19 Elderly Pain Management Mak Flashcards
What does PQRST stand for when assessing a patients pain?
P: Provoke or Palliate. Q: Quality. R: Radiation. S: Severity. T: Time
What two non-opioid agents are commonly used for Mild-to-Moderate pain?
APAP (max 2650mg) and Tramadol (watch for CrCl < 30, ER not recommended)
What is the AHA recommendation for mild-moderate agents in order of preference?
APAP > ASA > Tramdol > Short term opioids > NSAIDs
What should always accompany NSAID use in the elderly?
A PPI or Misoprostol for GI protection
When can adjuvant therapy be offered?
Can be offered at all stages of the analgesic ladder
What are some adjuvant classes?
TCAs, Anti-Convulsants, SNRIs
Which TCAs are the safest to use?
Desipramine and Nortriptyline. Amitriptyline should be avoided d/t its high ADRs
What are the Anti-Convulsant choices to use as adjuvant therapy?
Gabapentin, Pregabalin
Why is Gabapentin not used?
Patients can’t tolerate the ADRs (sedation and constipation) when getting the dose up to the therapeutic level for pain management
What is Pregabalin used for?
Fibromyalgia and Diabetic Peripheral Neuropathy (DPN). Schedule V that needs to be reduced if CrCl < 60
What are two common SNRIs that can be used?
Duloxetine, Milnacipran (CI: w/ MAOIs and NAG)
What are the SNRIs used for?
Fibromyalgia and Diabetic Peripheral Neuropathy (DPN)
When are NMDA Antagonists used?
Antagonists considered for opioid resistance and neuropathic pain. Eg. Methadone, Ketamine, Dextromethorphan
When should topical Lidocaine be considered?
In all patients who have localized neuropathic pain
Which long acting opioid options need to be adjusted with renal function?
Oxymorphone and Morphine need to be adjusted when CrCl < 50
What dosing Hydromorphone in geriatrics, what needs to be done?
Dosed reduced by 50%
What is an option for end-of-dose pain that is predictable?
SA opioid given 30-45 minutes before event
What is an option for end-of-dose pain that is unpredictable?
Fast acting oral Fentanyl
What are the characteristics of true breakthrough pain?
Moderate to severe intensity. Rapid onset (< 3 minutes in half the patients). Relatively short duration: < 30 minutes. Frequency: 1-4 episodes per day. Associated with more severe pain conditions
What are some common DDIs with opioids?
They enhance muscle relaxants and degree of respiratory depression. Reduce efficacy of diuretics by releasing ADH
Why is Methadone difficult to use in the elderly?
It is a CYP1A2, 3A4, and 2C19 substrate, causing it to interact with many other medications
What is Addiction?
Impaired control over drug use; Psychological dependence; compulsive use despite harm; crave
What is Physical Dependence?
Withdrawal symptoms from abrupt cessation, rapid dose reduction of drug, a/o administration of antagonist
What are some of the main medications with addiction concern?
Pentazocine, Meperidine, Fentanyl, Tramadol
