1. Question #1 What is the analgesic of choice for mild to moderate knee pain due to osteoarthritis in a 78 year old female patient? A.Acetaminophen B. Aspirin C. Celocoxib D. Propoxyphene E. Tramadol

2. Question #2 You are in the ED treating a 78 year old female patient with a history of breast cancer treated 7 years prior with surgery, chemotherapy, and radiation. She complains of severe, unrelenting pain in her low back without radicular symptoms or bowel or bladder dysfunction. The pain has been present for 3 months as a nagging ache, but, for the past 3 days, it has been unbearable. Her BP is 150/100, pulse 105, RR 18, Temp 98.8, pulse ox 96% on room air. What is the appropriate intravenous dose of morphine in mgs per kilogram of body weight to treat her pain? A.0.01 mg/kg B.0.05 mg/kg C.0.10 mg/kg D.1.00 mg/kg E.2.50 mg/kg

3. Question #3 Which of the following classifications best describes pain in the elderly resulting from inflammation, musculoskeletal, or ischemic disorders? A.Limbic system mediated B.Nocioceptive C.Neuropathic D.Parasympathetic mediated E.Sympathetic mediated

4. Acute And Chronic Pain Management In The Elderly Henry R. Schuitema, D.O., FACOEP Medical Director Department of Emergency Medicine Kennedy Health Systems Stratford Campus

5. Acute And Chronic Pain Management In The Elderly This Care of the Aging Medical Patient in the Emergency Room (CAMP ER ) presentation is offered by the Department of Emergency Medicine in coordination with the New Jersey Institute for Successful Aging. This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

6. Learning Objectives Perform a comprehensive, multi-dimensional assessment of the elderly patient presenting to the ED with acute or chronic pain Evaluate for untreated pain as the causative factor of agitation or delirium in older patients Increase awareness of untreated pain and use of non- verbal cues in agitated elderly patients with impairments in hearing, speech and cognitive function Identify both rapidly and accurately the patient’s goals of care and develop an appropriate, patient-centered plan of treatment for pain control

7. Learning Objectives, Cont. Discuss safety measures for the prevention of common ED iatrogenic pain complications from indwelling Foley catheters, central line placement, and endotracheal intubation Prescribe and appropriately dose medications for the treatment of acute or chronic pain Exercise caution when prescribing analgesic medications that increase morbidity in older patients Manage opioid related side effects

8. Case 1 79 year old woman presents with newly diagnosed recurrent metastatic breast cancer to bone and liver with underlying COPD. Her COPD has progressed over recent years leaving her oxygen and steroid dependent. Her recent pathologic hip fracture results in daily pain and her dyspnea is difficult to control. She is weakened by chronic anemia from PUD. Constipation and anxiety are daily concerns.

10. Aging In The United States 1900 – 3.1 million elderly 2000 – 35 million elderly 2020 – 54 million elderly **Incidence of pain increases as we age

11. What Is Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage Pain is whatever the person experiencing it says it is “Discomfort Management”

12. Oligoanalgesia The failure to recognize/treat pain Risk factors –Advanced Age –Minorities Failure to detect Joint Commission – “5 th Vital Sign”

13. Reason For Oligoanalgesia Lack of training Inappropriate pain assessment Reluctance to prescribe opioids

14. Consequences Of Untreated Pain Negatively impact on quality of life Depression and anxiety Social isolation Cognitive impairment Sleep disturbances

15. Pain Management Provider Responsibilities Pain relief is a moral and ethical professional responsibility Providers must help patients make their own decisions and determine their own actions Assessment focused on individual as a whole person and their response to pain

16. Pain Assessment Tools The Brief Pain Inventory –Measures severity of pain –Degree to which it interferes with life Pain Severity Worst Pain Least Pain Average Pain Pain Now Interference Relations with others Enjoyment of life Mood Sleep Walking General Activity Working

17. Pain Assessment The Short Form McGill Pain Questionnaire –Descriptor of pain graded on a scale 0,1,2,3 –Present Pain Intensity on scale 0-5

18. Pain Assessment Assessment in the ED must be rapid Report of pain intensity and other descriptors Past pain history and medication history Ongoing monitoring of pain intensity, duration, response Comprehensive assessment should be delayed

19. Obstacles To Pain Assessment Older patients fail to report pain (they view it as part of aging, don’t want more testing and medications) Accept as punishment for past actions Frequently deny pain – use terms like aching or sore Communication and cognitive status

20. Classification Of Pain Nociceptive Neuropathic Combination

21. Nociceptive Pain Visceral or Somatic Stimulation of pain receptors Inflammation, musculoskeletal, ischemic disorders Typically respond to both opioid and non- opioid therapy (and other non-pharmacologic treatment)

22. Neuropathic Pain Pathophysiologic disturbance of peripheral and central nervous system Examples: Post-herpetic neuralgia and diabetic neuropathy Respond better to anticonvulsants and antidepressants Pain of mixed origins – combination therapy

23. Management Of Acute Pain Combination of opioid/non-opioid analgesics Addition of adjunct medications Non-pharmacologic interventions

24. Pharmacologic Management Of Pain In Elderly Principal treatment modality for pain Significant adverse drug reactions Drug/drug and drug/disease interactions Typically requires trials of various agents

25. Pharmacologic Management General Principles Non-opioid mild pain Opioids for severe pain Select the agent that targets the issue Neuropathic – anticonvulsants Start Low and GO Slow

26. Non-Opioid Analgesics Mild to moderate musculoskeletal pain Acetaminophen –no effect platelet aggregation –no anti-inflammatory properties –well tolerated if no renal/hepatic failure –do not exceed 2 gm/day

27. Non-Opioid Analgesia NSAIDS Significant Risk in Elderly –GI Bleeding –Platelet dysfunction –Impaired coagulation Prolonged use in elderly should be avoided

28. Opioid Analgesia Cornerstone of acute pain management –Proper drug selection –Route of administration –Initial dose –Frequency of administration –Adjunct agent –Side effects

29. Opioid Potency Fentanyl Hydromorphone Morphine Oxycodone

30. Route Of Administration Intravenous preferred route Intramuscular should be avoided Inhaled very effective Oral mainstay in ambulatory ED setting Transdermal great outpatient

31. Dose And Frequency Start low and go slow!!! Elderly at risk oligoanalgesia and pharmaco- complications Many elderly opioid naïve

32. Adjunct Agents/Side Effects Anticipate, prevent, manage Nausea and itching Over-sedation Prophylactic bowel regimens Avoid chewing/crushing sustained release products

33. Specific Painful Conditions Head Injuries Migraines Chest Pain Abdominal Pain Fracture/Dislocations

34. Painful Procedures Foley Catheters Central Venous Access Endotracheal Intubation Cardioversion

35. Chronic Pain Painful condition lasting longer than 3 months 4 types –Pain persisting beyond normal healing time –Pain relating to chronic degenerative disease –Cancer related pain –Pain without identifiable cause

36. Chronic Pain Goals Of Therapy Pain reduction Return to functional status

37. Epidemiology Of Chronic Pain 1/3 of population affected Caused by chronic pathologic process to organ system Caused by prolonged dysfunction of peripheral/central nervous system Frequently psychiatric issues in play

38. Psychological Characteristics Of Chronic Pain Patients Misuse of narcotics Tendency to “Doctor shop” Bodily impairment related to physical/emotional factors Inability to work Feeling of helplessness Over-dramatization Despair and negative attitudes

39. Objective Findings Of Chronic Pain Muscle atrophy Skin temperature changes Trigger points

40. Chronic Pain And Treatment Management is controversial Opioids should only be used if they enhance function Single practitioner should be sole prescriber Narcotics are effective and recommended for cancer pain NSAIDS helpful but problematic in elderly

41. Chronic Pain And Anti-Depressants Very effective Lower doses needed compared to depression TCA enhance endogenous pain inhibitory mechanisms Used in conjunction with private physician

42. Chronic Pain And Anticonvulsants Effective Neuropathic Pain Prevent burst of action potentials Helps lancinating pain Carbamazepine, valproic acid frequently used

43. Chronic Pain Muscle relaxants Anxiolytics Tramadol

44. Special Pain Presentations Post Herpetic Neuralgia Follow acute course herpes zoster Characterized by shooting, lancinating pain Frequently have hyperesthesia Narcotics, antidepressants

45. Special Pain Presentations Fibromyalgia 11 of 18 specific tender points Muscle stiffness, generalized aching pain Sleeplessness Narcotics, short course NSAIDS, antidepressants, exercise

46. Special Pain Presentation Neurogenic Back Pain Very common with advanced age Frequently associated with neuropathy Narcotics, tapered steroids, muscle relaxants

47. Treating Cancer Pain Pain is cancer's most disturbing symptom Aggressive pain management can relieve >90% Pain management remains poor Long acting narcotics scheduled with bursts for breakthrough pain

48. Drug Seeking Behavior in Elderly Not well studied Prescription drug abuse increasing It knows no boundaries Substance abuse by “family members”

49. Most Common Abuse Presentations Back Pain Headache Extremity Pain Dental Pain

50. Case 1 79 year old woman presents with newly diagnosed recurrent metastatic breast cancer to bone and liver with underlying COPD. Her COPD has progressed over recent years leaving her oxygen and steroid dependent. Her recent pathologic hip fracture results in daily pain and her dyspnea is difficult to control. She is weakened by chronic anemia from PUD. Constipation and anxiety are daily concerns.

51. References 1.Cavalieri TA. Managing pain in geriatric patients. J Am Osteopath Assoc 2007;107(suppl 4):ES10-ES16. 2.Cavalieri TA. Pain management in the elderly. J Am Osteopath Assoc 2002;102(9):481-485. 3.Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am Geriatr Soc 1990;38(4):409-414. 4.Gibson SJ, Helme RD. Age-related differences in pain perception and report. Clin Geriatr Med 2001;17(3):433-456, v-v1. 5.Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist.1969;9(3):179-186. 6.Miller J, Neelon V, Dalton J, et al. The assessment of discomfort in elderly confused patients: A preliminary study. J Neurosci Nurs 1996;28(3):175-182. 7.Parmelee PA. Pain in cognitively impaired older persons. Clin Geriatr Med 1996;12(3):473-478.