Pain

Pain Issues
Issues and
and the
the Elderly
Elderly

Dr. Ann M. Berger, MSN, MD

Chief, Pain and Palliative Care
National Institutes of Health, Clinical Center
Acute vs. Chronic Pain
Acute Chronic
time course-transient vegetative
features-fight or flight Sleep disturbances
pupillary dilatation anorexia
sweating decreased libido
increased RR anhedonia
increased HR constipation
Increased shunting of Somatic pre-occupation
blood from Personality change
viscera to muscles lethargy
 Pathophysiologic
Mechanisms of Pain
Type Cause Characteristics
Somatic Nociceptor activation Aching or gnawing,
localized
Visceral Nociceptor activation Aching, vaguely
localized, often
referred

Neuropathic Destruction of a nerve Severe or dull

shooting pain on
background of burning,
aching sensations
Pain In the Elderly

• Prevalence in population based studies in

those 65+ are from 55%-86%.
 Step III
Step II

Step I: Mild Pain Step I

• OTC, non-opioid, and adjuvant

medications
• Common medications:
– Aspirin, acetaminophen, ibuprofen, naproxen,
Trilisate, COX-2 anti-inflammatories
– ketorolac (Toradol): IV or PO (< 5 days)

*
Step II: Moderate Step III
Step II

Pain Step I

• Opioid medication
– With/without adjuvant analgesics
– Common medications:
• Hydrocodone, oxycodone, tramadol (Ultram)
• Duration= 3-4 hour, (except may have longer
relief with tramadol)
• Common combination drugs: Tylenol #3, Percocet,
Roxicet, Oxycet, Vicodin, Lortab, Lorcet, Fioricet.
 Step III
Step II
Step III: Severe Step I

Pain
• Short acting opioids:
– For acute pain, rescue dosing, or titration of long acting
agents
– Common: Dilaudid, morphine sulfate IR, Roxanol, ACTIQ,
oxycodone

• Long acting:
– requires titration of short acting opioids
– Provides consistent 24 hr therapeutic blood levels
– 8-12 hrs: Oxycontin, MS Contin, Oramorph, methadone (long
t1/2 with shorter analgesic effect)
– 48-72 hrs duration: Duragesic
Opioids for Moderate to
Severe Pain
Long Acting
• Morphine (MS Contin, Oramorph SR,
Kadian
• Oxycodone (Oxycontin)
• Fentanyl (Duragesic)
• Methadone (Dolophine)
• Levorphanol (Levo-Dromoran)
Oxymorphone
Opioids for Moderate to
Severe Pain
Short Acting
• Morphine (Roxanol, MSIR)
• Oxycodone (Roxicodone, Oxy
IR)
• Fentanyl (Actiq)
• Hydromorphone (Dilaudid)
Oxymorphone
Management of Common
Opioid Side effects
• Constipation
- prophylactic use of laxatives and stool softeners
• Nausea and vomiting
- neuroleptics, metoclopramide, cisapride,
antivertigenous drugs
• Sedation
- discontinue other CNS depressants
- add psychostimulants
• Respiratory depression
- monitor if not severe; carefully titrate naloxone
if severe
Tolerance:
• pharmacological need to increase dose to
achieve the same effect over time in the
absence of advancing disease. Tolerance is
usually not problematic in chronic analgesic use.

Physical dependence:
• class-specific, predictable psycho-physiological
reaction to sudden cessation or blocking of a
drug. A tapering regimen will mitigate or stop
withdrawal.
Addiction
• overwhelming preoccupation with acquisition
• use of drug for non-medicinal purposes
• results in reduced quality of life and continued use
despite harm.
• Fewer than 0.1% of acute/chronic pain medication users
develop addiction behaviors (Jick, Portenoy).

Pseudo-addiction
• aberrant or illegal drug-seeking behavior similar to
addiction that is due to unrelieved pain, which stops
when adequate pain relief is achieved.
Neuropathic Pain-
Adjuvant Analgesics
• Tricyclic antidepressants
• Anticonvulsants
• Clonidine
• Corticosteroids
• Local anesthetics-Mexilitene
• Ketamine
• Baclofen
 Nature of Pain
Neuropathic
Mechanism
Somatic,Visceral Psychosocial
Nociception Influences
Pain
Psychological Total
State and Traits Spirituality
Pain
Loss of Work Suffering Social / Family
Functioning
Physical
Financial Concerns Fear of Death
Disability
Emotional Pain “ hurts all over”
Most common palliative care symptoms
Anxiety; may present as sleeplessness,
reluctant to be left alone or overt fright
Anticipatory Anxiety; previous negative
experience becomes overwhelming
Treatment: relaxation & imagery,
acupressure, massage, music therapy,
hypnosis…. then maybe pharmacotherapy
such as lorazepam, haloperidol
Emotional Pain;
Care Giver Burden “ communication,
communication, communication”
Spirit of cooperation
Complex family dynamics emerge
Support to work through accumulated emotions
Can not take away all of the symptoms all the time
Imposing own expectations
Sense of presence is the very best medicine
Spirituality
The part of self where search for meaning
takes place.

Distinction between religion and

spirituality

Intimate connection with life through

family, home, friends, leisure and work
 It
It takes
takes aa nurturing
nurturing interdisciplinary
interdisciplinary team
team to
to
practice
practice the
the nature
nature of
of palliative
palliative care
care
Recreational Therapy Thanatology
• Relaxation Core Team • Grief Counseling
• Stress Management • Comprehensive • Family Support,
• Pet, Music, & Art Therapy Assessment End-of-Life Issues
• Coordinate Interventions Co-morbidity
Treatment • Community Transition
• Discharge Planning Concomitant
Regimen
Disorder
Rehabilitation Complementary
• Functional Interventions Symptoms Clinical • Acupuncture/
• Assistive Devices
Disease
Trials Acupressure
• Energy Conservation Process • Tai Chi
Protocol
• Trigger Point Release
Individuals’
Quality of Life
Social Work SpiritualMinistry
• Socioeconomic Support Psychological Spirituality
• Community Resources • Pastoral Presence
Predisposition • Prayer
• Coping Skills Suffering • Hope & Peace
Roles and
Level of
Relationships
Function Nutrition
Isolation
Pharmacy • Satiety, Dysphagia
• Pharmacological Counseling Economic • Nausea
• Equianalgesia Grief Emotional • Intake Modification,
Burden
• Adjuvant Agents State TPN/Tube Feedings
Massage
A simple form of therapy with the potential of restoring
physical, emotional & spiritual well-being

• Relaxation • Replenishes energy

• Eases muscular tension, • Improves plasma & lymphatic

stiffness & pain circulation

• Promotes communication • Strengthens & tones muscles

• Lessens feeling of isolation, • Stimulates or calms functions

tactile stimulation of the nervous system
Electro Therapeutic Point
Stimulator
• Applies concentrated low frequency
stimulation to acutherapy points,
biochemical response, contracted motor &
trigger points

• Used to provide immediate or chronic pain

relief and decrease muscle tonicity
Transcutaneous Electrical Nerve
Stimulation (TENS)
• Blocks pain by directing a stimulating
current into local nerves
• Uses high-frequency signals
• At low frequencies, reduces pain by
stimulating acupuncture and trigger points
 Methods of Relaxation

Used to modify behavior, perception, feelings or

internal psychological state

• Centering • Passive & Progressive

Muscle Relaxation
• Breathing
• Stretching/Movement
• Meditation
• Affirmations
• Guided imagery
• Desensitization
• Visualization
Yoga

• Focuses on the physical & mental practice

of binding mind, body & spirit with
controlled movement

• Used to ease muscle tension, improve

flexibility, strength, balance & endurance
…increasing body awareness
Vibroacoustic Chair

• Delivers auditory & tactile vibrations to the

body to areas of greatest bone
conductivity

• Used to relieve symptom burden

Biofeedback

• Provides guidance for the validation of &

direct feedback to bodily processes
(peripheral body temperature, EMG, skin
conduction)

• Used for relaxation and self-regulation

Hypnosis
• Develops a purposeful altered state of
consciousness through focused attention
(responsiveness to suggestion, ability to
dissociate through time & space)

• Used to accomplish difficult psychophysical

changes
Acupuncture

• Therapeutic insertion of needles in

patterns at acupuncture points to
encourage the flow of energy (qi)

• Manual or electrical stimulation used to

elicit local & generalized effects
Acupressure

• Ancient Chinese healing method that

involves applying pressure to one or more
of the 14 meridian points…areas that carry
energy throughout the body

• Meridians start at the finger tips, connect

to the brain, then to the organ associated
with the specific meridian
Reiki

• Utilizes a universal energy healing system

that is applicable to all purposes,
conditions or situations

• Used for whole body energy balancing,

healing, well-being & maintaining immune
system integrity
Finger Labyrinth
• A replica of a walking Labyrinth, used as
a spiritual tool for meditation with the
aims of……

1. Releasing: as you enter, quiet the mind by focusing

on your breathing & sensing your finger on the path
2. Receiving: pause in the center, reflect where you are
in your life & ask for guidance
3. Renewal: as you exit, reconnect with universal life &
reflect on a positive quality you want to bring into your
life, allowing the guidance to lead you
Mandala
• An artistic design often used in meditation for
centering, focusing & contemplation
• A spiritual tool for creating symbolism, relating to the
relationship of one’s soul to the universe
• A means that allows the patient to explore self-
understanding, as a path to healing
- the center of the circle represents the most important thing in
your life
- surround the center with concentric circles, using symbols for
your life & symbols of that which threatens or protects you
- the outer circle represents the absolute boundary of the
universe as you know it
Animal –Assisted Therapy

• Designed for goal-directed interventions by

companion animals from the National Capital
Therapy Dogs

• Used to reduce the negative impact of a

medical environment, improve tactile
stimulation, maintain/improve social skills &
increase physical movement
Art Therapy

A supportive venue of psychotherapy that

enables the patient to break the barriers of
inhibition, while promoting emotional
expression & healing through non-verbal
means.
Music
• Incorporates active & passive experiences of
listening, participation, life review, lyric analysis,
song writing and toning *.
* Toning is the elongation of a note/tone from the voice, aimed at a
specific area of the body. The body has a relaxation response when
toning is applied to certain conditions such as localized pain, nausea
or constipation. It also has a soothing effect for emotional pain &
suffering.

• Used to achieve/maintain optimal physical,

emotional, spiritual & social well-being, as well
as enhancing communication
 Considerations in Complementary
Therapies
• Initiate one modality at a time
• Re-evaluate for effectiveness
• Therapies may have interactions;
synergistic use of Reiki and Hypnosis but
not Reiki and Acupuncture
• Complimentary therapies often require a
series of treatments, such as 6 to 12
sessions of Acupuncture
Take Back to Practice
Palliative Intervention
Early
Available
Integrative
Reassurance

To our patient-Heroes disguised as ordinary people

going on an extraordinary journey !

…and they lived at peace each day they had………