Palliative Approach to Pain Management

in the Older Adult

Amy M Corcoran, MD CMD FAAHPM

Associate Professor

Geriatric and Palliative Medicine

Milton S Hershey Medical Center

College of Medicine, Penn State University

Disclosure

• Speaker has no conflict of interest, financial agreement, or working affiliation with any group or organization.

Objectives

• Define palliative approach• Describe pain assessment tools,

including those utilized for cognitively impaired and nonverbal patients

• Create case-based pain management plans for older adults

Palliative Care

• Holistic patient-centered care• Focus on symptom management –

physical, psychosocial, spiritual• Interprofessional team approach

http://www.who.int/cancer/palliative/definition/en/

Review Major Types of PainType Somatic Visceral Neuropathic

Characteristics -well-localized-dull or achy

-poorly-localized-deep, squeezing, pressure-like-associated with nausea, vomit, sweating

-severe-burning or vise-like-occasionally shooting

Patho-physiology

-arises from cutaneous or deep tissues (i.e. post-op pain or bone mets)

-arises from organ infiltration, compression, or stretching (i.e. MI, cholecystitis, bowel obstruction)

-arises from traumatic or ischemic injury to PNS or CNS or other nerve damage

Review Pain Assessment

• Requires repeat comprehensive assessments

• Older adults under-report pain”normal aging”

• How is it affecting function and daily life?• How do you pick what scale to utilize?

AGS Panel on Pharmacologic Management of Persistent Pain in Older Persons. JAGS 57:1331-1346, 2009

0 1 2 3 4 5 6 7 8 9 10

No pain

Worst pain

imaginable

Numerical Scale

0 Very happy, no

hurt

2 Hurts just a little

bit

4 Hurts a little

more

6 Hurts even more

8 Hurts a whole lot

10 Hurts as much as you can imagine (don't have to be crying to feel this

much pain)

Whaley L, Wong, D. Nursing Care of Infants and Children, ed 3, p. 1070. ©1987 by C.V. Mosby Company. Research reported in Wong D, Baker C. Pain in children: Comparison of assessment scales. Pediatric Nursing 14(1):9-17, 1988.

Other Components to Assess

• Spiritual• Psychosocial• Depression/anxiety• Misc

Scenario

90 year-old patient with advanced dementia. She is non-ambulatory, non-verbal, and requires assistance with all basic ADLS. Her nursing aide is concerned that she is in pain.

What types of questions would you ask her aide to assist with assessing her for pain?

Scenario

Her aide reports that she scores a 5/10 on the PAIN-AD. She makes facial grimaces with personal care and any movement. She is sometimes moaning and inconsolable.

Given her history of osteoarthritis, what would be the best choice for her pain management?

Overview of Nonopioid Analgesics:Appropriate for MILD Pain

• Acetaminophen• NSAIDs• COX-2• Tramadol

Given her age, what types of pharmacological concerns do you have when choosing your medications?

Review of Geriatric Pharmacotherapy

• Kidney• Liver• CNS• Protein Binding• Body Composition• Drug-drug Interactions

Scenario

78y/o in the hospital with recently diagnosed with metastatic breast cancer. Although NSAIDs have given her some relief with the pain, she feels pain “in her bones”. She is still experiencing 5-8/10 constant, sharp pain. She has normal renal and hepatic function.

Her primary physician gave her Percocet and she reports taking 4-6/day.

Do you have any concerns about NSAIDS in older adults?

She is still experiencing 5-8/10 constant, sharp pain. She has known bone metastases causing his pain.

What are your options for treating bone pain?

Bone Pain• Bone Mets

– NSAIDS– Bisphosphonates—pamidronate, zalendronic

acid– Radiotherapy (XRT)—strontium-89, samarium-

153-lexidronan– Steroids

• Acute Fracture– Bisphosphonates– Calcitonin

• Paget’s Disease– Bisphosphonates

Her cancer doctor gave her percocets and she reports taking 4-6/day. She is still experiencing 5-8/10.

How long does it take for opioids to take affect given the route of administration?

Review of the Opioid Basics

• Morphine• Hydromorphine• Oxycodone• Fentanyl transdermal• Methadone

What type of regimen would you start?

• Her cancer doctor gave her percocet (10/325) and she reports taking 4-6/day. Taking into account that his pain is moderate-severe (5-8/10) could increase dose by 50-100%.

• Approximately 50mg oxycodone/dayincrease by 50% to 75mg/day

• Oxycontin (long-acting) 40mg bid with oxycodone (short-acting) 10mg q3hours/prn

What type of preventive medications or measures should you always consider

when prescribing opioids?• Bowel regimen (senna at a minimum!)• Nausea prophylaxis?

She expresses concern about addiction or fear of tolerance

– now what do you do?

• What is addiction?• What is tolerance?• What is dependence?

She agrees to start the regimen and then develops diffuse itching after about 3 days

of the regimen….what do you do next?

What if there is a neuropathic pain component

or mixed-pain?

Neuropathic Pharm Review

• Tricyclic antidepressants (TCAs)

• Anticonvulsants• NSAIDs• Steroids

Scenario

70 year-old with stage IV lung cancer. He is comfortable on a continuous infusion of morphine at 6mg/hr IV on home hospice.

However, he is experiencing “jerking, shock-like movements” and “moderately severe” cramping pain.

What is happening? What are your management options?

What are some non-pharmacological methods to treat pain?

• Hypnosis• Hyperstimulation analgesia

– Ice massage– Acupuncture– TENS (transcutaneous electrical nerve stimulation)

• Dry heat• Hydrotherapy• Orthotic devices• Trigger point injections with lidocaine or steroid

Common Pitfalls in Older Adults

• Not using a quantitative pain scale• Not prescribing opioids for patients whose pain

levels are moderate to severe• Not providing aggressive bowel regimen• Not discontinuing medications that contribute to

sedation• Not scheduling around the clock medications• Not re-assessing clinically for effectiveness of

pain regimen• Not utilizing the interprofessional team

Which of the following are non-verbal pain indicators?

A. Facial grimace

B. Restlessness

C. Tachycardia

D. All of the above

Which of the following are common pitfalls in palliative pain management of the older adult?

A. Inconsistent use of a pain assessment tool

B. Forgetting to discontinue medications that could be contributing

C. Forgetting to order a bowel prophylaxis regimen

D. Not re-evaluating the effectiveness of the regimen

E. All of the above

Helpful References• AGS Panel on Pharmacologic Management of Persistent Pain in Older

Persons. JAGS 57:1331-1346, 2009• AGS Clinical Practice Committee: Management of cancer pain in older

patients. JAGS. 1997 (45): 1273-76.• Cafiero, Angela C. PharmD, CGP. Geriatric Pharmacotherapy. Geriatric

Secrets. 3rd Edition. Henly and Belfus, Inc. 2004; 29-35.• Feldt, Karen PhD RN. The Checklist of Nonverbal Pain Indicators (CNPI).

Pain Management Nursing. March 2000; 13-17.• Hadjistavropoulus T., et al. An Interdisciplinary Expert Consensus

Statement on Assessment of Pain in Older Persons. Clinical Journal of Pain. January 2007 Supplement. Volume 23 (1):S1-43.

• Kapo, Jennifer MD and Janet Abrahm, MD. Pain Management. Geriatric Secrets. 3rd Edition. Henly and Belfus, Inc. 2004; 87-94.

• Mercadante, S. and Fabio Fulfaro. Management of Painful Bone Metastases. Current Opinion in Oncology. 2007 (19):308-314.

• Pavlakis N. et al. Bisphosphonates for Breast Cancer (review). Cochrane Review. John Wiley and Sons. 2007.

• Upton et al. Population pharmacokinetic modelling of subcutaneous

morphine in the elderly. Acute Pain. 2006 (8);109-116.