Chapter 58 Geriatric Pain Flashcards
Practitioners should be guided by two overarching principles when evaluating
the older adult with pain.
First, the rules of multiplicity rather than Occam’s razor should drive the assessment of the causes and contributors to pain. That is, pain should be
conceptualized as a syndrome potentially “caused by a multiplicity of pathologies in multiple organ systems. The second principle follows in that the symptom with which a patient presents may represent the
weakest link, but not necessarily the treatment target
Low back pain in older adults commonly contributed to by
hip osteoarthritis, fibromyalgia syndrome, and myofascial pain
Myofascial pain may be contributed to by
axial spondylosis, degenerative scoliosis, leg length discrepancy, and anxiety
pain may present subtly as
loss of function, or change in mood or cognition
Treatment may require targeting
biomechanics, insomnia, depression, and/or other
long-standing chronic disease often coexisting with persistent pain to optimize function and quality of life
Older patients with persistent pain conditions should be screened routinely for
concurrent mental health conditions (e.g., depression, anxiety, and dementia). Failure to treat comorbid psychiatric illness will likely result in ineffective analgesia
Other diseases common in older adults that may cause or exacerbate pain include
osteoporosis and osteoarthritis, diabetes, cancer, cardiovascular disease, and dementia.
Alzheimer’s disease (AD) may pose a significant
challenge to the treating practitioner for a number of reasons:
(1) Patients with AD may have difficulty communicating their pain. (2) Anxiety/fear of pain may amplify the experience and expression of pain in patients with AD,
thus the most appropriate treatment may be uncertain.
(3) Patients with AD may perseverate on, but not suffer from, their pain, thus use of pain self-report as the gold standard
for guiding treatment becomes complicated.
(4) As dementia progresses, patients with AD may lose treatment
expectancy that may compromise analgesic efficacy.
Risk factors for the development of disability include
high burden of medical comorbidities, depression, sensory impairments related to vision and hearing, and musculoskeletal disorders such as arthritis. Smoking, level of alcohol use, inactivity, and lack of social support also contribute significantly
morphologic and functional changes in the peripheral and central nervous system that may impact pain processing
decline in the number of myelinated and unmyelinated fibers, an increase in the number of damaged nerve fibers, slowed nerve conduction velocity, loss of serotonergic and noradrenergic neurons in the dorsal horn, and a reduction in serotonergic receptor density in the anterior cingulate and prefrontal cortex, among others
Neuropsychological performance (NP)
declines with age and brain volume loss, senile plaques, and neurofibrillary tangles occur in the absence of AD. Persistent pain itself is associated with deterioration of NP and evidence indicates that pain reduction is associated with improved NP
Because provider–patient communication is an essential component in the treatment of pain
impairments in vision and hearing may alter treatment efficacy and require modified assessments. Vision and hearing change both structurally and functionally with age
Common eye diseases
cataract, glaucoma, macular degeneration, and
diabetic retinopathy) associated with aging may result in moderate to severe vision loss
Presbycusis
loss of hearing with age. Assistive technologies such as hearing aids and a frequency modulation (FM) device for those patients with speech
recognition difficulty, may be helpful when practitioners evaluate these patients, as they afford the opportunity to engage in more meaningful conversation and improved care
Postural control abnormalities leading to
increased risk of falls. pain adds to this risk. assessment of balance should be a routine part of assessing the older adult with pain.
Common changes in the musculoskeletal system include
sarcopenia (i.e., progressive loss of lean body mass associated with muscle cell atrophy and infiltration of fat), degenerative arthritis, and decreased bone density. Pain practitioners need to be acutely aware of the fact that radiographic evidence of degeneration without pain is exceedingly common
Management of changes in the musculoskeletal system
Over half of older adults with radiographic evidence of hip osteoarthritis (OA) are without hip pain. Thus, the history and physical examination should provide strong evidence of disease before imaging is ordered to avoid unnecessary procedures such as injections and surgery that carry the potential for morbidity.
majority of older adults with chronic low back with or without leg pain have a combination of pathologies responsible for their symptoms. Ex
hip OA, fibromyalgia, iliotibial band pain
Vertebral compression
fractures
occur in the absence of acute pain, but
as kyphosis develops, they may contribute to pain in the upper and lower back
vitamin D deficiency
common in older adults and may contribute to muscular pain and falls. Assessment of serum 25-OH vitamin D may be considered as part of pain
assessment in older adults and correction of insufficiency a routine part of treatment.
Pharmacokinetics
Absorption
Remains unchanged
Increase Gastric pH
Decrease Secretory capacity and GI blood flow
Pharmacokinetics
Distribution
Decrease Plasma albumin, Protein affinity, Total body water
Increase alpha 1-acid glycoprotein, Expression and activity of
P-glycoprotein in live
Pharmacokinetics
Metabolism
Decrease Liver volume, Hepatic blood flow, First-pass metabolism, Phase I metabolism, Phase II metabolism in frail
Increase Interindividual variability with age
Pharmacokinetics
Elimination
Measurable and predictable decline
in renal function with age
Decrease Glomerular filtration rate and Renal plasma flow
Body Composition
Increase Body fat
Decrease Lean and total body mass
Central Nervous System
Decrease Blood supply to brain and Baroreceptor activity
Cardiovascular Function
Decrease Resting heart rate, stroke volume, and cardiac output
Renin-Angiotensin-
Aldosterone System
Decrease Plasma renin and Urine aldosterone
Medications that have a high hepatic extraction ratio may undergo
decreased clearance and experience a longer half life in older adults because of diminished liver size and blood flow
Meperidine and Morphine use in older patient
Meperidine (contraindicated in older adults because of its renally cleared active metabolite that can
cause seizures) and morphine are high extraction ratio analgesics whose first-pass effect and clearance is reduced with age.
long half-life nonsteroidal antiinflammatory drugs are hepatically metabolized and their clearance may be reduced in older adults:
celecoxib, diflunisal,
naproxen, oxaprozin, prioxican, salsalate, and sulindac
Analgesics that are affected by aging-associated decline in
renal function include
codeine, duloxetine, gabapentin, meperidine,
pregabalin, propoxyphene, salicylate, tramadol,
and the opioids morphine, oxycodone, hydromorphone,
fentanyl, and methadone
Cockcroft-Gault equation,
shown below, to estimate creatinine clearance
(CrCl) that helps to guide dose adjustment of renally cleared medications
CrCl = ( (140 ¬- age) * (Wt in kg) * (0.85 if female)) /
72 *Cr
Pharmacodynamics refers to
tissue sensitivity and how a drug interacts with its end organ. The body’s response to
medications may be therapeutic or adverse
Opioid sensitivity increases with associated decline
in mu opioid receptor density and increase in
opioid affinity. Thus older adults may respond to opioid doses that are significantly smaller than those in younger individuals.
The purpose of pain assessment is twofold:
(1) to identify contributors to pain that are usually multiple, and (2) to identify outcome measures to follow during the course of treatment, that is, each patient’s individual “pain signature
Pain assessment in older adults
Pain assessment should be an ongoing process to measure change in pain over time as this will affect any necessary modifications in the treatment course. Assessment of pain alone is not sufficient; providers should inquire about changes in appetite, sleep, and/or mood, loss of mobility, and diminished activity level.
indicative of an acute
pain event
Abnormalities in traditional vital signs such as abrupt changes in respiratory rate or heart rate
For cognitively intact older adults, there are many pain rating tools from which to choose
Numeric rating scales (NRS) and verbal descriptor scales (VDS)
Medication that enhance fall risk
opioids, tricyclic antidepressants, gabapentin, and pregabalin
How to manage patient who are taking Medication that enhance fall risk
it is prudent to optimize mobility (e.g., by referring the patient to a physiatrist or physical therapist for instruction in using the appropriate assistive device and gait/balance training) prior to prescribing medications that may further increase this risk
Assessment of cognitive function is critical. Mini-Cognitive Assessment Instrument
(Mini-Cog)
Step 1 Ask the patient to repeat three unrelated words, such as “ball,” “dog,” and “television.”
Step 2 Ask the patient to draw a simple clock set to 10 min after 11 o’clock (11:10). A correct response is a drawing of a circle with all of the
numbers placed in approximately the correct positions, with the hands point to the 11 and 2.
Step 3 Ask the patient to recall the three words from Step 1. One point is given for each item that is recalled correctly.
On Mini-Cognitive Assessment Instrument
(Mini-Cog) If there is evidence of dementia
in addition to treating the patient’s pain, the provider should refer the
patient for neuropsychological testing or to a specialist who can address this important problem such as a geriatrician or neurologist.
Cognitively impaired older adults are at increased risk of pain undertreatment because of
the belief among many health-care workers that their pain ratings are unreliable. In fact, patients with mild to moderate cognitive impairment can reliably report pain using verbal descriptor scales. In patients with more advanced dementia who have difficulty using self-report instruments, caregivers rely on behavioral cues to determine the presence and severity of pain
one of the most sensitive and reliable behavioral indicators of pain in patients with dementia or poor verbal communication
Facial grimacing
other indicators of pain in patients with dementia or poor verbal communication
guarding, bracing, rubbing and sighing
Common Pain Behaviors in Cognitively Impaired
Elderly Persons
Facial expressions
- Frown; sad, frightened face, Grimace, wrinkled forehead, tightened eyes
Verbalizations/ vocalizations
- Sighing, moaning, groaning, grunting
Calling out, asking for help
Noisy breathing; verbally abusive
Body movements
Rigid, tense body posture; guarding, fidgeting
Pacing, rocking; restricted movement
Gait or mobility changes
Common Pain Behaviors in Cognitively Impaired
Elderly Persons
Changes in interpersonal interactions
Changes in activity patterns or routines
Mental status changes
Changes in interpersonal interactions
Aggressive, combative, resisting care
Decreased social interactions, withdrawn
Socially inappropriate, disruptive
Changes in activity patterns or routines
Refuses food, appetite change
Sleep, rest pattern changes
Sudden cessation of common routines
Mental status changes
Crying, tears
Increased confusion
Irritability or distress
For all patients presenting with pain ruling out serious
conditions (i.e., red flag symptoms) that require immediate attention is paramount
fever, sudden unexplained weight loss, acute onset of severe pain, neural
compression, loss of bowel or bladder function, jaw claudication, new headaches, bone pain in a patient with a history of malignancy or that awakens the patient from
sleep, and sudden pain in an extremity that is associated with pallor, pulselessness, and paresthesias
After determining the older adult’s pain signature, multifaceted
treatment should be designed
an antidepressant, cognitive behavioral
therapy, and physical therapy may be the most appropriate components of the treatment regimen.
For the older adult with dementia and excessive fear of pain because of social isolation
placement in an assisted living facility may most
effectively improve quality of life. If the practitioner determines that pain itself requires treatment, a stepped care approach should be utilized
EXERCISE
participation in regular
exercise improves psychological well-being, reduces pain, and increases functional capacity in older adults with persistent pain. A combination of endurance, resistance, balance, and flexibility exercises may yield important health benefits
exercise prescribed for treating osteoarthritic pain
individualized programs should be created to meet the patient’s unique needs. It has been demonstrated in older adults with knee OA that both low-intensity and high-intensity stationary bicycling for 25 min three times a week promote decreased pain and improved function
Goal of Physical therapy
Reducing pain, optimizing fitness, and promoting functional dependence should be the goals of treatment. It is critical that the patients view themselves as taking an active role in treatment rather than as a passive recipient.
key to successful pain rehabilitation in Physical therapy
being committed to maintaining a home exercise program, learning how to pace activities and self-manage pain flares
Assistive devices for older adults with pain serve the following purposes:
(1) pain relief, (2) enhancement of mobility
and stability, and (3) modification of painful activities.
Assistive devices
canes and walkers exert their analgesic effect by reducing load (e.g., canes for lower extremity arthritis, walkers for low back pain). Canes are generally used for those patients with mild to moderate mobility impairment; walkers tend to be prescribed for those patients with “generalized weakness, extreme inability for lower-limb weight bearing, debilitating conditions or poor balance control
Upper extremity assistive devices can help
to modify painful activities
Reachers, jar openers, button aids, and zipper pulls are often prescribed for patients with osteoarthritis
Topical therapies for pain are an attractive option for older adults given
their mild side effect profile, less systemic
absorption compared to oral medications, and ease of application
Topical therapies for pain
capsaicin cream and a topical lidocaine patch 5%
for joint and low back pain, postherpetic neuralgia, and other neuropathic symptoms; diclofenac gel for osteoarthritis; and a topical diclofenac epolamine patch for acute pain associated with minor strains and sprains
side effects of Topical therapies
local irritation or rash and a burning sensation,
the latter occurring most commonly with capsaicin
cream
intra-articular corticosteroid and/or hyaluronic acid injections may be beneficial
patients with pauciarticular joint pain associated with inflammatory and noninflammatory arthritides
Patient with neuropathic pain (e.g., postherpetic neuralgia) treated with
nerve blocks may aid in reducing pain but their benefits are typically shortlived, lasting only a few days or weeks
Trigger-point injections with local anesthetic have proven effective in alleviating
myofascial pain
Epidural steroid injections (ESI) have been used to treat pain conditions associated with
lumbar spinal stenosis involving the central and/or lateral canal. Patients with herniated discs, spondylolisthesis, scoliosis, and degenerative disc disease may see benefits following ESI
Two of the most commonly used medications in the older adult with mild to moderate pain are
acetaminophen (APAP) and nonsteroidal anti-inflammatory drugs (NSAIDs)
first-line treatment in patients with osteoarthritis and other types of musculoskeletal pain
Acetaminophen
a risk of unintentional acetaminophen overdose
> 4000 mg/day
treatment of patients with inflammatory pain (e.g., gout, pseudogout
NSAIDs may be indicated for short-term use although intra-articular corticosteroid injections may be used when one or two joints are involved.
Chronic use of NSAIDs may be fraught with a number of risks including
congestive heart failure,
exacerbation of hypertension, renal insufficiency, and
gastrointestinal bleeding.
risk factors for GI bleeding
age 75 and older, peptic ulcer disease, GI bleed, and use of glucocorticosteroids.
Risk factors associated with renal insufficiency include
age 75 and older, diabetes mellitus,
hypertension, and use of angiotension-converting enzyme
inhibitor or diuretics.
Avoiding NSAIDs in patients with congestive heart failure due to
the possibility of exacerbation and in patients with renal dysfunction who have serum Cr concentration over 150 mmol or glomerular filtration rate of less than 50 ml/hr.
Corticosteroids are commonly prescribed in older adults with
inflammatory disorders (e.g., giant cell arteritis, polymyalgia rheumatica, rheumatoid arthritis).
Corticosteroids are indicated for pain associated with malignancy because they
reduce tumor-associated edema that can cause spinal cord compression, brain herniation, and compressive neuropathy
Corticosteroids common side effects include
glucose intolerance,
hypertension, psychosis, and osteoporosis,
Consider using opioids for the treatment of
moderate to severe pain (both nociceptive and neuropathic), earlier in the course of disease than previously recommended to avoid the multiple potential toxicities associated with NSAIDs
A general rule is that long-acting opioids should
never be initiated in the older adult who is opioid-naïve. A short-acting preparation should always be initiated and once the total daily dose requirement is determined, the patient can then be switched to a long-acting preparation, supplemented with an as-needed short-acting drug for breakthrough pain
adverse effects of opioids
constipation, falls and fractures, urinary retention (e.g., in the patient with prostatic enlargement) and delirium
Buprenorphine has been shown to be both effective
and well-tolerated in patients with
cancer and nonmalignant
persistent pain such as neuropathic pain
Fentanyl patches vs. transdermal buprenorphine
Fentanyl patches have been used increasingly to treat persistent pain in the older adult; while it appears that transdermal buprenorphine may have a better side effect profile, therapeutic index, and ease of titration, inadequate data exist to support recommending its use in older adults
Contraindications of using
buprenorphine
Patients with opioid dependence, myasthenia gravis, respiratory depression, and delirium tremens
methadone may be very useful
Given its low cost, long-acting properties, and efficacy when used in small doses in frail older adults
Risk of metahdone
its very long and variable half-life. In addition to having all of the same potential adverse effects as the other opioids, patients on methadone may suffer from QTc prolongation. patients being started on methadone
should receive an EKG at baseline, 30 days after initiating methadone, and then annually
and sleep-disordered breathing.
first-line treatment for Neuropathic Pain
antidepressants with both norepinephrine and serotonin reuptake inhibition properties (SNRIs), calcium channel a2-d ligands, and topical lidocaine
second line treatment for Neuropathic Pain
opioids and tramadol
Most commonly studied SNRI antidepressants for treating neuropathic pain
duloxetine and venlafaxine. Both have evidence of efficacy for painful diabetic neuropathy
Venlafaxine
used in cases of painful polyneuropathies,
although caution should be exercised in patients
with cardiovascular disease
Treatment of trigeminal neuralgia
is different from that of other neuropathic pain states
For this disorder, carbamazepine or oxcarbazepine are recommended as first line
Treatment of postherpetic
neuralgia
gabapentin, pregabalin, and tricyclic antidepressants
Tertiary amines should be avoided
in older adults because of
Tertiary amines (amitriptyline, imipramine, trimipramine, doxepin, clomipramine) should be avoided in older adults because of their anticholinergic side effects (sedation, delirium, urinary retention, constipation, glaucoma exacerbation, and dizziness).
Secondary amines have been shown to have more tolerable side effect profiles
nortriptyline, desipramine, protriptyline, amoxapine
a baseline EKG should be obtained prior to starting
a tricyclic antidepressant and monitored periodically with dose titration
Because of their potential for QT prolongation
For Neuropathic pain opioids
have proved efficacious in patients with
postherpetic neuralgia
and painful peripheral neuropathy
Tramadol
weak mu-opioid receptor agonist that also inhibits the reuptake of norepinephrine and serotonin, may fare better in older adults at reducing neuropathic pain.
Benzodiazepines have been used to treat
Muscular spasms, neuropathic pain, and anxiety related to pain crises.
Benzodiazepines should generally be avoided in older adults for the treatment of neuropathic pain because of
the risk of symptomatic rebound, dizziness, falls, and confusion
Fibromyalgia
symptoms occurring for longer than 3 months varying
from morning stiffness, fatigue, and nonrestorative sleep to headaches, myofascial pain, and pelvic pain
Treatments for fibromyalgia
low-dose tricyclic antidepressants, cyclobenzaprine, aerobic exercise, cognitive behavioral therapy, or a combination of these treatment methods
Food and Drug Administration (FDA) approved for the treatments of fibromyalgia
Duloxetine, pregabalin, and
milnacipra
Outcomes used to monitor treatment efficacy in patients with fibromyalgia
include
pain intensity and physical and emotional functioning
complementary and alternative medicine (CAM) approaches to persistent pain
Meditation, vitamin and mineral supplements, herbs, and chiropractic medicine are commonly used in older adults with back pain, arthritis, and
mental illness.
eight common behavioral modalities in treating
persistent pain in older adults
biofeedback, progressive muscle relaxation, meditation, guided imagery, hypnosis, tai chi, qi gong, and yoga. The benefits of complementary therapies such as these improve not only the self-reported pain but also pain related comorbidities such as depression, anxiety, and disability.
In the practice of interdisciplinary pain medicine
it is important to consider geriatricians, geriatric psychiatrists, physiatrists, rheumatologists,
neurologists, and endocrinologists as important potential collaborators in the care of frail older adults with complex conditions.
Anticonvulsant
Carbamazepine (Tegretol)
100 mg daily
SE: Monitor hepatic transaminases (aspartate transaminase, alanine
transaminase), complete blood count, creatinine, blood urea nitrogen, electrolytes, serum carbamazepine levels.
Multiple drug-drug interactions
Anticonvulsant
Gabapentin (Neurontin)
100 mg at bedtime
Monitor sedation, ataxia, edema
Anticonvulsant
Pregabalin (Lyrica)
50 mg at bedtime Monitor sedation, ataxia, edema
Anticonvulsant
Lamotrigine (Lamictal)
25 mg at bedtime Monitor sedation, ataxia, cognition.
Associated with rare cases of Stevens-Johnson syndrome
Antiarrhythmic
Mexiletine (Mexitil)
150 mg twice daily Monitor electrocardiogram at baseline and after dose stabilization.
Avoid use in patients with conduction block, bradyarrhythmia
Corticosteroids (prednisone, methylprednisolone, e.g.,
Deltasone, Medrol dose pak Liquid Pred, Orasone)
5 mg prednisone daily
and taper as soon as feasible.
Use lowest possible dose to prevent steroid effects. Anticipate fluid retention and glycemic effects in short-term use and cardiovascular and bone demineralization with long-term use.
Lidocaine (topical)
Lidoderm 5%
1–3 patches for 12 hr per day
Monitor for rash or skin irritation
Muscle Relaxants
Baclofen (Lioresal)
5 mg up to 3 times daily Monitor muscle weakness, urinary function, cognitive effects,
sedation.
Avoid abrupt discontinuation because of central nervous system
irritability.
Older persons rarely tolerate doses greater than 30 to 40 mg per day
Muscle Relaxants
Tizanidine (Zanafex)
2 mg up to 3 times daily Monitor muscle weakness, urinary function, cognitive effects, sedation, orthostasis. Potential for many drug–drug interactions.
Muscle Relaxants
Clonazepam (Klonopin)
0.25–0.5 mg at bedtime Monitor sedation, memory, complete blood count
Cannabinoid
Nabilone (Cesamet)
1 mg 1 or 2 times daily Monitor ataxia, cognitive effects, sedation.
High incidence of dizziness or drowsiness.
Cardiovascular effects with tetrahydrocannabinol or cannabidiol.
Older persons may be prone to postural hypotension.
Nabilone is approved for nausea and vomiting but may help with some pain syndromes.
Cannabinoid
Dronabinol (Marinol)
2.5 mg 1 or 2 times daily Dizziness, somnolence, cognitive impairment, dysphoria
Tramadol (Ultram/Ultram ER)
12.5–25 mg every 4–6 hr Mixed opioid and norepinephrine or serotonin reuptake inhibitor mechanisms of action. Monitor for opioid side effects, including drowsiness, constipation,
and nausea. Risk of seizures if used in high doses or in predisposed patients. May precipitate serotonin syndrome if used with selective serotonin reuptake inhibitors.
Tapentadol (Nucynta)
50 mg every 4–6 hr by mouth
(equivalent to oxycodone 10 mg every 4–6 hr by mouth) Clinical trials of tapentadol suggest lower incidence of gastrointestinal adverse events than comparator opioids.
Sustained release (Avinza,
Kadian, MSContin,
Oramorph SR)
15 mg every 8–24 hr
Usually started after initial dose determined by effects of immediate-release opioid or as an alternative in a different long-acting opioid due to indications for opioid rotation. Toxic metabolites of morphine may limit usefulness in patients
with renal insufficiency or when high-dose therapy is required. Continuous-release formulations may require more-frequent dosing if end-of-dose failure occurs regularly.
Significant interactions with food and alcohol toxicity
Hydromorphone (Dilaudid,
Hydrostat)
Methadone (Dolophine)
1–2 mg every 3–4 hr For breakthrough pain or for around-the-clock dosing.
Highly variable half-life and nonlinear dose equivalencies when
switching from other opioids. Not recommended as first-line agent.
Tricyclic Antidepressant
Desipramine (Norpramine),
Nortryptyline (Aventyl,
Pamelor), Amitriptyline (Elavil)
10 mg at bedtime Significant risk of adverse effects in older patients. Anticholinergic effects (visual, urinary, gastrointestinal); cardiovascular effects (orthostasis, atrioventricular blockade). Older persons rarely tolerate doses greater than 75 to 100 mg per day.
Duloxetine (Cymbalta
30 mg daily Monitor blood pressure, dizziness, cognitive effects, and memory. Has multiple drug-drug interactions.
Venlafaxine (Effexor)
37.5 mg daily Venlafaxine associated with dose-related increases in blood pressure
and heart rate.
