|
 |  |  |  |  |  |  |  |
Recognize the Need for Pain Management in Older Patients
By: SHARON WORCESTER, Elsevier Global Medical News |
The burden of pain among older patients is great, and its consequences can be "serious and significant," according to Perry G. Fine, MD,professor of anesthesiology at the University of Utah, Salt Lake City. The prevalence of pain ranges from 25% to 50% in the older population, and it increases with age. In fact, among older nursing home residents, the prevalence is estimated at 45%-80%.
The sources of pain in these patients are many and varied, and the consequences can include mood disorders, sleep disturbances, decreased socialization, increased health care utilization and costs, limitations in activities of daily living, comorbidities, and polypharmacy, all of which can lead to diminished function and quality of life, said Dr. Fine, who earlier this year at the Congress of Clinical Rheumatology reviewed pain and its treatments in the elderly.
Studies have repeatedly shown that pain in older adults is frequently undertreated, Dr. Fine said. This may be the result of one or more of the numerous, identified barriers to the management of pain in older patients, including language and cultural barriers, fear of judgment, fear of addiction, cognitive impairment, sensory impairment, and adverse effects such as fear of falling, constipation, sedation, and drug-drug interactions. Barriers for clinicians can include the lack of objective measures of pain and pain response, concerns regarding addiction and/or drug seeking, fear of causing harm from medication-related adverse effects, lack of time in the office setting, and lack of pain management training, according to findings from two studies on the topic (Clin. J. Pain. 2007;23[suppl. 1]:S1-43; J. Adv. Nurs. 2009;65:2-10).
Following a list of 10 "universal precautions" in pain management can help with overcoming some of these barriers, Dr. Fine said (Pain. Med. 2005;6:107-12). These include the following:
Making a diagnosis with appropriate differential diagnoses.
Performing psychological assessment, including evaluation for risk of addictive disorders.
Obtaining informed consent.
Developing treatment agreements.
Performing pain and function assessments.
Using pain medication and particularly opioids on a trial basis.
Reassessing pain, function, and behavior.
Regularly reassessing the "Four As" (analgesia, activities of daily living, adverse events, and aberrant drug-taking behaviors).
Periodically reviewing diagnosis and comorbidities.
Documenting thoroughly.
Also, keep in mind that aging results in a number of physiological changes that will influence both pharmacokinetics and pharmacodynamics, including changes in body composition; decreases in gastrointestinal motility, hepatic metabolism, renal clearance, and protein binding; and increased central nervous system sensitivity to noxious stimuli and medication effects, Dr. Fine said (Neurobiol. Aging 2010;31:494-503; Clin. J. Pain. 2004;20:220-6).
Dr. Fine listed the following general principles to follow when it comes to pharmacotherapy in light of these changes and the needs of older adults:
Titrate according to individual circumstances.
Anticipate and monitor for adverse effects, prevent them when possible, and treat them when necessary.
Practice synergy by combining lower doses of drugs that mediate analgesia via different mechanisms.
Know and understand the distinctions among tolerance, dependence, addiction, and pseudoaddiction.
In those with cognitive impairment, in whom pain assessment can be particularly challenging, consider alternatives to standard numeric rating scales for pain assessment. Patients who have difficulty reporting pain based on these types of scales may do better with the Iowa Pain Thermometer, which allows a patient to rate pain using increments on a picture of a thermometer (Pain Med. 2007;8:585-600), or with the Brief Pain Inventory. Reports from caregivers may also be useful, Dr. Fine said.
Dr. Fine reported having no conflicts of interest that were relevant to his presentation.
An AMDA workgroup is currently revising the clinical practice guideline "Pain Management in the Long Term Care Setting."
Sharon Worcester is a freelance writer based in Sterrett, Ala.
LTC Perspective
"Although a helpful reminder about judicious use of long-term opioid therapy, the universal precautions concept does not specifically outline a remedy to the undertreatment of pain in the elderly," said William Smucker, MD, CMD, medical director at Altenheim Nursing Home in Strongsville, Ohio.
"For that to happen, each facility must commit to a facilitywide process to improve pain assessment and treatment using quality improvement methods that involve all members of the interdisciplinary team. Assuming a process of shared decision making regarding treatment a mainstay of AMDA [clinical practice guidelines] neither a signed informed consent nor a treatment agreement for opioid use in long-term care seems to offer an important benefit, and neither is particularly practical. Hospitals do not use such tools, and like the hospital, the long-term care setting has very tight control over administration of controlled substances. In such controlled environments, the potential for willful misuse or diversion of opioids by a patient is less than in a home environment. Individual LTC facilities with younger patients or patients with a history of drug misuse or addiction may find such agreements useful.
"The greatest barriers to treatment of pain in the long-term care setting are; 1) fears and biases about opioids among patients, families, pharmacists, nurses, and physicians; 2) inadequate knowledge about appropriate use of opioids and judicious dosing and titration of opioids; 3) a misconception that since pain is so prevalent in the elderly, it is normal; 4) an overestimation of adverse events associated with short- and long-term opioid therapy and an underestimation of the beneficial effects of appropriate use of opioids, such as relief of suffering, improvement in ability to participate in rehabilitation, and improvement in ADLs, sleep, and mood; 5) perception that the liability risk of undertreatment of pain is less than the liability risk of prescribing opioids; and 6) burdensome regulations that slow the process of prescribing and dispensing of controlled substances in long-term care."
Join AMDA Now
AMDA is the only national organization guided exclusively by the needs and issues affecting long term care medicine. For a full array of benefits and services exclusively for LTC professionals, click here to join today!