Pain assessment and management in geriatric care Flashcards
1
Q
What is pain
A
- An unpleasant sensation and emotional experience
- Subjective defined
- Multi-dimensional; shaped by physical and psychological factors
- Can be influenced by underlying emotional trauma
2
Q
Types of pain: direct vs indirect
A
Direct versus indirect
- Due to the disease or as a consequence of treatment
3
Q
Types of pain: acute vs chronic
A
Acute
- short term and self limiting
- dissipates after injury heals
Persistent or chronic pain
- Present for 3 months or longer than the time of expected healing
- Malignant
- Nonmalignant; also called chronic non-cancer pain (CNCP)
4
Q
Types of pain: nociceptive
A
- Tissue damage
Somatic – localized, sharp, e.g. a broken bone
- Superficial
- deep
Visceral – dull, ache, can be vague
- Colicky (obstruction)
- Capsular (stretching)
Referred Pain – Originates in one location but is felt in another
5
Q
Types of pain: central pain
A
- Caused by damage to the central nervous system
- e.g. stroke
6
Q
Types of pain: neuropathic
A
- Injury to the central, peripheral, or autonomic nervous system
7
Q
Types of pain: sympathetically maintained
A
e.g. complex regional pain syndrome
8
Q
How do we assess pain?
A
- Interview and review of systems
- In-depth pain and medical history
- Pain assessment tools
- Physical exam
- Diagnostic as required to determine the cause of pain
9
Q
Acronyms for pain interview: OPQRSTUV (PQRSTU-AAA)
A
O - onset P - provocation/palliative/preferred analgesic Q - quality R - region/radiation/relieving factors S - severity/significance T - timing U - understanding V - values
10
Q
Acronyms for pain interview: OLD CART
A
O - onset L - location D - duration C - character A - aggravating factors R - relieving factors T - treatment
11
Q
Assessment tools for pain
A
- Brief pain inventory
- Short-form McGill pain questionnaire
- Visual analogue scale
- Numeric rating scale
- Faces pain scale
- Pain diaries or journals
- Vital signs are not a reliable indicator!!!
12
Q
Barriers to pain assessment in the elderly (RNAO)
A
- Less frequent reports of pain
- Choosing to suffer in silence
- Perception of pain by others
- Fear of losing self control
- Fear of addiction
- Inability or difficulty swallowing pills
13
Q
Under-treatment of pain
A
- Common in patients with cognitive impairment
- Clinicians often underestimate pain in this population
Consequences:
- Depression
- Anxiety
- Falls
- Malnutiriton
- Reduced cognition
- Impaired sleep
- Functional disturbances
- Declines in socialization and recreation
- Increased healthcare costs
- Decreased quality of life
14
Q
Non-verbal signs of pain
A
- Grimacing
- Wincing
- Moaning
- Rigidity
- Arching
- Restlessness
- Shaking
- Pushing
- Responsive behaviour
- Mood changes
- Change in routine or activity patterns
15
Q
PAINAD tool
A
- Used for cognitively impaired individuals
- Gives a score out of 10
- Breathing independent of vocalization
- Negative vocalization
- Facial expression
- Body language
- Consolability
16
Q
Types of pain management
A
- Non-pharmacological
- Pharmacological
- Holistic; consider all facets of the individual
17
Q
Non-pharmacological pain management
A
- Mindfulness meditation
- Hot and cold therapies; are these safe? (potential for burn or frostbite)
- Physical therapy and exercise
- Massage
- Reiki
- Acupuncture
- Counselling
- Stress and coping strategies
- Functional assistance with painful activities
- TENS; transcutaneous electric nerve stimulation
18
Q
Pharmacological pain management
A
- Type of pain dictates appropriate management
- Cancer versus noncancer, acute versus chronic
- Consider the Beers Criteria; Medications that are high risk for the elderly
- Take into account over the counter (OTC) medications
- Follow the WHO pain ladder where possible
- Always anticipate and prepare for side effects
- Consider patient safety and falls risk
- How will medication be administered and monitored?
- Start low and go slow (based on goals of care)
- End-of-life pain management is often more aggressive than what is practiced in other clinical areas
19
Q
WHO pain ladder
A
- Include non-pharm for all treatment of pain
- Seek out and manage underlying cause
Level 1
non-opioid
+/- adjuvant
Level 2
mild opioid
+/- non-opioid
+/- adjuvant
Level 3 potent opioid \+/- non-opioid \+/- non-opioid \+/- adjuvant
20
Q
Equianalgesic
A
- Equivalent amounts of medication in a similar drug class (opiates) that also takes into account the route of administration
Morphine 30mg Codiene 200mg Fentanyl Transfermal 12.5mcg/hr Hydrocodone 30mg Methadone 4mg Oxycodone 20mg Oxymorphone 10mg
21
Q
Opioid use in geriatric care
A
- Can be an appropriate option; do not exclude from consideration
- Use smaller doses!
- May be used on a schedule or as needed
- Short acting or long acting
Examples: Morphine 2.5-5mg PO Q4H Hydromorphone 0.5-1mg PO Q4H Oxycodone 1-2.5mg PO Q4H Codeine 8-15mg PO Q4H
22
Q
Opioid use in geriatric care
A
- Can be an appropriate option; do not exclude from consideration
- Use smaller doses!
- May be used on a schedule or as needed
- Short acting or long acting
Examples: Morphine 2.5-5mg PO Q4H Hydromorphone 0.5-1mg PO Q4H Oxycodone 1-2.5mg PO Q4H Codeine 8-15mg PO Q4H
23
Q
Total pain; holistic management (Dame Cicely Saunders concept of total pain)
A
Realms:
- Physical
- Spiritual
- Psychological
- Social
24
Q
Other considerations when doing pain management
A
- Drug coverage
- Medication management
- Side effects
- Fulfilling responsibilities; driving, working, caregiving
- Tolerance
- Stigma
- Preconceived notions and previous experiences
- Medication interaction
- Multiple prescribers
- Prescriber preference
- Rena; and hepatic function
- History of or current opioid or substance use disorder
- Polypharmacy
- Risk of intentional or unintentional diversion; storage and medication sharing
25
Is it an allergy or a side effect?
- Assess if its an allergy or a just a side effect
- Look at the dosing
- Patient and caregiver education is essential
- Dis-spell myths
- Start low, go slow
- Reassess, reassess, reassess!
- Always anticipate side effects and plan accordingly!
26
Side effect management: opioids
- Constipation; Narcotics must come with cathartics!
- Nausea and/or vomiting
- Respiratory depression
- Myoclonus; neurotoxicity
- Pruritis
- Sedation; *NPs must report to MOT if unsafe to drive
- Delirium
- Potential for overdose ; Naloxone
- Follow-up and monitoring!
27
Side effect management: NSAIDs
- Black box warning
- GI symptoms
- Risk of bleeding
- Consider topical to reduce side effects
28
Side effect management: acetaminophen
- Risk of hepatic dysfunction
| - Safe to typically take 4g or less daily, new recommendations say <3g/day
29
Points for OTC medication use
- Medication reconciliation is important
- Ask clients to bring in medications to their
visit, not just the list
- Home visits help greatly with this
- Always ask about over the counter analgesia and any natural/herbal remedies, include topical options as well
- Did you know? – Gabapentin can be prescribed as a cream compound!
- Patients often don’t know that OTC options have an upper limit
30
Other therapeutic options
- Antidepressants (TCA, SNRI, SSRI)
- Anticonvulsants (gabapentin,
carbamazepine, pregabalin)
- Steroids; oral or by injection
- Bisphosphonates for bone pain in cancer
- Surgical options; e.g. vertebroplasty
- Radiotherapy
- Intrathecal
- Patient controlled analgesia
- Continuous opioid infusion
- Cannabis; CBD – not covered by ODB, can be obtained without script
31
Overall messages about pain and it's management
- Pain is an unpleasant multifaceted experience that can have detrimental consequences for elderly patients
- Pain is more than just a sign of physical harm; account for psychological pain as well
- Assessment should be systematic and thorough, and take into account patient deficits
- Pain assessment tools can help to screen for and evaluate pain overtime
- Assessment tools must result in intervention to relief suffering
- Nonpharmacological options should always be incorporated into a plan of care as appropriate
- Pharmacological options include many options that should be initiated slowly, cautiously, and with the patient’s goals of care in mind
- Side effects must be anticipated and treated
- Nurses play a crucial role in pain management and can make a meaningful difference for elderly patients in their advocacy, care, and intervention
32
Pain and Dementia: clinical and experimental pain studies
- Pain not adequately trained in patients with dementia; undertreatment of pain
○ Particularly in non-communicative patients with white matter lesions
○ Demented patients report less prevalent & intense pain
- The impact of dementia on pain processing varies in direction and quality, depending on type of pain, neuropathology & stage of dementia
○ The more severe the cognitive impairment, the more pronounced the differences in pain experience b/w demented & non-demented populations
- Findings from clinical &experimental studies do not suggest that pain is less frequent & intense even if no longer reported
○ Likely that any sign of pain made in presence of cognitive impairment requires even greater attention and a more proactive treatment response
33
Pain & Dementia: pain assessment
- Way that pain sensation is interpreted by the older person impacts expression of pain and how those are interpreted by observer
○ This makes assessment of pain challenging
- Recommended procedures for identification of pain
- Simple verbal descriptor scales, pain thermometers, & facial pain scales
○ Assumption: pain conditions are similarly painful in those that can & cannot self-report
○ Recommended first step: self-report to determine & rate pain severity
- Many persons with dementia are able to self report
- Note: if efforts to establish reliability indicate that report is not reliable, use other methods
○ Health care provider can observe key behaviours -> grimacing/guarding
- Or gather info from surrogate reports (from family & caregivers)
- Note: Association b/w patient reports and surrogate reports strong for presence of pain but not strong for reporting pain severity
34
Pain and dementia: treatment
- Few studies in literature on pain treatment in older persons with dementia
- Adequate pain control in patients with dementia depends on good pain evaluation
○ May express itself as improvement in behaviour and activities of daily life
- Factors to consider
○ Serious adverse effects/side effects
○ Drug-drug interactions
○ synergy of drug treatment with non-pharmacological approaches
- In general: need a broader holistic approach
35
Clinical barriers in pain assessment
● Insufficient training
● Suboptimal communication methods
● Lack of use of appropriate assessment tools
● Relating pain to age
● Misinterpretation and poor detection of pain (usually problem in patients w/ cognitive impairments)
○ Patients w/ dementia are at high risk of under treatment of severe pain
■ Due to diminished ability to describe the characteristics of pain or how it differs throughout the days
36
What can untreated pain in OAs
● Burden in their family, family and society. Leading to:
- Depression
- anxiety
- falls
- malnutrition
- reduced cognition
- impaired sleep
- functional disturbances
- declines in socialization and recreational activities
- increased healthcare costs
- reduced quality of life
37
What does higher postoperative pain lead it
● longer hospital stays
● increased time to ambulation
● chronic functional impairment
38
What is the most important risk factor for developing cognitive impairment?
- Advanced age
- The severity of cognitive impairment has been directly correlated to an increased risk of under treatment of pain
● Cognitively impaired persons are more likely to be given “as needed” pain medications , which are inappropriate for individuals with moderate-to-severe cognitive impairment who are unable to communicate the presence of pain
39
Components of a comprehensive clinical assessment of pain
● Detailed investigation of the patient’s pain
● Medical history
● Physical examination
● Diagnostic testing
● Consider sensory impairments
- dysphasia, aphasia and cognitive impairment
- Limitations on the direct information gathered
● PQRSTAAA
- Use pain assessment instruments
● Non verbal cues for older patients who cant verbalize pain
- guarding, grimacing and restricted movement
- Gather information from family members
● Comprehensive assessment in older adults allows
- gathering of complete information on regions of pain and conditions that may be causing the pain
40
Pathological conditions that can cause pain in OAs
```
● UTI
● Skin infections
● Dental problems
● Incisions
● Fractures
● Positioning
● Bladder distention or kidney stones
● Skin breakdown
● Ulcer or irritation
● Constipation
● Gout
● Peripheral arterial disease
```
41
Common sites of pain in OAs
● MSK
| ● Neurological systems
