Pain Management in Older Adults

1. Pain Management in Older Adults JasminGuisao, RN Sergey Nefedov, RN DinaraAnafieva, RN Tehila Cohen, RN

2. Introduction Pain • A sensation of distress occurring at the physical, psychological, and spiritual levels. Touhy & Jett, 2010, p. 259

3. What Do We Know? Myths About Pain in the Elderly • Pain is a normal part of aging. • Pain sensitivity and perception decrease with aging. • If patients don’t complain of pain, they do not have pain.

4. What Do We Know? Myths continued • A person who has no functional impairment, appears occupied, or is otherwise distracted from pain must not have pain. • Narcotic medications are inappropriate unless used for short periods of time. • Potential side effects of narcotic medication make them too dangerous to use in the elderly. Touhy & Jett, 2010, p. 261

5. What Do We Know? Statistics • 25% to 50% of community dwelling seniors suffer from pain that interferes with their ability to function normally • Prevalence of pain in the nursing home is 45% to 80% • Analgesics being used in 40% to 50% of nursing home residents Gloth, 2002, P. 188

6. What Do We Know? Reasons why older people do not report pain. • Fear of pain indicating serious illness. • Loss of independence. • Addiction to pharmacological relief measures.

7. Why Address Pain Management? • Pain management is a crucial element to be addressed to deter limitations in functioning, deconditioning, and worsening of health status Klassen, Liu, & Warren, 2009, p. 176

8. Why Address Pain Management? • Pain that has not been controlled is associated with a lower quality of life, depression, anxiety, agitation, and falls particularly in women Hausum, Fastborn, Fratiglioni, & Johnell, 2011, p. 284

9. Pain in Older Adults • Older individuals have an increased risk for developing pain-causing conditions and illnesses like osteoarthritis, rheumatoid arthritis, back and neck pain, diabetic polyneuropathy and post-stroke syndrome Curtiss, 2010, p. 7-8

10. Types of Pain • Nociceptive pain may be visceral or somatic and is most often derived from the stimulation of pain receptors. It responds well to traditional approaches. • Neuropathic pain results from the pathophysiology of peripheral and central nervous system. It responds to unconventional analgesic drugs like tricyclic antidepressants and anticonvulsants. Neuropathic pain may require higher doses of opioids. Dalacorte et al, 2011, p. 350

11. Assessment of Pain in Older Adults • An effective management of pain should start with a comprehensive, individualized, and ongoing assessment Curtiss, 2010, p. 9

12. Helpful Tips on Pain Assessment • Consider personal, cultural, spiritual, and ethnic beliefs that may impact care • In patients with persistent pain, physiologic indicators of pain like heart rate, blood pressure, respiratory rate, and diaphoresis may not reliably indicate the presence or absence of persistent pain because sympathetic nervous system attenuates and does not produce signals that lead to changes in vital signs • An assessment of pain is more challenging in individuals with cognitive impairment due to their non-expressive facial expressions Curtiss, 2010, p. 8

13. Helpful Tips on Pain Assessment • Utilize different assessment techniques like Faces Pain Scale, Verbal Descriptor Scale, Numeric Rating Scale, and Behavioral pain assessment tools • Responses to analgesic trials may alert nurses of the presence of pain • Ask direct questions about pain because some patients avoid discussing pain unless they are asked • Use different words when asking about pain: hurt, sore, ache, and discomfort • Older adults, particularly those with cognitive impairment, tend to prefer vertical rather than horizontal scales Curtiss, 2010, p. 9-10

14. Scales of Pain Assessment Curtiss, 2010, p. 10

15. Pain Management • Pain management may be more effective when medications are administered on a schedule or around-the-clock, rather than as needed • For the best management of pain, the researchers recommend a combination of pharmacological (PS) and non-pharmacologic (NPS) strategies Curtiss, 2010, p. 11

16. NPS Techniques • Nutritional supplements, herbal remedies, vitamins, meditation, relaxation, massage, exercise, ointments, reiki (palm healing), heat, and cold • Avoid potential drug interactions and side effects while providing pain relief • Diminish pain perception by reducing intensity and increasing pain tolerance, reduce pain-related distress, strengthen coping abilities, and give the patient and family a sense of control over pain • Many older adults are unaware of different NPS strategies and their efficacy Fouladbakhsh et al, 2011, p. 73

17. Barriers to Effective Pain Management • Patient-related: fears about addiction, sensory and cognitive impairments, stoicism, reluctance to report pain, side effects, and belief that pain is normal part of aging. • Caregiver-related: lack of knowledge, difficulty communicating with patients, physicians' attitudes, and nurses' attitudes toward pain. • Systems-related: experts not being available, lack of ability to consult with peers, difficulty contacting or communicating with physicians, limited access to clinical pharmacists, lack of in-depth pain assessments at baseline, and lack of standardized approaches Coker et al, 2010, p. 141

18. ACTION PLAN A comprehensive action plan in pain management entails three core activities: • target group • detailed assessment • effective treatment

19. TARGET GROUP • This plan targets ageing adults residing in nursing homes and those hailing from minority groups, which, according to Touhy & Jett, are at the highest risk of inadequate assessment and under treatment (2010, p.261 ). • This target group suffers from misconceptions regarding pain, such as the notions that pain is a normal part of ageing, patients with dementia do not experience pain, and unreported pain is a positive indicator of lack of it. The plan also targets the ageing since they are most vulnerable to pain-causing states, such as, rheumatoid arthritis, back and neck pain, diabetic polyneuropathy, among others (Curtiss, 2010, p. 7-8).

20. DETAILED ASSESSMENT • The second stage of the plan entails undertaking comprehensive assessments, on an individual and continuous basis for each patient. • The initial assessment entails evaluating a patient’s cultural, personal, ethnic and spiritual bearing to care (Pawasauskas & Luisi, 2001, p. 73). This stage requires culturally competent nurses. This attribute enhances their ability to relate to different patients, their perceptions, and expressions of pains. • Patients express pain differently. Mourning, groaning, muscle guarding, and a variety of other physical responses. Responses to pain may also be physiological, including, but not limited to variations in pulse rates, blood pressure, and respiratory rates (Curtiss, 2010, p. 8). The latter manifestations may not be as reliable in confirming presence or absence of relentless pain.

21. ASSESSMENT CON’D • Assessment goes further to involve patients and individuals with cognitive impairments, and many challenges emerge at this stage. Cognitive impairment inhibits some physical and facial responses to pain, hampering the observation and analysis process. • Curtiss highlights some effective assessment scales whose use is imperative when dealing with cognitive impaired patients. The Faces Pain Scale, Numeric Rating Scale and Verbal Descriptor Scale are some of the scales applicable (2010, p. 10). • In this target group of older adults, and especially those with cognitive impairment, preference is on vertical, rather than horizontal scales. Results of analgesic trials are indicative of presence of pains, as analyzed by the nurses. Progressive assessment requires the use of the same scale throughout the management program, to enhance efficiency.

22. TREATMENT • Treatment and care is the final stage of the action plan. • The nature of pain, either nociceptive or neuropathic pain, as deduced by the assessment, determines the nature of treatment. Nociceptive pain commonly springs from stimulation of pain receptors, and traditional treatment approaches offer solutions to this kind of pain. • The complexity of Neuropathic pain requires the intervention of opioids, since such pain arises from changes in normal mechanical, physiological, and biochemical functions of the body, affecting the peripheral and central nervous system (Dalacorte et al, 2011, p. 350).

23. TREATMENT CON’D • Administrations of treatment on a systematic, scheduled and progressive program achieve maximum treatment levels. • In this age group, pharmacological treatment posses a great challenge due to the delicate precautionary measures taken in adult prescriptions (Stewart et al, 2012, p. 1). • Pharmacological (PS) and non-pharmacologic (NPS) approaches to treatment yield the maximum positive results. • Some non-pharmacological approaches include, but not limited to relaxation, meditation, exercise, massages, vitamins, and nutritional supplements. • NPS approaches seek to avert the patient from the possible adverse side effects arising from interaction with PS treatment. PS treatment is applicable in extreme scales where pain persists, leading to physical and psychological distress. • Educating patients on PS and NPS treatment is an important final step in the action plan.

24. Before Medication • Test baseline mental status exam • Know baseline renal function • Know concurrent chronic illness, • Hepatic function and hydration status

25. Treatment Recommendations • Non medication treatments • Schedule meds if pain is daily, patient is cognitively impaired • Opioids –longer interval • Combine low doses of 2 classes of RX • Avoid constipation. Use bowel softeners • Know hepatic, renal function, mental status

26. Educate Patients and Families • The importance of taking analgesia for acute or chronic pain and the side effects • Risk for depression and impairment of ADL’s • Importance of completing medication history • Have a list of medication handy at all times • Address fears about opioids; and how getting addicted is rare • Morphine does not cause death!! • Discuss pain care plan with patient/family • Ask the local pharmacists for help • Communicate pain care plan to other involved in the patients’ health care

27. Non medication treatment Use other methods to reduce pain by: • Listening to music • Soft lighting • Decreased noise • Add distraction • Massage • Warm or cold packs • Repositioning • Exercise • Emotional and spiritual support

28. Pain Communication

29. References Hausum, Y., Fastborn, J., Fratiglioni, L., Kareholt, I., Johnell, K. (2011). Pain Treatment in Elderly Patients With or Without Dementia. Drugs & Aging, 283-293. Klassen, B. L., Liu, L., Warren, S. A. (2009). Pain management best practice with older adults: effects of training on staff knowledge, attitudes, and patient outcomes. Physical and Occupation Therapy in Geriatrics, 173-196. Touhy, T. A., & Jett, K. F. (2010). Ebersole and Hess' Gerontological Nursing & Healthy Aging 3rd Edition. Missouri: Mosby

30. References • Coker, E., Papaioannou, A., Kaasalainen, A., Dolovich, L.,Turpie, I., et al. (2010). Nurses' perceived barriers to optimal pain management in older adults on acute medical units. Applied Nursing Research, 23, 139-146. • Curtiss, C. P. (2010). Challenges in pain assessment in cognitively intact and cognitively impaired older adults with cancer. Oncology Nursing Forum, 37(5), 7-16. • Fouladbakhsh, J. M., Szczesny, S., Jenuwine, E. S., & Vallerand, A. H. (2011). Nondrug therapies for pain management among rural older adults. American Society for Pain Management Nursing, 12(2), 70-81. • Pawasauskas, J. E., & Luisi, A. F. (2001). Pain management in long- term care: Update on guidelines and JCAHO standards. Marquette Elder's Advisor, 2(3), 70-74. • Dalacorte, R. R., Rigo, J.C., & Dalacorte, A. (2011). Pain management in the elderly at the end of life. North American Journal of Medical Sciences, 3(8), 348-354. • Stewart, C., Leveille, S.G., Shmerling, R.H., Samelson, E.J., Bean, J.F., et al. (2012). Management of persistent pain in older adults: The Mobilize Boston Study. The American Geriatrics Society, 1-6.