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.
Identifying Pain in Advanced Cognitive Impairment
- Pain Assessment in Advanced Dementia Scale (PAINAD) – PDF
- Link to PAINAD MDCalc
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reminder of standard tools for gathering HPI
the WHO suggestion of codeine is a terrible suggestion and should be ignored!
o-v – ok
I wouldn’t use codein
clinicaly about 20% of population doesn’t have a enzimes to convert codein to morphine so we can be mislead with codein use and opioids needs
nice set goals
these are very long modules
pain scale is very good to manage pain
okay sounds good
many ways in assessing pain
pain management is a human right (Joint Commission)
U is my favorite; I like to get to the root of issues.
i like U and V in that pneumonic. It’s always been OPQRST for me
Important to start with least analgesia and increase in small doses especially if subtherapeutic.
Adjunct therapies like paracentesis would need to be considered.
i like de recommendation
I would definitely urgently image the 1st one and probably refer to rad onc for radiation. And potentially start steroids. The second one could probably be managed with therapeutic paracentesis. The 3rd would warrant a discussion with the family for sure. Most likely, aggressive pain management would be the choice there given that she is unresponsive.
Like the mnemo
are there any issues to be concerned about when using the WHO pain ladder among the elderly? Do NSAIDs appear in the WHO pain ladder when managing pain in the elderly?
Assessment and re-assessment with the WHO pain treatment model
The menmonic at top of page is good to apply in each of the cases.
Agree with Victor re the WHO pain model.
would need to know Mr Scacic’s goals of care, and his level of knowledge regarding his conditions
same for Mrs Mah and her family/POA has someone had the discussion with them?
the 3rd; does the family require any further support?
I would avoid Codeine and Morphine in these patients, given their age and co-morbidities they may have difficulties clearing the metabolites. Hydromorphone is a good parenteral drug and oxycodone would be a good oral choice.
For the first case i would be concerned about cord compression. Early diagnosis and surgery or radiation could preserve QOL, and gabapentin or pregabalin combined with the opioid would be the ideal pain management
My understanding is that recommended daily dose of acetaminophen in the elderly is 3g (divided)
As long as they are not heavily malnourished 4 g should be ok.
It is important to follow WHO pain treatment model.