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Challenges and Solutions in Pain Management in the Elderly

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Challenges and Solutions in Pain Management in the Elderly ChallengesChallenges andand SolutionsSolutions inin PainPain ManagementManagement inin thethe ElderlyElderly March 5th 2014 Perley Rideau Veteran’s Health Centre By Dr Cuong Ngo-Minh CFPC CoI Templates: Slide 1 Faculty/PresenterFaculty/Presenter DisclosureDisclosure • Faculty: Dr Cuong Ngo-Minh • Relationships with commercial interests: – Grants/Research Support: NIL – Speakers Bureau/Honoraria: Jansenn, Johnson and Johnson, Lilly, Pfizer, Medical Futures Inc, Paladin, Purdue Pharma, Valeant – Consulting Fees: Medical Futures Inc. – Other: NIL CFPC CoI Templates: Slide 2 DisclosureDisclosure ofof CommercialCommercial SupportSupport • This program has received financial support from Regional Geriatric Program of Eastern Ontario in the form of Honorarium. • This program has received in-kind support from Regional Geriatric Program of Eastern Ontario in the form of Organisation logistical support. • Potential for conflict(s) of interest: – Dr Cuong Ngo-Minh has received Honorarium from Regional Geriatric Program of Eastern Ontario – Pain medications products from these pharmaceutical companies (Jansenn, Johnson and Johnson, Lilly, Pfizer, Medical Futures Inc, Paladin, Purdue Pharma, Valeant) will be discussed in this program. CFPC CoI Templates: Slide 3 MitigatingMitigating PotentialPotential BiasBias This information is intended solely for EDUCATIONAL purposes and is not intended to promote the use of any Purdue Pharma medication. All materials or information provided by Purdue Pharma for this learning program comply with applicable regulatory standards. Full editorial control of this learning program, including personal opinions and views, resides with the presenter. Purdue Pharma Canada supports discussion of its products consistent with the approved prescribing information in the product monograph. Any off-label discussion of products represents the personal opinion of the presenter and unsolicited questions should be directed to the presenter. Learning Objectives At the end of this presentation, the participant will be able to: Able to use TOOLS to ASSESS Pain in the Elderly who are cognitively impaired or not. Recognize Causes of Chronic nociceptive vs neuropathic pain, understand how pain is transmitted. Apply the concept of multimodal analgesia Be Informed of treatment modalities options including non-pharmacological (eg ice, physio) and pharmacoligical (topicals, pills, injection, ...) PainPain inin OlderOlder People:People: UNDERTREATMENTUNDERTREATMENT May be confused and/or have difficulty communicating Given non-opioids or weak doses of medications with SUB- OPTIMAL pain relief/function Have other chronic diseases and more than one source of pain Are at increased risk for drug-drug interactions, drug- disease interactions Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guidelines No. 9. March, 1994. Classification of Pain Non Cancer Pain C Acute a Chronic/Persistent • Symptom of danger n • Not a symptom • Helps to heal/survive c • Meaningless • Meaningful e • Normal delay for • It will end r healing is overdue • It’s a disease P • Lasts > 3-6 months a Nociceptive i Neuropathic In response to tissue injury and the resulting n In response to damage or dysfunction of either inflammatory process peripheral or central nervous system • Somatic: constant or intermittent, aching, • Constant burning, paresthesias, tingling, localized, superficial or deep occasionally radiates • Visceral: constant, aching, squeezing, • Lancinating, shooting cramping, poorly localized and sometime referred PainPain CharacteristicsCharacteristics Neuropathic Pain - pain associated with damage in the peripheral or central nervous system Burning, tingling, pins-and-needles, electric shocks, numbness, hot or cold 1. Peripheral (eg Shingles, Diabetic neuropathy) 2. Central (eg. Multiple Sclerosis pain, post-stroke pain) Nociceptive Pain - pain associated with actual or perceived tissue damage Sharp, piercing, stabbing, Dull, “achey”, throbbing A) Somatic (eg Arthritis, MSK problem) B) Visceral (eg. Kidney/gallbladder stone, liver metastases) ComprehensiveComprehensive PainPain HistoryHistory When/How did the pain start (acute vs progressive) ? Injury,at work (WSIB?) accident or illness? Location (s), radiating? Constant vs crampy, intermittent or colicky Characteristics of the pain What makes the pain worse - better? How Pain Interferes with Daily Activities/Function? ComprehensiveComprehensive PainPain HistoryHistory –– otherother keykey informationinformation Past treatment trials including pharmacological (duration, doses tried –pharmacist can Fax you drug history!), and non pharmacological. Coverage for Rx and non-Rx Past medical (Diabetes?, Gout, Shingles), Surgical , Psych (depression, anxiety,…) history Current medications (prescribed and Over-The-Counter) Hx Recreational Substance Use/ Addiction screening Social history/support including marital status, children, what the patient likes to do for fun/relax FEWFEW WordsWords aboutabout PainPain “Prevention”“Prevention” If you can safely prevent “flare-up” of painful conditions please do so (eg. Plaquenil for Rheumatoid Arthritis; allopurinol/ uloric for recurrent gout) Treat cause of pain (eg glaucoma eye drops) Zostavax immunization to prevent Shingles and post- herpetic neuralgia Use LONG-ACTING pain medication formulation for Chronic pain conditions CHANGING THE CHRONIC PAIN SPIRAL: FUNCTION‐ CENTRED LIFE Analgesia Active coping Education Self Management Skills ↓Anxiety, depression, anger ImprovedImproved Function- IncreasedIncreased SocialSocial centered activityactivity FunctioningFunctioning Life PhysicalPhysical reconditioningreconditioning ABéland MD 2012 | [email protected] Adapted from: http://prc.canadianpaincoalition.ca/en/self_management.html AssessingAssessing FunctionFunction (vs(vs BASELINEBASELINE FUNCTIONALFUNCTIONAL Status)Status) Important to assess function on current therapies Help your patients to set goals and monitor their progress BPI (Brief Pain Inventory) tool for function may also be helpful SMART goals Assess Functional SMART Goals Reassess attainment of SMART goals/expectations at each visit S pecific M easurable A ction-oriented / Achievable R ealistic / Relevant T ime-Dependent goals Think of treatment modalities as a TEST What can he/she expect to do …… that he/she cannot do now? BriefBrief PainPain InventoryInventory (BPI)(BPI) –– ShortShort FormForm Self-assessment measure of severity of pain and the interference of pain with function • Severity and interference ratings range from 0 (no pain/does not interfere) to 10 (pain as bad as can imagine/completely interferes) • Patients assess pain severity of 4 types: worst pain, least pain, 24-hr average pain, pain right now • Patients assess interference of pain on 7 functions: 1. General activity 5. Mood 2. Walking ability 6. Relationships with others 3. Normal work 7. Enjoyment of life 4. Sleep No Worst Pain Pain 0 1 2 3 4 5 6 7 8 9 10 DPNP Cleeland et al. Ann Acad Med Singapore 1994;23(2):129-38. DoDo ImprovementsImprovements inin PainPain RatingsRatings CorrespondCorrespond toto PatientsPatients ActuallyActually FeelingFeeling Better?Better? Pain assessment: BPI Average Pain Severity No Please rate your pain by circling the one number Pain as bad Pain that best describes your pain on average as you can imagine 0 1 2 3 4 5 6 7 8 9 10 Global assessment: PGI-Improvement Check one box that best describes how you have felt overall since you began taking this medication 1 Very much better 3 A little better 5 A little worse 2 Much better 4 No change 6 Much worse 7 Very much worse Prior Research: An average pain reduction of 2 points or 30% represents a clinically important difference to patients1,2 DPNP 1. Farrar et al. J Pain 2010;11(2):109-18. 2. Farrar et al. Pain 2001;94(2):149-58. UnidimensionalUnidimensional PainPain AssessmentAssessment ScalesScales Verbal Pain Intensity Scale Visual Analog Scale No Mild Moderate Severe Very Worst pain pain pain pain severe possible No Pain as pain pain pain bad as it could be *Incapacitating, God awful, soul stealing * Length of line is irrelevant beyond discrimination 0-10 Numerical Rating Scale Faces Rating Scale 0 1 2 3 4 5 6 7 8 9 10 No Moderate Worst 0 1 2 3 4 5 pain pain possible No Hurts Hurts Hurts Hurts Hurts pain hurt little little even whole worst bit more more lot *Limits people to 11 “intensities” *Intended for children; “used” with nonverbal patients McLafferty E, Farley A. Nursing Standard 2008;22:42 PainPain inin OlderOlder People:People: GoalsGoals Achieve comfort with minimal (least) side effects American Geriatrics Society Panel on Chronic Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 1998;46:635-651. Restore function as fully as possible Maintain patient’s autonomy, dignity and cognitive capacity Provide relative freedom from pain and relief from pain-associated anxiety and depression TreatmentTreatment ConsiderationsConsiderations forfor PersistentPersistent PainPain inin OlderOlder AdultsAdults *Quality/frequency of assessments Goal: Optimal Pain Relief *Optimized nondrug approaches *Balance risk/benefits and optimize use *Minimize ADR/misuse/abuse Safety Risks *Monitor & document outcomes Efficacy Tolerability Function/ Patient QOL Characteristics (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons. JAGS, 2009;57(8):1331-1346; Arnstein. Pain Manage Nsg; 11(2):S11-S22; Bruckenthal P, et al. Pain Medicine. 2009;10(S2):S67-S78)
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