1. Geriatric Pain

2. By the year 2030, the number of older adults will double that in 2000, increasing from 35 million to 71.5 million, representing close to 20% of the total U.S population.

3. - More atypically - Two principles ∘Multiplicity ∘ Symptoms may represent the weakest link Presentation of disease

4. Multiplicity ∘ Low back pain in older adults, for example, is commonly contributed to by hip osteoarthritis, fibromyalgia syndrome, and myofascial pain. Presentation of disease

5. WEAK Link ∘in older adults with delirium, for example, the brain is the weakest link, but the treatment targets are most commonly infections and adverse drug reactions. Similarly, the treatment target in the older adult with low back pain may be vitamin D deficiency or Parkinson’s disease rather than degenerative disease of the lumbar spine. Presentation of disease

6. Treatment focused exclusively on analgesia in the vulnerable older adult often fails. Presentation of disease

7. The older man should be screened routinely for concurrent mental health conditions (e.g., depression, anxiety, and dementia) Common comorbidities

8. Other common disease ∘Osteoporosis ∘ Osteoarthritis ∘ DM ∘ Cancer ∘ Cardiovascular disease ∘ Alzheimer’s disease Common comorbidities

9. Alzheimer ’s disease ∘Difficult communication ∘ Amplification of pain ∘ Invalid self-report ∘ May lose treatment experiment expectancy Common comorbidities

10. Risk factors: ∘Medical comorbidities ∘ Depression ∘ Vision & hearing loss ∘ Musculoskeletal disorders ∘ Inactivity Aging & disability

11. While musculoskeletal disorders are the largest contributor to persistent pain and functional impairment in older adults, all contributors to disability require treatment to optimize outcom

12. Neurologic: ∘ Decreased neuropsychological performance ∘ Vision & hearing loss ∘ Postural control abnormality Aging – associated physiology & pathology

13. Musculoskeletal : ∘Sarcopenia ∘ Degenerative arthritis ∘ Decreased bone density Aging – associated physiology & pathology

14. radiographic evidence of degeneration without pain is exceedingly common. Over 90% of pain-free older adults have degenerative disc and facet disease of the lumbar spine. An estimated 21% of pain-free people over age 65have moderate to severe lumbar spinal stenosis. Aging – associated physiology & pathology

15. Thus, the history and physical examination should provide strong evidence of disease before imaging is ordered to avoid unnecessary procedures such as injections and surgery that carry the potential for morbidity. Aging – associated physiology & pathology

16. vitamin D deficiency is common in older adults and may contribute to muscular pain and falls. Assessment of serum 25-OH vitamin D may be considered as part of pain assessment in older adults and correction of insufficiency a routine part of treatment. Aging – associated physiology & pathology

17. Drug Metabolism

18. Pharmacokinetics ∘Meperidine is contraindicated ∘ Increased half –life of opioids & NSAID’s DRUG METABOLISM

19. Pharmacodynamics: ∘ Opioid sensitivity increases with associated decline in mu opioid receptor density and increase in opioid affinity. DRUG METABOLISM

20. 1.Identify contributors to pain (multiple) 2.Identify outcome measures(pain signature) Comprehensive pain assessment

23. Assessment of pain alone is not sufficient; providers should inquire about changes in appetite, sleep, and/or mood, loss of mobility,and diminished activity level

24. Older adults may be less likely to state when they are experiencing pain due to possible beliefs that pain is a normal part of aging and fears about addiction to pain medications and cognitive impairments. Comprehensive pain assessment

25. -Vital signs -Numeric rating scale (NRS) -Verbal descriptor scale (VDS) -Screening for mobility function -Screening for cognitive function Assessment tools

27. 1.Facial grimacing (most sensitive & valuable) 2.Guarding 3.Bracing 4.Rubbing 5.Sighing Special considerations for cognitively impaired Pain behaviors :

29. -fever -sudden unexplained weight loss -acute onset of severe pain -neural compression - loss of bowel or bladder function Red flags( بیرق های سرخ )

30. -jaw claudication new headaches - bone pain in a patient with a history of malignancy or that awakens the patient from sleep -sudden pain in an extremity Red flags( بیرق های سرخ )

31. Because of the risk of medication non adherence, and drug–drug and drug–disease interactions, pain treatment should almost always start with non pharmacologic or non systemic pharmacologic modalities, as described below. Treatment

32. -Inactivity promotes pain-related disability -Regular exercise : ∘Improves psychological well-being ∘ Reduce pain ∘ Increases functional ability Exercise

33. -Combination of ∘Endurance ∘ Resistance ∘ Balance ∘ Flexibility exercise - Weight loss for overweight patients Exercise

34. -Alone may be adequate to manage pain -Goals : ∘Reducing pain ∘ Optimizing fitness ∘ Self-manage learning -Analgesic 30-60 min prior to exercise / Physical therapy Physical therapy

35. -Purposes ∘Pain relief ∘ Mobility & stability ∘ Modification of painful activities Assistive devices

36. -Cane -Walker -Reaches -Jar openers -Button aids Assistive devices

37. -Mild side effect -Less systemic absorption -Ease of application Topical therapies

38. -Capsaicin cream -Lidocaine patch 5% joint pain LBP post herpetic neuralgia Diclofenac gel osteoarthritis Topical therapies

39. -Intra articular corticosteroid -Hyaluronic acid osteoarthritis -Nerve block for neuropathic pain -Trigger-point LA injections for myofascial pain -Epidural steroid for lumbosacral disorders Injection therapies

40. must begin with a careful medication history that includes concomitantly used over-the- counter analgesics, herbal and dietary supplements, vitamin preparations, illicit drugs, and alcohol. Oral analgesics

44. THE END