Here are three of the many examples of painful conditions — acute, chronic, both — which older people present with. Think about what you would need to know about each one in order to decide how you would approach pain management.
78 year old man with prostate cancer and known bone mets; normally on Hydromorphone sustained-release, 12 mg BID; now in ED because of sudden increase in low back pain and intense paresthesias in both legs.
82 year old woman with early dementia living at home with known malignant ascites and steady increase in abdominal pain, in ED for pain management.
80 year old, advanced dementia, well-established advance directives of “full comfort measures only” in a nursing home. She has fallen out of bed. She has a fractured hip and pelvis and massive subdural hemorrhage and is unresponsive to any stimulus.
Assessment of Pain
It’s important to get a good pain history with particular emphasis on current treatment. One approach to a pain history is:
Quality (nociceptive, neuropathic, mixed)
Treatment (what are you currently taking: regularly? breakthrough? other strategies?)
Understanding by the patient of the cause (“it’s an infection”, “there’s nothing to do”, “it’s God’s punishment”
Value (what is the goal of intervening: complete eradication, to feel “a bit better”
Identifying the quality or type of pain is important when considering management options.
- The standard approach to analgesia is stepped and polymodal (see WHO Analgesic Ladder)
- Start with Acetaminophen at maximum dose (4000 mg per day in divided dose; NSAIDs in the older patient may cause more problems than they solve, but can be appropriate for short courses in select patients)
- Add opioids (in short- and long-acting formulations)
- Consider adjuvants (corticosteroids, antiepileptics)
- Consider physical therapies (heat, cold, positioning, massage), acupuncture, hypnotherapy
- Consider referrals for palliative radiotherapy or surgery
- Patients who are in the ED usually need expert administration and modification of their opioid dosing.