1. Caring for Geriatric Patients in the Emergency Department Setting Part 6: Caring for Older Patients with Pain who are High Utilizers of the ED Michael DiMarco, Jr. Psy.D. Emergency Department Consult Psychologist Clement J. Zablocki VA Medical Center Assistant Professor, Psychiatry & Behavioral Medicine Medical College of Wisconsin

2. VETERANS HEALTH ADMINISTRATION Disclosures Michael DiMarco, Jr. Psy.D. – No disclosures. – No conflicts of interest to report. 1

3. VETERANS HEALTH ADMINISTRATION A Common ED Dilemma Patient comes to ED with complaint of low back pain, longstanding, but recent increase has been unbearable. There is an opiate agreement in the EHR. Patient has a PCP who prescribes pain medication, including opiates. What do you do? 2

4. VETERANS HEALTH ADMINISTRATION Managing the Dilemma 1.Believe the patient’s report of pain 2.Assess pain using numerical, visual, or other standard pain scale 3.Determine diagnosis – Acute pain issue – Exacerbation of a chronic non-cancer condition – Disease progression 3

5. VETERANS HEALTH ADMINISTRATION Managing the Dilemma 4.Review the opiate agreement in the EHR 5.Make a decision – Administer Rx the ED i.e. injection – Write a prescription to be filled – Provide non-opiate medication 6.Discuss the benefits of follow up with the PCP/PS 4

6. VETERANS HEALTH ADMINISTRATION Staff Reactions to Pain Patients Empathy Mistrustful Frustration Confrontation Anger Lecturing Investigation Delay treatment Rush treatment – aka “treat & street” 5

7. VETERANS HEALTH ADMINISTRATION “Frequent Flyers” Common terminology used in the ED Terminology may have pejorative connotations The terminology may negatively impact pain care. Consider the impact of the term. Consider replacing the term with “Reoccurring” “Mr. Matthews is a 69 year old man reoccurring to the emergency department due to persistent lower extremity neuropathic pain.” 6

8. VETERANS HEALTH ADMINISTRATION “Frequent Flyers” Reasons Patients Come to the ED for Pain Control Lack health insurance No established primary care provider (PCP) or pain specialist (PS) Disagreement with PCP/PS regarding the pain management plan Abrupt pain increase that may be exacerbated by a recent physical activity Pain increase due to rapid disease progression Fear/catastrophizing beliefs about pain 7

9. VETERANS HEALTH ADMINISTRATION “Frequent Flyers” Reasons Patients Come to the ED for Pain Control Regimen is not effective – Developed a physical tolerance to the RX – Under medicated in the first place Running out of RX before time of refill –Rx overuse Poor planning of routine prescription refills Addiction (personal use, self-medicating of MH condition) Criminal behavior -intent to sell Rx (diversion) Victim of abuse (patient’s Rx is being taken from them) 8

10. VETERANS HEALTH ADMINISTRATION Screening for Abuse (Screen the Patient Alone) “Who helps you organize your pain medications?” “Where do you keep your pain medications?” “Have you ever had to hide your medications from anyone?” If so, “Tell me about that.” “Has anyone ever offered you any money for some of your medications.” If so, “For which medications?” “Has anyone ever offered you food or other kind of help in exchange for some of your medications?” “Has anyone ever taken your medication from you?” 9

11. VETERANS HEALTH ADMINISTRATION Aberrant Medication Taking Behavior: “To abuse or not to abuse…is the question!” Addiction – Escalating Rx use with no therapeutic benefit on reducing pain Tolerance – The need for increase doses of Rx to maintain the same level of pain relief Pseudo-addiction – Patient appears drug-seeking but not due to addiction. Drug seeking is in the context of being under medicated in the first place. – Drug seeking behavior diminishes once appropriate analgesia is achieved 10

12. VETERANS HEALTH ADMINISTRATION Consequences of Untreated Pain in Elderly Further physical limitations Loss of independence Decreased socialization Depression Impaired sleep Cognitive impairment Increase risk for falls and other injuries Increased healthcare utilization/cost Lacas & Rockwood, 2012 11

13. VETERANS HEALTH ADMINISTRATION Myths About Treating Pain in the Elderly Analgesics are too dangerous. Analgesics will cause more cognitive dysfunction. Older people cannot accurately report pain –they’re just demented. Older people don’t understand pain rating scales. 12

14. VETERANS HEALTH ADMINISTRATION Assessment Issues ED culture –fast paced and not “geriatric-friendly.” Assessment biases based on gender, race, age Differences in how younger vs older patients experience pain psychologically Cognitive Impairment 13

15. VETERANS HEALTH ADMINISTRATION Biases in Pain Treatment Patients who are members of racial or ethnic minorities are under evaluated and undertreated for painful conditions in the emergency department. Some literature suggests females may receive more analgesia in the ED than males Some literature suggests that elderly patients receive less analgesia compared to their younger counterparts. Reference: Motov & Khan, 2009 14

16. VETERANS HEALTH ADMINISTRATION Age Bias Jones et al. (1996) found that out of a sample of 231 hospital patients, 66% of elderly patients received less analgesia compared to 80% of their younger counterparts. The study also found that elderly patients had a prolonged wait time for administration of pain Rx, significant under dosing of pain Rx, and received less opiate analgesics. 15

17. VETERANS HEALTH ADMINISTRATION Age Bias Lee et al. (2006) did not find any association between advanced age, gender, ethnicity in pain management including delays in administration of analgesic agents among the elderly presenting with abdominal pain to an emergency department. The study was unique in that it looked at the interaction of gender, race, and age. The original hypothesis was that female, non-Caucasian, an advanced age would expect delays in the administration of analgesia in comparison to their younger counterparts. 16

18. VETERANS HEALTH ADMINISTRATION Differences in Pain-Related Fear: Older vs. Younger Younger people have more generalized pain-related fears – global catastrophizing. Older people are more fearful of re-injury and further loss of autonomy and control that comes with aging. Gagliese, L. (2009) 17

19. VETERANS HEALTH ADMINISTRATION Pain Assessment in the Elderly Cognitively Intact Cognitively Impaired 18

20. VETERANS HEALTH ADMINISTRATION General Considerations for Pain Assessment in Elderly Ask about pain. Be aware that older patients may deny pain but endorse other descriptions such as aching, soreness, stiffness. Be aware that a decrease in physical activity may be the only indicator of pain because geriatric patients may not verbalize pain. 19

21. VETERANS HEALTH ADMINISTRATION Vertical Pain Scales Use assessment approaches that include both self-report and observational measures when possible. Involve the family in the assessment of pain. 20

22. VETERANS HEALTH ADMINISTRATION General Considerations for Pain Assessment Be aware that pain recall may pose some challenges – pain yesterday versus pain today. Be aware that deficits in language skills may pose challenges in the report of pain and explanation of pain – i.e. stroke. Be aware that facial expression associated with pain may be reduced/masked in the elderly. Be aware that impairments in executive function pose problems in noticing the early emergence of lower level pain intensity. 21

23. VETERANS HEALTH ADMINISTRATION Strategies for Cognitively Impaired Patients Don’t write these patients off. Reassess pain frequently. Minimize distractions when making a pain assessment. 22

24. VETERANS HEALTH ADMINISTRATION Strategies for Cognitively Impaired Patients Account for both visual and auditory deficits if possible. Use a nonverbal rating scale. Pain assessment during a movement (activity during transferring, bathing, dressing, and ambulating) is more likely to identify an underlying persistent pain problem than observation at rest. 23

25. VETERANS HEALTH ADMINISTRATION Pain Assessment in Advanced Dementia (PAINAD) 24

26. VETERANS HEALTH ADMINISTRATION Coordinated Care View alert – PCP – PC-SW – PC-psychologist Referral to the PC Home-Based Program 25

27. Management & Follow-up Care Coordination for Older Patients with Pain in the ED Jelili A. Apalara, MD, MPH, FACP, CPE, FACHE. Assistant Clinical Professor of Medicine, University of California, San Francisco Medical Director – Emergency Dept. VA Central California Healthcare System MARCH 2014

28. VETERANS HEALTH ADMINISTRATION Disclosure 27

29. VETERANS HEALTH ADMINISTRATION Objectives By the End of this Presentation, participants will be able to: acquaint themselves with the consequences of inadequate pain treatment in the Elderly. familiarize themselves with the legal position on pain management. describe different modalities for pain management in the Elderly. recognize their roles in subsequent follow-up and management of the patients. 28

30. VETERANS HEALTH ADMINISTRATION Recommendation Grading Evidence Quality High1 Moderate2 Low3 Strength of Recommendation StrongA WeakB InsufficientI 29

31. VETERANS HEALTH ADMINISTRATION Introduction In 2009, the Elderly population, persons 65 years and older, represents only one out of every eight Americans. This denoted 12.9% of the US population., or 39.6 million people in that year. 30

32. VETERANS HEALTH ADMINISTRATION Introduction (Based on online data from the U.S. Census Bureau’s 1) Population Estimates and Projections; 2) Table 1. Projected Population by Single Year of Age (0-99, 100+), Sex, Race, and Hispanic Origin for the United States: July 1, 2012 to July 1, 2060, Release Date: 2012; and 3) Table 5. Population by Age and Sex for the United States: 1900 to 2000, Part A. Hobbs, Frank and Nicole Stoops, Census 2000 Special Reports, Series CENSR-4, Demographic Trends in the 20th Century.) 31

33. VETERANS HEALTH ADMINISTRATION Realities and Challenges One major challenge faced by the elderly people is physical disability. Physical disability in this group often worsens with age. Majority have at least one chronic medical problem, and many have multiple chronic conditions. Arthritis and degenerative joint disease top the list, and often associated with Pain.

34. VETERANS HEALTH ADMINISTRATION Types of Pain 33

35. VETERANS HEALTH ADMINISTRATION Pain should be Evaluated and Treated in the Elderly. 34

36. VETERANS HEALTH ADMINISTRATION Treating Pain is Both a MORAL and an ETHICAL responsibility for Healthcare Providers. 35

37. VETERANS HEALTH ADMINISTRATION The mission of DEA's Office of Diversion Control is to prevent, detect, and investigate the diversion of controlled pharmaceuticals and listed chemicals from legitimate sources while ensuring an adequate and uninterrupted supply for legitimate medical, commercial, and scientific needs. 36

38. VETERANS HEALTH ADMINISTRATION Consequences of Untreated Pain Functional Impairment. Depression. Increased Suicide Risk. Increased Mortality. 37

39. VETERANS HEALTH ADMINISTRATION Treatment Modalities TREATMENT MODALITIES Pharmacologic Interventional Surgical Procedure Behavioral Medicine Physical Therapy Neuromodulation 38

40. VETERANS HEALTH ADMINISTRATION Treatment Modalities NSAIDs Opioids Antidepressants NMDA-ra Anti-epileptics α2 adrenergic agonists Muscle Relaxants Tramadol Topical Agents 39

41. VETERANS HEALTH ADMINISTRATION Pharmacological Treatment WHO’s Pain Relief Ladder WHO 1980. 40

42. VETERANS HEALTH ADMINISTRATION Pharmacological Treatment WHO recommends a progressive increment in doses and types of analgesic to ensure effective pain management. Modality of treatment is not static, it changes with the characteristics of the pain. Mild pain should be treated with acetaminophen, aspirin or other Non-steroidal Anti-inflammatory Drugs (NSAIDs). Moderately persistent or worsening pain requires addition of opioid such as codeine or hydrocodone. 41

43. VETERANS HEALTH ADMINISTRATION Pharmacological Treatment Opioids with fixed dose acetaminophen provides additive analgesia. If pain worsens, and higher doses of opioid are necessary, separate dosage of opioid and non-opioid analgesic. This ensures maximally recommended doses of acetaminophen or NSAIDs are not surpassed. Severe pain requires more potent opioids, such as morphine, hydromorphone, methadone or fentanyl. 42

44. VETERANS HEALTH ADMINISTRATION Pharmacological Treatment Patients with persistent cancer-related pain should be on around-the-clock schedule, with additional “PRN" doses. Patients who have moderate to severe pain when first seen by the clinician should be started at the second or third step of the ladder. Adjuvant drugs should be used at any step as necessary to enhance analgesic efficacy and treat concurrent symptoms exacerbating pain. 43

45. 44

46. VETERANS HEALTH ADMINISTRATION 45

47. VETERANS HEALTH ADMINISTRATION Geriatrics Pain Management 46

48. VETERANS HEALTH ADMINISTRATION Physician’s Role PHYSICIAN & PATIENT PHYSICIAN & PATIENT Interventional Social Work Behavioral Medicine Physical Therapy Physicians and Other Healthcare Providers are central to ensuring effective interdisciplinary pain management. 47

49. VETERANS HEALTH ADMINISTRATION Interdisciplinary Pain Management GOALSGOALS Pain Reduction. Increased activity levels. Increased functionalilty. Early return to work or vocation. Reduced opioids use or more appropriate dosing. Reduced depression and anxiety. Improved coping skills. Reduced use of medical resources 48

50. VETERANS HEALTH ADMINISTRATION Interdisciplinary Pain Management Proc (Bayl Univ Med Cent). Jul 2000; 13(3): 240–243. 49

51. VETERANS HEALTH ADMINISTRATION Key Points Acetaminophen should be considered as initial and ongoing pharmacotherapy in the treatment of persistent pain, particularly musculoskeletal pain, owing to its demonstrated effectiveness and good safety profile (1-A). Most patients with moderate to severe pain, pain-related functional impairment, or diminished quality of life due to pain should be considered for opioid therapy (3-A). Most patients with neuropathic pain are candidates for adjuvant analgesics (1-A). Most patients with localized neuropathic pain are candidates for topical lidocaine (2-A) or capsaicin. Pharmacological Management of Persistent Pain in Older Persons. JAGS. 2009. 50

52. VETERANS HEALTH ADMINISTRATION Key Points Patients should not take more than one nonselective NSAID or COX-2 selective inhibitor for pain control (3-A). Clinicians should anticipate, assess for, and identify potential opioid-associated adverse effects (2-A). Only clinicians well-versed in the use and risks of methadone should initiate it. Methadone must be titrated cautiously (2-A). Long-term systemic corticosteroids should be reserved for patients with pain- associated inflammatory disorders or metastatic bone pain. Osteoarthritis should not be considered an inflammatory disorder (2-A). Therapy should begin with the lowest possible dose and increase slowly based on response and side effects, with the caveat that some agents have a delayed onset of action and therapeutic benefits are slow to develop. For example, gabapentin may require 2 to 3 weeks for onset of efficacy (2-A). Pharmacological Management of Persistent Pain in Older Persons. JAGS. 2009. 51

53. VETERANS HEALTH ADMINISTRATION Conclusion Optimal Pain Control improves elderly patient’s quality of life! Pharmacological Approach should not be the only focus of management!! Optimal Pain Control improves elderly patient’s quality of life! Pharmacological Approach should not be the only focus of management!! Interdisciplinary and Collaborative Approach provide better management outcomes in Elderly patients. 52

54. VETERANS HEALTH ADMINISTRATION 53