1. Pain Management in the Geriatric Population
Ali R. Rahimi,MD,FACP,AGSF
Professor of Medicine
Mercer University School of Medicine
Clinical Professor
University of Georgia School of Pharmacy

2. Pain:
Webster:
a : usu. localized physical suffering associated with a bodily disorder; also : a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive action
b : acute mental or emotional distress or suffering
Urandictionary.com:
What happens when you reach into the blender to dislodge a stuck icecube without unplugging it first.
A subjective, unpleasant, sensory, and emotional experience assoc with actual or potential tissue damage, or described in terms of such damage

3. Pain & elderly
Pain is what many people say they fear most about dying.
Pain is undertreated at the end of life
Older patients are likely to have a increased pain threshold but to be less toleant to severe pain.

4. PAIN IS MC REASON FOR INDIVIDUALS TO SEEK MEDICAL CARE
Abdominal Pain
3 of the 20 most common reasons for outpatient department office visits
Back pain
Head pain

5. Definitions: Addiction: Psychological dependence on a drug.
Physical Dependence: Development of physical withdrawal reaction upon discontinuation or antagonism of a drug
Tolerance: Need to increase amount of drug to obtain the same effect
Pseudoaddiction: Behavior suggestive of addiction occurring as a result of undertreated pain

6. Pain can be assoc w/: Psychologic and physical disability
a source of individual suffering
Familial distress

7. Pain in nursing home patients
30% reported daily pain
26% of these patients received no analgesia
Only 26% of them received strong opioids
What predicted inadequate pain management?
1 Advanced age: >85 years old
2 Poor cognitive function
3 Minority status
Bernabei (1998), N = 13,625 cancer patients
“AGS reports that 18% of people 65 and over are taking analgesic medications regularty (several times a week), and 63% of those had taken presciption pain medications for more than 6 mo.”

8. Obstacles of geriatric pain management:
Accessibility to treatment
$$$
SEs
Comorbidities
Ex- NSAID use in pt w/ HTN or heart disease
Ex- Acetominophen use in Liver dz pt
Interactions with the current meds
Pts with cognitive impairments
The assumption that pain is normal party of aging
Practitioner’s bias (pain seeker..)
fear of legal repercussions…
although MDs have been successfully sued for undertreatment as well.

9. Decreased activity bc of pain
It’s a risk factor!
Myofacial deconditioning
Decreased activity bc of pain
Gait distrubances
INJURIES from falls

10. Types of pain:
Nociceptive pain- Nerves responding appropriately to a painful stimulus
Neuropathic pain- results from NS dysfunction, and may originate centrally or peripherally
Somatic pain- originates in the skin, bones, myo, and connective tissue, and usually is located specifically.
Visceral pain- originated in internal body structures and organs, and is located more genearlly.
Central example- phantom pain or post CVA pain

11. Neuropathic pain: Origin: Palliates/potentiates: Quality: Radiation:
Nerve damage
Palliates/potentiates:
Set off by unusual stimuli, light touch, wind on skin, shaving (trigeminal neuralgia)
Quality:
Electric, burning, tingling, pins & needles, shooting (system isn’t working right)
Radiation:
Nerve-related pattern

12. Nociceptive Pain: Origin: Palliates/potentiates: Quality: Radiation:
Easier to treat than Neuropathic!!
Origin:
Tissue damage
Palliates/potentiates:
Worse with stress, pressure
Responds better to opioids, NSAIDs
Quality:
Sharp, dull, stabbing, pressure, ache, throbbing
Radiation:
Occasionally radiates (less well-defined), but not along an obvious nerve distribution

13. Differentiating between somatic, visceral, and neuropathic pain is ESSENTIAL to proper tailoring of pain treatments

14. Specific Goals: 1- determining the presence and cause of pain
2- identifying exacerbaing comorbidities
3- reviewing beliefs, attitudes and expectations regarding pain
Overall: to decrease pain and increase function and quality of life!

15. Common pain syndromes in elderly
MUSCULOSKELETAL CONDITIONS OA
Degenerative disk dz
Osteoporosis & Fxs
Gout
RHEUMATOLOGIC CONDITIONS: RA
Polymyalgia rheumatics
Fibromyalgia
NEUROPATHIC CONDITIONS:
Biabetic neuropathy
Postherpatic neuralgia
Trigeminal neuralgia
Central poststroke pain
Radicular pain secondary to degenerative disc dz

16. Aging takes a toll… In the PNS:
Loss of myelinated and unmyelinated fibers
Axonal atrophy common
Nerve conduction and endoneural blood flow are reduced w/ age
Less nerve regeneration observed
progressive loss of serotonergic and noradrenergic neurons in the superficial lamina of the spinal dorsal horn, and bc serotonin and norepineph have important roles in the descending inhibitory control pathways, such a loss may upset the natural endogenous pain-suppressing mechanisms.
Therefore, pain treatment of the elderly obviously differs from that of young patients!

17. Models of the prevalence of pain
1- Pain increases with age and then decreases at older ages (ie, 70 and beond). They suppose that this pain typically has a mechanical etiologic component and possibly is assoc with the occupational envioroment
2- pain increases with age. This has a mechanical etilogic component but also an assoc with increasing prevalence of degenerative dz, particulary at older ages.
3- age-independent pain that (obviously) lacks a mechanical etiologic component. (ie- risk factors that are constant throughout the life course)
4- A decrease in pain prevalence at older ages. It is not clear whether the trajectory is caused by age-related changes in pain and pain perception, or by changes in pain reportin.
There has been research to support all 4 models

18. Effect of age on human (via clinical observation):
Clinical observation examples:
increased incidence of silent MI in elderly patients
atypical presntation of an inflamed appendix, (absence of RLQ pain)
Study example: (pg 208)
Yunis compared elderly and young patients with fibromyalgia. They found that chronic head aches, anxiety, tension, mental stress and poor sleep were all less common in the elderly patients w this condition.

19. Lonliness and pain
The comorbidity of pain and psychological distress is WELL DOCUMENTED-
The feeling of lonliness is the single most important predictor of psychologic state of distress in older persons.
A study by Eisenberger supported the hypothesis that Pain distress and social distress share neurocognitive substrates
Study on page 193

20. Sleep and pain
Multiple studies have demonstrated the comorbidity of pain and sleeplessness
Pain is among the best predictors of sleep disturbances among older adults
Thus, it appears that improved pain leads to improved sleep, and impoved sleep leads to improved pain!
Study =pg 193
Pg 193

21. HOW TO QUANTIFY THE PAIN?

22. Details!
Onset
Duration
Freq
Intensity
Locaiton
Contributing factors

23. Troubleshooting pain assessment:
Demented/Confused patient:
Have to look for:
Agitation, agressiveness, etc.

24. Pain control vs quality of life
OVERALL GOAL:
to abolish pain with minimal adverse effects.
Ex- Patient with COPD and pain:
Cant treat their pain too vigorously bc we will exacerbate the COPD symptoms

25. Treating the pain:

26. Pharmacologic approaches:
Opiods
Anti-inflammatory agents (asa, NSAIDS, cyclooxygenase [COX-2] inhinitors, steroids)
Acetaminophen
Tramadol
Myo relaxants
Tricyclic antidepressants
SRIs
Antielileptic drugs (AEDs)

27. Non-pharmocologic approaches:
Behavioral therapy
Spiritual counseling
Physical therapy
Psychotherapy
Splinting
Surgical correction
Cold packs
Meditation
Support groups
Radiation therapy
Acupuncture
Hypnosis
Cultural healing rituals
Heat packs
Prayer
Community resources
Behavioral includes: biofeedback (BFB), CBT, hypnosis, relaxation techniques, psychoanalytic theray, distration techniques, guided imagery, and progresive myo relaxation
CAM: acupuncture, yoga, tai chi, gi gong herbal therapy meditation, music therapy, massage, reiki/therapeutic touch, and prayer.

28. How to choose an analgesic?
Severe pain:
Opioids
Moderate to severe:
Use in combo with opioids
The who’s analgesic stepping laddar.
Mild to Moderate pain: Acetominophen
Aspirin
NSAIDS

29. Drug Classes

30. Salicylates:

31. Salicylates
Analgesic, antipyretic, anti-inflammatory and anti-rheumatic activity.
MOA:
Inhibits prostaglandin synthesis producing analgesic.
antiplatelet effect by inhibiting the production of thromboxane
Much higher levels needed for anti-inflammatory effect than for anti-platelet, anti-pyretic and analgesic effects.
Metab: Gut & plasma (ASA); liver (salicylate) CYP450
Excrition: renal
Can cause: GI irritation and bleeding.
Use w caution in ppl with hx of gastric or peptic ulcercs.
Thromboxane- which under normal circumstances binds platelet molecules together to create a patch over damage of the walls within blood vessels.

32. Acetominophen analgesic and antipyretic agent MOA:
Inhibits central prostaglandin synthesis with minimal inhibition of peripheral prostaglandin synthesis
Antipyretic effect by direct action on the hypothalamic heat-regulating center
Benefits:
Absorbed rapidly
No gastric mucosa effects
No effect on platelet aggregation
Metab by liver
Excretion: urine (metabolites can accumulate w renal impairment)
Hepatotoxic
Not antiinflammatory
No adverse effects on gastric mucosa and platelet function like salycylates.
Good drug but problem is that ppl overlook the recommended dose limits. And a lot patients take it with their opiod analgesics which contain acetaminophen.
Excretion: urine (metabolites can accumulate w renal impairment)
Use with caution in ppl with: liver disease, chronic alcoholism, and malnutrition.
Can take mg orally q 6hr
Older pts and Pts with liver dz: do not exceed 2g/day

33. NSAIDS Antipyretic, analgesic and anti-inflammatory properties MOA:
Reduce central and peripheral prostaglandin synthesis but they do not inhibit the effects of the prostaglandins already present, resulting in analgesia, followed by relatively delayed anti-inflammatory effects.
Metab: liver
Excretion: urine
Adverse effects:
n/v, bleeding
Hepato and nephrotoxicity
1.5 times higher risk of GI bleeding (more so in the elderly)
Concurrent use of PPI for prevention

34. NSAID: 18 available in the US
All NSAIDS have similar mechanism of action BUT differ in:
Potencies
Time to onset
Duration
Response among patients
Common uses:
After surgeries
Painful chronic conditions (ex- OA)
Benefit more notable when used in combo w an opiod.
Opiod SEs like sedation, n/v decreased when used w NSAID

35. COX 2 NSAIDS: Purpose in pharmacology unclear
Only available: celecoxib
Cox2 and NSAIDS are CI in pts with cardiac disease!
estimated to be responsible for up to 20 percent of hospital admissions for congestive heart failure.
BY INCREASING SYSTEMIC VASCULAR RESISTANCE and REDUCING RENAL PERFUSION
Other cox 2s were removed from market due to safety questions
(bc all others ones were assoc with increased risk of MI)

36. OPIOID:
a chemical that works by binding to opioid receptors, which are found principally in CNS and the GI.
Hence, the GI Ses
Effects:
decreased perception of pain
decreased reaction to pain
increased pain tolerance
Opium poppy

37. Opioids Cornerstone of the analgesic regimen for mod-sev pain MC ones:
Morphine
Oxycodone
Hydromorphone
Transdermal fentanyl
Opioid is prefered name for this class of analgesics bc nartotic is primarily a legal term used to refer to drugs from various pharmacologic clase and is assoc w important psychological barriers to pain management.

38. 3 Main Opioid receptors:
Mu, delta and kappa receptors.
Mu agonists: produce analgesia
affect numerous body systems
influence mood & reward behavior
Delta agonists produce analgesia
not a lot on market
Kappa agonists produce analgesia
may cause less resp depression and miosis
psych effects, can produce dysphoria
Opioids LACK the adverse renal, and hematologic effects of NSAIDs

39. MU-receptor agonists are MC used
although drugs may interact with more than one type of receptor.
Ex- the mu receptor antagonist and kappa receptor agonist drugs were deigned to cause less respiratory depression.

40. Opioids pharmacokinetics
Pharmacokinetic properties of an opioid can dictate the circumstance which they are appropriate in:
Ex- Lipid-soluble drug such as fentanyl, which diffuse rapidly acros the BBB, are preferable if analgesia is required immediately before a short, painful procedure.
Elimination half life very short:
So, steady state reached in a day or less!
Thus, you can adjust the dose daily knowing we are seeing it’s effect.

41. Adverse effects: Respiratory depression sedation N/V Constipation
Urinary retention
Itching
Itching due to histamine release?

42. 1. Respiratory depression
Caused by directly acting on respiratory center
Naloxone is specifically used to counteract life-threatening depression of the central nervous system and respiratory system
Therapeutic doses of morphine can affect:
Resp rate, minute volume tidal exchange
Although, tolerance to this effect is usually achieved with repeated doses of opioids.
Avoid/Monitor in pts with:
Imparied resp function
Sleep apnea
Or bronchial asthma
Usually, co2 stimulates the central chemoreceptors which tell your body to breath.. BUT OPIOIDS shift the co2 response curve so that the level of co2 needed to stimulate respiration becomes higher.
Naoloxone is pretty short acting, so we usually put the patient on a drip.
Not common if begin with low dose and titrate upward!!

43. 2. Nausea and vomiting MC SE
Likely due to changing blood serum levels , not steady state
The freq of nausea and vomiting is higher in ambulaory patients (vestibular component?)
Antiemetics (metoclopramide or droperidol) can be used along with the opioid.
N&V relate more to changing blood serum levels of opioids than the steady state dose

44. 3. Constipation: Acts on receoptors of GI tract and spinal cord
to produce decrease in peristalsis and intestinal secretions
Tolerance to this effect is not common-
Result- prescribe prophylactic laxatives
… use stood softener AND a stimulant laxative.

45. 4. Urinary retention causes increased smooth muscle tone
increases sphincter tone

46. 5. Itching Mechanism not fully known~
Hypot: related to the release of histamine from mast cells.
If itching is with rash- consider allergy.
Can use an antihistamine to treat this

47. Opioids: Morphine Morphine = standard of opioids
BUT if pt doesnt respond well, they may switch to an equianalgesic dosage of:
Hydroporphone
Oxycodone
Fentanyl
Oxymorphone
Or methadone
If pt has diminished renal function, they may benefit from:
Oxycodone or hydromorphone (bc these don’t have clinically significant active metaolites)
e—kwi-en-al-gez-ic

48. The dosages of any full opioid agonist used to control pain can be converted into an equivalent dose of any other opioid. In this way, 24-hours opioid requrements and dosing regimens established using shorter action opioid medicatnions can be translatee into equivalent dosages of longer-acting medicaitons or formulations.

49. Opioid Combos~ Full opioid agonists: Morphine Hydrocodone Codeine
Dextropropoxyphene
Typically combined with acetaminophen or an NSAID

50. Acetaminophen con Codeine
Advantages:
Low regulatory control
Inexpensive
Widely available
Disadvantages:
10% cannot convert codeine to morphine
Many drugs interfere with conversion
Codeine is the pro drug. Gets converted to morpheine

51. Acetaminophen with Oxycodone, Hydrocodone
Oxycodone combination contains 325 mg acetaminophen
Hydrocodone combination contains 500 mg acetaminophen
No clear advantage between the two

52. Three mu=receptor agonist to avoid whenever possible!! ..
Meperidine
Propoxyphene
codeine
mu= most common used

53. 1.Meperidine (DEMEROL) Low potency relative to morphine
A short duration of action – so have to dose it more frequently
And a toxic metabolite (normeperidine)
Ex- meperidine 75mg = mg of morphine
can cause irritability and seizures
Normeperidine can cause irritability and seizures

54. 2. Propoxyphene (DARVOCET)
treat mild to mod pain
Toxicities assoc with it’s primary metabolite: norpropoxyphene
can cause cardiotoxicity and pulmonary edema
Half life: 6-12 hour;Metabolite half life hours
Pts with Dec Renal function or pts getting repeat doses: higher risk
Puts geriatric pts at higher risks of falls (d/t CNS effects)
[study found that propoxy users have twofold higher risk for hip frature compared with nonusers of analgesics]
ALSO, it has no clinical advantage over nonopioid analgesics such as acetominaphen
289
PG 289

55. 3. Codeine
Must be converted to morphine by means of the cytochrome P-450 pathway to provide analgesia.
Lots of Caucasians are poor metabolizers of this isoenzyme -thus cant make the conversion!
So, they do not get any of the codeine’s benefit but still suffer the Side effects.

56. Principles of opioid use:
No ceiling effect
Dose to pain relief without side effects
Give orally when possible
Sub-cutaneous administration is basically equivalent to intravenous (and preferable)
Treat constipation prophylactically
Full opioid agonists are best choice for severe pain..
the dose of opioid is not limited by the toxicities of the acetaminophen, asa, or NSAID component of cobo preparations.

57. Where to start?

58. Treating Chronic pain:
Basal pain medicine plus a different therapy for spikes:
Predictable spikes - Short-acting agent prior to event
Unpredictable spikes - Short-acting agent readily available (prn)
Ex- give some med before changing bandage
Allow enough time to allow maximal effect (45 minutes for most oral opioids).

60. Treating Neuropathic Pain;
Opioids and NSAIDS less effective

61. Classes of Agents Tricyclic for dysesthetic pain
Anticonvulsants for shooting pain
Steroids to decrease peri-tumor edema
An example of dysesthetic pain would be? (e.g., neuropathy from chemotherapy)
An example of shooting pain? (e.g., spinal compression from tumor)

62. Tricyclic for dysesthetic pain
Dysesthesia is pain not experienced by a normal nervous system.
Eg- neuropathic burning from chemotherapy
Considered "Dante-esque" pain.
Amitriptyline
Nortriptyline
Desipramine
Dante’s inferno
The terminology used to describe it is usually interchangeable with descriptions of Hell in classic literature.

63. Anticonvulsants for shooting pain
Gabapentin
Pregabalin

64. Steroids to decrease compression
Nerve infiltration by tumor or spinal cord compresion:
Corticosteroids
Deamethasone
Prednisone
*Usu used for pts near end of
Life bc of detrimental SE of
Long term steroid use.

65. Opioid analgesics available in US
Mu agonists
Alfentanil
Codeine
Hydrocodone
Ydromorphone
Fentanyl
Levorphanol
Meperidine
Methadone
Morphine
Opium
Oxycodone
Oxymorphone
Remifentanil
Sufentanil
Tramadol
Kappa agonist/mu antagonist
Butorphanol
Nalbuphine
Pentazocine
Mu antagonists
Nalmefene
Naloxone
Naltrexone
Mu partial agonist/kappa antagonist
Buprenorphine

66. When to refer: Pain not respsoning to opoiods at typical doses
Neuropathic pain not responding to first line treatments
Comples methadone management issues
Intolerable side effects from oral opioids
Severe pain from bone mets
For a surgical or anesthesia-based procedure, intrathecal pump, nerve block, or rhizotomy

67. When to admit:
For severe exacerbation of pain that is not responsive to previous stable oral opioid around-the-clock plus breakthrough doses.
Pateints whose pain is so severe that they cannont be cased for at home
Uncontrollable side effects from opioids, including nausea, vomiting, and altered mental status

68. Good to know..
Older individuals tend to be more sensitive to benzodiazepines and opiods.
Pain from bone mets more susceptible to NSAID pain relief than opioids
The 1998 guidelines recommended earlier use of narcotics than is typical for treatment of younger patients because of the significant toxicities assoc with NSAIDS.

70. Trigeminal neuralgia
Characterized by: severe, unilateral facial pain described as lancinating electrics shock-like jolts in one or more distributions of the trigeminal nerve.
Maxillary and Mandibular divisions = MC
Careful clinical evaluation and MRI is recommended

72. Postherpetic neuralgia
Follows outbreak of Herpes zoster
Sensory findings:
Allodynia (wind against skin hurts, sheet on area hurts etc) hyperalgesia

73. Post stroke pain An underrecognized consequence following storke
May present as shoulder pain in the paretic limb or present as central poststroke pain.
Characterized as pain that is severe and persistnet w accompanying sensory abmomalities
Ex- the guy from Oceanside.

74. Metastatic bone pain
Bone pain that is worse at night, when laying down or not assoc with acute injury
Pain that gradually but rapidly increase in intensity or with weight-bearking or activity.
Freq sites:
Hips, vertebrae, femur, ribs, and skull

75. Temporal Arteritis: More than 95% of TA are ppl >50 Presentation:
New onset headache, malaise, scalp tenderness and jaw claudication
PE: indurated temporal arterly that is tender with a diminihed or abent pulse
Irreversible bliness is consequence of untreted.. So timely assesment and tx is

76. Pain perception in rats:
When nociception is tested in mice using an electrical current, it seems that there are age related changes in nociception .
The graphic representaion of electical thresholds needed to induce a vocal reponse was of a U-shap pattern. (high pain tolerance in young and old- lower in the middle aged)
Pg 204

77. Effect of age on human experimental pain
50 studies total
21 concluded an increase in pain threshold with advancing age
3 reporeted a decrease
17 noted no change
However,
Temporal vs Spatial summation:
It was fround that temopral summation to a heat pain stimulus, for example, is more pronounced in the elderly as compared with younger subjects. Whereas spatial summation is not significantly influenced by age.
Pg 206 temporal vs summative??