Presentation on theme: "Pain Management in the Geriatric Population"— Presentation transcript:
1Pain Management in the Geriatric Population Ali R. Rahimi,MD,FACP,AGSFProfessor of MedicineMercer University School of MedicineClinical ProfessorUniversity of Georgia School of Pharmacy
2Pain:Webster:a : usu. localized physical suffering associated with a bodily disorder; also : a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive actionb : acute mental or emotional distress or sufferingUrandictionary.com:What happens when you reach into the blender to dislodge a stuck icecube without unplugging it first.A subjective, unpleasant, sensory, and emotional experience assoc with actual or potential tissue damage, or described in terms of such damage
3Pain & elderlyPain is what many people say they fear most about dying.Pain is undertreated at the end of lifeOlder patients are likely to have a increased pain threshold but to be less toleant to severe pain.
4PAIN IS MC REASON FOR INDIVIDUALS TO SEEK MEDICAL CARE Abdominal Pain3 of the 20 most common reasons for outpatient department office visitsBack painHead pain
5Definitions: Addiction: Psychological dependence on a drug. Physical Dependence: Development of physical withdrawal reaction upon discontinuation or antagonism of a drugTolerance: Need to increase amount of drug to obtain the same effectPseudoaddiction: Behavior suggestive of addiction occurring as a result of undertreated pain
6Pain can be assoc w/: Psychologic and physical disability a source of individual sufferingFamilial distress
7Pain in nursing home patients 30% reported daily pain26% of these patients received no analgesiaOnly 26% of them received strong opioidsWhat predicted inadequate pain management?1 Advanced age: >85 years old2 Poor cognitive function3 Minority statusBernabei (1998), N = 13,625 cancer patients“AGS reports that 18% of people 65 and over are taking analgesic medications regularty (several times a week), and 63% of those had taken presciption pain medications for more than 6 mo.”
8Obstacles of geriatric pain management: Accessibility to treatment$$$SEsComorbiditiesEx- NSAID use in pt w/ HTN or heart diseaseEx- Acetominophen use in Liver dz ptInteractions with the current medsPts with cognitive impairmentsThe assumption that pain is normal party of agingPractitioner’s bias (pain seeker..)fear of legal repercussions…although MDs have been successfully sued for undertreatment as well.
9Decreased activity bc of pain It’s a risk factor!Myofacial deconditioningDecreased activity bc of painGait distrubancesINJURIES from falls
10Types of pain:Nociceptive pain- Nerves responding appropriately to a painful stimulusNeuropathic pain- results from NS dysfunction, and may originate centrally or peripherallySomatic pain- originates in the skin, bones, myo, and connective tissue, and usually is located specifically.Visceral pain- originated in internal body structures and organs, and is located more genearlly.Central example- phantom pain or post CVA pain
11Neuropathic pain: Origin: Palliates/potentiates: Quality: Radiation: Nerve damagePalliates/potentiates:Set off by unusual stimuli, light touch, wind on skin, shaving (trigeminal neuralgia)Quality:Electric, burning, tingling, pins & needles, shooting (system isn’t working right)Radiation:Nerve-related pattern
12Nociceptive Pain: Origin: Palliates/potentiates: Quality: Radiation: Easier to treat than Neuropathic!!Origin:Tissue damagePalliates/potentiates:Worse with stress, pressureResponds better to opioids, NSAIDsQuality:Sharp, dull, stabbing, pressure, ache, throbbingRadiation:Occasionally radiates (less well-defined), but not along an obvious nerve distribution
13Differentiating between somatic, visceral, and neuropathic pain is ESSENTIAL to proper tailoring of pain treatments
14Specific Goals: 1- determining the presence and cause of pain 2- identifying exacerbaing comorbidities3- reviewing beliefs, attitudes and expectations regarding painOverall: to decrease pain and increase function and quality of life!
15Common pain syndromes in elderly MUSCULOSKELETAL CONDITIONSOADegenerative disk dzOsteoporosis & FxsGoutRHEUMATOLOGIC CONDITIONS:RAPolymyalgia rheumaticsFibromyalgiaNEUROPATHIC CONDITIONS:Biabetic neuropathyPostherpatic neuralgiaTrigeminal neuralgiaCentral poststroke painRadicular pain secondary to degenerative disc dz
16Aging takes a toll… In the PNS: Loss of myelinated and unmyelinated fibersAxonal atrophy commonNerve conduction and endoneural blood flow are reduced w/ ageLess nerve regeneration observedprogressive loss of serotonergic and noradrenergic neurons in the superficial lamina of the spinal dorsal horn, and bc serotonin and norepineph have important roles in the descending inhibitory control pathways, such a loss may upset the natural endogenous pain-suppressing mechanisms.Therefore, pain treatment of the elderly obviously differs from that of young patients!
17Models of the prevalence of pain 1- Pain increases with age and then decreases at older ages (ie, 70 and beond). They suppose that this pain typically has a mechanical etiologic component and possibly is assoc with the occupational envioroment2- pain increases with age. This has a mechanical etilogic component but also an assoc with increasing prevalence of degenerative dz, particulary at older ages.3- age-independent pain that (obviously) lacks a mechanical etiologic component. (ie- risk factors that are constant throughout the life course)4- A decrease in pain prevalence at older ages. It is not clear whether the trajectory is caused by age-related changes in pain and pain perception, or by changes in pain reportin.There has been research to support all 4 models
18Effect of age on human (via clinical observation): Clinical observation examples:increased incidence of silent MI in elderly patientsatypical presntation of an inflamed appendix, (absence of RLQ pain)Study example: (pg 208)Yunis compared elderly and young patients with fibromyalgia. They found that chronic head aches, anxiety, tension, mental stress and poor sleep were all less common in the elderly patients w this condition.
19Lonliness and painThe comorbidity of pain and psychological distress is WELL DOCUMENTED-The feeling of lonliness is the single most important predictor of psychologic state of distress in older persons.A study by Eisenberger supported the hypothesis that Pain distress and social distress share neurocognitive substratesStudy on page 193
20Sleep and painMultiple studies have demonstrated the comorbidity of pain and sleeplessnessPain is among the best predictors of sleep disturbances among older adultsThus, it appears that improved pain leads to improved sleep, and impoved sleep leads to improved pain!Study =pg 193Pg 193
31SalicylatesAnalgesic, antipyretic, anti-inflammatory and anti-rheumatic activity.MOA:Inhibits prostaglandin synthesis producing analgesic.antiplatelet effect by inhibiting the production of thromboxaneMuch higher levels needed for anti-inflammatory effect than for anti-platelet, anti-pyretic and analgesic effects.Metab: Gut & plasma (ASA); liver (salicylate) CYP450Excrition: renalCan cause: GI irritation and bleeding.Use w caution in ppl with hx of gastric or peptic ulcercs.Thromboxane- which under normal circumstances binds platelet molecules together to create a patch over damage of the walls within blood vessels.
32Acetominophen analgesic and antipyretic agent MOA: Inhibits central prostaglandin synthesis with minimal inhibition of peripheral prostaglandin synthesisAntipyretic effect by direct action on the hypothalamic heat-regulating centerBenefits:Absorbed rapidlyNo gastric mucosa effectsNo effect on platelet aggregationMetab by liverExcretion: urine (metabolites can accumulate w renal impairment)HepatotoxicNot antiinflammatoryNo adverse effects on gastric mucosa and platelet function like salycylates.Good drug but problem is that ppl overlook the recommended dose limits. And a lot patients take it with their opiod analgesics which contain acetaminophen.Excretion: urine (metabolites can accumulate w renal impairment)Use with caution in ppl with: liver disease, chronic alcoholism, and malnutrition.Can take mg orally q 6hrOlder pts and Pts with liver dz: do not exceed 2g/day
33NSAIDS Antipyretic, analgesic and anti-inflammatory properties MOA: Reduce central and peripheral prostaglandin synthesis but they do not inhibit the effects of the prostaglandins already present, resulting in analgesia, followed by relatively delayed anti-inflammatory effects.Metab: liverExcretion: urineAdverse effects:n/v, bleedingHepato and nephrotoxicity1.5 times higher risk of GI bleeding (more so in the elderly)Concurrent use of PPI for prevention
34NSAID: 18 available in the US All NSAIDS have similar mechanism of action BUT differ in:PotenciesTime to onsetDurationResponse among patientsCommon uses:After surgeriesPainful chronic conditions (ex- OA)Benefit more notable when used in combo w an opiod.Opiod SEs like sedation, n/v decreased when used w NSAID
35COX 2 NSAIDS: Purpose in pharmacology unclear Only available: celecoxibCox2 and NSAIDS are CI in pts with cardiac disease!estimated to be responsible for up to 20 percent of hospital admissions for congestive heart failure.BY INCREASING SYSTEMIC VASCULAR RESISTANCE and REDUCING RENAL PERFUSIONOther cox 2s were removed from market due to safety questions(bc all others ones were assoc with increased risk of MI)
36OPIOID:a chemical that works by binding to opioid receptors, which are found principally in CNS and the GI.Hence, the GI SesEffects:decreased perception of paindecreased reaction to painincreased pain toleranceOpium poppy
37Opioids Cornerstone of the analgesic regimen for mod-sev pain MC ones: MorphineOxycodoneHydromorphoneTransdermal fentanylOpioid is prefered name for this class of analgesics bc nartotic is primarily a legal term used to refer to drugs from various pharmacologic clase and is assoc w important psychological barriers to pain management.
383 Main Opioid receptors: Mu, delta and kappa receptors.Mu agonists: produce analgesiaaffect numerous body systemsinfluence mood & reward behaviorDelta agonists produce analgesianot a lot on marketKappa agonists produce analgesiamay cause less resp depression and miosispsych effects, can produce dysphoriaOpioids LACK the adverse renal, and hematologic effects of NSAIDs
39MU-receptor agonists are MC used although drugs may interact with more than one type of receptor.Ex- the mu receptor antagonist and kappa receptor agonist drugs were deigned to cause less respiratory depression.
40Opioids pharmacokinetics Pharmacokinetic properties of an opioid can dictate the circumstance which they are appropriate in:Ex- Lipid-soluble drug such as fentanyl, which diffuse rapidly acros the BBB, are preferable if analgesia is required immediately before a short, painful procedure.Elimination half life very short:So, steady state reached in a day or less!Thus, you can adjust the dose daily knowing we are seeing it’s effect.
41Adverse effects: Respiratory depression sedation N/V Constipation Urinary retentionItchingItching due to histamine release?
421. Respiratory depression Caused by directly acting on respiratory centerNaloxone is specifically used to counteract life-threatening depression of the central nervous system and respiratory systemTherapeutic doses of morphine can affect:Resp rate, minute volume tidal exchangeAlthough, tolerance to this effect is usually achieved with repeated doses of opioids.Avoid/Monitor in pts with:Imparied resp functionSleep apneaOr bronchial asthmaUsually, co2 stimulates the central chemoreceptors which tell your body to breath.. BUT OPIOIDS shift the co2 response curve so that the level of co2 needed to stimulate respiration becomes higher.Naoloxone is pretty short acting, so we usually put the patient on a drip.Not common if begin with low dose and titrate upward!!
432. Nausea and vomiting MC SE Likely due to changing blood serum levels , not steady stateThe freq of nausea and vomiting is higher in ambulaory patients (vestibular component?)Antiemetics (metoclopramide or droperidol) can be used along with the opioid.N&V relate more to changing blood serum levels of opioids than the steady state dose
443. Constipation: Acts on receoptors of GI tract and spinal cord to produce decrease in peristalsis and intestinal secretionsTolerance to this effect is not common-Result- prescribe prophylactic laxatives… use stood softener AND a stimulant laxative.
454. Urinary retention causes increased smooth muscle tone increases sphincter tone
465. Itching Mechanism not fully known~ Hypot: related to the release of histamine from mast cells.If itching is with rash- consider allergy.Can use an antihistamine to treat this
47Opioids: Morphine Morphine = standard of opioids BUT if pt doesnt respond well, they may switch to an equianalgesic dosage of:HydroporphoneOxycodoneFentanylOxymorphoneOr methadoneIf pt has diminished renal function, they may benefit from:Oxycodone or hydromorphone (bc these don’t have clinically significant active metaolites)e—kwi-en-al-gez-ic
48The dosages of any full opioid agonist used to control pain can be converted into an equivalent dose of any other opioid. In this way, 24-hours opioid requrements and dosing regimens established using shorter action opioid medicatnions can be translatee into equivalent dosages of longer-acting medicaitons or formulations.
49Opioid Combos~ Full opioid agonists: Morphine Hydrocodone Codeine DextropropoxypheneTypically combined with acetaminophen or an NSAID
50Acetaminophen con Codeine Advantages:Low regulatory controlInexpensiveWidely availableDisadvantages:10% cannot convert codeine to morphineMany drugs interfere with conversionCodeine is the pro drug. Gets converted to morpheine
51Acetaminophen with Oxycodone, Hydrocodone Oxycodone combination contains 325 mg acetaminophenHydrocodone combination contains 500 mg acetaminophenNo clear advantage between the two
52Three mu=receptor agonist to avoid whenever possible!! .. MeperidinePropoxyphenecodeinemu= most common used
531.Meperidine (DEMEROL) Low potency relative to morphine A short duration of action – so have to dose it more frequentlyAnd a toxic metabolite (normeperidine)Ex- meperidine 75mg = mg of morphinecan cause irritability and seizuresNormeperidine can cause irritability and seizures
542. Propoxyphene (DARVOCET) treat mild to mod painToxicities assoc with it’s primary metabolite: norpropoxyphenecan cause cardiotoxicity and pulmonary edemaHalf life: 6-12 hour;Metabolite half life hoursPts with Dec Renal function or pts getting repeat doses: higher riskPuts geriatric pts at higher risks of falls (d/t CNS effects)[study found that propoxy users have twofold higher risk for hip frature compared with nonusers of analgesics]ALSO, it has no clinical advantage over nonopioid analgesics such as acetominaphen289PG 289
553. CodeineMust be converted to morphine by means of the cytochrome P-450 pathway to provide analgesia.Lots of Caucasians are poor metabolizers of this isoenzyme -thus cant make the conversion!So, they do not get any of the codeine’s benefit but still suffer the Side effects.
56Principles of opioid use: No ceiling effectDose to pain relief without side effectsGive orally when possibleSub-cutaneous administration is basically equivalent to intravenous (and preferable)Treat constipation prophylacticallyFull opioid agonists are best choice for severe pain..the dose of opioid is not limited by the toxicities of the acetaminophen, asa, or NSAID component of cobo preparations.
58Treating Chronic pain: Basal pain medicine plus a different therapy for spikes:Predictable spikes - Short-acting agent prior to eventUnpredictable spikes - Short-acting agent readily available (prn)Ex- give some med before changing bandageAllow enough time to allow maximal effect (45 minutes for most oral opioids).
60Treating Neuropathic Pain; Opioids and NSAIDS less effective
61Classes of Agents Tricyclic for dysesthetic pain Anticonvulsants for shooting painSteroids to decrease peri-tumor edemaAn example of dysesthetic pain would be? (e.g., neuropathy from chemotherapy)An example of shooting pain? (e.g., spinal compression from tumor)
62Tricyclic for dysesthetic pain Dysesthesia is pain not experienced by a normal nervous system.Eg- neuropathic burning from chemotherapyConsidered "Dante-esque" pain.AmitriptylineNortriptylineDesipramineDante’s infernoThe terminology used to describe it is usually interchangeable with descriptions of Hell in classic literature.
63Anticonvulsants for shooting pain GabapentinPregabalin
64Steroids to decrease compression Nerve infiltration by tumor or spinal cord compresion:CorticosteroidsDeamethasonePrednisone*Usu used for pts near end ofLife bc of detrimental SE ofLong term steroid use.
65Opioid analgesics available in US Mu agonistsAlfentanilCodeineHydrocodoneYdromorphoneFentanylLevorphanolMeperidineMethadoneMorphineOpiumOxycodoneOxymorphoneRemifentanilSufentanilTramadolKappa agonist/mu antagonistButorphanolNalbuphinePentazocineMu antagonistsNalmefeneNaloxoneNaltrexoneMu partial agonist/kappa antagonistBuprenorphine
66When to refer: Pain not respsoning to opoiods at typical doses Neuropathic pain not responding to first line treatmentsComples methadone management issuesIntolerable side effects from oral opioidsSevere pain from bone metsFor a surgical or anesthesia-based procedure, intrathecal pump, nerve block, or rhizotomy
67When to admit:For severe exacerbation of pain that is not responsive to previous stable oral opioid around-the-clock plus breakthrough doses.Pateints whose pain is so severe that they cannont be cased for at homeUncontrollable side effects from opioids, including nausea, vomiting, and altered mental status
68Good to know..Older individuals tend to be more sensitive to benzodiazepines and opiods.Pain from bone mets more susceptible to NSAID pain relief than opioidsThe 1998 guidelines recommended earlier use of narcotics than is typical for treatment of younger patients because of the significant toxicities assoc with NSAIDS.
70Trigeminal neuralgiaCharacterized by: severe, unilateral facial pain described as lancinating electrics shock-like jolts in one or more distributions of the trigeminal nerve.Maxillary and Mandibular divisions = MCCareful clinical evaluation and MRI is recommended
72Postherpetic neuralgia Follows outbreak of Herpes zosterSensory findings:Allodynia (wind against skin hurts, sheet on area hurts etc) hyperalgesia
73Post stroke pain An underrecognized consequence following storke May present as shoulder pain in the paretic limb or present as central poststroke pain.Characterized as pain that is severe and persistnet w accompanying sensory abmomalitiesEx- the guy from Oceanside.
74Metastatic bone painBone pain that is worse at night, when laying down or not assoc with acute injuryPain that gradually but rapidly increase in intensity or with weight-bearking or activity.Freq sites:Hips, vertebrae, femur, ribs, and skull
75Temporal Arteritis: More than 95% of TA are ppl >50 Presentation: New onset headache, malaise, scalp tenderness and jaw claudicationPE: indurated temporal arterly that is tender with a diminihed or abent pulseIrreversible bliness is consequence of untreted.. So timely assesment and tx is
76Pain perception in rats: When nociception is tested in mice using an electrical current, it seems that there are age related changes in nociception .The graphic representaion of electical thresholds needed to induce a vocal reponse was of a U-shap pattern. (high pain tolerance in young and old- lower in the middle aged)Pg 204
77Effect of age on human experimental pain 50 studies total21 concluded an increase in pain threshold with advancing age3 reporeted a decrease17 noted no changeHowever,Temporal vs Spatial summation:It was fround that temopral summation to a heat pain stimulus, for example, is more pronounced in the elderly as compared with younger subjects. Whereas spatial summation is not significantly influenced by age.Pg 206 temporal vs summative??