elizabeth mcmanamy, rph risk of sudden cardiac death 10 atypical prescribing considerations...
TRANSCRIPT
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Elizabeth McManamy, RPhPharmacist Quality Monitor
Jennifer Wills, BSN, RNNurse Manager
DADS Quality Monitoring Program
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Objectives
1.Summarize the pharmacology of the antipsychotic
drug class
2.Describe how the use of antipsychotic medications
burden the quality of life in the elderly
3.Explain the CMS appropriate use of antipsychotic
medications in the long-term care setting
4.Describe the dementia disease process
5.Describe strategies to monitor and target behaviors in
the long-term care population
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What’s the Big Deal?
Antipsychotics are:
• extensively used in nursing homes
• prescribed for the off-label for dementia-related illnesses where effectiveness is little and use is unsupported
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Antipsychotic Mechanism of Action Block neurotransmitters in the brain at dopaminergic,
histaminic, cholinergic, and serotonergic receptors in the brain
A specific antipsychotic drug may be prescribed over another due to varying activity at these brain receptor sites
The main action is to block dopaminergic pathways to reduce the core symptoms of psychosis: hallucinations, delusions, and paranoid ideation
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Treatment for Schizophrenia-Related Disorders
Antipsychotics have been the first-line treatment since the 1950’s with first-generation antipsychotics (i.e. the typical antipsychotics)
The down-side risk of blocking dopaminergic receptors is the occurrence of extrapyramidal side effects (EPS)
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Common Typical Antipsychotics
Haloperidol (Haldol®)
Chlorpromazine (Thorazine®)
Fluphenazine (Prolixin®)
Perphenazine (Trilafon®)
Thioridazine (Mellaril®)
Thiothixene (Navane®)
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Atypical Antipsychotics
Second-generation antipsychotics were developed in the 1980’s with the first being Clozapine (Clozaril®)
Atypicals commonly seen in the long-term care setting:
Aripiprazole (Abilify®) Lurasidone (Latuda®)
Olanzapine (Zyprexa®) Paliperidone (Invega®)
Quetiapine (Seroquel®) Ziprasidone (Geodon®)
Risperidone (Risperdal®)
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Atypical Antipsychotic DesignAlong with treating hallucinations and delusions these newer drugs have a better side effect profile and greater effects on other symptoms seen in schizophrenia:
› emotional withdrawal/blunted affect
› suspiciousness or persecution
› grandiosity
› hostility
› poor impulse control
› active social avoidance
› anxiety
› somatic concerns
Reference: http://effectivehealthcare.ahrq.gov/ehc/products/146/1054/CER_63_Antipsychotics%20in%20Adults_08-20-121.pdf
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Antipsychotic Side Effects
sedation; drowsiness/dizziness; disorientation
confusion; memory or functional impairment
risk of delirium
fall risk; orthostatic hypotension (sudden drop in blood pressure when standing)
constipation, urinary retention, dry mouth; blurred vision
restlessness; inability to sit still; anxiety; sleep disturbances
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Antipsychotic Side Effects
tremor; slowed movements; muscle rigidity; strong muscle spasms (neck, tongue, face, or back); drooling
tardive dyskinesia
low white blood cell count; irregular heart rate; seizures; metabolic issues; neuroleptic malignant syndrome; increased risk of sudden cardiac death
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Atypical Prescribing Considerations
Quetiapine and aripiprazole cause the least amount of extrapyramidyl side effects (EPS). Quetiapine or aripiprazole are often a choice in Parkinson’s disease
Quetiapine and risperidone have a higher risk of orthostatic hypotension (a significant factor in fall risk)
Olanzapine has the highest risk factor for obesity, hyperglycemia, and dyslipidemia
Aripiprazole, quetiapine, and risperidone have a risk factor of QT prolongation (dangerous heart arrhythmias)
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Atypical Prescribing & Decision Making
“The American Psychiatric Association (APA) currently recommends that selection of an antipsychotic medication should be based on a patient’s previous responses to the drug and its side-effect profile”.
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FDA Approved Non-Schizophrenia Related Conditions
Bipolar disorder (some as monotherapy & some as adjunct)
Tourette’s syndrome
Nausea, vomiting, and hiccups
Major depressive disorder (adjunctive with antidepressants)
Short-term treatment of generalized non-psychotic anxiety
Management of manifestations of psychotic disorders13
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Antipsychotics: Off-label Prescribing
Off-label: a drug company does not have FDA approval to market or advertise a medication to treat a specific disorder or condition
Physicians can prescribe drug off-label to treat any condition, disorder, or diagnosis
Physicians will normally prescribe within the currently accepted standards and principles found in medical literature
In dementia care, there are no current medications available to treat the behavioral and psychological symptoms of dementia (BPSD)
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Antipsychotics are NOT Approvedto Treat Dementia
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FDA Black Box Warning: Increased Mortality in Elderly Patients with Dementia-Related Psychosis
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124830.htm
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Alzheimer’s vs. Dopamine Pathway
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Understanding Dementia
Symptoms of dementia depend on the location of damage in the brain:
Frontal Lobe
The Hippocampus
Occipital Lobe
Temporal Lobe
Parietal Lobe
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Dementia Disease Process Permanent degenerative changes in the brain
Lack of acetylcholine presence
Beta-amyloid plaques causing inflammation and brain cell death
Tau protein tangles causing brain cell dysfunction and cell death
The “psychosis-like” symptoms seen in dementia are unlike the psychoses in chronic mental illness (e.g. schizophrenia)
Disturbances arise from short-term memory/recall problems causing disorientation to time, place, and environment
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Advanced Stages of Dementia
Confusion of surroundings (disorientation)
Inability to communicate or find the words to express unmet needs
Wandering or pacing
Sleep-wake cycle disturbances
Emotional distress
Disrobing or dressing inappropriately in public places
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Advanced Stages of Dementia
Delusions
Hallucinations (auditory and/or visual)
Agitation (irritability, restlessness, anxiety)
Aggression (lashing out, verbal outbursts or cursing,
resisting care, sexually inappropriate behaviors)
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Dilemmas of Dementia
BPSD is troublesome, irregular, disturbing, and difficult to manage
80% of dementia residents will develop neuropsychiatric symptoms over the course of the disease
Behavioral disturbances cause caregiver stress, burden, possible injury
Behavioral disturbances can worsen the functioning of other residents or the resident themselves
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“The strongest people are
not those who show strength
in front of us, but those who
win battles we know nothing about.”
-Unknown
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Antipsychotic Challenges
Behavioral disturbances tend to be episodic and can diminish spontaneously
Antipsychotics are likely to be prescribed with comorbid conditions and many medications
Antipsychotics are more likely to be prescribed for those already on psychotropic medications
Over time, antipsychotics are barely more effective than placebo
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Prescribing Precautions: Advanced Age
Less muscle mass, less body weight, and are prone to malnutrition affecting drug transport and drug distribution
Less liver and kidney capacity to metabolize and excrete medications, along with dehydration, urinary retention, and urinary infections, can cause drugs to build up in the body
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Prescribing Precautions: Advanced Age
All medications have the potential to interact with other medications or medical conditions
Adverse reactions can resemble symptoms of acute illness which may be overlooked
Polypharmacy (9 or more meds*) with comorbid conditions put individuals at higher risk for adverse events and status decline
* CMS SOM Appendix PP26
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CATIE-AD Project
When atypical antipsychotics are prescribed in dementia care, they are risky and are only modestly effective
Side effects can cause both direct and indirect factors that contribute to decreased health and well being
Steady and significant declines in both cognition and functional ability can increase the need for care, and can diminish overall quality of life.
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Antipsychotics Risks
Worsening or complications with dysphagia
Increased risk of aspiration pneumonia and upper respiratory infections
Increased risk of urinary tract infections
Contribute to the risk of developing delirium
Increased risk for pressure ulcers
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Antipsychotics Risks
Declines with decision-making capability ( think about safety awareness)
Increased risk of falls
Decreased ability to be understood/understand
Declines in functional ability and independence
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Burdens on Quality of Life: Cognitive Decline
Decreased ability to self-report illness and infection
Decreased ability to communicate pain/discomfort
Decreased recognition of the need for toileting
May be unaware of thirst or unable to communicate the need for drink (dehydration risk) or food (weight loss)
possible decreases in socialization with other residents, staff, family & friends
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Burdens on Quality of Life: Functional Decline
Decreased independence (this can increase staff burdens)
Decreased mobility (ability to walk properly or self-propel)
Decreased ability to reposition oneself properly or in a timely manner
Possible physical changes in functional eating & drinking
Decreased enjoyment due to sedation/drowsiness31
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Avoidable Re-Hospitalizations
Individuals with dementia on antipsychotics either 6 months before or after hospital admission were more likely to be readmitted back to the hospital than those without an antipsychotic in their drug regimen
Reference: L.A. Daiello, et al. Archives of Gerontology and Geriatrics, July-August 201432
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CMS Approved Diagnoses
Chronic conditions
Schizophrenia Schizo-affective disorder
Delusional disorder Mood disorders
Tourette’s disorder Huntington’s disease
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CMS Approved Diagnoses
Acute conditions
Psychosis in the absence of dementia
Medical illness with psychotic symptoms and/or treatment related psychosis or mania
Hiccups
Nausea and vomiting with cancer/chemotherapy34
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End-of-Life Care
Off-label as a comfort measure in end-of-life care
This is not CMS or FDA approved, but during hospice the goals are to promote sedation, stabilize the individual, and maintain comfort
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Warnings
“When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective.”
“The problematic use of medications, such as antipsychotics, is part of a larger growing concern. This concern is that nursing homes and other setting (i.e. hospitals, ambulatory care) may use medications as a “quick fix” for behavioral symptoms or as a substitute for a holistic approach that involves a thorough assessment of underlying causes of behaviors and individualized person-centered interventions.”
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Avoid Antipsychotics with BPSD
Antipsychotics should only be used when clinically necessary to treat targeted behaviors that are causing harm or significant distress to others or the resident themselves.
Antipsychotics should be used at the lowest dose and for the shortest period of time to treat specific targeted behavior(s), and are subject to gradual dose reduction.
Non-pharmacological interventions and therapeutic approaches are considered first-line therapy for BPSD.
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Pre-psychotropic Assessment and Care Planning
Target the behavior as a problem/risk in the care plan
Discuss interventions and approaches with all members of the interdisciplinary team and obtain input from family members
Document individualized person-centered non-pharmacological interventions and therapeutic approaches in the care plan
Implement those interventions and approaches across various disciplines
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Recognize Disturbances Early
Rule out potential medical & psychiatric causes first
Behaviors are commonly triggered by the actions, inactions, or the reactions of others
Behaviors can arise from frustrations that are caused when choices or personal preferences limit independence
Recognize harmful or significantly distressing behaviors, as opposed to the behavioral and psychological disturbances
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Problem Solving Requires New Approaches
‘Insanity:
Doing the same thing
over and over again, and
expecting different results.’
-Albert Einstein
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Become a Detective
Are there any physical or functional limitations that can be remedied? Promote independence with cueing, repositioning, or simple adjustments may be needed
What is the resident seeing, hearing, smelling, touching, or tasting that may be leading to behaviors? Review environmental considerations
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Become a Detective
Does the resident need emotional support? If they are seeking reassurances, they probably need more emotional support (medication may not be needed)
Do the activities offered match the cognitive and functional abilities of the individual? Structure them to promote meaningful active participation
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Address Depressive Symptoms
Depression
Highly prevalent in the nursing home setting
Can worsen cognition and functioning potentially leading to an acceleration of the dementia disease process
Can worsen the experience of pain and discomfort
can precipitate ruminating thoughts of worry
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Address Depressive Symptoms
Antidepressants (SSRIs and SNRIs)
Therapy is often necessary with extended use, but only at the lowest dose needed to treat depression
Avoid the use of multiple antidepressants unless clinically indicated
Caution: fall risk is highest during the first 2 weeks of initiation or with increasing dosages
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Serial Trial Intervention Approach
Individuals may not be able to express that they are having pain and discomfort
Behaviors can be easily misconstrued and treated with psychotropic medications
The STI recognizes that routine mild analgesia should be started as a comfort measure when behaviors are exhibited
Monitor for a response such as decreased behaviors and improved mood
If analgesia is successful, don’t forget to continue other non-pharmacological interventions
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CMS Definition of Monitoring
"The ongoing collection and analysis of information (such as observations and diagnostic test results) and comparison to baseline and current data in order to ascertain the individual's response to treatment and care, including progress or lack of progress toward a goal. Monitoring can detect any improvements, complications or adverse consequences of the treatments; and support decisions about adding, modifying, continuing, or discontinuing any interventions.“ -RAI Manual
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Monitoring Psychotropic Medications Target specific behavior(s) and linking them with treatment
of a specific medication
At least daily, monitor (shift-by-shift is suggested) for presence of targeted behavior(s)
Document non-drug interventions implemented for targeted behavioral occurrences
Periodically evaluation (quarterly, but more often is recommended) of targeted behavior(s), effectiveness of non-drug interventions and/or drug therapy with considerations for gradual dosage reductions
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Reducing Unnecessary Antipsychotic Medications
Gradual Dosage Reduction: GENERAL GUIDELINES
Monitor dosages regularly; consider adverse reactions, resident’s response and level of functioning
Review and trend behavior from monitoring system
Titrate drug reduction slowly
Monitor behavior stabilization
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Reducing Unnecessary Antipsychotic Medications
Gradual Dosage Reduction
The physician may order dosage titrations downward at 1 to 2 week intervals.
Everyone must “know” titration is happening to increase surveillance
Keep documentation- what’s working and what’s not working
Allow intervals of adjustments and continue to perform non-pharmacological interventions. 51
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Care Planning Recognition or identification of the problem/need (target)
Ongoing assessment (root-cause analysis & triggers)
Identification of a diagnosis/cause
Development of management techniques and/or treatments (non-pharmacological interventions / adjunct medications)
Monitoring the efficacy and adverse consequences of those techniques and treatments
Periodic reviewing, re-evaluating, and revising those techniques and treatments
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“It’s not that caregivers have
so much time, it’s that they
have so much heart.”
-Elizabeth Andrew
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What’s the Bottom Line?
Identify ALL residents on antipsychotic medications
Determine which antipsychotic medications are clinically appropriate
Implement gradual dose reduction as needed/indicated
Manage unmet needs (behaviors) through improved dementia care using person-centered care
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Changing the Culture of Prescribing in Dementia Care
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Change Starts with Asking Questions
Does the interdisciplinary team question why the antipsychotic was initiated? Was it for
an acute behavioral or psychological reason which may no longer be present?
Does the interdisciplinary team recognize the actual number of occurrences of the
behavior(s), or could they be recalling the severity of just a few distant behaviors when
making decisions about dosage reductions (subjective views may be influencing
opinions more than actual objective documentation from behavior monitoring)?
If the targeted behavior is no longer present, or the resident is stable with non-drug
interventions, or the behavior is no longer harmful to self or others, then ask “why
haven’t dosage reductions been attempted”? Is the drug kept unnecessarily?
Does the staff have any preconceived notions which need to be addressed regarding
attempted dosage reductions such as “they have gone poorly in the past” (the staff may
be projecting those feelings with making requests for future attempts)?
Are these behaviors distressing to family members who are unable to cope with the
disease’s progression? Do family members have unrealistic notions about
antipsychotics such as “they are used to improve dementia”? Is the family hesitant
about trying a dosage reduction due to the severity of distant behaviors?
Are psychotropic drugs seen as a “positive” by the staff, to be utilized as the only
solution for treating behavioral problems? It has become ingrained in our society that
“medications are the solution to all our woes”. We seek them out, yet we rarely address
their long-term consequences.
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Changing the Culture of Prescribing in Dementia Care
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Changing the Culture of Prescribing in Dementia Care
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Changing the Culture of Prescribing in Dementia Care
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Changing the Culture of Prescribing in Dementia Care
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Changing the Culture of Prescribing in Dementia Care
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Elizabeth McManamy, RPhPharmacist Quality Monitor
Jennifer Wills, BSN, RNNurse Manager
DADS Quality Monitoring Program
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ObjectivesAt the conclusion of the presentation, the participate will be able to…
Describe at least two negative outcomes associated with the use of antipsychotic medications to manage pain related behaviors in elderly persons with dementia.
Explain the three types of pain
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Objectives
Explain at least three common causes and related manifestations of pain in elderly persons with dementia
Explain three best practice pain management strategies for elderly persons with dementia
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Consequences of Antipsychotic Use
Increased risk of stroke and death
Side effects – tremors, rigidity, restlessness, muscle spasms, drowsiness, dizziness, blurred vision, rapid heartbeat
Can lead to immobility, decline in ADLs, decreased socialization, sleep disturbances, decreased appetite, depression, increase in behaviors
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Untreated PAIN
psychological67
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Consequences of Untreated Pain
Immobility – pressure ulcers, incontinence, circulatory and respiratory problems, falls
Increased functional limitations – decline in ADLs, decreased socialization
Sleep disturbances, decreased appetite
Depression and anxiety
Agitation and aggression
Inappropriate use of antipsychotics to treat pain related behaviors
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OUCH!
striking out69
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Impact of Dementia on Pain Estimated 35 million people worldwide have
dementia
71% of Texas nursing home residents 65 y.o. and older have diagnoses of Alzheimer’s, dementia or cognitive impairment
45-80% of nursing home residents with dementia experience pain on a daily basis
Generally persons with dementia receive less pain medication than those who are cognitively intact 70
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What is Pain?
Pain is an unpleasant sensory or emotional experience
Pain is present whenever a person says it is
Pain may be acute or chronic/persistent
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What is Pain? Nociceptive pain – results from actual or
potential tissue damage
Neuropathic pain – results from a disturbance of function or pathologic change in the peripheral or central nervous system
Unspecified or Mixed pain – results from unspecified or mixed mechanisms and includes both nociceptive and neuropathic pain
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What Causes Pain? Degenerative joint disease
Low back disorders
Rheumatoid arthritis
Gout
Headaches
Fibromyalgia
Neuropathies
Peripheral vascular disease
Vertebral compression fractures 73
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What Causes Pain? Post-stroke syndromes
Oral or dental pathology
Cancer
Gastrointestinal conditions
Renal conditions
Immobility, contractures
Pressure ulcers
Surgical procedures
Falls, other injuries 74
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“Pain is such an uncomfortable feeling that even a tiny amount of it is enough to
ruin every enjoyment.”
- Will Rogers
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Is it Pain? Frowning, grimacing
Fearful facial expressions
Grinding of the teeth
Fidgeting, restlessness
Striking out, increased agitation
Sighing, groaning, crying
Breathing heavily76
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Is it Pain? Decreasing activity levels,
socialization
Resisting certain movements
Inability to participate in activities of daily living
Depression, anxiety
Changes in gait
Eating or sleeping poorly77
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Pain Assessment
Should be conducted on admission, quarterly and with a change in condition
In a language the person understands
According to the person’s cognitive and verbal abilities
Using a validated pain scale(s)
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Validate Pain Scales
Self-reporting pain intensity scales
– allow the resident to rate his/her pain
Note: Wong-Baker Faces Scale is not recommended for use in the geriatric population
Behavioral pain scales
– allow the licensed nurse to observe for behaviors which might suggest pain is present
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Self-reporting Pain Intensity Scales
Numeric Rating Scale (NRS)
Verbal Descriptor (VDS)
Faces Pain Scale – Revised (FPS-R)
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Behavioral Pain Scales
Pain Assessment in Advanced Dementia (PAINAD)
Pain Assessment Checklist for Senior with Limited Ability to Communicate (PACSLAC)
Discomfort Scale for Dementia of the Alzheimer’s Type (DS-DAT)
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Behavioral Pain Scale: PAINAD
5 observational indicators
• Breathing
• Negative Vocalization
• Facial Expression
• Body Language
• Consolability
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Behavioral Pain Scale: PAINAD0 1 2 Score
Breathing
Independent of
vocalization
Normal Occasional labored
breathing.
Short period of
hyperventilation
Noisy labored breathing.
Long period of hyperventilation.
Cheyne-Stokes respirations
Negative
Vocalization
None Occasional moan or groan.
Low level speech with a
negative or disapproving
quality
Repeated troubled calling out.
Loud moaning or groaning.
Crying
Facial
expression
Smiling, or
inexpressive
Sad. Frightened. Frown Facial grimacing
Body Language Relaxed Tense.
Distressed pacing. Fidgeting
Rigid. Fists clenched, Knees
pulled up.
Pulling or pushing away.
Striking out
Consolability No need to
console
Distracted or reassured by
voice or touch
Unable to console, distract or
reassure
TOTAL84
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Mildred
85
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Behavioral Pain Scale: PAINAD0 1 2 Score
Breathing
Independent of
vocalization
Normal Occasional labored
breathing.
Short period of
hyperventilation
Noisy labored breathing.
Long period of hyperventilation.
Cheyne-Stokes respirations
Negative
Vocalization
None Occasional moan or groan.
Low level speech with a
negative or disapproving
quality
Repeated troubled calling out.
Loud moaning or groaning.
Crying
Facial
expression
Smiling, or
inexpressive
Sad. Frightened. Frown Facial grimacing
Body Language Relaxed Tense.
Distressed pacing. Fidgeting
Rigid. Fists clenched, Knees
pulled up.
Pulling or pushing away.
Striking out
Consolability No need to
console
Distracted or reassured by
voice or touch
Unable to console, distract or
reassure
TOTAL86
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Behavioral Pain Scale: PAINAD0 1 2 Score
Breathing
Independent of
vocalization
Normal Occasional labored
breathing.
Short period of
hyperventilation
Noisy labored breathing.
Long period of hyperventilation.
Cheyne-Stokes respirations1
Negative
Vocalization
None Occasional moan or groan.
Low level speech with a
negative or disapproving
quality
Repeated troubled calling out.
Loud moaning or groaning.
Crying
Facial
expression
Smiling, or
inexpressive
Sad. Frightened. Frown Facial grimacing
Body Language Relaxed Tense.
Distressed pacing. Fidgeting
Rigid. Fists clenched, Knees
pulled up.
Pulling or pushing away.
Striking out
Consolability No need to
console
Distracted or reassured by
voice or touch
Unable to console, distract or
reassure
TOTAL87
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Behavioral Pain Scale: PAINAD0 1 2 Score
Breathing
Independent of
vocalization
Normal Occasional labored
breathing.
Short period of
hyperventilation
Noisy labored breathing.
Long period of hyperventilation.
Cheyne-Stokes respirations1
Negative
Vocalization
None Occasional moan or groan.
Low level speech with a
negative or disapproving
quality
Repeated troubled calling out.
Loud moaning or groaning.
Crying2
Facial
expression
Smiling, or
inexpressive
Sad. Frightened. Frown Facial grimacing
Body Language Relaxed Tense.
Distressed pacing. Fidgeting
Rigid. Fists clenched, Knees
pulled up.
Pulling or pushing away.
Striking out
Consolability No need to
console
Distracted or reassured by
voice or touch
Unable to console, distract or
reassure
TOTAL88
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Behavioral Pain Scale: PAINAD0 1 2 Score
Breathing
Independent of
vocalization
Normal Occasional labored
breathing.
Short period of
hyperventilation
Noisy labored breathing.
Long period of hyperventilation.
Cheyne-Stokes respirations1
Negative
Vocalization
None Occasional moan or groan.
Low level speech with a
negative or disapproving
quality
Repeated troubled calling out.
Loud moaning or groaning.
Crying2
Facial
expression
Smiling, or
inexpressive
Sad. Frightened. Frown Facial grimacing 2
Body Language Relaxed Tense.
Distressed pacing. Fidgeting
Rigid. Fists clenched, Knees
pulled up.
Pulling or pushing away.
Striking out
Consolability No need to
console
Distracted or reassured by
voice or touch
Unable to console, distract or
reassure
TOTAL89
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Behavioral Pain Scale: PAINAD0 1 2 Score
Breathing
Independent of
vocalization
Normal Occasional labored
breathing.
Short period of
hyperventilation
Noisy labored breathing.
Long period of hyperventilation.
Cheyne-Stokes respirations1
Negative
Vocalization
None Occasional moan or groan.
Low level speech with a
negative or disapproving
quality
Repeated troubled calling out.
Loud moaning or groaning.
Crying2
Facial
expression
Smiling, or
inexpressive
Sad. Frightened. Frown Facial grimacing 2
Body Language Relaxed Tense.
Distressed pacing. Fidgeting
Rigid. Fists clenched, Knees
pulled up.
Pulling or pushing away.
Striking out
2
Consolability No need to
console
Distracted or reassured by
voice or touch
Unable to console, distract or
reassure
TOTAL90
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Behavioral Pain Scale: PAINAD0 1 2 Score
Breathing
Independent of
vocalization
Normal Occasional labored
breathing.
Short period of
hyperventilation
Noisy labored breathing.
Long period of hyperventilation.
Cheyne-Stokes respirations1
Negative
Vocalization
None Occasional moan or groan.
Low level speech with a
negative or disapproving
quality
Repeated troubled calling out.
Loud moaning or groaning.
Crying2
Facial
expression
Smiling, or
inexpressive
Sad. Frightened. Frown Facial grimacing
2
Body Language Relaxed Tense.
Distressed pacing. Fidgeting
Rigid. Fists clenched, Knees
pulled up.
Pulling or pushing away.
Striking out
2
Consolability No need to
console
Distracted or reassured by
voice or touch
Unable to console, distract or
reassure 1
TOTAL 891
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Mildred
92
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Comprehensive Pain Assessment
Predisposing factors
Onset of pain
Location of pain
Frequency of pain
Duration of pain
Description of pain
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Comprehensive Pain Assessment
Aggravating factors
Relieving factors
Validated pain scale(s) utilized
Acceptable level of pain
Current and previous treatment and results of both
Impact of pain on individual’s physical and psychosocial functioning – ADLs and behaviors
94
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Pain Re-evaluations
Pain re-evaluations should be conducted for persons on routine medications or other non-pharmacological interventions based on the severity and chronicity of the pain.
• At least daily for response when starting a new medication
• At least weekly when well managed
95
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Pain Re-evaluations
Pain re-evaluations should be conducted before PRN pain medications are administered and after at peak effect of treatment.
Peak effect of treatment: Timing when a person experiences the highest level of pain relief from a given intervention.
96
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Pain Management Interventions
Interdisciplinary team approach:
Education
Frequent assessment with consistent use of validated pain scales
Pain medications and adjunct medications
Non-pharmacological interventions
Physician notification/communication97
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Analgesic Trials
Serial Trial Intervention (STI) www.geriatricpain.org
STI serves as a guideline for analgesic use when non-pharmacological interventions and other approaches have not been effective.
98
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Non-Pharmacological Interventions
Physical therapy
Routine exercise
Activities
Massage
TENS
Aromatherapy
Spiritual therapy
Comfort foods
Hot/cold therapies
Music therapy
Cryotherapy
Diathermy/ ultrasound
99
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Improving Outcomes
“One good thing about music, when it hits you, you feel no pain.”
- Bob Marley
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Improving Outcomes
Goal: Relief and control of pain.
Outcomes consistent with evidence-based best practice:
Implement the individualized interventions identified in the care plan
Monitor and evaluate the individualized interventions for effectiveness
101
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Evidence-based Best Practice SummaryAssessment
• Recognize each person’s cognitive and verbal abilities
• Use a language the person understands
• Complete comprehensive pain assessments on admission/readmission, change in condition and quarterly
• Re-evaluate the person’s needs based on the severity and chronicity of their pain
102
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Care Plan Process• Identify the source(s) of the pain
• Develop measurable goals based on the assessment
• Develop individualized interventions Outcome
• Implement the individualized interventions identified in the care plan
• Monitor and evaluate the individualized interventions periodically for effectiveness
Evidence-based Best Practice Summary
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Knowing My Pain - by Kathy
Pain-racked and unstable, Still, somehow, You see me as able. You see my cane as a toy, Used, not for need, But for ploy.
You are not in my body, My pain you cannot feel. How dare you tell me My pain is less real?
You may have pain, Others have pain as well. Pain is dealt with In many different ways. For some merely existing Can be a living hell.
So, think ere you tell me There's something I can do, Because you don't know The pain I'm going through, You're not me And I certainly am not you!104
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Resources www.AHRQ.gov. Agency for Healthcare Research Quality
www.CMS.gov. Centers for Medicare and Medicaid Services
www.fda.gov. Food and Drug Administration
Reference: “Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review” Dallas P. Seitz, et al. Int Psychogeriatr. Feb 2013; 25(2): 185–203.
Cheryl L.P. Vigen, Ph.D. et al. “Cognitive Effects of Atypical Antipsychotic Medications in Patients with Alzheimer’s Disease: Outcomes from CATIE-AD”. Am J Psychiatry. 2011 August ; 168(8): 831–839.
http://www.nursinghometoolkit.com/#!clinical/c7ax105
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Resources
“The association of psychotropic medication use with the cognitive, functional, and neuropsychiatric trajectory of Alzheimer’s disease” P. B. Rosenberg, et al. Int J Geriatr Psychiatry. Dec 2012; 27(12): 1248–1257
State Operations Manual Appendix PP @ https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
http://www.nursinghometoolkit.com/#!clinical/c7ax
Nursing Home Compare: www.medicare.gov
“Use of Antipsychotics among Older Residents in Veterans Administration Nursing Homes” WF Gellad, et al. Med Care. 2012 Nov; 50(11):954-60. 106
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Pain Management References American Medical Directors Association,
www.amda.com American Society for Pain Management Nursing,
www.aspmn.org American Geriatrics Society,
www.americangeriatrics.org International Association for the Study of Pain,
www.iasp-pain.org American Academy of Pain Medicine,
www.painmed.org American Academy of Pain Management,
www.aapainmanage.org Geriatric Pain: www.geriatricpain.org 107
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Additional trainings:
Alzheimer’s Disease & Dementia Care Seminar
Virtual Dementia Tour
Texas Taking the Next Step: Dementia in Long Term Care and Community Settings (Geriatric Symposium) –August 20, 2015 in Austin
TRAIN Big Bang Conference (not an official title) –November & December 2015 in 5 locations around the state
For more information: www.texasqualitymatters.org
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