Pain Management

in
Postsurgical Geriatric Patients
CPD
Pain Manangement
IDSAI
Objectives
Problem in post-operative geriatric
patients
Pain pathway
Pain management in postoperative
geriatric patients
Definition of Pain
(International Association for the Study of Pain)
An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage, or described in terms of
such damage

From the Latin root poena which
means punishment
Physiological effects of Pain
Increased catabolic demands:
poor wound healing
Weakness
muscle breakdown
Decreased limb movement : increased risk of DVT/PE
Respiratory effects:
shallow breathing
Tachypnea
cough suppression increasing risk of
pneumonia and atelectasis
Increased sodium and water retention (renal)
Decreased gastrointestinal mobility
Tachycardia and elevated blood pressure

Psychological effects of Pain
Negative emotions:
Anxiety
Depression
Sleep deprivation
Existential suffering:
May lead to patients seeking active end of life.
Immunological effects of Pain
Decrease natural killer cell counts
Effects on other lymphocytes not yet defined.
Increase the possibility of infection
Potensial problems of geriatric patients
Aging is associated with declining
physiologic reserves and an increased
susceptibility to disease
In the eldery : physiologic reserve used to
maintain homeostasis
Increase demands of surgical stress or
acute illness reserve no longer present
imbalance between demands and
reserves organ failure may result
Potensial problems of geriatric patients
Cardiac :
Progressive decrease in the number of myocyte and
increase in collagen content decrease in
ventricular compliance
Autonomic tissue is replaced by conective tissue, fat,
and fibrosis caused abnormalities of conduction
system ( sick sinus syndrome, atrial arrhythmia,
bundle branch block )
Progressive stiffening of the outflow tract and great
vessels increase systolic BP, increased
resistance to ventricular emptying, and
compensatory ventricular hypertrophy


Potensial problems of geriatric patients
Cardiac :
Resting cardiac output, and ejection fraction are
maintained
Maximal heart rate, maximal aerobic capacity, peak
exercise cardiac output, and peak ejection fraction
decrease with increasing age
In young age during exercise CO maintained by
increasing HR caused by sympathetic outflow
In elderly hyposympathetic state in exercise
CO maintained by increasing ventricular filling
( preload ) and stroke volume
Minor hypovolemia can result in significant
compromise in cardiac function
Potensial problems of geriatric patients
Cardiac disease is the most common
comorbid condition
In the Framingham Heart Study:
In the age 75 84 years myocardial
infarction was unrecognized ( silent ) in >
40% of patients compare to < 20% in the
age 45 54 years
In the elderly MI frequently present with the
symptoms of shortness of breath, acute
confusion, stroke ( and not chest pain )
Potensial problems of geriatric patients
Respiratory
Progressive decrease in :
Chest wall compliance ( structural changes and
kyphosis and vertebral collapse )
Strength of respiratory muscle cause Maximum
Inspiratory and Expiratory force decrease by 50%
Loss of elasticity of the lung increase alveolar
compliance and collaps of small airway
Leads to ventilation perfusion mismatch decline in
PaO2 0.3 0.4 mmHg/per year
The control of ventilation ventilatory responses to
hypoxia and hypercapnia fall by 50% and 40%
The loss of cough reflexes predisposed to
aspiration
Progerssive decrease in T cell function leads to
infections



Potensial problems of geriatric patients
Renal
Between 25 85 years old 40% of the
nephrons become sclerotic
The remaining functional unit become
hypertrophy in a compensatory manner
RBF falls by 50%
Decline in GFR ; 45% in the age 80 years
Creatinin clearance decline 0.75cc/min per
year

PAIN THRESHOLD WITH AGING
Author Stimulus Threshold
Shumacher, 1940 Thermal No Change
Birren, 1950 Thermal No Change
Sherman, 1964 Electric/Tooth Higher
Collins, 1968 Electric/Skin Lower
Harkins, 1977 Electric/Tooth No Change
Tucker, 1989 Electric/Skin Higher


Age Related Differences in Sensory
Receptor Function
Encapsulated end organs
50% reduction in Pacinis
10-30% reduction Meissners/Merkels
Disks
Free nerve endings
no age change
Age Related Differences in
Peripheral Nerve Function
Myelinated nerves
Reduction in density (all sizes including small)
Increase in abnormal/degenerating fibres
Decrease in action potential/slower
conduction velocity
Unmyelinated nerves
Reduction in number (1.2-1.6un) not (.4un)
Substance P, CGRP content decreased
Neurogenic inflammation reduced
Age Related Differences in
Central Nervous System Function
Loss of dorsal horn spinal neurons
Altered endogenous inhibition, hyperalgesia.

Loss of neurons in cortex, midbrain, brain stem
(18% reduction in thalamus, no change
cingulum cortex)
Altered cerebral evoked responses (increased
latency, reduced amplitude)
Reduced catecholamines, acetylcholine, GABA,
5HT, not neuropeptides
NOCICEPTION
PAIN
SUFFERING
PAIN BEHAVIOR
Postoperative
pain
Pain has several detrimental effects in older
persons
Physical / functional
Increase morbidity and worsen
the existing comorbidity
CVS morbidity
Delayed wound healing
Increase risk of infection
sleep disruption
appetite disturbance
weight loss
cognitive impairment
limitations in performance of
daily activities
Global
quality of life
poorer health status
use health care services
Psychosocial
depression
suicide risk
anxiety
social isolation

Sensitization of Pain Transmission
Pain transmission system can be sensitized
by noxious stimuli.
Explains many chronic pain syndromes
where pain perception is distorted
Allodynia - lowering of pain thresholds to
normally non-noxious stimuli
Hyperalgesia - lowering of pain thresholds to
noxious stimuli
Secondary hyperalgesia - spread of pain and
hyperalgesia to uninjured areas
Spontaneous pain - pain in absence of
noxious stimulation, pain memory

Peripheral
sensitization
to pain:
Hyperalgesia
increased sensitivity to
an already painful
stimulus
Allodynia
normally non painful
stimuli are felt as
painful
Strategy in Postoperative Pain Management
Preemptive strategy
Balance analgesia multimodal approach
Consider pharmacodynamics and
pharmacokinetics of the drugs used in pain
management
Assessment and evaluation of the treatment
effect
Early intervention to under-treatment and side
effect
Narcotics
Sustained Release
ATC
Immediate Release
PRN
Nonsteroidal
anti-inflammatory
Non-narcotic
analgesic
Multi-modal
approach
The Concept of post operative acute pain
treatment and rehabilitation.
From Kehlet H : Modification of responses to surgery by neural blockade : Clinical implication
( Critical care clinics 1999)
Pre-Op Education, Preparation,Planning
Pre and Intra-Op Analgesia and Physiological
Stabilization
Post-Op
Analgesia
Acute
Rehabilization
Drug Modalities
Spinal Route first 24-48 hrs
Early deletion of Opioids
Non Drug Modalities
Surgical care
Local (eg. Wound, avoidance of tubes )
General ( eg. CVS, respiratory, metabolic,
nutrition - early use of oral route )
Physical and mental Reactivation
Emphasis on spinal/epidural
Regional where appropriate
1) Geriatric
Postoperative Pain Management in Elderly
Pain is better managed with combination of
- medications - educational programs
- physical therapy - social interventions
- psychological methods - complementary therapies
Must be adapted to their specific needs
Older person and his/her family must be involved in
every step of the pain management plan
Effective treatment of pain in older persons requires
expertise in pain medicine combined with advanced
knowledge of older persons medical and psychosocial
characteristics
Postoperative Pain Management in Elderly
Evaluation requires multifaceted and
comprehensive assessment
- pain characteristics
- other medical illnesses
- pain impacts
- cognitive functions
- utilization of coping strategies
- functional status
- beliefs and attitudes toward pain
- social situation and support

The most reliable indicator of
the existence pain and its
intensity is the patients
description.
Assessment and
Evaluation of Pain
intensity
MISCONCEPTIONS ABOUT PAIN
Myth: If they dont complain, they dont have pain

Fact: There are many reasons patients may be
reluctant to complain, despite pain that
significantly effects their functional status and
mood.
REASONS PATIENTS MAY NOT
REPORT PAIN
Fear of diagnostic tests
Fear of medications
Fear meaning of pain
Perceive physicians and nurses too busy
Complaining may effect quality of care
Believe nothing can or will be done
Postoperative management in the elderly
Existing of multiple medical and
nutritional problems, and take several
different medications
treatment with analgesics limited due to
risk of adverse effects and problems with
complex drug interactions
Older persons with dementia or
communication problems are even more
at risk
Postoperative management in the elderly
likelihood of atypical pain presentations
due neurologic degeneration
Under-report of pain
Misinterpretation of physical sensations
Difficulty using standard pain assessment scales
False beliefs about pain and its management
Lack of scientific evidence to support treatment
approaches
Local
Anesthetic /
regional block,
epidural
Transmision
Modulation
Opioid
Presynaptic fiber
Substance P, glutamat, neurokininA,
peptide,CGRP
NMDA
AMPA
Wind Up allodynia
hyperalgesia
Dorsal Horn
medula spinalis
Elderly postoperative pain management
Opiat
Respiratory depression iv > im > oral GI
absorbtion ?
Dose titration is important iv is more
predictable
Opiat epidural more effective : use short
acting opioid
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
12.00 16.00 20.00 24.00
Sedation/side
effect




Analgesia





Pain
T i m e (hour)
Analgesic
drug
concen-
tration in blood
THEORETICAL THERAPEUTIC
WINDOW
PHARMACOKINETIC GOALS
HOURS
PAIN
NO PAIN
SIDE EFECTS
Epidural analgesia local anesthetic and
opiat
Epidural analgesi local anesthetic and opiat
Limiting the dose of opiat to provide analgesia
Excelent analgesia
Long lasting
Minimal stress response
Side effect :
Local anesthetic :
Sympatethic respons
Diastolic dysfunction preload dependent
Volume maldistribution
Opiat :
Respiratory depression
The Ten Basic Principles of
Pain Management

1. Believe the patients report of pain
2. Assess and reassess the patients
response to pain interventions
3. Do not be afraid of prescribing or
administering opioid analgesics.
4. Do not prescribe inadequate amounts of
any analgesic.

Contd
The Ten Basic Principles of
Pain Management

5. Do not use the analgetic PRN for
continuous pain, but ATC (around the clock)
6. Reassure the patient and family that risk of
opioid addiction is rare
7. Provide support for the whole family
8. Do not limit modality of approach simply to
the use of analgesics, but also adjuvant
drugs and mind-body techniques.

The Ten Basic Principles of
Pain Management

9. Prevent or treat side effects of opioids
10. Do not be afraid to ask colleagues advice.


References
Rosenthal RA,Kavics SM. Assessment and management of the geriatric
patients. Critical Care Medicine 2004;32:S92 S105
Bandolier Extra. Evidene based health care. February 2003
Beilin B, et al. The effects of Postoperative pain Management on Immune
Response to Surgery. Anaesthesia Analgesia 2003;97:822 827
Rabah DM, et al. Postoperative Pain Current management concepts.
Contemporary Urology Archive; August 2003: 1 11
Karani R, et al. Systemic Pharmacologic postoperative pain management in
the geridatric orthopaedic patients. Clinical Orthopaedics and related
research, 2004: 425; 26 34.
Vaurio LE, et al. Postoperative Delirium : The Importance of pain and pain
management. Anaesthesia and Analgesia 2006; 102: 1267 1273.
Levine WC, et al. Anesthesia for the elderly: selected topics. Current
opinion in Anaesthesiology. 2006;19:320 324
Wu CL, et al. Postoperative pain and quality of recovery. Current opinion in
Anaesthesiology. 2004; 17: 455 460
Auburn F, et al. Presictive factors of severe postoperative pain in the
postanaesthesia care unit. Anaesthesia Analgesia 2008; 106:1535 1541
Chia YY. Et al. Does postoperative pain induce emesis ?. The clinical
Journal of pain 2002; 18: 317 323.
Atanassoff P. Effect of regional/ epidural anaesthesia on perioperative
outcome in high risk patients. contemporary surgery @doedenhealth.com
Modified from Twycross, R: Practical Palliative Care Today. Spring 2000, Vol. 2. Center for
Palliative Studies at San Diego Hospice, San Diego.