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Pain Issues and the Elderly

Pain Issues and the Elderly. Dr. Ann M. Berger, MSN, MD Chief, Pain and Palliative Care National Institutes of Health, Clinical Center. Acute time course-transient features-fight or flight pupillary dilatation sweating increased RR increased HR Increased shunting of

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Pain Issues and the Elderly

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  1. Pain Issues and the Elderly Dr. Ann M. Berger, MSN, MD Chief, Pain and Palliative Care National Institutes of Health, Clinical Center

  2. Acute time course-transient features-fight or flight pupillary dilatation sweating increased RR increased HR Increased shunting of blood from viscera to muscles Chronic vegetative Sleep disturbances anorexia decreased libido anhedonia constipation Somatic pre-occupation Personality change lethargy Acute vs. Chronic Pain

  3. Type Somatic Visceral Neuropathic Cause Nociceptor activation Nociceptor activation Destruction of a nerve Characteristics Aching or gnawing, localized Aching, vaguely localized, often referred Severe or dullshooting pain onbackground of burning, aching sensations PathophysiologicMechanisms of Pain

  4. Pain In the Elderly • Prevalence in population based studies in those 65+ are from 55%-86%.

  5. Step III Step I: Mild Pain 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 (< 5 days) *

  6. Step III Step II: Moderate Pain 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.

  7. Step III Step III: Severe Pain 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

  8. Opioids for Moderate to Severe Pain Long Acting • Morphine (MS Contin, Oramorph SR, Kadian • Oxycodone (Oxycontin) • Fentanyl (Duragesic) • Methadone (Dolophine) • Levorphanol (Levo-Dromoran) Oxymorphone

  9. Opioids for Moderate to Severe Pain Short Acting • Morphine (Roxanol, MSIR) • Oxycodone (Roxicodone, Oxy IR) • Fentanyl (Actiq) • Hydromorphone (Dilaudid) Oxymorphone

  10. 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

  11. 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.

  12. 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.

  13. Neuropathic Pain-Adjuvant Analgesics • Tricyclic antidepressants • Anticonvulsants • Clonidine • Corticosteroids • Local anesthetics-Mexilitene • Ketamine • Baclofen

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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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 MassageA simple form of therapy with the potential of restoring physical, emotional & spiritual well-being

  20. 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

  21. 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

  22. Centering Breathing Meditation Guided imagery Visualization Passive & Progressive Muscle Relaxation Stretching/Movement Affirmations Desensitization Methods of RelaxationUsed to modify behavior, perception, feelings or internalpsychological state

  23. 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

  24. Vibroacoustic Chair • Delivers auditory & tactile vibrations to the body to areas of greatest bone conductivity • Used to relieve symptom burden

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

  26. 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

  27. 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

  28. Acupressure • Ancient Chinese healing method that involves applying pressure to one or more of the 14 meridian points…areas 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

  29. 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

  30. 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

  31. Mandala • An artistic design often used in meditation for centering, focusing & contemplation • A spiritual tool for creating symbolism, relating to the relationship of one’s 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

  32. 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

  33. 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.

  34. 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

  35. 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

  36. 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………

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