0. Caring for Geriatric Patients in the Emergency Department Setting Part V: Pain Management Challenges
Laurie A. Hanly, BA, BSN, RN, MS
Emergency Department, VA Medical Center, Portland, OR
Ula Hwang, MD, MPH
Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY
Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, NY, NY
Timothy F. Platts-Mills, MD, MSc
Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
February 2014

1. Discussion today 1. Introduction (Hwang) 2. Assessment (Hanly)
3.       Pharmacological treatment options (Platts-Mills)
4.       Non-pharmacological treatment options (Platts-Mills)
5.       General challenges and recommendations (Hanly)

2. Part I. Introduction - Pain in the ED
Pain as 5th vital sign
Identified as an area for quality improvement
Pain is common ED cc
70% of ED conditions
34% of all medications used in ED for pain
Inconsistent & inadequate analgesia (oligoanalgesia)

3. Disparities in Analgesia
Differences in prescribing patterns found in cancer pain, fracture treatment, and postoperative pain patients across gender, AGE , and race/ethnicity
In the ED setting, blacks or Latinos (vs. whites) received less analgesia for long bone fractures
Awareness of disparities may allow for targeting to reduce

4. Pain and Outcomes
Under treated and untreated pain associated with increased risk of developing delirium
Patients with higher pain scores at rest with longer hospital LOS, delays in functional recovery, and risk of long-term functional impairment

5. High prevalence of pain in older adults
Self-doubt, reluctant, and reticent to complain
50% ED MDs uncomfortable giving analgesics to elderly
Co-morbidities, drug-drug interactions, age-related drug metabolism changes, and fear of adverse reactions makes giving analgesia a challenge

6. 90% older adults on  1 medications 40% on >5 medications
Polypharmacy
90% older adults on  1 medications
40% on >5 medications
30-50% receive new prescription at ED discharge
Risk adverse drug reaction with
Multiple meds
Severity of illness
Multiple comorbidities
Changes in physiologic reserve

7. Physiologic Reserve Loss
Lower body mass, total body water, hepatic and renal function, increased fatty tissue…
Pharmacodynamics
(how drugs act at receptor sites and affect the body)
Pharmacokinetics
(drug distribution/elimination)
 Caution and awareness in analgesia choice and dosing (do no harm…start low and go slow…)

8. Geriatric ED Pain Care
Frequent assessments
Do no harm
(Start low and go slow)  Start low and REASSESS

9. Consensus based pharmacologic guidelines for older adults
Beers Criteria
Consensus based pharmacologic guidelines for older adults
Defines “inappropriate use of medications”
List of medications to avoid
Most recent update in 2012

10. Geriatric ED Pain Care Quality Indicators
Quality indicators describe minimum level of care
Pain assessed <1 hour arrival
F/U assessment <6 hours
F/U prior to discharge if received pain med
Pain med if mod-sev pain
Avoid meperidine
Bowel regimen if discharged with opioid Rx
(Terrell KM, et.al. Quality indicators for geriatric emergency care. Acad Emerg Med. 2009)

11. Part II. Pain Assessment - Laurie Hanly
1. Introduction (Hwang) 2. Assessment (Hanly) 3. Pharmacological treatment options (Platts-Mills) 4. Non-pharmacological treatment options (Platts-Mills) 5. General challenges and recommendations (Hanly)

12. The first step toward improving patient comfort is recognizing pain
66% of geriatric nursing home residents have chronic pain but
34% had pain that went undetected by their physician
Basic pain rating assessment tools:
1. Verbal
Numerical rating scale
Verbal rating scale
Functionally descriptive
2. Non-verbal
Pictorial
Behavioral
(Kay AD, Baluch A, Scott J. Pain Management in the Elderly Population: A Review. Ochsner Journal. 2010)

13. Verbal Pain Scales
Numerical pain rating scale: Rate your pain from 0 – 10
Verbal rating scale: Choose the phrase that best describes your pain
No mild moderate severe unbearable
pain pain pain pain pain

14. Verbal Pain Scales continued
Functional Pain Scale:
0 No Pain (pain free) 1
2 Functional:
3 pain is present but does not get in the way of my daily activities or quality of life 4
5 Uncomfortable:
6 hard to move, cannot concentrate, impacts ability to function and enjoyment of life 7
8 Severe: Not able to leave home, unable to do anything, spends time in bed
9 high effect on daily activities and quality of life
10 Unbearable: pain out of control, overwhelmed, can not tolerate, seeks immediate care
(Evans CM, Chronic Pain is a Chronic Condition, Not Just a Symptom. Permanente Journal )

15. Non-verbal Pain Scales
Wong Baker Pain Faces Scale:
Visual Analog Scale: 10 cm in length
No pain
Worst pain imaginable

16. Other Non-verbal Pain Scales
3. Behavioral Scale:
Facial Expressions
Vocalizations
Body Movements
Social Interactions
Clenched teeth
Wrinkled forehead
Biting lips
Scowling
Closes eyes tightly
Widely opened eyes or mouth
Crying
Moaning
Grasping
Groaning
Grunting
Restlessness
Protective body movement
Muscle tension
Immobility
Rhythmic movements
Silence
Withdrawal
Reduced attention
Focus on pain relief measures

17. Assessing Pain “O” to “T”
O: origin (when, what was the patient doing)
P: provocation and palliation
Q: quality (sharp, achy, throbbing, tingly, burning, dull, etc….)
R: region, radiation
S: severity
T: treatment (What do you take or do for your pain?)
Remember to use open-ended questions.

18. Tim Platts-Mills
1. Introduction (Hwang) 2. Assessment (Hanly) 3. Pharmacological treatment options (Platts-Mills) 4. Non-pharmacological treatment options (Platts-Mills) 5. General challenges and recommendations (Hanly)

19. Part III. Selecting Pharmacologic Therapies for Pain
Acetaminophen
NSAIDs
Opioids
Other Medications
Shared Decision Making

20. Acetaminophen
Safe except in patients with liver disease, chronic alcohol use
First-line therapy for outpatient treatment of pain in older adults
Dose in older adults: 500 mg every 4 hours
Max dose: 3 gm in 24 hours
Increase dosing interval if renal impairment:
CrCl mL/min = q 6 hours
CrCl < 10 mL/min = q 8 hours)
Adjust dosing in patients taking combination opioid + acetaminophen

21. NSAIDs - Risks More effective for pain than acetaminophen
But due to risks, prescribed on a case-by-case basis
Risks: cardiovascular events, upper GI bleeding, acute renal failure, CHF exacerbations
Most common cause of severe adverse drug reactions leading to hospitalization
Considered inappropriate for long-term treatment of pain in older adults by most experts
(Onder G, et.al. Adverse drug reactions as a cause of hospital admissions: results from the Italian group of pharmacoepidemiology in the elderly. JAGS. 2002)

22. NSAIDs - Risks
Even short-term use (i.e. <48 hours) of NSAIDs unsafe in high risk patients
Avoid NSAIDs (including Ketorolac/Toradol) in high risk patients:
Renal failure
CHF
History of upper GI bleed
Taking ACE Is, ARBs, of metformin
(Platts-Mills TF, et al. Life-threatening hyperkalemia after 2 days of ibuprofen. Am J Emerg Med. 2012)

23. NSAIDs – which one?
In low risk patients, consider NSAIDs for short-term or intermittent pain management.
Naproxen (Aleve)
lowest cardiovascular risk
similar GI bleeding risk to ibuprofen.
COX-2’s (e.g. Celebrex)
lowest risks of upper GI bleeding
use of proton pump inhibitor further reduces risk of GI bleeding
(Bhala, N et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials." Lancet. 2013)

24. IV Opioids IV Opioids are appropriate for acute severe pain
Typical agents are morphine or dilaudid
Use lower doses (i.e. 2-4 mg morphine) for frail, small individuals who are opioid naïve and those with respiratory conditions
Reassess and give more as needed frequently (q 20 minutes): “start low but reassess often”
Use continuous cardiac and oxygen saturation monitor
Pre-treat for anticipated pain (e.g. during movements for x-rays)

25. Oral Opioids, Short-Term Use
Use oral opioids for moderate or severe pain in patients who can tolerate oral medications and for outpatient treatment of pain
Prescribed as supplement to scheduled acetaminophen
Side effects among older adults in first week of opioid treatment:
Tiredness (30%)
Constipation (20%)
Nausea (20%)
Dizziness (17%)
(Hunold KM et al. Side effects from oral opioids in older adults during the first week of treatment for acute musculoskeletal pain. Acad Emerg Med. 2013)

26. Oral Opioids, Short-Term Use
Prevent constipation. Tell your patients to:
Drink plenty of water
Eat at least 30 grams of fiber a day
Stay physical active (especially walking)
Senna 17 mg / day (increases bowel motility)
If history of constipation, Senna plus stool softener
Polyethylene glycol (e.g. Miralax)
Docusate (e.g. Colace).

27. Oral Opioids, Long-Term Use
Safety concerns – all are increased compared to NSAID therapy:
cardiovascular events
fractures
hospitalizations
Best if managed by a single provider to
Ensure consistent dosing
Reduce risk of inappropriate use, overdose
(Solomon DH et al. The comparative safety of analgesics in older adults with arthritis. Arch Intern Med. 2010)

28. Questions to Consider When Deciding on Long-Term Opioid Treatment for Older Adults
What is usual practice for this type of pain?
Are there safer, effective alternatives?
Does this patient have increased risk of opioid-related adverse effects?
Can patient take opioids responsibly?
Are patient’s medical, behavioral, or social circumstances so complex as to warrant referral to a pain medicine specialist?

29. Opioids – which one?
Safest Most Dangerous All Cause Mortality: Tramadol/Hydrocodone Oxycodone Fractures: Tramadol Hydrocodone/Oxycodone GI events: No Difference CV Events: Tramadol/Hydrocodone Oxycodone
(Solomon DH et al. The comparative safety of opioids for nonmalignant pain in older adults. Arch Intern Med. 2010)

30. Other Medications to Treat Pain
SNRIs (duloxetine, venlafaxine) – neuropathic pain. Side effects: nausea, dizziness.
Gabapentin –neuropathic pain, may be safer than SNRIs
Muscle relaxants – baclofen or benzodiazepines favored
Calcitonin –inhibits osteoclast activity – effective in reducing bone pain from fractures, metastases. Side effect: nausea.
Topical Treatments
Topical NSAIDs –not demonstrated to be better than placebo after first 2 weeks (BMJ 2004 systematic review)
Lidoderm patch 5% – good for post-herpetic neuralgia

31. Femoral Nerve Block
Use in patients with hip fractures, particularly those without good and long-lasting relief from an initial dose of opioids
Technique:
Use ultrasound to identify femoral nerve or find nerve 1 cm lateral to femoral artery pulse (see next slide)
Bupivicaine 0.5% 20 mL
Provides pain relief in first and reduces need for opioids
Side effect – short-term quadriceps muscle weakness/falls
(Fletcher AK et al. Three-in-one femoral nerve block as analgesia for fracture neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2010)

32. Three-in-one refers to anesthesia to femoral, obturator, and lateral cutaneous nerves.
(Fletcher AK et al. Three-in-one femoral nerve block as analgesia for fracture neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2010)

33. Selecting Medications for Outpatient Treatment of Pain – Shared Decision Making
Choosing the best pain medication is difficult:
acetaminophen often insufficient
NSAIDs and opioids significant risks
Patients often know what works for them
Or, they have preferences regarding balance between pain relief and risks
Provide patients with information and working with them to reach decision
fewer side effects
better pain relief.
Shared decision making takes time, but the extra time is likely to help your patient.
(Isaacs CG et al. Shared decision making in the selection of outpatient analgesics in older adults. JAGS. 2013)

34. Part IV: Non-Pharmacologic Treatments for Pain
Generally more appropriate for chronic pain, but emergency providers should be aware of these issues.
Conceptual Basis
Cognitive Behavioral Therapy / Pain Coping Skills Training
Treatment of Depression
Other Non-pharmacologic Therapies

35. Conceptual Basis
Biopsychosocial model – pain is a complex experience that is influenced by biological, psychological, and social context
Evidence for the biopsychosocial model of pain in older adults:
Pain often not correlated with tissue injury
Treatments that correct tissue injury often fail to relieve pain
Psychological and social factors strongly associated with pain
If we accept this model, it makes sense to consider treatment the psychological and social factors
(Keefe FJ et al. Psychosocial interventions for managing pain in older adults: outcomes and clinical implications. Br J Anesth. 2013)

36. Cognitive Behavioral Therapy / Pain Coping Skills Training
Goal: Alter pain-related thoughts, emotions, and behaviors so that patients experience less pain.
Best approach in older adults is pain coping skills training, including:
Muscle relaxation
Imagery
Identifying and challenging negative thoughts
Problem solving
Benefit shown for osteoarthritis and cancer pain
Active learning better than didactic
More benefit if you include a spouse / significant other
(Keefe FJ et al. Effects of spouse-assisted coping skills training and exercise training in patients osteoarthritic knee pain: a randomized controlled study. Pain. 2004)

37. Treatment of Depression
Two question screen for depression:
In past month, have you been bothered by feeling down, depressed, or hopeless?
In past month, have you been bothered by little interest or pleasure in doing things?
Antidepressant medication + psychotherapy focused on problem solving
Results:
Less pain
Improved function
(Lin EH et al. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. JAMA. 2003)

38. Other Non-Pharmacologic Therapies
Physical Therapy – mostly studied for low back pain; no benefit or small benefit over usual care
Spinal Manipulation – mostly studied for low back pain; no benefit or small benefit over usual care
Electrical nerve stimulation – some evidence of benefit for knee osteoarthritis
(Cherkin DC et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. NEJM. 1998)
(Osiri M et al. Transcutaneous electrical nerve stimulation for knee osteoarthritis (Review). The Cochrane Library. 2009)

39. Part IV. General Challenges and Recommendations - Laurie Hanly
1. Introduction (Hwang) 2. Assessment (Hanly) 3. Pharmacological treatment options (Platts-Mills) 4. Non-pharmacological treatment options (Platts-Mills) 5. General challenges and recommendations (Hanly)

40. Pain Management Challenges in Geriatric Patients
Major Challenge Areas
Generational differences
Assessment of Pain
Psychosocial issues
Lack of pain related education in physician and nursing programs
Disconnect between knowledge and practice
Nurse-Physician Communication
(Kay, A.D., Baluch, A., Scott, J.: Pain Management in the Elderly Population: A Review. Ochsner Journal 2010)

41. Generational Pain Management Challenges
Differences in acceptance of pain
Pain generally accepted as an inevitable part of aging
Under-reported by patients out of fear of potential diagnosis
WWII population stoic, therefore less likely to admit to pain or request pain medication
Increased incidence of dementia with aging
Narrower view of how pain is defined

42. The Psychosocial Components of Pain Management
Subtherapeutic and/or compliance of home pain management
Support systems
Family relationships (particularly spousal support)
Caregiver involvement
Faith or faith-based association
Other Social supports
Mood
-- depression
-- suicidality
Potential of/for abuse
(Koizumy Y et al. Association between social support and depression status in the elderly: results of a 1-year community-based prospective cohort study in Japan. Psychiatry Clin Neurosci )
(Martire LM et al. Older Spouses’ Perceptions of Partners’ Chronic Arthritis Pain: Implications for Spousal Responses, Support Provision, and Caregiving Experiences. Psychology and Aging, 2006)

43. Physician/Nurse Education Related Challenges
Many physician and nursing programs devote minimal, if any, time to pain management.
Lack of knowledge specific for geriatric care:
Recent study showed 50% of geriatric patients got pain medication administered IM
Inability to assess pain in patients with dementia
(Titler MG et al. Acute pain Treatment for Older Adults Hospitalized with Hip Fracture: Current Nursing Practices and Perceived Barriers. Applied Nursing Research )

44. Disconnect Between Knowledge and Practice
Medications contraindicated or those needing to be dose adjusted for geriatric patients
Around the clock medication administration
Routes of medication administration
(Titler MG et al. Acute pain Treatment for Older Adults Hospitalized with Hip Fracture: Current Nursing Practices and Perceived Barriers. Applied Nursing Research )

45. Barriers to Effective Pain Management in Geriatrics
Communication between nurses and physicians
Lack of communication between nurses and patients
Difficulty separating the elderly and the younger patient who may or may not look old but is physiologically old
Fear of side effects

46. Pain Related Orders Can Facilitate Effective Pain Management
Scheduled
example: 2mg Morphine IV q30 minutes PRN to a maximum of 8mg
PRN
example: 4mg Zofran IV for nausea and/or vomiting
Parameters
example: 0.25mg Hydromorphone IV q20minutes to maximum of 1mg, hold if respiratory rate drops below 10 or O2 < 94%
The comfort of a prescribing provider for any of these types of orders is of course dependent upon the trust one has in the nursing staff.

47. Changing Practice to Improve Care
Studies have shown that continuing education alone leads to only minimal changes in practice in physicians or nurses.
Reinforcing strategies such as the following have been shown to be helpful in changing practice.
automated reminders integrated into orders
change champions
audits and/or peer feedback
(Titler MG et al. Acute pain Treatment for Older Adults Hospitalized with Hip Fracture: Current Nursing Practices and Perceived Barriers. Applied Nursing Research )

48. Pain Improvement Programs currently in place at Portland VA MC
ED Pain Reassessment
2. Pain Resource Nurse Program (PR-RN)
If you would like more information on the ongoing
Pain Resource Nurse Program or Pain Reassessment Study at PVAMC
feel free to contact me at

49. Thank you for joining us today!
Older patients are likely to continue to be untreated or undertreated for pain until we adopt in practice what we know from research…
Thank you for joining us today!