2. An unpleasant sensory or emotional experience associated with actual or potential tissue damage The World Health Organization (WHO) has stated that pain is one of the most underestimated healthcare problems in the world…

4. Reduced quality of life Decreased appetite, poor nutrition Impaired sleep Mood disorders, particularly depression Diminished function Reduced cognitive performance Risk of disability, inability to perform ordinary activities May be a form of “elder abuse”!

5. Experts in geriatrics, pain management and medication safety Represented many parts of healthcare –academia, government, health care plans, consumer advocacy Discussed challenges to optimal use of pain medications in older adults Task: Identify area(s) of focus for safe use activities

6. Challenges Failure to effectively use available procedures and processes Insufficient training of health providers Lack of patient education and awareness Failure to engage, educate, and communicate with relevant stakeholders

8. General Approach To Assessment And Treatment improve functional ability 3 general principles Optimal clinical outcome treatable but not curable

9. Pathogenesis Nociceptive tissue damage and a normal nervous system (e.g. pain associated with osteoarthritis) Neuropathic physiological nervous system dysfunction (e.g. diabetic neuropathy, postherpetic neuralgia)

10. Specific Chronic Pain Disorders Myofascial Pain Osteoarthritis and Chronic Low Back Pain Fibromyalgia Syndrome Peripheral Neuropathy

11. Increasing the risks for in older patient higher percentage of body fat and decreases in body water and muscle mass The livers is smaller and have less blood flow Increase renal disease

12. Pain Assessment Taking a Careful History A physical examination laboratory diagnostic studies X-rays

13. TREATMENTTREATMENT

14. Treatment Nonpharmacologic Pharmacologic

15. Nonpharmacologic Treatment Physical therapy Cognitive-behavioral therapy

16. Pharmacologic Treatment – Nonopioid Pharmacologic Therapy NSAIDs Anticonvulsants Antidepressants Tramadol APAP – Opioid Therapy for Nonmalignant Pain

17. Non-steroidal anti- inflammatory drugs (NSAIDs)

18. NSAID – Risks in Older Adults – GI toxicity especially among ≥ 75 years; similar to risk of patients with peptic ulcer – 1.7 x more likely to require antihypertensive therapy vs. younger patients – 10 fold increase in risk of falls Suspicion that CNS effects are the cause Falls also linked with CNS agents, diuretics, and hypnotics

19. Prescribing non steroidal anti-inflammatory drugs (NSAIDs) in older adults: general considerations _ Before prescribing an NSAID, clinicians should take a thorough medical history that includes all co-morbidities, medications (including over-the – counter and herbal medications) and alcohol and tobacco use _ Before beginning therapy, patients should have tests for renal function, hepatic enzymes, platelets, and complete blood count _ After initiation of NSAID therapy, patients should be evaluated every 2-4 weeks for the first 3 or4 visits.

20. _ NSAIDs should be administrated at the lowest effective therapeutic dose  Brief episodic NSAID therapy is preferable to long-term NSAID therapy  NSAIDs with a shirt half-life may pose less risk of gastrointestinal bleeding than those with a longer half-life  Topical NSAIDs are an option for patients with pain in superficial joints  Tramadol or Tramadol paracetamol (acetaminophen) is an alternative to stronger Opioids when central analgesia is required and NSAIDs are contraindicated _ Patients receiving NSAIDs should consult physician before taking additional prescribed or over-the-counter analgesics. NSAIDs and COX-2 inhibitors should be considered rarely, and with extreme caution …Prescribing non steroidal anti-inflammatory drugs (NSAIDs) in older adults: general considerations