19 Elderly Pain Management Mak

Question 1

What does PQRST stand for when assessing a patients pain?

Answer 1

P: Provoke or Palliate. Q: Quality. R: Radiation. S: Severity. T: Time

Question 2

What two non-opioid agents are commonly used for Mild-to-Moderate pain?

Answer 2

APAP (max 2650mg) and Tramadol (watch for CrCl < 30, ER not recommended)

Question 3

What is the AHA recommendation for mild-moderate agents in order of preference?

Answer 3

APAP > ASA > Tramdol > Short term opioids > NSAIDs

Question 4

What should always accompany NSAID use in the elderly?

Answer 4

A PPI or Misoprostol for GI protection

Question 5

When can adjuvant therapy be offered?

Answer 5

Can be offered at all stages of the analgesic ladder

Question 6

What are some adjuvant classes?

Answer 6

TCAs, Anti-Convulsants, SNRIs

Question 7

Which TCAs are the safest to use?

Answer 7

Desipramine and Nortriptyline. Amitriptyline should be avoided d/t its high ADRs

Question 8

What are the Anti-Convulsant choices to use as adjuvant therapy?

Answer 8

Gabapentin, Pregabalin

Question 9

Why is Gabapentin not used?

Answer 9

Patients can’t tolerate the ADRs (sedation and constipation) when getting the dose up to the therapeutic level for pain management

Question 10

What is Pregabalin used for?

Answer 10

Fibromyalgia and Diabetic Peripheral Neuropathy (DPN). Schedule V that needs to be reduced if CrCl < 60

Question 11

What are two common SNRIs that can be used?

Answer 11

Duloxetine, Milnacipran (CI: w/ MAOIs and NAG)

Question 12

What are the SNRIs used for?

Answer 12

Fibromyalgia and Diabetic Peripheral Neuropathy (DPN)

Question 13

When are NMDA Antagonists used?

Answer 13

Antagonists considered for opioid resistance and neuropathic pain. Eg. Methadone, Ketamine, Dextromethorphan

Question 14

When should topical Lidocaine be considered?

Answer 14

In all patients who have localized neuropathic pain

Question 15

Which long acting opioid options need to be adjusted with renal function?

Answer 15

Oxymorphone and Morphine need to be adjusted when CrCl < 50

Question 16

What dosing Hydromorphone in geriatrics, what needs to be done?

Answer 16

Dosed reduced by 50%

Question 17

What is an option for end-of-dose pain that is predictable?

Answer 17

SA opioid given 30-45 minutes before event

Question 18

What is an option for end-of-dose pain that is unpredictable?

Answer 18

Fast acting oral Fentanyl

Question 19

What are the characteristics of true breakthrough pain?

Answer 19

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

Question 20

What are some common DDIs with opioids?

Answer 20

They enhance muscle relaxants and degree of respiratory depression. Reduce efficacy of diuretics by releasing ADH

Question 21

Why is Methadone difficult to use in the elderly?

Answer 21

It is a CYP1A2, 3A4, and 2C19 substrate, causing it to interact with many other medications

Question 22

What is Addiction?

Answer 22

Impaired control over drug use; Psychological dependence; compulsive use despite harm; crave

Question 23

What is Physical Dependence?

Answer 23

Withdrawal symptoms from abrupt cessation, rapid dose reduction of drug, a/o administration of antagonist

Question 24

What are some of the main medications with addiction concern?

Answer 24

Pentazocine, Meperidine, Fentanyl, Tramadol

Question 25

What does the Opioid Risk Tool (ORT) look at?

Answer 25

Family and personal history of substance abuse. Age and psychological disease. Hisotry of preadolescent sexual abuse

Question 26

What does the SOAPP-R look at?

Answer 26

SOAP: Screening to predict Opioid misuse Among chronic Pain Patients. Looks at mood swings, history of pain medications. A score of 7+ is a sign of opioid abuse