Pain An introductory module for clinicians Paul S. Tumber, MD FRCPC

Pain An introductory module for clinicians Paul S. Tumber, MD FRCPC
Pain Management Consultant: UHN, Women’s College Hospital and Wasser Pain Clinic, Mt. Sinai Hospital Assistant Professor of Anesthesiology

This module is part of the sfCare approach
The RGP of Toronto has developed a comprehensive set of materials for 7 clinical topics. Each topic has a PPT Presentation, a Patient Awareness poster, and Patient handout PowerPoint Presentation 8.5 x 11 Poster Patient Handout

Objectives Identify the physiologic changes in older adults that impact pain management Describe a structured approach to the detection of pain in older adults Give examples of non-pharmacological strategies for pain management in older adults Recognize considerations for pharmacotherapy use to treat pain in older adults Apply a senior friendly approach to pain Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References By the end of this module, the learner will be able to Identify the physiologic changes in older adults that impact pain management Describe a structured approach to the detection of pain in older adults Give examples of non-pharmacological strategies for pain management in older adults Recognize considerations for pharmacotherapy use to treat pain in older adults Apply a senior friendly approach to pain

Physiologic changes with aging*
Nervous System loss of nerve fibres slowed nerve conduction velocity Pain Modulation impaired Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Musculoskeletal decreased muscle mass Hepatic System decreased hepatic blood flow Renal System decreased creatinine clearance Body Composition increased fat / decreased body water This slide shows some of the changes that occur with normal aging that pain practitioners need to keep in mind when considering a treatment plan. Nervous system: (loss of nerve fibres / slowed nerve conduction velocity. Greater risk of: cognitive deficit decreased balance leading to falls / fractures Musculoskeletal: (decreased muscle mass) Renal System (decreased creatinine clearance) Have to decrease dose for renal-excreted medications Gastrointestinal System (decreased gut motility) More prone to constipation Pain Modulation (impaired) Reduced tolerance to pain Hepatic System (decreased hepatic blood flow) Possible increased half life of drugs that have a high hepatic extraction ratio Body Composition (increased fat / decreased body water) Increased half life for fat soluble drugs possible higher plasma levels for water soluble drugs Renal clearance decreases by 10% per decade after age 50, so drugs that are normally excreted by the kidney need to have their dosage adjusted downwards (e.g. gabapentin). Net result for pharmacotherapy: decrease initial medication doses by 25-50% compared to healthy adults (e.g., start with low dose acetaminophen, not the maximal dose) Gastrointestinal System decreased gut motility

Challenges in the older adult
“Homeostenosis” Frail: impaired bio-psychosocial function Multiple comorbidities: Osteoarthritis Osteoporosis Dementia Diabetes Polypharmacy Drug interactions and adverse effects Increased sensitivity to certain medications (e.g., benzodiazepines) Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References HOMEOSTENOSIS: this is a special consideration when it comes to dealing with the older adult. Homeostenosis refers to a decreased ability to respond to a stressor due to decreased biologic, psychologic, and social reserves. This leads to a decreased ability to protect oneself from injury, falls, burns, etc., and a decreased ability to recover back to normal after any severe illness that affects organ function. FRAIL: Older persons may under report pain due to fear of greater loss of independence, fear of being a greater burden on caregivers, and may lead to barriers like cost of treatments/difficulty with mobility and transportation to doctors offices and clinic visits. Also frail older adults may already have difficulty with communication. Many analgesic medications may cause more side effects in this group of older adults. COMORBIDITIES: There is also an increased incidence of comorbidities in the older adult (such as diabetes, osteoarthritis, osteoporosis, cancer) and this leads to a greater complexity in medical management as well. As many as 80% of older persons diagnosed with cancer experience pain during the course of their illness and new onset of pain or progression of pain in an older adult may herald advancement of cancer. POLYPHARMACY: Have to be careful not to try and treat every symptom with medication alone (e.g., insomnia, depression, anxiety) as medications themselves can lead to adverse effects.

Organ function declines over time
Organ function declines over time in normal, healthy humans, as indicated by Line 1. Chronic disease will accelerate this decline, as noted by Line 2. Acute disease will cause temporary, rapid but reversible declines, as shown by Line 3. Regardless of cause, reserve function is lost when organ function declines into the shaded area. Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References As we age, we all normally experience a decline in organ function. Unfortunately, for those with a chronic illness such as diabetes, this decline may be accelerated and with acute conditions (e.g. poorly controlled diabetes and renal disease) this can lead to an accelerated decline into insufficient organ function. It is important to maintain normal vibrant health function (e.g. exercise, good control of blood pressure, cholesterol, etc.) in order to best counter any illness that will result in impaired organ function. Adapted from Bouchon22. Used with permission. Rivera, R. and Antognini, J.F. Perioperative Drug Therapy In Elderly Patients. Anesth 2009; 110:

Barriers to pain management in older adults
Barriers encompass bio/psychosocial/spiritual issues Cost Caregiver burnout / transportation Impairments Mood Cognition Physical (falls) Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References When developing a treatment plan you may have to address various barriers to pain management, such as: read slide

Barriers to pain management in older adults (cont.)
Barriers encompass bio/psychosocial/spiritual issues Attitudes and belief system: Tendency to under report pain / stoicism Catastrophizing, fear of injury, fear of impending loss of independence, death and hopelessness Poor compliance, addiction concern Health care: Polypharmacy Myths about pain treatments, including opioids Lack of knowledge or resources Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References When developing a treatment plan you may have to address various barriers to pain management, such as: read slide

How to assess pain …ask about F.I.F.E. Iowa Pain Thermometer
Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Before treatment can start, the cause of pain should be determined. The assessment must rule out pathological causes for pain such as cancer, fractures, infections, blood clots, ischemia, etc. There are very different analgesic treatments based on whether the source of the pain is due to activation of nociceptive pathways (e.g. arthritis) versus neuropathic pain states (e.g. post-herpetic neuralgia). A thorough patient assessment is thus important and is comprised of a careful history, physical examination and any appropriate laboratory or radiological investigations. It can be a challenge in the older adult to complete a proper pain assessment for a number of reasons especially if there are issues such as dementia, frailty, visual and hearing impairment. Family tend to overestimate how much pain an older adult know has, whereas healthcare providers tend to underestimate the degree of pain (but not at higher levels of pain intensity). If the older adult is demonstrating agitation then it is easy to have a disagreement about how much pain a patient has. An agitated older adult with cognitive impairment can be very difficult to assess. Verbal agitation/ complaints / restlessness and pacing tend to improve with analgesia but NOT if they are physically aggressive in their behavior (Husebo, AM J Ger. Psych 2014) The best way to assess pain is to ask the patient and obtain a self-report as to intensity and how it affects daily function. Visual analog (FACES) scale: high error rate Numeric scale: okay if no cognitive impairment Verbal descriptor: okay if mild to moderate cognitive impairment Faces / Iowa Pain thermometer : better if there is cognitive impairment Also ask about FIFE (Feelings, Ideas, Function, Expectations), which we will cover on the next slide. …ask about F.I.F.E. (Feelings, Ideas, Function, Expectations) Iowa Pain Thermometer

Ask the patient these F.I.F.E questions
Example questions Feelings How does your chronic pain make you feel about yourself? What specific fears or worries do you have about your condition? Ideas Do you have any ideas about what may be causing your pain, beyond what you have been told by your healthcare provider? What do you think about the meaning of this pain? Function What does your chronic pain prevent you from doing? What would you like to be able to do (goals)? Expectations What did you expect was going to happen at today’s clinic visit? What is your expectation about the future of your condition? What do you think about this treatment plan? Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References An important part of a pain assessment includes “FIFE”: patient feelings, ideas, function and expectations in order to gauge a patient’s belief system about pain, how it impacts their psychosocial and spiritual being in addition to the limitations that the pain imposes on their daily activities or goals for activity.

Pain assessment in older adults with dementia
Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Read slide Thomas Hadjistavropoulos, Keela Herr, Kenneth M. Prkachin, Kenneth D. Craig, Stephen J. Gibson, Albert Lukas, Jonathan H. Smith, Lancet. Dec 2014

Pain assessment in older adults who can’t self report
Consider causes of pain (e.g. nerve damage, arthritis) Observe patient behaviors (e.g. eating, walking) Use proxy reports (family, caregivers, etc.) Attempt a cautious analgesic trial (and observe the response to treatment) Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References In older adults with cognitive impairment or barrier to communication, you may need to look at other modalities of pain assessment as listed here. Patient behaviours may include: facial expressions such as grimacing, wincing; vocalizations such as moaning; body movements such as flinching, refusal to move, rubbing or holding painful areas, clenching of fists, shaking; changes in interpersonal interactions such as withdrawal from normal interaction, difficulty in being consoled or reassured (Hadjistavropoulos, T et al, Lancet 2014) Herr, K et al. Pain Assessment in the Patient Unable to Self-Report: Position Statement With Clinical Practice Recommendations. Pain Manag Nurs 2011:

How to manage pain There are four strategies for managing pain in older adults… Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Physical strategies Psychological strategies Procedural interventions Pharmacotherapy Makris, U. et al. Management of Persistent Pain in the Older Patient. A Clinical Review. JAMA. 2014; 312(8): Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society, 2009. There are 4 major treatment categories to consider when instituting a treatment plan for any individual with pain.

How to manage pain 1. Physical Strategies
Physical activity can reduce pain: Neuromuscular: decreased joint load, better joint stability, increased energy absorption by muscles Periarticular: flexibility, connective tissue health, bony mass Intra-articular: cartilage, reduced inflammation, improved joint nutrition General fitness: reduced comorbidity, weight loss, aerobic fitness, psychosocial wellbeing, placebo, improved self-efficacy The mainstay of persistent pain management includes: Massage therapy Physiotherapy Physical activity Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Physical modalities: One of the most important goals of pain management in the older adult is to keep them mobile and able to engage in the activities of daily living. Massage can give temporary relief. Adverse effects from aging, cognitive decline, and physical effects of pain/pain treatments can lead to issues such as falls; thus home safety and preventative measures need to be considered (e.g. walker, handrails) Clin Geriatr Med 32 (2016)

How to manage pain 1. Physical Strategies (cont.)
Exercise with a friend / group (YMCA, senior center, community) Calendar Set goals Smartphone fitness app / fitbit, etc. Vary the exercise type (resistance, aerobic, aquatic, walking route, etc.) Pick activities that the person enjoys Websites: American Geriatrics Society, Arthritis foundation, American Diabetes Association, Centres for Disease Control and Prevention, etc. Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Encourage active physical therapy. Consider Tai Chi, yoga, aqua therapy programs.

How to manage pain 2. Psychological Strategies
Education. Reassurance. Support. Address misbeliefs: hurt does not equal harm Cognitive Behavioral Training Meditation / Mindfulness- Based Relaxation Shared Decision-Making Model Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Psychologic strategies: Address fears, expectations, catastrophizing, support and education Form a strong therapeutic alliance - pivotal between patient and provider! Also need to consider a Shared Decision Making model with patient/family and provider in terms of the risks vs benefits for all the various treatment approaches.

How to manage pain 3. Procedural Strategies Examples: Acupuncture
Trigger point injections Joint injections Appropriate for a select population of older adults Limited role for persistent pain states Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Procedural Interventions may include, for a select population of older adult: Acupuncture Trigger point injections (lidocaine) Botulinum toxin injections (e.g. piriformis syndrome, focal muscle spasm) Facet joint injections or denervation procedures SI joint injections Epidural steroids (have become less common recently in older adult due to accumulated risks and only short term benefit likely) Shoulder, hip, knee joint injections (steroids, hyaluronic acid and more recently platelet rich plasma)

How to manage pain 4. Pharmacotherapy Over-the-counter medications
Opioids Pharmacotherapy for neuropathic pain Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Read slide

How to manage pain 4. Pharmacotherapy Acetaminophen Over-the-counter
Well-tolerated (minimal adverse effects) Still considered first line agent for mild pain, osteoarthritis Ceiling effect on analgesia Maximum initial dose is 1000mg orally up to four times a day Chronic dosing should reduce to maximum 2500mg / day (especially for older adults) Beware liver toxicity if overdose, alcoholic, malnourished Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Need to be aware of all the over-the-counter products that contain acetaminophen in order to keep the daily dose below mg/day. NOTE: 3000mg is the daily dose recommended by the manufacturer (USA) but there are some specialists that advocate 2500mg for chronic daily dosing in older adults. Beware possible increased bleeding risk (INR elevation) with warfarin. Starts to work 30-60min after ingestion and effects can be decreased by concomitant food administration, increased effect with caffeine. Oscier and Milner. Perioperative use of paracetamol. Anaesthesia 2009; 64: 65-72

Older adults are especially vulnerable!
How to manage pain 4. Pharmacotherapy NSAIDs All NSAIDS and coxibs inhibit the cardioprotective effects of ASA; thus avoid in patients at risk of heart attack or stroke All NSAIDs can cause renal dysfunction All NSAIDS and coxibs can cause peptic ulcer disease (less risk with coxibs), may need to add proton-pump inhibitor if long-term use or at risk population (older adult; using corticosteroids; prior history of ulcers; using anticoagulants or ASA, alcohol) May increase blood pressure or worsen CHF Over-the-counter Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References BEWARE! NSAIDs: can be very useful for arthritis/ nociceptive pain. Have a ceiling effect. Efficacy is similar amongst commonly used NSAIDs. Can try different NSAIDs from different classes to find the one that has the best analgesic response. Debatable as to how long to try NSAIDs before switching to other classes of agents. General recommendation is a 1-2 week trial if pain appears to be nociceptive. Neuropathic pain would not be an indication to try NSAIDs. Some patients respond better to one particular class of NSAID than another (example one patient may respond to diclofenac whereas another may find celecoxib effective). 2019 BEERS Criteria for Potentially Inappropriate Medication Use in Older Adults: Journal of American Geriatric Society avoid long term use of PPI (without any indication) due to risk of C difficile, bone loss, fractures (malabsorption) but can use if older patient needs long term NSAID therapy for pain management – ensure SHARED DECISION MAKING ! Upper GI ulcers, bleeding, perforation occur in about 1percent of patients treated for 3-6 months and about 2-4% if treated for more than 1 year (trend up continues with longer duration of use) Older adults are especially vulnerable! Karsh, J. Anti-inflammatory drugs: What is safe? CMAJ. 175(5) 2006; 449

Older adults are especially vulnerable!
How to manage pain 4. Pharmacotherapy Over-the-counter Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References NSAIDs (cont.) Lowest dose Shortest duration consider drug holidays to allow GI / GU system to recover Assess analgesic efficacy Not indicated for neuropathic pain Protect from ulcers Monitor kidney function BEWARE! Comment: For a drug holiday, you can encourage the older adult to use acetaminophen, ice/heat, massage, transcutaneous electrical stimulation, acupuncture, topical analgesics for example. There is no good evidence to guide the clinician in terms of an exact number of days involved in a drug holiday…just that it seems reasonable to try to encourage the older adult to minimize daily reliance on NSAIDs without any break in use. In my practice I ask patients to try 3-7days off NSAIDs every other week/skip on days they are less active, since I have seen many patients taking NSAIDs with NO reassessment of their use or break in their use for months or years in a row (see article by Hatt, KM, et al. Safety Considerations in Prescription of NSAIDs for Musculoskeletal Pain: A Narrative Review. PMR 10(2018): ) Older adults are especially vulnerable! Karsh, J. Anti-inflammatory drugs: What is safe? CMAJ. 175(5) 2006; 449

How to manage pain 4. Pharmacotherapy Opioids
Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References “Opioid therapy for older adult patients can be safe and effective…” Lower starting dose Slower titration Longer interval between doses More frequent monitoring Tapering of benzodiazepines In the discussion of the guidelines for the use of opioids in the older adult it is mentioned that opioid therapy for the older adult maybe underutilized. As a class, opioids cause less organ toxicity then nonsteroidal anti-inflammatory drugs. It is noted that clinics caring for older adults with well defined pain conditions have found very low rates of abuse and addiction. Several pharmacokinetic factors put the older adult at greater risk for opiate overdose including lower serum binding, lower stroke volume which slows liver metabolism, and a greater sensitivity to psychoactive and respiratory effects of opioids. 2017 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, R17 Recommendation Statement

Reducing risk from opioid use: Educate patient and caregiver about signs of overdose, e.g. slurred or drawling speech, emotional lability, ataxia, nodding off… Avoid opioids in cognitively impaired older adults living alone, unless ongoing medication supervision can be organized Consider a three-day “tolerance check” Monitor renal function Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References In terms of the three day tolerance check it is recommended that patients are contacted within the first three days after starting an opioid prescription to check for any signs of sedation or adverse effects - t is a reminder that if older adult are started on any medication they should be reassessed more frequently then younger patients. 2017 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, R17 Recommendation Statement

Opioid prescribing cautions for the older adult: Start titration at no more than 50% of the suggested initial dose and lengthen time interval between dose increases Among strong opioids, oxycodone and hydromorphone may be preferred Morphine solutions are preferable to tablets in some situations (e.g. patients with swallowing problems) For older adults on benzodiazepines, try to taper the dose to reduce the risk of falls and cognitive impairment Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Notes from the 2017 Canadian Guidelines: For frail older adults, the dose of morphine should be lowered, for example 5mg every 4 hours or even less frequently will help to reduce the likelihood of drowsiness, confusion or unsteadiness. Oxycodone, for example, start at 2.5mg every 6 hours for older adults instead of 5mg every 4hours in younger adults. Consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids recommends a preference for sustained release preparations because they may increase patient compliance however I would recommend that older adults start with immediate release preparations especially for the treatment of breakthrough pain before considering the use of controlled release preparations. The use of short acting immediate release opioids should be used initially to demonstrate efficacy and tolerability of the medication prior to switching to any controlled release formulation. 2019 BEERS Criteria for Potentially Inappropriate Medication Use in Older Adults: Journal of American Geriatric Society: Recommends avoidance of benzodiazepine use with opioids Also recommends that opioids not be combined with gabapentinoids due to risk of over-sedation, respiratory depression and death. Do not recommend opioid use in older adults that have a history of falls and fractures (unless necessary for acute pain, postoperatively) 2017 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, R17 Recommendation Statement

How to manage pain 4. Pharmacotherapy Neuropathic pain Drug class
Over-the-counter: NSAIDs 4. Pharmacotherapy Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Neuropathic pain Drug class Examples 1st Line Tricyclic Antidepressants Nortriptyline, desipramine Anticonvulsants Gabapentin, pregabalin (carbamazepine: tic douloreux) SNRI Duloxetine, venlafaxine 2nd Line Tramadol Opioids 3rd Line Cannabinoids Sativex buccal spray, dronabinol 4th Line SSRI Topical lidocaine Methadone Other anticonvulsants Lamotrigine, topiramate, valproic acid The next few slides review some of the other analgesics used for neuropathic pain. Read slide. Moulin DE, et al. Pharmacological management of chronic neuropathic pain: Revised consensus statement from the Canadian Pain Society. Pain Res Manage 19(6) Nov/Dec 2014

How to manage pain First line medications for neuropathic pain
Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Tricyclic Antidepressants Adverse Effects Common: dry mouth, drowsiness, confusion, orthostatic hypotension, urinary retention / prostatism, constipation, arrhythmia Amitriptyline: greatest anticholinergic side effects, possible weight gain, glaucoma Nortriptyline: least adverse cardiac arrhythmia risk, reduced anticholinergic side effects Desipramine: less sedation Read slide. Avoid tertiary amine tricyclic (amitriptyline and doxepin) due to high incidence of adverse effects

Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Gabapentinoids for older adults START LOW GO SLOW Monitor closely and reduce dose (check creatinine clearance) Risks: cognitive impairment ataxia / falls weight gain, etc. Read slide.

Serotonin Noradrenaline Reuptake Inhibitors Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Duloxetine is FDA-approved in diabetic neuropathy and fibromyalgia SSRI’s are not as useful in neuropathic pain Trade name Initial dose Max dose Adverse effects Venlaxafine Effexor 37.5mg/day 225mg/day Nausea, dizziness, sedation, diaphoresis, hypertension Duloxetine Cymbalta 30mg/ day 60mg/ day Sedation or insomnia, nausea, ataxia, dry mouth: avoid if narrow angle glaucoma incr. bleeding risk hyponatremia Read slide. Duloxetine is approved by Health Canada for chronic back pain and major joint arthritis, also useful to consider for diabetic neuropathic pain. Maximum dose in older adult is 60mg per day. Generally well tolerated, suggested to take with some food. Many will take it at night but some feel more activated and thus can take during the day.

How to manage pain Third line medications for neuropathic pain
Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Cannabinoids Likely only have a modest effect on chronic pain CBD component is commonly used for pain management (avoid THC due to its psychoactive effects) Do not recommend smoking or inhalation route: more common use seems to be in form of CBD oil Problems include supply interruptions and lack of standardization of quality of the product The second line of drugs used for neuropathic pain is Tramadol Opioids. Refer to previous slides about opioids. The third line of drugs is Cannabinoids. More research is underway to best guide clinicians. Read slide.

How to manage pain Fourth line medications for neuropathic pain
Topical Lidocaine Mechanism of action: sodium channel blocker Most helpful is the 5% Lidocaine patch but this is not available in Canada and thus it is used as a % cream up to tid. Best indication is post-herpetic neuralgia, also can be used in cases of localized allodynia Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Read slide. Topical preparations represent an excellent idea in regard to reducing medication toxicity to major organs like the heart/liver/kidney, but they are limited in terms of efficacy and are limited by how much they cost. There are lots of topical compounds found in the pharmacy that can be obtained without a prescription: TOPICAL MENTHOL and menthol salicylate: aches and pains, 1.5-3% OTC remedies Other topical agents that have been tried E.g. topical 10% ketamine, 5% amitriptyline, 10% gabapentin. Need compounding pharmacist: expensive Lynch, ME and Watson, P. The pharmacotherapy of chronic pain: A review. Pain Res Manage 11(1) Spring 2006:

Topical capsaicin (chili pepper extract) Mechanism: reduces pain- related neuropeptides especially substance P, and causes degeneration of epidermal nerve fibres Need to use it 4 times a day for up to 6 weeks Compliance may drop off due to burning effect on skin May be used in cases of small joint arthritis, diabetic neuropathy Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Read slide. Lynch, ME and Watson, P. The pharmacotherapy of chronic pain: A review. Pain Res Manage 11(1) Spring 2006:

Topical NSAIDs (especially diclofenac) and topical rubefacients (various salicylate preparations) May be helpful for acute / localized musculoskeletal pain Topical diclofenac (Pennsaid) can provide pain relief in some cases of osteoarthritis Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Read slide. Lynch, ME and Watson, P. The pharmacotherapy of chronic pain: A review. Pain Res Manage 11(1) Spring 2006:

How to manage pain Follow up for pharmacotherapy in pain management
Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Reasonable intervals Document: Analgesia, activity, adverse effects, aberrant drug taking behaviors, affect (mood disorder), accurate medication log Helpful to have corroboration of efficacy from family, significant others, workplace, other healthcare providers including pharmacist Read slide Gourlay D.L. et al. Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain. Pain Medicine 6(2) 2005;

How to manage pain Remember: Ask about pain regularly and assess pain systematically (do not “set and forget”) Believe the patient and family in their report of pain, and relieving factors Choose pain control options appropriate for the setting, patient and family (think multimodal) Deliver interventions in a timely, logical and coordinated fashion (team approach) Empower (educate) patients and families to take control as much as possible Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Read slide. Carr, Eur J Pain 2001 Frenette, Crit Care Clin, 1999

Summary Consider the outcome of the pain management plan:
Reduction in pain Minimization of adverse effects / risk Improvement in activity (leisure, socialization, mobility) Improved quality of life / well-being / satisfaction Reduced polypharmacy / health care utilization / cost Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Read slide.

The senior friendly approach
How all healthcare providers can address pain using a senior friendly care approach Ask leaders to remove barriers to care, and provide education for staff, patients and caregivers. Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Organizational Support Organizational Support Emotional & Behavioural Environment Pain is not due to age! Treat pain as you would for adults of all ages. Emotional & Behavioural Environment Processes of Care Processes of Care Ethics in Clinical Care and Research Always assess for and treat pain in adults with cognitive impairment. Ethics in Clinical Care and Research All the content we have covered today has been around the processes of care for pain management. This slide provides an overview of all the other components of a senior friendly approach to address pain. In order to address pain we need more than just adequate processes of care. Organizational support: Ask leaders to support the delivery of senior-friendly pain care by removing barriers to care, and providing education for staff, patients and caregivers. Emotional & Behavioural Environment: Pain is not due to age! Treat pain as you would for adults of all ages. Ethics in Clinical Care and Research: Always assess for and treat pain in adults with cognitive impairment. Involve family in the identification of non-verbal pain cues. Physical Environment: Remove barriers such as transportation or cost related to non-drug therapies and medications. Make the environment comfortable by providing extra pillows, hot and cold packs, and music. Remove barriers such as transportation or cost of non-drug therapies and medications. Make the environment comfortable. Physical Environment Physical Environment

Discussion questions What are some of your barriers to pain management in older adults? What is one pain management strategy you might start using after going through this module? How can each member of your interprofessional team contribute to pain management? Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Options for discussion: Brainstorm as a large group Think independently, pair off and discuss, come back and share with the large group Round-robin style discussion so that all voices are heard

References American Society Geriatrics (2009) Pain Management in Elderly Guidelines Fine, Perry G. Treatment Guidelines for the Pharmacological Management of Pain In Older Persons. Pain Medicine 2012; 13: s57-66 [U of Iowa] [AGS] National Institute on Aging National Center on Caregiving CDC and Prevention Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References

The sfCare Learning Series received support from the Regional Geriatric Programs of Ontario, through funding provided by the Ministry of Health and Long-Term Care. The sfCare Learning Series received support from the Regional Geriatric Programs of Ontario, through funding provided by the Ministry of Health and Long-Term Care. You can access more sfCare materials at V1 July 2019

Pain An introductory module for clinicians Paul S. Tumber, MD FRCPC

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