate Interventions Discharge
Planning
Co-morbidity Concomitant Disorder
Treatment Regimen
Rehabilitation Functional
Interventions Assistive Devices Energy
Conservation
Complementary Acupuncture/
Acupressure Tai Chi Trigger Point Release
Symptoms
Clinical Trials Protocol
Disease Process
Individuals Quality of Life
Social Work Socioeconomic Support
Community Resources Coping Skills
SpiritualMinistry Pastoral Presence Prayer
Hope Peace
Psychological Predisposition
Spirituality
Suffering
Roles and Relationships Isolation
Level of Function
Nutrition Satiety, Dysphagia
Nausea Intake Modification, TPN/Tube
Feedings
Pharmacy Pharmacological
Counseling Equianalgesia Adjuvant Agents
Economic Burden
Emotional State
Grief
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MassageA simple form of therapy with the
potential of restoring physical, emotional
spiritual well-being

• Relaxation
• Eases muscular tension, stiffness pain
• Promotes communication
• Lessens feeling of isolation, tactile stimulation

• Replenishes energy
• Improves plasma lymphatic circulation
• Strengthens tones muscles
• Stimulates or calms functions of the nervous
  system

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Electro Therapeutic Point Stimulator

• Applies concentrated low frequency stimulation to
  acutherapy points, biochemical response,
  contracted motor trigger points
• Used to provide immediate or chronic pain relief
  and decrease muscle tonicity

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Transcutaneous Electrical Nerve Stimulation (TENS)

• Blocks pain by directing a stimulating current
  into local nerves
• Uses high-frequency signals
• At low frequencies, reduces pain by stimulating
  acupuncture and trigger points

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Methods of RelaxationUsed to modify behavior,
perception, feelings or internal psychological
state

• Passive Progressive
• Muscle Relaxation
• Stretching/Movement
• Affirmations
• Desensitization

• Centering
• Breathing
• Meditation
• Guided imagery
• Visualization

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Yoga

• Focuses on the physical mental practice of
  binding mind, body spirit with controlled
  movement
• Used to ease muscle tension, improve flexibility,
  strength, balance endurance
• increasing body awareness

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Vibroacoustic Chair

• Delivers auditory tactile vibrations to the
  body to areas of greatest bone conductivity
• Used to relieve symptom burden

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Biofeedback

• Provides guidance for the validation of direct
  feedback to bodily processes (peripheral body
  temperature, EMG, skin conduction)
• Used for relaxation and self-regulation

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Hypnosis

• Develops a purposeful altered state of
  consciousness through focused attention
• (responsiveness to suggestion, ability to
  dissociate through time space)
• Used to accomplish difficult psychophysical
  changes

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Acupuncture

• Therapeutic insertion of needles in patterns at
  acupuncture points to encourage the flow of
  energy (qi)
• Manual or electrical stimulation used to elicit
  local generalized effects

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Acupressure

• Ancient Chinese healing method that involves
  applying pressure to one or more of the 14
  meridian pointsareas that carry energy
  throughout the body
• Meridians start at the finger tips, connect to
  the brain, then to the organ associated with the
  specific meridian

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Reiki

• Utilizes a universal energy healing system that
  is applicable to all purposes, conditions or
  situations
• Used for whole body energy balancing, healing,
  well-being maintaining immune system integrity

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Finger Labyrinth

• A replica of a walking Labyrinth, used as a
  spiritual tool for meditation with the aims of
• Releasing as you enter, quiet the mind by
  focusing on your breathing sensing your finger
  on the path
• Receiving pause in the center, reflect where you
  are in your life ask for guidance
• Renewal as you exit, reconnect with universal
  life reflect on a positive quality you want to
  bring into your life, allowing the guidance to
  lead you

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Mandala

• An artistic design often used in meditation for
  centering, focusing contemplation
• A spiritual tool for creating symbolism, relating
  to the relationship of ones soul to the universe
• A means that allows the patient to explore
  self-understanding, as a path to healing
• - the center of the circle represents the most
  important thing in your life
• - surround the center with concentric circles,
  using symbols for your life symbols of that
  which threatens or protects you
• - the outer circle represents the absolute
  boundary of the universe as you know it

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Animal Assisted Therapy

• Designed for goal-directed interventions by
  companion animals from the National Capital
  Therapy Dogs
• Used to reduce the negative impact of a medical
  environment, improve tactile stimulation,
  maintain/improve social skills increase
  physical movement

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Art Therapy

• A supportive venue of psychotherapy that
• enables the patient to break the barriers of
• inhibition, while promoting emotional
• expression healing through non-verbal
• means.

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Music

• Incorporates active passive experiences of
  listening, participation, life review, lyric
  analysis, song writing and toning .
• Toning is the elongation of a note/tone from
  the voice, aimed at a specific area of the body.
  The body has a relaxation response when toning is
  applied to certain conditions such as localized
  pain, nausea or constipation. It also has a
  soothing effect for emotional pain suffering.
• Used to achieve/maintain optimal physical,
  emotional, spiritual social well-being, as well
  as enhancing communication

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Considerations in Complementary Therapies

• Initiate one modality at a time
• Re-evaluate for effectiveness
• Therapies may have interactions synergistic use
  of Reiki and Hypnosis but not Reiki and
  Acupuncture
• Complimentary therapies often require a series of
  treatments, such as 6 to 12 sessions of
  Acupuncture

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Take Back to Practice

• Palliative Intervention
• Early
• Available
• Integrative
• Reassurance
• To our patient-Heroes disguised as ordinary
  people going on an extraordinary journey !
• and they lived at peace each day they had