1. Special situations Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

2. Objectives Discuss alternative options for assessing pain in patients that may have problems communicating – PAINAD scale Review how to manage pain in elderly patients Determine how to assess and treat pain for patients with sickle cell disease 2

3. Pain in the elderly Chronic pain is common among the elderly Dementia and problems communicating often make assessment of pain challenging Compliance with medications can also be a challenge – Impaired vision – Limited mobility – Memory problems Beating Pain, 2 nd Ed. APCA (2012)3

4. Pain assessment 4 Observational tools may be used to assess pain in patients who have trouble communicating their pain or are cognitively impaired Communication boards could also be used for this subset of patients Health care providers should assess the pain of such patients as accurately as possible Beating Pain, 2 nd Ed. APCA (2012)

5. Options for cognitive impairment or dementia Many patients who appear cognitively impaired may still be able to provide useful information concerning pain Interview caregivers: patterns of particular behaviors may have developed that indicate pain (e.g. placing a hand on the forehead for a headache) Review medical record for known pain-inducing pathology Observe facial expression, body posture, vocalizations, appetite, interactivity Utilize Pain Assessment in Advanced Dementia (PAINAD) Beating Pain, 2 nd Ed. APCA (2012); Guide to Pain Management in Low-Resource Settings: International Association for the Study of Pain, 2010 5

6. Pain Assessment in Advanced Dementia (PAINAD) Scale Beating Pain, 2 nd Ed. APCA (2012), adapted from Warden et al, 20036 Items012Score Breathing independent of vocalization NormalOccasional labored breathing. Short period of hyperventilation Noisy labored breathing. Long periods of hyperventilation. Cheyne- Stokes respiration Negative vocalization NoneOccasional moan or groan. Low level speech with a negative or disapproving quality Repeated troubled calling out. Loud moaning or groaning. Crying Facial expressionSmiling or inexpressive Sad. Frightened. FrownFacial grimacing (an ugly or disapproving facial expression) Body languageRelaxedTense. Distressed pacing. Fidgeting Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out ConsolabilityNo need to console Distracted or reassured by voice or touch Unable to console, distract, or reassure

7. Managing pain in the elderly Include family in the process Provide written information and in clear writing, enlarged as needed Anticipate pain and treat accordingly Titrate doses individually – Start low and titrate upward slowly Use care with adjuvant co-analgesia to avoid drug interactions and unwanted side effects Beating Pain, 2 nd Ed. APCA (2012)7

8. Pain in sickle cell disease Most patients with sickle cell disease experience pain on a daily basis Crisis pain: the most severe pain experienced by sickle cell patients – Patient feels that “all my bones are breaking” – Reported to occur about 13% of all days – Characterized by abrupt onset, episodic and unpredictable, and with severe pain – May last several hours to a week or more Oxford Textbook of Palliative Medicine, (2010); Guide to Pain Management in Low-Resource Settings: International Association for the Study of Pain, 2010 8

9. Pain in sickle cell disease Patients may need chronic pain management and rescue medication for acute pain crises Those with three or more pain crises per year are candidates for hydroxyurea therapy, which significantly decreases their occurrence Oxford Textbook of Palliative Medicine, (2010); Guide to Pain Management in Low-Resource Settings: International Association for the Study of Pain, 2010 9

10. Sickle cell pain treatment Assess pain frequently and treat as an emergency Maintain adequate hydration Investigate other possible causes of pain, including complications of the diseases (acute chest syndrome, priapism, splenic sequestration, cholelithiasis) Do not withhold opioids when pain is severe: treat according to the WHO analgesic ladder Some patients may require chronic use of opioids on a daily basis to manage pain and improve function Oxford Textbook of Palliative Medicine, (2010); Guide to Pain Management in Low-Resource Settings: International Association for the Study of Pain, 2010 10

11. Alternative routes of administration Use the oral route whenever possible Exceptions may be: – Need for rapid pain relief in pain emergencies: intravenous or subcutaneous route – Oral route is not accessible: rectal, buccal, intravenous, subcutaneous, nasogastric, or transdermal – Check to see if dose conversion is needed to move from oral to alternative route Avoid intramuscular injection: causes more pain Beating Pain, 2 nd Ed. APCA (2012).11

12. Take home messages Though chronic pain is common in the elderly, pain can be assessed and managed, even for those suffering from dementia Sickle cell pain should be assessed frequently Sickle cell crisis should be treated as an emergency 12

13. References African Palliative Care Association. Beating Pain: a pocketguide for pain management in Africa, 2nd Ed. [Internet]. 2012. Available from: http://www.africanpalliativecare.org/images/stories/pdf/beating_pain.pdf African Palliative Care Association. Using opioids to manage pain: a pocket guide for health professionals in Africa [Internet]. 2010. Available from: http://www.africanpalliativecare.org/images/stories/pdf/using_opiods.pdf Amery J, editor. Children’s Palliative Care in Africa [Internet]. 2009. Available from: http://www.icpcn.org/wp-content/uploads/2013/08/Childrens-Palliative-Care-in- Africa-Full-Text.pdf Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings [Internet]. 2010. Available from: http://www.iasp- pain.org/files/Content/ContentFolders/Publications2/FreeBooks/Guide_to_Pain_ Management_in_Low-Resource_Settings.pdf The Palliative Care Association of Uganda and the Uganda Ministry of Health. Introductory Palliative Care Course for Healthcare Professionals. 2013. 13