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Description : Check out this medical PowerPoint presentation titled "Pain - An introductory module for clinicians” by Paul S. Tumber, MD FRCPC.

This medical PowerPoint presentation is about pain management in older adults which can be complex because of age-related changes in the body, as well as the presence of other medical conditions that may affect how the body responds to pain medications.

Tags : pain management in older adults, chronic conditions, Geriatrics, Geriatric Medicine, Geriatrics PowerPoint presentation

Published on : May 09, 2023 | Views : 886 | Downloads : 0

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Slide 1-

Pain Paul S. Tumber, MD FRCPC Pain Management Consultant: UHN, Women’s College Hospital and Wasser Pain Clinic, Mt. Sinai Hospital Assistant Professor of Anesthesiology An introductory module for clinicians
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This module is part of the sfCare approach 2 PowerPoint Presentation 8.5 x 11 Poster Patient Handout
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Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Objectives Identify the physiologic changes in older adults that impact pain management Describe a structured approach to the detection of pain in older adults Give examples of non-pharmacological strategies for pain management in older adults Recognize considerations for pharmacotherapy use to treat pain in older adults Apply a senior friendly approach to pain
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Physiologic changes with aging* Body Composition increased fat / decreased body water Gastrointestinal System decreased gut motility Hepatic System decreased hepatic blood flow Pain Modulation impaired Renal System decreased creatinine clearance Nervous System loss of nerve fibres slowed nerve conduction velocity Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Musculoskeletal decreased muscle mass
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Challenges in the older adult Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References “Homeostenosis” Frail: impaired bio-psychosocial function Multiple comorbidities: Osteoarthritis Osteoporosis Dementia Diabetes Polypharmacy Drug interactions and adverse effects Increased sensitivity to certain medications (e.g., benzodiazepines)
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Organ function declines over time in normal, healthy humans, as indicated by Line 1. Chronic disease will accelerate this decline, as noted by Line 2. Acute disease will cause temporary, rapid but reversible declines, as shown by Line 3. Regardless of cause, reserve function is lost when organ function declines into the shaded area. Organ function declines over time Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Adapted from Bouchon22. Used with permission. Rivera, R. and Antognini, J.F. Perioperative Drug Therapy In Elderly Patients. Anesth 2009; 110: 1176-81
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Barriers to pain management in older adults Barriers encompass bio/psychosocial/spiritual issues Cost Caregiver burnout / transportation Impairments Mood Cognition Physical (falls) Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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Barriers to pain management in older adults (cont.) Barriers encompass bio/psychosocial/spiritual issues Attitudes and belief system: Tendency to under report pain / stoicism Catastrophizing, fear of injury, fear of impending loss of independence, death and hopelessness Poor compliance, addiction concern Health care: Polypharmacy Myths about pain treatments, including opioids Lack of knowledge or resources Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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How to assess pain …ask about F.I.F.E. (Feelings, Ideas, Function, Expectations) Iowa Pain Thermometer Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References NRS and Iowa Pain Thermometer reproduced with permission from Keela Herr, PhD, RN, AGSF, FGSA, FAAN, College of Nursing, University of Iowa, 2019. Numeric Rating Scale (NRS) Wong-Baker FACES Pain Rating Scale
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Ask the patient these F.I.F.E questions Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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Pain assessment in older adults with dementia Thomas Hadjistavropoulos, Keela Herr, Kenneth M. Prkachin, Kenneth D. Craig, Stephen J. Gibson, Albert Lukas, Jonathan H. Smith, Lancet. Dec 2014 Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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Pain assessment in older adults who can’t self report Consider causes of pain (e.g. nerve damage, arthritis) Observe patient behaviors (e.g. eating, walking) Use proxy reports (family, caregivers, etc.) Attempt a cautious analgesic trial (and observe the response to treatment) Herr, K et al. Pain Assessment in the Patient Unable to Self-Report: Position Statement With Clinical Practice Recommendations. Pain Manag Nurs 2011: 230-250 Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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How to manage pain Makris, U. et al. Management of Persistent Pain in the Older Patient. A Clinical Review. JAMA. 2014; 312(8): 825-836. Pharmacological Management of Persistent Pain in Older Persons. American Geriatrics Society, 2009. Physical strategies Psychological strategies Procedural interventions Pharmacotherapy There are four strategies for managing pain in older adults… Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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How to manage pain The mainstay of persistent pain management includes: Massage therapy Physiotherapy Physical activity Physical activity can reduce pain: Neuromuscular: decreased joint load, better joint stability, increased energy absorption by muscles Periarticular: flexibility, connective tissue health, bony mass Intra-articular: cartilage, reduced inflammation, improved joint nutrition General fitness: reduced comorbidity, weight loss, aerobic fitness, psychosocial wellbeing, placebo, improved self-efficacy Clin Geriatr Med 32 (2016) 737-762 Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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How to manage pain Exercise with a friend / group (YMCA, senior center, community) Calendar Set goals Smartphone fitness app / fitbit, etc. Vary the exercise type (resistance, aerobic, aquatic, walking route, etc.) Pick activities that the person enjoys Websites: American Geriatrics Society, Arthritis foundation, American Diabetes Association, Centres for Disease Control and Prevention, etc. Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References 1. Physical Strategies (cont.)
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How to manage pain Education. Reassurance. Support. Address misbeliefs: hurt does not equal harm Cognitive Behavioral Training Meditation / Mindfulness-Based Relaxation Shared Decision-Making Model Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References 2. Psychological Strategies
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How to manage pain Examples: Acupuncture Trigger point injections Joint injections Appropriate for a select population of older adults Limited role for persistent pain states Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References 3. Procedural Strategies
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How to manage pain Over-the-counter medications Opioids Pharmacotherapy for neuropathic pain Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References 4. Pharmacotherapy
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Over-the-counter How to manage pain Acetaminophen Well-tolerated (minimal adverse effects) Still considered first line agent for mild pain, osteoarthritis Ceiling effect on analgesia Maximum initial dose is 1000mg orally up to four times a day Chronic dosing should reduce to maximum 2500mg / day (especially for older adults) Beware liver toxicity if overdose, alcoholic, malnourished Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References 4. Pharmacotherapy Oscier and Milner. Perioperative use of paracetamol. Anaesthesia 2009; 64: 65-72
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Over-the-counter How to manage pain Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References 4. Pharmacotherapy NSAIDs All NSAIDS and coxibs inhibit the cardioprotective effects of ASA; thus avoid in patients at risk of heart attack or stroke All NSAIDs can cause renal dysfunction All NSAIDS and coxibs can cause peptic ulcer disease (less risk with coxibs), may need to add proton-pump inhibitor if long-term use or at risk population (older adult; using corticosteroids; prior history of ulcers; using anticoagulants or ASA, alcohol) May increase blood pressure or worsen CHF Karsh, J. Anti-inflammatory drugs: What is safe? CMAJ. 175(5) 2006; 449 BEWARE! Older adults are especially vulnerable!
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Over-the-counter How to manage pain Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References 4. Pharmacotherapy Karsh, J. Anti-inflammatory drugs: What is safe? CMAJ. 175(5) 2006; 449 BEWARE! Older adults are especially vulnerable! NSAIDs (cont.) Lowest dose Shortest duration consider drug holidays to allow GI / GU system to recover Assess analgesic efficacy Not indicated for neuropathic pain Protect from ulcers Monitor kidney function
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Opioids How to manage pain Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References 4. Pharmacotherapy “Opioid therapy for older adult patients can be safe and effective…” Lower starting dose Slower titration Longer interval between doses More frequent monitoring Tapering of benzodiazepines 2017 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, R17 Recommendation Statement
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Opioids How to manage pain Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References 4. Pharmacotherapy Reducing risk from opioid use: Educate patient and caregiver about signs of overdose, e.g. slurred or drawling speech, emotional lability, ataxia, nodding off… Avoid opioids in cognitively impaired older adults living alone, unless ongoing medication supervision can be organized Consider a three-day “tolerance check” Monitor renal function 2017 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, R17 Recommendation Statement
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Opioids How to manage pain Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References 4. Pharmacotherapy 2017 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, R17 Recommendation Statement Opioid prescribing cautions for the older adult: Start titration at no more than 50% of the suggested initial dose and lengthen time interval between dose increases Among strong opioids, oxycodone and hydromorphone may be preferred Morphine solutions are preferable to tablets in some situations (e.g. patients with swallowing problems) For older adults on benzodiazepines, try to taper the dose to reduce the risk of falls and cognitive impairment
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How to manage pain Neuropathic pain Moulin DE, et al. Pharmacological management of chronic neuropathic pain: Revised consensus statement from the Canadian Pain Society. Pain Res Manage 19(6) Nov/Dec 2014 Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Over-the-counter: NSAIDs 4. Pharmacotherapy
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How to manage pain Tricyclic Antidepressants Adverse Effects Common: dry mouth, drowsiness, confusion, orthostatic hypotension, urinary retention / prostatism, constipation, arrhythmia Amitriptyline: greatest anticholinergic side effects, possible weight gain, glaucoma Nortriptyline: least adverse cardiac arrhythmia risk, reduced anticholinergic side effects Desipramine: less sedation First line medications for neuropathic pain Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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Gabapentinoids for older adults START LOW GO SLOW Monitor closely and reduce dose (check creatinine clearance) Risks: cognitive impairment ataxia / falls weight gain, etc. Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References How to manage pain First line medications for neuropathic pain
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Serotonin Noradrenaline Reuptake Inhibitors Duloxetine is FDA-approved in diabetic neuropathy and fibromyalgia SSRI’s are not as useful in neuropathic pain Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References How to manage pain First line medications for neuropathic pain
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Cannabinoids Likely only have a modest effect on chronic pain CBD component is commonly used for pain management (avoid THC due to its psychoactive effects) Do not recommend smoking or inhalation route: more common use seems to be in form of CBD oil Problems include supply interruptions and lack of standardization of quality of the product Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References How to manage pain Third line medications for neuropathic pain
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Topical Lidocaine Mechanism of action: sodium channel blocker Most helpful is the 5% Lidocaine patch but this is not available in Canada and thus it is used as a 5-10% cream up to tid. Best indication is post-herpetic neuralgia, also can be used in cases of localized allodynia Lynch, ME and Watson, P. The pharmacotherapy of chronic pain: A review. Pain Res Manage 11(1) Spring 2006: 11-33. Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References How to manage pain Other topical agents that have been tried E.g. topical 10% ketamine, 5% amitriptyline, 10% gabapentin. Need compounding pharmacist: expensive Fourth line medications for neuropathic pain
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How to manage pain Topical capsaicin (chili pepper extract) Mechanism: reduces pain-related neuropeptides especially substance P, and causes degeneration of epidermal nerve fibres Need to use it 4 times a day for up to 6 weeks Compliance may drop off due to burning effect on skin May be used in cases of small joint arthritis, diabetic neuropathy Lynch, ME and Watson, P. The pharmacotherapy of chronic pain: A review. Pain Res Manage 11(1) Spring 2006: 11-33. Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Fourth line medications for neuropathic pain
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How to manage pain Lynch, ME and Watson, P. The pharmacotherapy of chronic pain: A review. Pain Res Manage 11(1) Spring 2006: 11-33. Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Topical NSAIDs (especially diclofenac) and topical rubefacients (various salicylate preparations) May be helpful for acute / localized musculoskeletal pain Topical diclofenac (Pennsaid) can provide pain relief in some cases of osteoarthritis Fourth line medications for neuropathic pain
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How to manage pain Reasonable intervals Document: Analgesia, activity, adverse effects, aberrant drug taking behaviors, affect (mood disorder), accurate medication log Helpful to have corroboration of efficacy from family, significant others, workplace, other healthcare providers including pharmacist Follow up for pharmacotherapy in pain management Gourlay D.L. et al. Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain. Pain Medicine 6(2) 2005; 107-112 Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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Remember: Ask about pain regularly and assess pain systematically (do not “set and forget”) Believe the patient and family in their report of pain, and relieving factors Choose pain control options appropriate for the setting, patient and family (think multimodal) Deliver interventions in a timely, logical and coordinated fashion (team approach) Empower (educate) patients and families to take control as much as possible Carr, Eur J Pain 2001 Frenette, Crit Care Clin, 1999 Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References How to manage pain
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Summary Consider the outcome of the pain management plan: Reduction in pain Minimization of adverse effects / risk Improvement in activity (leisure, socialization, mobility) Improved quality of life / well-being / satisfaction Reduced polypharmacy / health care utilization / cost Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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The senior friendly approach Ask leaders to remove barriers to care, and provide education for staff, patients and caregivers. Pain is not due to age! Treat pain as you would for adults of all ages. Always assess for and treat pain in adults with cognitive impairment. Remove barriers such as transportation or cost of non-drug therapies and medications. Make the environment comfortable. How all healthcare providers can address pain using a senior friendly care approach Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References Organizational Support Emotional & Behavioural Environment Ethics in Clinical Care and Research Physical Environment Processes of Care Organizational Support Ethics in Clinical Care and Research Processes of Care Emotional & Behavioural Environment Physical Environment
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What are some of your barriers to pain management in older adults? What is one pain management strategy you might start using after going through this module? How can each member of your interprofessional team contribute to pain management? Discussion questions Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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American Society Geriatrics (2009) Pain Management in Elderly Guidelines Fine, Perry G. Treatment Guidelines for the Pharmacological Management of Pain In Older Persons. Pain Medicine 2012; 13: s57-66 www.geriatricpain.org [U of Iowa] www.healthinaging.org [AGS] National Institute on Aging National Center on Caregiving CDC and Prevention References Objectives Pain management in older adults How to assess How to manage Summary Senior friendly approach Questions References
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The sfCare Learning Series received support from the Regional Geriatric Programs of Ontario, through funding provided by the Ministry of Health and Long-Term Care. V1 July 2019