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Discussion today 1. Introduction (Hwang) 2. Assessment (Hanly)

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Presentation on theme: "Discussion today 1. Introduction (Hwang) 2. Assessment (Hanly)"— Presentation transcript:

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, 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, 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!

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