MANAGEMENT OF CHRONIC PAIN IN OLDER ADULTS L EANNE R. C IANFRINI , P H D Clinical Psychologist Program Director The Doleys Clinic OVERVIEW OF TOPICS We’ll discuss: • How important effective pain management is for older adults • Unique physiological and psychosocial factors that influence chronic pain perception and response to treatment modalities in older adults • Practical methods for assessing and managing pain • Nonpharmacological • Pharmacological • Guidelines THE PREVALENCE AND NATURE OF PAIN IN OLDER ADULTS (1 OF 2) • High prevalence of pain in general American population • As much as 50% of the older adult population report chronic pain. • Studies show up to 80% of nursing home residents have clinically significant pain. • Older adults more likely to be affected by joint pain and other forms of musculoskeletal pain. 1
Diseases associated with chronic pain in later life, by system or specialty • Dermatology — pressure or ischemic ulcers, burns, scleroderma • Gastrointestinal — constipation, diverticulitis, IBD • Cardiovascular — advanced heart disease, peripheral vascular disease • Pulmonary — advanced COPD, pleurisy • Rheumatology — OA, RA, gout, polymyalgia rheumatica, spinal stenosis and other low back syndromes, myofascial syndromes, osteoporotic related fractures • Endocrine — diabetic neuropathy • Nephrology — chronic cystitis, end stage renal disease • Immune — herpes zoster, post-herpetic neuralgia, HIV/AIDs neuropathy • Neurology — headache, peripheral neuropathies, compressive neuropathies, radiculopathies, Parkinson’s disease, post-stroke pain • Oncology — cancer • Miscellaneous — depression, tendonitis, bursitis THE PREVALENCE AND NATURE OF PAIN IN OLDER ADULTS (2 OF 2) • We have an aging population. • Pain is still under-recognized and under-treated in older adults. WHY IS THIS IMPORTANT? • Undertreated pain is associated with: • Sleep disturbance • Functional decline • Risks associated with polypharmacy • Malnutrition • Prolonged hospital stay • Challenging behaviors • Cognitive decline • Increased healthcare utilization • Lawsuits • Impact on family • Impact on society “I must die. But must I die groaning?” -- Epictetus, 135 AD 2
CHRONIC PAIN BASICS (1 OF 3) DEFINITIONS: • IASP: “An unpleasant sensory and emotional experience…” • McCaffery: “Whatever the experiencing person says it is, existing whenever the experiencing person says it does.” -- SUBJECTIVE • A disease in its own right. Chapman, Tuckett, Song. J Pain , 2008; 9 (2): 122-45 CHRONIC PAIN BASICS (2 OF 3) ACUTE VS. CHRONIC Acute pain: Makes sense to focus on location, • sensory aspects for rehabilitation purposes Sensory- Cognitive- Affective- Discriminative Evaluative Motivational Chronic pain: Danger of too much focus on • peripheral “generators” Cognitive- Affective- Sensory- Discriminative Evaluative Motivational WHO ‘GETS’ THE DISEASE OF CHRONIC PAIN? From Birth Childhood • Genetics, female sex, ethnicity, • Physical/sexual abuse and other congenital disorders, prematurity traumatic events • Parental anxiety, irregular feeding and • Low SES sleeping • Emotional, conduct, and peer • Parents’ pain exposure and reactions problems • Temperament and personality • Hyperactivity Adulthood • Vivid recall of childhood trauma Adolescence • Lack of social support; accum. stress • Changes of puberty, gender roles • Surgery • Educational level, learning • Overuse of joints and muscles (behavioral reactions to pain) • Occupational exposures, job • Injuries dissatisfaction, low work status • Obesity • Development of chronic disease • Low fitness levels • Aging Relieving Pain in America. Institute of Medicine. National Academic Press. Washington, D.C. 2011 3
CHRONIC PAIN BASICS (3 OF 3) CONSIDER A “MECHANISTIC-BASED” APPROACH TO PAIN ASSESSMENT AND TREATMENT Central Pain Nociceptive Pain Neuropathic Pain Inflammatory Pain Amplification (ie, Burn) (ie, Herpes zoster) (ie, Rheumatoid arthritis) (ie, Fibromyalgia) Noxious stimuli Neuronal damage Inflammation Abnormal pain processing by CNS Woolf C. Ann Intern Med. 2004;140:441-451. Neuroanatomy of Nociception AGE-RELATED CHANGES IN PAIN PROCESSING AND PRESENTATION • Pain modulatory imbalance • Bio: • Systemic inflammation (increased “inflamm-aging”) • Changes in structure of peripheral nerves that transmit pain signals • Studies of pain threshold • Brain structure and function changes (reduction in gray matter in certain regions of the brain) • Psychosocial: • Cope with pain differently? E.g., under-reporting • Present with more behavioral expressions • Late life depression in OA (risk factor) • Social (isolation is more likely) 4
ASSESSMENT “TO HEAR ABOUT PAIN IS TO HAVE DOUBT; TO EXPERIENCE PAIN IS TO HAVE CERTAINTY”. - ELAINE SCARRY, THE BODY IN PAIN: THE MAKING AND UNMAKING OF THE WORLD 5
IS PAIN PRESENT? • Ask about the presence of pain in regular and frequent intervals: • Upon admission • During periodic scheduled assessments • Whenever a change occurs in patient’s condition • Considerations: • Simply ask the patient! • Myth – pain is a normal part of aging • Assume pain if patient has conditions or procedures that are typically painful • Involve family, staff • In nonverbal patients, may need to use observation – at rest and during activity (e.g., repositioning) BEHAVIORAL OBSERVATIONS INDICATIVE OF CHRONIC PAIN • Facial expressions: grimacing, fearful expression, grinding of teeth • Vocalizations: crying, moaning, groaning, sighing, breathing heavily • Body movements: bracing, guarding, rubbing • Change in movement: rigid posture, limping, resistance to motion during care, fidgeting/restlessness • Change in interpersonal interactions: combative, resistant, withdrawm • Change in mental status: confusion, irritability, agitation, crying • Change in usual activity: refusing food/appetite change, increased wandering, change in sleep habits Loss of function OBSERVATIONAL PAIN TOOLS • 2006 BMC Geriatrics systematic review • Compared psychometric qualities and criteria for 12 observational tools • Concluded that PACSLAC & DOLOPLUS2 most appropriate scales • The APS recommends ABBEY or PAINAD. 6
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PAIN CHARACTERISTICS • Pain Intensity: VAS, NRS, Facial Pain Scales, Pain Thermometer • Location: pain map • Explore different descriptive words, such as “aching,” “burning,” “stabbing” • Distinguishes muscular, nerve, inflammatory pain and can guide treatment • E.g., McGill Pain Questionnaire • Basic sensory questions: • Please tell me all of the places you experience pain or discomfort. What does it feel like? What words come to mind? • Is your pain or discomfort with you all of the time or does it come and go? How long has it been present? What makes it better, what makes it worse? Faces Pain Scale Horizontal Visual Analogue Scale Iowa Pain Thermometer McGill Pain Questionnaire 8
DETERMINE CAUSES OF PAIN • Physical exam • Musculoskeletal, neurologic • Performance-based measures • Rule out: Is it something as basic as toileting needs? • Laboratory, radiologic, and other diagnostic tests as appropriate • Can be overused, does not “prove” presence or absence of pain • Consultation if needed BIOPSYCHOSOCIAL PERSPECTIVE – EFFECT ON FUNCTIONING • Functional impact: • Has pain affected your ability to do every day activities? To do things you enjoy? • How about relating with others? If so, how? • Emotional impact: • Has pain affected your mood, sense of wellbeing, energy level? • Are you worried about your pain or what may be causing it? • Consider PHQ9 or PHQ2 BIOPSYCHOSOCIAL PERSPECTIVE – PSYCHOSOCIAL HISTORY • Other psychosocial factors: • History of mood disorders or mental illness? • History of addiction? • Family involvement? • Is there anyone at home or in the community that you can turn to for help and support when your pain is really bad? • Does patient act differently around family members? • Do family members seem insistent on a particular treatment? 9
BIOPSYCHOSOCIAL PERSPECTIVE – OTHER QUESTIONS • Attitudes and beliefs • Do you have any thoughts or opinions about experiencing pain at this point in your life that you believe would be important for me to know? • Do you have any thoughts or opinions about specific pain treatments that you believe would be important for me to know? • Coping styles • What things do you do to help you cope with your pain? This could be listening to your favorite music, praying, sitting still, or isolating yourself from others • Treatment expectations and goals • What do you think is likely to happen with the treatment I have recommended? • What are the most important things you hope will happen as a result of the treatment? TREATMENT “If we know that pain and suffering can be alleviated, and we do nothing about it, then we ourselves become the tormentors.” - Primo Levi MULTIMODAL APPROACH TO PAIN MANAGEMENT Pharmacotherapy Physical Therapy Treatment Approaches Interventional Approaches Complementary and Alternative Medicine Exercise Psychological Support 10
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