1. Pain Assessment and Management

2. Module 1: Pain in residents in RACFs
Pain is a personal experience, occurring when and where the resident says it does
Pain management in RACFs is not addressed well. The incidence of pain is higher in residents who have impaired cognition or a communicative disability.
There are multiple barriers to effective pain management which are related to false beliefs and attitudes of residents, families and health professionals

3. Barriers to effective Pain Management
For health professional:
lack of pain assessment skills
lack of knowledge of current therapeutic approaches
uncertainty about the role of opioid treatment
insufficient knowledge of opioid treatment
overestimation of the risks of addiction
concern about the management of adverse effects
concern about regulation of controlled prescription drugs

4. Barriers to effective Pain Management
For residents/families:
fear of addiction
fear of adverse effects
an inability to comply with complicated programs
communication difficulties (language differences cultural issues, intellectual disability)
fear that pain may suggest worsening disease
pain is an expected part of ageing.

5. Factors affecting a residents experience of pain
The perception of pain can be influenced by the resident’s mood, past pain experiences, social and physical situation.

6. Module 2: Types of Pain Pain can be classified as: Acute Chronic
Nociceptive
Neuropathic
Incident pain
Breakthrough

7. Module 3: Pain Assessment
Pain assessment tools provide a framework for staff to obtain an accurate pain assessment and assists in determining response and on-going treatment for the pain.
Important elements to be included in a tool include; the site of the pain, quality of pain, severity, exacerbating and relieving factors, its exact onset, interference with activities of daily living, impact on the patient’s psychological state, response to previous and current analgesic therapies.

8. Estimating pain in the absence of direct communication
Changes in behaviour
Vocalizations
Facial expressions
Observations of caregivers/relatives
Changes in physiological responses
Increase in pulse rate
Increase or decrease in BP
Response to a trial dose of analgesia

9. Abbey Pain Scale For measurement of pain in people with dementia who cannot verbalise
Q1. Vocalisation (eg whimpering, groaning, crying) Absent 0 Mild 1 Moderate 2 Severe 3
Q2. Facial expression (eg looking tense, frowning, grimacing, looking frightened) Absent 0 Mild 1 Moderate 2 Severe 3
Q3. Change in body language (eg fidgeting, rocking, guarding part of body, withdrawal) Absent 0 Mild 1 Moderate 2 Severe 3
Q4. Behavioural change (eg  confusion, refusing to eat, alteration in usual pattern) Absent 0 Mild 1 Moderate 2 Severe 3
Q5. Physiological changes (eg temp, pulse/BP outside normal limits, perspiring, flushing, pallor) Absent 0 Mild 1 Moderate 2 Severe 3
Q6. Physical changes (eg skin tears, pressure areas, arthritis, contractures) Absent 0 Mild 1 Moderate 2 Severe 3
Total pain score
Tick the box that matches the total pain score
Tick the box that matches the type of pain
0-2 No pain
3-7 Mild
7-13 Moderate
14+ Severe
Chronic
Acute
Acute on chronic
Abbey, J 'Ageing, Dementia and Palliative Care' in O'Connor, M and Aranda, S (Eds) 2003 Palliative Care Nursing . A guide to practice , Ausmed Publications, Melbourne, pp ( the pain scale is on page 323).
Jennifer Abbey, Neil Piller, AnitaDe Bellis, Adrian Esterman, Deborah Parker, Lynne; Giles and Belinda Lowcay (2004) The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia , International Journal of Palliative Nursing, Vol 10, No 1pp 6-13.

10. Module 4: Pain Management
General WHO principles of pain management
By the mouth
By the clock
By the ladder
Individual treatment
Supervision

11. WHO Pain Ladder FREEDOM FROM PAIN STEP 3: Opioid for strong pain
+non-opioid + adjuvant
FREEDOM FROM PAIN
STEP 2:Opioid for mild to moderate pain
+non-opioid + adjuvant
Pain
persisting ↑
STEP 1: Non-opioid + adjuvant
Pain
persisting ↑

12. Adjuvant Analgesics
Defined as drugs with other indications that may be analgesic in specific circumstances
Numerous drugs in diverse classes

13. Pharmacology of Analgesics in the Elderly
Decline in the ratio of lean body mass to total body weight
Decreased hepatic metabolism
Decline in renal drug clearance
Poor compliance
Drug-disease interactions
E.g. CCF causes diminished hepatic blood flow

14. Precautions with Drugs in the Elderly
Start with the lowest anticipated effective dose
Monitor frequently, on the basis of expected absorption and known pharmacokinetics
Titrate the dose on the basis of likely steady state blood levels
Likelihood of side effects
 Sensitivity to central acting analgesics

15. Schedule 8 Drugs (Step 3 WHO Ladder)
IMMEDIATE
RELEASE- ORAL
Ordine
Oxycodone
OxyNorm
OxyNorm Syrup
Hydromorphone
Methadone
Palfium
Morphine
Sulphate
Fentanyl Lollipops
Sevredol
SLOW RELEASE ORAL
MS Contin
MS Contin Suspension
OxyContin
Kapanol
MS Mono
Palladone XL
INJECTABLES
Morphine
Hydromorphone
Fentanyl
TRANSDERMAL
Fentanyl

16. Breakthrough Medication
50 – 100% of the 4-hourly dose OR
1/12 to 1/6 of total daily dose
i.e. MS Contin 30mg BD
B/T = 5mg

17. Opioid Conversion (Tramadol 8 × 50mg (400mg) = 50mg morphine)
Panadeine (codeine 8mg) = oral Morphine 1mg
Panadeine Forte (codeine 30mg) = oral Morphine 3.75mg
Codeine Phos 30mg = oral Morphine 3.75mg
Tramadol 50mg = oral Morphine 6.25mg
Endone 5 mg = oral Morphine 7.5mg
Fentanyl 12.5mcg = oral Morphine 30mg
(Tramadol 8 × 50mg (400mg) = 50mg morphine)

18. Morphine Myths There is a limit to the dose of morphine I can use
If I use it now, it will be ineffective when I really need it
I will become addicted
Morphine is only used when death is imminent
The parental dose is more effective
Morphine causes respiratory depression

19. Morphine common side effects
95% constipated
100% dry mouth
< 20% nausea & vomiting
> 60% mild sedation resolves within 24 – 48 hrs
<2% confusion – need to reduce dose

20. Non-pharmacological methods of pain relief
Massage – muscle tension, headaches, anxious patient
Heat & cold applications – muscle spasm
Distraction – periodic or procedural pain
Transcutaneous Electrical Nerve Stimulation (TENs) – musculosketal problems
Complimentary and alternative therapies
Aromatherapy