1. PAIN MANAGEMENT IN THE ELDERLY Swapneel Shah, MD Fernando Almenas, MD Cesar Castillo, MD Anesthesiology Residents Edward Vaynberg, MD Assistant Professor of Anesthesiology
AGS
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
Topic

2. Objectives Discuss sources of pain in the elderly patient
Review methods for evaluating pain in the elderly patient
Describe therapeutic regimes for the older adult
Slide 2
Topic

3. Why is this important? Pain is common in the elderly
Pain is under-recognized and undertreated
JCAHO, ACGME/RRC requirements
Lack of formal education on pain control
Why is the topic of pain assessment and management important to teach? Pain is extremely common in the older adult population. Studies have shown that chronic pain is reported in over 80% of nursing home residents and 50% of community dwellers. Although the numbers on inpatients are unknown and likely vary across institutions, given the level of acuity of illness one can assume that the prevalence is high in the hospital setting.
Despite the high prevalence of pain in this population, it is widely under- recognized and undertreated. Studies have reported that only 40% of oncology and 30% of hip fracture patients report “adequate treatment” of their pain. A large part of under-recognition may be due to incomplete assessment of pain in people who are cognitively impaired.
Clinical care and education in pain assessment and management is mandated by JCAHO and ACGME/RRC requirements, respectively. According to an AAMC survey in 2001, only 3% of medical schools required a separate course on pain management, and fewer than one third of schools offered pain management as an elective course. Although this has improved over the past several years there are still major gaps regarding education in pain management.
Weissman DE , Block S. ACGME requirements for end-of-training in selected residency and fellowship programs: a status report. Acad Med ;77(4):

4. Why is pain control often not optimal?
Clinician unfamiliarity with assessment and treatment
Misconceptions about opioids by patients, families, and clinicians
Fear of side effects
Concerns about addiction, regulatory reprimands, and lawsuits
Why, given the mandates by JCAHO and educational programs such as ACGME and RRC, is pain control in hospitalized older adults suboptimal? Several barriers described in the literature serve as explanations.
Physicians may be unfamiliar with appropriate methods of assessing pain in people with cognitive impairment or assume that certain behavioral changes are part of dementia (agitation, calling out) instead of a new illness or pain.
Clinicians may be uncomfortable or unfamiliar with effective modalities of treating pain in this vulnerable population.
There are still many general misconceptions regarding opiates, including addiction, and fear of side effects such as sedation, respiratory depression, and delirium.
There are still a fair number of physicians who are fearful of regulatory or legal reprimands when using opiate medications.

5. SOURCES OF PAIN IN THE ELDERLY
Degenerative joint disease
Spinal stenosis
Fractures
Pressure ulcers
Neuropathic pain
Urinary retention
Post-stroke syndrome
Improper positioning
Fibromyalgia
Cancer pain
Contractures
Postherpetic neuralgia
Oral/dental sources
Constipation
When we think of pain in general we usually think of cancer pain, arthritis, etc. It’s important to note that many other comorbidities, which may not be as obvious, also predispose older adults to pain. In particular, persons with advanced dementia who progressively lose functional ability are at risk for pressure ulcers, contractures, and improper positioning, all of which are shown to be painful conditions. Pain management can get more complex as many of these disorders coexist in one person.

6. Consequences of unrelieved pain
Sleep disturbance
Functional decline
Depression, anxiety
Polypharmacy
Malnutrition
Prolonged hospital stay
Challenging behaviors
Increased healthcare utilization
Lawsuits
Unrelieved pain can lead to adverse outcomes in patients. Clinicians caring for persons with cognitive impairment may assume that new, challenging behaviors (agitation, aggression, withdrawal) are due to dementia and prescribe medications that do not treat the underlying pain (antipsychotics). This can lead to polypharmacy and increased costs.
There have been reports of lawsuits in the United States where family members have been awarded financial compensation for inadequate treatment of a patient’s pain in the nursing home setting.

7. Age Differences in Pain: CHANGES IN PERCEPTION
Decrease in pain receptors at the skin are a possible mechanism, but no uniform consensus among studies
Regardless of number, function in pain receptors is decreased (both C and A)
Conduction velocities are impaired in both myelinated and unmyelinated fibers at the CNS
Loss of neurons at dorsal horns has been documented

8. Age Differences in Pain: CHANGES IN BRAIN PERCEPTION
Decrease in EEG amplitude and increase in latency to painful stimuli have been reported
Painful thermal stimuli activates midline and central cortical regions in young and old, but older adults show activation of frontal and lateral sites
This implies wider recruitment of neurons and slower cognitive processing
The elderly have been shown to be more reluctant than young people to report painful stimuli

9. Age Differences in Pain: OTHER CHANGES
Normal aging may be associated with impairment in descending endogenous pain inhibition networks
This suggests that adaptation to painful stimuli is reduced in the elderly with age-related dysfunction of both opioid and hormonal systems

10. Age Differences in Pain: PRESENTATION
What may be painful to a young adult may present in the elderly as behavioral changes such as confusion, restlessness, aggression, anorexia, and fatigue
When pain is reported, it may be referred from the site of origin in an atypical manner
Example: Atypical or asymptomatic MI is rare in younger pts; in elderly survivors, 30% do not report acute symptoms, and 30% have atypical presentations
Elderly women are more likely than elderly men to present with atypical pain

11. Pain in the Setting of Cognitive Impairment (1 of 2)
The intensity of painful conditions and the administration of analgesic medication seem to be inversely related as dementia progresses
Patients may have difficulty expressing the experience or inability to associate the actual experience due to neuropathological changes
In response to pain, cognitively impaired people might show more facial expressiveness
This might be related to generalized emotional and behavioral disinhibition rather to pain per se
Although it may seem simplistic, it is important to ask the patient if they are having pain, regardless of cognitive status. Even people with moderate impairment (eg, MMSE = 12) can still reliably report pain with good test-retest reliability. People with dementia may not recall prior pain, so it is important to ask about present pain.
Preferred pain terminology is very important, as the word for “pain” varies from person to person. For example, older adults may equate “pain” to an intense sharp sensation, which is different from moderate aching or hurting. At bedside, one should ask a variety of qualifiers: “Are you aching? Hurting? Having discomfort?” to identify the patient’s preferred pain terminology.
It is important to use a pain scale whenever possible, as it can help guide you in terms of treatment efficacy. Studies have shown that more than 80% of cognitively impaired persons are able to reliably complete a pain scale. The importance is in finding one that works for the individual. I will give you some examples in the next few slides.
When describing the tool to a cognitively impaired individual, one wants to be patient, give simple and clear explanations, and provide examples whenever possible. One needs to give the patient time to process the information and formulate a response. The patient may need to have instructions repeated a few times before understanding of the task. Older patients are often hard of hearing and have poor vision and may need to wear glasses or hearing aids when completing the pain scale.

12. Pain in the Setting of Cognitive Impairment (2 of 2)
As dementia worsens, self-report becomes impossible and it is necessary to rely on pain behaviors and facial expressions
Abrupt changes in behavior and function might be the best indicators of pain
Family members and frequent caregivers can aid in obtaining this information

13. ONE-DIMENSIONAL PAIN SCALES
Here are a few examples of pain intensity scales.
In general, short simple verbal rating scales such as the first scale listed above (eg, no pain, slight pain, moderate, or severe pain), which use adjective descriptions of intensity, may be the easiest and most appropriate for use in older adults. Numeric pain intensity scales can be difficult for some older patients to understand, regardless of cognitive status.
Although many clinicians use physiologic measures such as blood pressure and pulse as indicators of pain severity, they are not reliable markers and should not be used, especially in someone with chronic pain. Blood pressure and pulse rate can vary depending on medications (nodal blocking agents, antihypertensives), comorbidities (heart disease), or the normal aging process (age-related blunting of sympathetic response to painful stimulus).
Republished with permission from Agency for Health Care Policy and Research (now Agency for Healthcare Research and Quality). Acute Pain Management Guideline Panel. Acute Pain Management in Adults: Operative Procedures. Quick Reference Guide for Clinicians. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research (now Agency for Healthcare Research and Quality). February AHCPR Pub. No

14. Faces Pain Scale
At the University of Chicago they use the Wong-Baker Faces Scale, which is similar to the Faces Pain Scale. It was developed and validated in children. Visual scales may be more suitable for people with communication difficulties such as aphasia, illiteracy, or language barriers. The only caution would be that older adults may mistake the Faces Pain Scale for a measure of depression or sadness rather than pain intensity.
Hicks CL, von Baeyer CL, Spafford P, et al. The Faces Pain Scale-Revised: Toward a common metric in pediatric pain measurement. Pain. 2001;93:

15. IOWA Pain Thermometer
Some patients relate to a vertical scale better than horizontal tools.
In summation, when using a pain scale it is important to find one that works for the individual and continue to use it with subsequent assessments.
Copyright 2012 by Dr. Keela Herr, College of Nursing, University of Iowa. Reprinted with permission.

16. Nonverbal Pain Indicators (1 of 2)
Facial expressions: grimacing
Less obvious: slight frown, rapid blinking, sad/frightened, any distortion
Vocalizations: crying, moaning, groaning
Less obvious: grunting, chanting, calling out, noisy breathing, asking for help
Body movements: guarding
Less obvious: rigid, tense posture, fidgeting, pacing, rocking, limping, resistance to moving
And then, of course, we do our own assessment at bedside. Nonverbal pain behaviors are seen throughout all of those complex tools that have been published. The difficulties with this are lack of a gold standard for diagnosis of pain and the fact that many of these behaviors can be manifestations of other disease processes (depression, behaviors related to the dementia). But if you see these new behaviors in a patient, pain should certainly be high up in your mind, especially if it fits the clinical picture.
A number of studies have shown that pain-related behaviors can be observed with excellent interobserver reliability. They exhibit good construct validity, discriminant validity, and response to treatment effects.
The key points I want to make are that physiologic indicators such as heart rate and BP are not as useful in older patients because of the attenuation of autonomic responses secondary to comorbid conditions, medications, and normal physiologic changes with aging. Facial expressions may vary as some patients with dementia may have more muted facial expression and may not show pain.

17. Nonverbal Pain Indicators (2 of 2)
Changes in interpersonal interactions
Combative, disruptive, resisting care, decreased social interactions, withdrawn
Changes in mental status
Confusion, irritability, agitation, crying
Changes in usual activity
Refusing food/appetite change, increased wandering, change in sleep habits
These nonverbal pain indicators represent challenging behaviors that impact the caregivers. If we note any of these behaviors to be new to the patient, it is our responsibility to work it up (and consider pain as a potential etiology).

18. Assessing pain: Nonverbal, Moderate to Severe Impairment (AGS Panel 2002)
Presence of nonverbal pain behaviors?
Assess at rest and with movement
Timely, thorough physical exam
Ensure basic comfort needs are being met (eg, hunger, toileting, loneliness, fear)
Rule out other causative pathologies (eg, urinary retention, constipation, infection)
Consider empiric analgesic trial
People who are nonverbal or have advanced cognitive impairment are at risk of underdiagnosis of pain. This slide describes a framework for assessing a change in behaviors in this vulnerable population.
First, it is important to look for the nonverbal pain behaviors described in the previous slide, both at rest and during activity such as turning or repositioning. The importance of performing a timely, thorough exam cannot be underestimated as a way to find causes of the behavior change. The patient could have an unmet need such as a soiled diaper or hunger. Or there could be a physical problem such as constipation or urinary retention.
Once one has ruled out reversible causes and if the patient has a medical problem that could be associated with pain, one could consider an empiric trial of an analgesic (such as low-dose morphine) to see if the behaviors improve. A handful of small studies in the nursing home population have shown an improvement in agitation and reduction in dose of antipsychotic medications in people with dementia.

19. Multimodal Approach to Pain Management
Pharmacotherapy
Physical Therapy
Treatment Approaches
Interventional
Approaches
It is important to note that pain in older adults is often multifactorial and therefore treatment is usually multimodal. Non-pharmacological strategies may reduce the amount of medications needed to treat physical pain and therefore reduce propensity for side effects and drug interactions. For the remainder of this talk, however, we are going to focus on one of the treatment approaches—pharmacologic therapy for physical pain.
Complementary
and Alternative
Medicine
Exercise
Psychological Support

20. Medication Selection Good pain history Target to the type of pain
Neuropathic, nociceptive
Consider non-pharmacologic or non-systemic therapies alone or as adjuvant therapy
Use the WHO 3-step ladder
It is very important to obtain a complete pain history whenever possible so that the treatment will target the right type of pain. For example, neuropathic pain is often described as burning, numbness, or stabbing, and treatment may involve anticonvulsants or antidepressants. Nociceptive pain may come from a somatic (musculoskeletal) or visceral source. This pain may be treated with NSAIDs or opiate medication. Most types of pain will respond to opiates, but the adjuvant medications (acetaminophen, NSAIDs, topical preparations, etc.) or non-medicinal modalities may be added at any point and can help to reduce the total amount of opiates needed over time.
Not every pain needs to be treated with medication. In one study, post-op pain was reduced in 20% of patients simply by repositioning the patients. Likewise, pain can be have multiple sources, including psychological and spiritual sources. It is important when evaluating patients to consider nonphysical pain, especially in patients not responding to increasing doses of pain medication.
The World Health Organization 3-step ladder provides a useful framework for proper medication selection and adjustment based on level of pain.

21. WHO 3-STEP LADDER
The World Health Organization 3-step analgesic ladder was developed and validated in the cancer population in the early 1990s. When used correctly, over 90% of patients reported adequate pain control. It is now endorsed by the American Geriatrics Society for treatment of chronic, noncancer pain in older adults.
Each step of the ladder corresponds to a patient’s level of pain. If using the numeric rating scale (0 to 10), step 1 (mild pain) would be 1 to 3, step 2 (moderate pain) would be 4 to 6, and step 3 (severe pain) would be 7 to 10.
The type of medication selected corresponds to the level of pain. For example, if the patient reports mild pain, one would consider starting with Tylenol. If pain is worsening or not controlled with this regimen, then one may add or substitute an agent listed under step 2. Climbing each step of the ladder sequentially is not necessary, especially if the patient’s pain is severe.
World Health Organization. Technical Report Series No. 804, Figure 2. Geneva: World Health Organization; 1990.

22. Adjuvants Topical preparations Acetaminophen NSAIDs Anticonvulsants
Lidocaine patch, capsaicin
Acetaminophen
NSAIDs
Celecoxib, steroids
Anticonvulsants
Antidepressants
Non-pharmacologic (TENS, PT/OT)
Adjuvants are essentially any pharmacologic or non-pharmacologic therapies, other than opioids, that can be used as adjuncts to treat a patient’s pain. An example would be agents commonly used for neuropathic pain, such as anticonvulsants (eg, gabapentin, pregabalin) and antidepressants (tricyclics, norepinephrine/serotonin reuptake inhibitors). Adjuvants are recommended in all steps of the World Health Organization ladder, as they may work in synergy with opioids and reduce the amount of opioid used.
For older patients, as with any medication, careful consideration must be given to prescribing systemic medications. Tricyclic antidepressants, especially amitriptyline, have proven to be effective in treating neuropathic pain syndromes such as postherpetic neuralgia or diabetic neuropathy. However, this class of medication is associated with significant anticholinergic side effects and may not be a good choice for patients with a propensity for urinary retention, falls, sedation, or cardiac arrhythmias. When using a tricyclic antidepressant in an older adult, it is recommended that nortriptyline or desipramine be used as they may have fewer anticholinergic side effects.

23. Step 1 (Mild PAIN): Non-opioids
Acetaminophen
NSAIDs
Cox-2 inhibitors
Non-systemic therapies
Non-medication modalities
 Other adjuvants
Step 1 medications are generally non-opioid medications. Acetaminophen is a safe choice in the majority of older adults. The maximum daily dose is 4 g, or 2 g in persons with liver disease.
NSAIDs should be used judiciously due to gastrointestinal bleeding and renal toxic side effects. The prolonged use of any anti-inflammatory medication should be reevaluated in any older person and is generally not recommended.
Topical preparations such as capsaicin cream have been modestly effective in patients with postherpetic neuralgia, osteoarthritis, and painful diabetic neuropathy. Capsaicin cream works by depleting substance P from synapses and must be reapplied several times a day to work. Lidocaine patches and EMLA cream are other options that have also shown modest benefit in some patients. Patients should not wear more than 3 lidocaine patches at one time, so this method of pain management is not ideal for patients with multiple sources of pain.

24. Step 2 (Moderate PAIN): Mild Opioids, Opioid-like
Codeine (eg, Tylenol No. 3 with codeine)
Hydrocodone (eg, Vicodin)
Oxycodone (eg, Percocet)
Tramadol (eg, Ultram)
 Adjuvants
Codeine is probably one of the most emetogenic and constipating opioids. Therefore, it is usually not well tolerated in older adults at higher doses (maximum suggested dose = 1.5 mg/kg/day in divided doses). In addition, codeine is metabolized to morphine through the CYP2D6 isoenzyme. It is thought that roughly 10% of the population lacks this functioning enzyme. If a patient is not responding to this medication at all, one may consider switching to an alternative opioid.
Oxycodone is actually more potent, mg per mg, than morphine. However, it is listed as a “moderate” medication when given in combination with acetaminophen or NSAIDs as it is provided in small doses.
Tramadol is a synthetic non-opioid analog of codeine with complex pharmacology. In addition to reuptake inhibition on the serotonin and norepinephrine receptors, it is a mu-opioid-receptor agonist with analgesic effect approximately equivalent to that of Tylenol #3. The side effects are similar to those of opioids when using high doses (eg, nausea, confusion, dizziness, constipation). It is recommended that elderly patients receive no more than 300 mg/day in divided doses. Patients with reduced GFR may require further dose reduction. In addition, tramadol is not to be used in patients taking a high-dose SSRI, because drug-drug interaction can precipitate a serotonin crisis.

25. Step 3 (Severe PAIN): Strong Opioids
Morphine
Oxycodone
Hydromorphone (Dilaudid)
Fentanyl
Oxymorphone
Methadone
 Adjuvants
For patients who are not responding to increasing doses of moderate level of medications, or those who are in severe pain, it is appropriate to consider the use of stronger opioid medications. Morphine is widely used and has been the most studied. It can be given in any form: IV, PO, PR, SQ. Oral oxymorphone is a relatively new opioid that comes in both immediate-release and sustained-release forms. Fentanyl and methadone will be discussed in the next few slides.

26. Transdermal Fentanyl Duration 2472 hours
1224 hours to reach full analgesic effect
Not recommended as first-line treatment in opiate-naive patients
Lipophilic
Simple conversion rule:
1 mg PO morphine = 0.5 mcg fentanyl
(60 mg morphine roughly = 25-mcg patch)
Transdermal fentanyl is a popular method of pain control for patients with chronic pain syndromes. The convenience of the patch reduces the number of oral medications taken by patients. As with other long-acting preparations, it is not recommended that a patient not be started on the Duragesic patch until they have successfully attained adequate pain control with short-acting medications.
The patches start at 12 micrograms every 72 hours, which is approximately equivalent to 30 mg of oral morphine. Because it takes 12 to 24 hours for the medication to work, the patient should remain on their previous opioid for the first 24 hours after the patch is applied. It should be placed on the torso, as it is lipophilic and requires fat for maximum efficacy. Occasionally the patch is not as effective in persons with cachexia and minimal adipose tissue available for absorption and storage. In the setting of fever, more drug gets absorbed through dilated capillaries, so the patch may wear off earlier and need to be replaced sooner (eg, within 48 instead of 72 hours).
Opioid conversions will be reviewed in subsequent slides; however, since we are on the subject, if one has a patient on an oral or parenteral therapy and the plan is to convert him/her to a fentanyl patch, there is a relatively simple conversion rule. Take whatever medication the patient is on, convert it to an oral morphine equivalent, and then divide by 2 to calculate amount of fentanyl. For example, if the patient is on 100 mg of morphine oral per day, the fentanyl Duragesic equivalent would be 50 mcg every 72 hours. There will be more discussion of this later in the module.

27. Other Fentanyl Intravenous Transmucosal Iontophoretic fentanyl patch
Equivalent to patch dose
(eg, Duragesic 100 mcg / 72 = 100 mcg/hr IV)
Transmucosal
Actiq
Fentora
Iontophoretic fentanyl patch
Ionsys
Fentanyl comes in other forms. The intravenous form is often the drug of choice in ICU settings because its metabolism is minimally impacted by renal disease and because the medication is short-acting and can be cleared rather quickly when discontinued. There are also transmucosal forms available, which are currently expensive and rarely used in the elderly population.
The iontophoretic fentanyl patch is a relatively new form of patient- controlled analgesia approved for the post-op setting. The patch is roughly the size of a credit card, and the polarity charge of skin facilitates absorption once the patient presses the button. The delivery system provides a 40-mcg dose with 10-minute lockout. The duration of the patch is 24 hr or 80 doses.

28. Methadone (1 of 2)
A complicated drug—should be used only by those with experience!
Mu, kappa, delta agonist
Inhibits reuptake of serotonin and norepinephrine
NMDA antagonist (neuropathic pain)
Significant inter-individual variability
Drug interactions (Coumadin-like)
Methadone has been widely available for decades and has recently been coming back into favor for use in chronic pain and patients under palliative care and in hospice programs. Its mechanism of action works on multiple receptors. One difference between methadone and alternative opioids is that it has some effect on the NMDA receptor, which has been implicated in neuropathic pain syndromes. The drug is metabolized in the liver and excreted fecally and is therefore minimally impacted by renal disease. It is also very inexpensive compared to alternative treatments and may have less street value as well.

29. Methadone (2 of 2) Initial rapid tissue distribution
Slow elimination phase
Long and variable half-life (1358 hours)
Dose interval is variable (q6h or q8h)
Dose usually adjusted every 47 days
Minimally impacted by renal disease
Inexpensive; less street value than other opioids
However, caution must be applied when using methadone. It has the propensity for significant drug interactions, and the half-life is very variable from person to person. Its dosing interval is typically every 6 to 8 hours, which does not correlate with the half-life, which has been reported in patients to be as long as 60 to 120 hours. What this means is that if a patient is started on this medication and the drug is titrated up too rapidly, because of the prolonged half-life the patient may experience very significant side effects such as respiratory depression and death.
In addition, there has been some concern that the medication is associated with torsades de pointe when given at high doses.
Therefore, all patients treated with methadone for pain control should be closely monitored by clinicians with experience and familiarity with the drug.

30. Drugs to Avoid IN THE ELDERLY
Meperidine
Demerol
Mixed agonist-antagonists
eg, Pentazocine (Talwin)
Propoxyphene
Darvon, Darvocet
Meperidine is poorly absorbed orally and has a short half-life (3 hours), which is not ideal for patients with continuous pain. In addition, it has an active metabolite, normeperidine, that has no analgesic properties but a long half-life (6 hours). This metabolite can accumulate over time, especially in the setting of dehydration and reduced GFR, and may cause tremulousness, dysphoria, myoclonus, and seizures.
Any mixed agonist-antagonist, such as pentazocine, should not be used because of the potential to precipitate a withdrawal reaction.
Propoxyphene, like meperidine, has an active metabolite with CNS toxicity. In addition, its analgesic efficacy is no better than that of acetaminophen.

31. Opioid Pharmacology
Block the release of neurotransmitters in the dorsal horn of spinal cord
Mu, delta, kappa expressed differently, depending on opioid medication
Conjugated in liver
Excreted via kidney (90%–95%)
Exception: methadone is excreted fecally
There are 3 major classes of opioid receptors—mu, kappa, and delta— located in the dorsal horn of the spinal cord and other areas within the peripheral and central nervous systems. Opioids bind to these receptors and modulate pain through inhibition of calcium channels and release of neurotransmitters such as substance P. Most opioids are conjugated by the liver and excreted via the kidney. As mentioned before, methadone is one exception to this rule, as it is excreted through feces. Therefore, decisions regarding medication selection, dose, and dose titration are impacted by the individual patient’s hepatic and renal function.

32. Opioid Use in Renal Failure
Avoid meperidine, codeine, dextropropoxyphene, morphine
Use with caution: oxycodone, hydromorphone
Safest: fentanyl, methadone
Opioid dosing by creatinine clearance:
>50 mL/min Normal dose
1050 mL/min 75% of normal dose
<10 mL/min 50% of normal dose
Choice of opioid and dosing is very dependent on the patient’s underlying renal disease. Here is a list of medications that should be avoided or used with caution. Medications like morphine have active metabolites such as glucuronides that can accumulate in the setting of reduced GFR, anuria, or dehydration. These metabolites can lead to CNS adverse effects such as delirium and myoclonus. Because fentanyl does not have active metabolites and methadone is excreted fecally, these drugs are considered to be preferred agents in the setting of renal disease. If other opioids are used, the doses should be adjusted based on the creatinine clearance or GFR.

33. Clearance Concerns Dehydration, renal failure, severe hepatic failure:
 dosing interval (extend time) or
 dosage size
With oliguria or anuria:
Stop around-the-clock dosing of opioids
Use only PRN
If the patient is oliguric, around-the-clock dosing should be discontinued and the opioid should be dosed PRN based on symptoms.

34. Opioid adverse effects
Common
Constipation
Dry mouth
Nausea/vomiting
Sedation
Sweats
Uncommon
Bad dreams/hallucinations
Dysphoria/delirium
Myoclonus/seizures
Pruritus/urticaria
Respiratory depression
Urinary retention
Hypogonadism
SIADH
This is a list of common and less common side effects seen with opioid medications. Because of the aging kidney and liver, and altered pharmacokinetics with normal aging, older adults are often more sensitive to these side effects than younger patients are.

35. GI Side Effects OF OPIOIDS
Constipation
Never resolves
Prevent with scheduled softeners plus stimulants
Avoid bulking agents (eg, Metamucil)
Nausea and vomiting
Encourage patients to eat frequent, small meals
Treat with:
Pro-motility agents (metoclopramide)
Serotonergic blocking agents (odansetron)
Dopaminergic blocking agents (haloperidol, metoclopramide, prochlorperazine)
It has been reported that 30% of cancer patients experience nausea when opioid therapy is initiated. This is often listed as an “allergy,” which is incorrect.
If the patient develops watery, loose stools, it is important to consider the possibility of fecal impaction with leakage of stool around the site of impaction. Patients who do not have a bowel movement in several days should have a rectal exam and possibly enemas.

36. Sedation and Delirium WITH OPIOIDS
Consider trying one of the following:
If pain control is adequate, decrease dose by 25%
Rotate to a different opioid preparation
Use small dose of a psychostimulant (2.55 mg methylphenidate or dextroamphetamine) for excessive somnolence
Use nonsedating antipsychotics for delirium (haloperidol, risperidone)
Consider that the patient may be sleeping a lot because pain is finally controlled and they are responding to sleep deprivation and exhaustion that occurred from inadequate pain control.
Generally, patients become tolerant to sedation from opioids within 2 to 4 days after starting or titrating up the dose of an opioid. However, if the sedation remains and is excessive, one can consider decreasing the dose of the opioid. Another option is rotating to a different opioid. A patient may be more sensitive to side effects from one type of opioid but not another. Occasionally we temporarily use psychostimulants for excessive somnolence.

37. OTHER References (1 of 4)
Levy M. Drug therapy: pharmacologic treatment of cancer pain. N Engl J Med. 1996;335(15):
EPEC Project. The Robert Wood Johnson Foundation
Storey P, Knight CF. UNIPAC 3: assessment and treatment of pain in the terminally ill. AAHPM 2003.
Gazelle G, Fine PG. Methadone for the treatment of pain. J Palliat Med. 2003;6(4):
AGS Panel on Persistent Pain in Older Persons. JAGS. 2002;50:S205-S224.
American Pain Society. APS Glossary of Pain Terminology.
Bruera E, Portenoy R. Cancer Pain Assessment and Management. Cambridge University Press, 2003.
Cherny N, Ripamonti C, Pereira J, et al. Strategies to manage the adverse effects of oral morphine: an evidence-based report. J Clin Oncol. 2001;19:
Topic

38. OTHER References (2 of 4)
Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):
Gordon DB, Stevenson KK, Griffie J, et al. Opioid equianalgesic calculations. J Palliat Med. 1999;2(2):
Herr K, Bjoro K, Decker S. Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review. J Pain Symptom Manage. 2006;31(2):
Hewitt DJ, Portenoy RK. Adjuvant drugs for neuropathic cancer pain. In: Topics in Palliative Care. New York: Oxford University Press; 1998:31-62.
Kirsh KL, Passik SD. Palliative care of the terminally ill drug addict. Cancer Invest. 2006;24:
Klaschik E, Nauck F, Ostgathe C. Constipation—modern laxative therapy. Support Care Cancer. 2003;11:
Topic

39. OTHER References (3 of 4)
McCleane G. Topical analgesics. Med Clin N Am. 2007;91:
Mercadante S, Bruera E. Opioid switching: a systematic and critical review. Cancer Treat Rev. 2006;32:
Meuser T, Pietruck C, Radbruch L, et al. Symptoms during cancer pain treatment following WHO guidelines: a longitudinal follow-up study of symptom prevalence, severity, and etiology. Pain. 2001;93:
Skaer TL. Transdermal opioids for cancer pain. Health Qual Life Outcomes. 2006;4(24):1-9.
Swegle JM, Logemann C. Management of common opioid-induced adverse effects. Am Fam Physician. 2006;74:
Topic

40. OTHER References (4 of 4)
End of Life/Palliative Education Resource Center.
American Medical Association Pain Management Series. Management of cancer pain: other analgesic approaches and end-of-life care.
Bruera E and Sweeney C. Methadone use in cancer patients with pain: a review. J Palliat Med. 2002;5(1):
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41. Acknowledgments
Supported by a grant from the Geriatric Education for Specialty Residents Program (GSR), which is administered by the American Geriatrics Society and funded by the John A. Hartford Foundation of New York City
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42. www.americangeriatrics.org Thank you for your time! Visit us at:
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