Pain in Older Patients

PAIN IN THE
OLDER
PERSON
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
A national telephone-based survey in US:

Older adults reported similar prevalence rates
of current pain as their younger counterparts
Persistent pain:
Over age 60 people are twice as likely as
younger counterparts
By 80, adults are three times more likely to
have than those under 18 years of age
Aging alters functions,

Degeneration of peripheral neuronal
structure
Slows
transduction &
transmission

Once pain is established;

the lower density of descending
inhibitory circuits and an impaired
ability to recover from hyperalgesic
or allodynic states is attributed to
aging

The decline in function of the

endogenous
antinociceptive mechanisms as well as
the capacity to reverse spinal and
supraspinal sensitization places older
patients
at greater risk for developing
persistent pain following an illness,
surgery, or trauma
Prevalence of pain may be as high as

25% to 50% in community-dwelling
older persons and 45% to 80% in
nursing home residents
Many physicians and patients
incorrectly
view pain as an expected part of aging
In presence of multiple comorbid

conditions,
and their medical care , Little attention
may be paid to the alleviation of
associated symptoms such as pain
Pain is unrecognized and
undertreated
Significant portion of those over age 65

do not receive analgesics:
over a quarter of older adults with cancer
pain,
40% of elders with hip fracture in the
Emergency
Department
40% to 80% of elders living with pain in
the community
Uncontrolled pain
Functional status
Psychosocial well-being and quality of life
Impaired mobility
Decreased socialization
Depression
Sleep disturbances
Increased health use and costs,
Gait impairment , falls,
Polypharmacy
Cognitive dysfunction
Malnutrition
It is time to
Replace unrealistic fears and
mistaken beliefs
Greatest opportunity for improvement
is:
Halting the practices of using
placebos
Halting recommending treatments
such as acetaminophen alone for
severe pain
Change in Pain Threshold and

Tolerance
Evidence supports an age-related
increase in thresholds to thermal,
pressure,
and electrical stimulation
In advancing age, pain threshold
increases while tolerance of pain
decreases
Clinical Presentation of
Acute Pain
In older
adults pain may be absent or atypical
in acute infectious, metabolic, or
traumatic disorders
(Eg: Up to 30% of older adults with MI
report an absence of acute
symptoms)

ASSESSMEN
T
ASSESSMENT OF PAIN

Assessment of Chronic Pain

History
Physical Examination
Functional Status
Psychological and
Social Assessment
Psychological and Social

Assessment
Depression is a common problem
among
older persons
Research has supported an association
between pain and depressed mood in
this patient population
Measurement of Pain
Intensity and
Pain Assessment
Scales

Multidimensional instruments
They are often long, time-consuming,
and difficult to score at the bedside
Unidimensional instruments
These tools take less time to administer
and
are more practical for use in various
clinical settings



Pain Assessment
in the Cognitively
Impaired
In patients with mild to moderate

cognitive impairment the Pain
Thermometer and the VDS are
generally recommended for use

In patients with severe cognitive

impairment:
1-May be able to convey through yes
and no answers to simple questions
2-Observational indicators of pain
Facial expression is often the first or

most common indication of pain, and
It may be the only one
The most reliable behavior may relate
to guarding during examination or
routine activities such as walking,
morning care, and transfers
An atypical behavior in a patient with

severe
dementia should trigger assessment
for pain
Family members, caregivers, and
others
who know the patient well may provide
useful qualitative information
BEHAVIORAL MANIFESTATIONS OF
PAIN IN THE COGNITIVELY IMPAIRED

PHARMACOLOGIC
TREATMENT
OF PAIN IN
OLDER PERSONS
With the exception of the rectal route,

the rate of medication absorption is
typically not affected by aging
less total body water, and more body
fat is seen in older adults
Increase distribution and
accumulation of lipophilic (fentanyl)
agents and decreasing that of
hydrophilic (morphine) drugs
Decline in serum protein

concentrations
Increase the bioavailability
of (NSAIDs)

Liver with age:

Smaller size
Lower blood flow
Reduced function
Metabolism and
excretion
of NSAIDs

Renal system
Reductions in renal size
Glomerular filtration rate
Renal blood flow
NSAIDs

Side effects and

toxicity to drugs
Pharmacodynamic changes
The density and sensitivity of mu
receptors change and often increase
sensitivity to both the desired and
undesired effects of opiods

Greater risk of sedation and

respiratory depression with the initial
administration of opioid analgesics
Using lower doses and longer intervals
with advanced age, especially with
known hepatic or renal impairment
suggested
NSAIDs
Acetaminophen
Acetaminophen is considered the
safest nonopioid analgesic and First
line analgesic of choice for older
patients
When combined with warfarin
overanticoagulation can result

Acetaminophen
Persistent excessive use of
acetaminophen
may impair renal function and cause
hepatotoxicity, especially in patients
with chronic alcoholism and liver
disease
Dosage limits of 2-3 g per day will
minimize the risk
Caution
Renal dysfunction
History of aspirin hypersensitivity
Serious skin disorders (e.g. Stevens- Johnson syndrome)
Anticoagulant therapy
History of organ transplantation
Blood disorders (e.g., coagulopathy, neutropenia)
Hypertension, or congestive heart failure
Patients are on warfarin, digoxin, anticonvulsants,
or oral antidiabetic agents


10% to 20% of older adults are

prescribed
NSAIDs, which account for 3300 deaths
and 41,000 hospitalization mostly
from gastrointestinal (GI) bleeding
GI safety:
Ibuprofen > Diclofenac sodium and
naproxen >
piroxicam and ketorolac

COX-2 selective NSAIDs appear to have

less risk of GI ulcerations but
GI safety advantages reduced :
combination with
low-dose aspirin in high doses
with multiple NSAIDs
a year of continuous therapy

of Rofecoxib is withdrawan from the

worldwide market in September of 2004
Valdecoxib was later voluntarily withdrawn
from the market
Celecoxib remains on the U.S. market, with
other
COX-2 agents available elsewhere,
Safe NSAIDS Selection and

Monitoring Use
Prolonged NSAID therapy should be

used with extreme caution and
baseline and periodic monitoring for
these potential
problems and occult GI bleeding is
recommended
Start at a low dose and asked to record

the analgesic effect for 1-2 weeks
before increasing the dose. If, after
titrating to a higher dose, there is no
analgesic advantage,
return to the lower dose

Drink a full glass of water with the

NSAID.
If therapy extends over a few weeks or
longer, a gastroprotective drug, such
as a proton pump inhibitor (PPI) or
misoprostol, is advised

Topical agents are particularly

beneficial when pain is localized as it
places a higher concentration at the
target tissue

OPIOIDS
Opioid therapy is the cornerstone of

treatment for moderate and severe
levels of pain
Opioids must be used cautiously in

older
adults who have increased sensitivity
to their effects especially in the
presence of renal or hepatic
dysfunction
Respiratory depression is more common

with acute or intermittent therapy
First day of opioid therapy
During periods of dose escalation
Pre-existing respiratory dysfunction
( COPD, emphysema, kyphoscoliosis, severe
obesity,
or cor pulmonale)
Especially concerning is sleep

apnea(%30)
(Methadone in particular)
Orthostatic hypotension and a

corresponding risk of faIling
Endocrine and immune system
suppression
long-term use of opioids poses a lower
risk of life-threatening events than
sustained NSAID therapy
The most common side effects, with

the exception of constipation,
diminish over the
first couple of weeks of therapy

Opioids to Avoid in Older Adults

Propoxyphene
No more effective than acetaminophen , adding liver
toxicity of acettaminophenand two-fold increased risk
of hip fractures
Meperidine
Normeperidine has approximately a 30 hour half-life, and
risk of
neurotoxicity-induced seizure especially in renal
insufficency
Pentazocine
CNS excitement, confusion, and agitation
Methadone did not make the most

recent Beers Criteria list of
medications to avoid in older adults,
but due to its complex
pharmacokinetics, its link to
hypertension and sleep apnea,
caution is advised in older adults

Beers Criteria
ergot mesyloids
(Hydergine)
estrogens
ethacrynic acid
(Edecrin)
ferrous sulfate (iron)
fluoxetine (Prozac)
flurazepam (Dalmane)
guanadrel (Hylorel)
guanethidine (Ismelin)
halazepam (Paxipam)
hydroxyzine (Vistaril,
Atarax)
hyoscyamine (Levsin,
Levsinex)
indomethacin
(Indocin, Indocin SR)
isoxsuprine
(Vasodilan)
ketorolac (Toradol)
lorazepam (Ativan)
meperidine (Demerol)
clidiniumchlordiazepoxide
(Librax)
clonidine (Catapres)
clorazepate (Tranxene)
cyclandelate
(Cyclospasmol)
cyclobenzaprine
(Flexeril)
cyproheptadine
(Periactin)
desiccated thyroid
dexchlorpheniramine
(Polaramine)
diazepam (Valium)
dicyclomine (Bentyl)
digoxin (Lanoxin)
diphenhydramine
(Benadryl)
dipyridamole
(Persantine)
disopyramide
Dr
Mehran Rezvani pain fellowship
(Norpace, Norpace CR)
alprazolam (Xanax)
amiodarone
(Cordarone)
amitriptyline (Elavil)
amphetamines
anorexic agents
barbiturates
belladonna alkaloids
(Donnatal)
bisacodyl (Dulcolax)
carisoprodol (Soma)
cascara sagrada
chlordiazepoxide
(Librium, Mitran)
chlordiazepoxideamitriptyline
(Limbitrol)
chlorpheniramine
(Chlor-Trimeton)
chlorpropamide
(Diabinese)
chlorzoxazone
(Paraflex)
oxybutynin (Ditropan)
pentazocine (Talwin)
perphenazine-amitriptyline
(Triavil)
piroxicam (Feldene)
promethazine (Phenergan)
propantheline (Pro-Banthine)
propoxyphene (Darvon) and
combination products (Off the
market)
quazepam (Doral)
reserpine (Serpalan, Serpasil)
temazepam (Restoril)
thioridazine (Mellaril)
ticlopidine (Ticlid)
triazolam (Halcion)
trimethobenzamide (Tigan)
tripelennamine
meprobamate (Miltown, Equanil)

mesoridazine (Serintil)
metaxalone (Skelaxin)
methocarbamol (Robaxin)
methyldopa (Aldomet)
methyldopa-hydrochlorothiazide
(Aldoril)
methyltestosterone (Android,
Testred, Virilon)
mineral oil
naproxen (Naprosyn, Avaprox,
Aleve)
Neoloid
nifedipine (Procardia, Adalat)
nitrofurantoin (Microdantin)
orphenadrine (Norflex)
oxaprozin (Daypro)
oxazepam (Serax)

Safe Product Selection and Use of

Opioids
Oxycodone and morphine are probably
the best first-line opioid agents for an
opioid naIve patient with acute pain
Hydrocodone is another reasonable
firstline
option; it is available only in fixed-dose
combinations with acetaminophen
Tramadol is commonly chosen, but it

has low potency and an association
with seizures
In Europe, buprenorphine is emerging
as a potential first-line opioid
The transdermal buprenorphine patch
is ideally suited for older adults, but
not exist in US
ADJUVANTS

Amitriptyline is the best studied

adjuvant for pain, but it should be
avoided in the elderly due to its
cardiac, anticholinergic, and sedative
effects
Nortriptyline or desipramine are better
choices with a 75% lower incidence
of side effects at comparable doses
Duloxetine, has approved labeling for

certain pains and appears to be a
better tolerated antidepressant for
older adults

Antiepileptic drugs are first-line

agents to treat neuropathic pain in
older persons
Gabapentin and pregabalin have
labeled
indications for specific neuropathic
pain disorders
Dosing should be initiated as low as
100 mg at bedtime
Carbamazepine also has U.S. FDA

approved labeling for trigeminal
neuralgia, but like many older
antiepileptic agents, drug-drug
interaction, liver, and hematologic
toxicity
make them less than ideal in older
adults
when pain is complex and refractory to

initial
treatment attempt:
Additional complementary and
alternative medicine
Multidisciplinary pain treatment
programs are likely the most beneficial
in optimizing
the outcomes


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PAIN IN THE

A national telephone-based survey in US:

Aging alters functions,

Dr Mehran Rezvani pain fellowship

Once pain is established;

Dr Mehran Rezvani pain fellowship

The decline in function of the

Prevalence of pain may be as high as

In presence of multiple comorbid

Significant portion of those over age 65

Change in Pain Threshold and

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Assessment of Chronic Pain

Dr Mehran Rezvani pain fellowship

Psychological and Social

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

In patients with mild to moderate

Dr Mehran Rezvani pain fellowship

In patients with severe cognitive

Facial expression is often the first or

An atypical behavior in a patient with

Dr Mehran Rezvani pain fellowship

With the exception of the rectal route,

Decline in serum protein

Dr Mehran Rezvani pain fellowship

Liver with age:

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Side effects and

Dr Mehran Rezvani pain fellowship

Greater risk of sedation and

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

10% to 20% of older adults are

Dr Mehran Rezvani pain fellowship

COX-2 selective NSAIDs appear to have

Dr Mehran Rezvani pain fellowship

of Rofecoxib is withdrawan from the

Safe NSAIDS Selection and

Prolonged NSAID therapy should be

Start at a low dose and asked to record

Dr Mehran Rezvani pain fellowship

Drink a full glass of water with the

Dr Mehran Rezvani pain fellowship

Topical agents are particularly

Dr Mehran Rezvani pain fellowship

Opioid therapy is the cornerstone of

Opioids must be used cautiously in

Respiratory depression is more common

Especially concerning is sleep

Orthostatic hypotension and a

The most common side effects, with

Dr Mehran Rezvani pain fellowship

Opioids to Avoid in Older Adults

Methadone did not make the most

Dr Mehran Rezvani pain fellowship

meprobamate (Miltown, Equanil)

Dr Mehran Rezvani pain fellowship