Professor Trisha Dunning AM Recurrent pain Professor Trisha Dunning AM Chair in Nursing and Director Centre for Nursing and Allied Health Research, Deakin University and Barwon Health, Australia

Case history Mr XY has long standing type 2 diabetes and he requires insulin He has erectile dysfunction and cardiovascular disease Generally he is able to take good care of himself, but he requires some assistance to administer his insulin because his ‘eyesight is not what it used to be’ He drives short distances to the shops and to visit family His HbA1c 12 months ago was 9% (75mmol/mol) Mr XY presents with painful burning and tingling in his feet that keeps him awake at night Lives at home with his wife who helps with his insulin administration Mr XY has not visited his doctor or other health professional for 12 months

Key points about pain in older people Pain is : common in older people often undertreated usually multifactorial in origin always subjective Pain may be acute or chronic, the prevalence of chronic pain steadily increases with increasing age Persistent pain of long duration is often associated with psychological and social consequences including depression and compromises the ability to perform usual activities of daily living (ADLs) Older people may not report severe, chronic or excruciating pain There are many definitions of pain Pain perception is essentially personal and is affected by cultural perceptions of pain Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. The inability to verbally communicate does not negate the presence of pain (International Association for the Study of Pain 2011)

Key points about pain Pain originating from chemical, mechanical or thermal stimulation of peripheral receptors is likely to respond to: non-opioids non-steroidal anti-inflammatory (NSAIDS) Pain originating from damage to the peripheral or central nervous system may respond to centrally acting medicines such as: Tricyclic antidepressive and anticonvulsive agents Psychological pain is often present and is harder to detect an quantify. Mr XY might be concerned about his erectile dysfunction and the effects on his sexual health and wellbeing. Pain originating in the nervous system (NS) occurs more frequently in older people and has a worse prognosis than nociceptive pain NS pain is often described as burning, tingling, bursts of shooting pain or a mixture , which fits Mr XY’s description of his pain NS pain is less responsive to simple and opioid analgesia First line medicine treatment includes Tricyclic antidepressive agents but these are generally not recommended for people with cardiovascular disease (Mr XY has cardiovascular disease) Anticonvulsive agents such as Gabapentin are also first line treatment as are NSAIDs but they all have side effects, consequently the risks and benefits of the available medicine options for Mr XY need to be considered carefully

Assessment Undertake a thorough history, physical examination and psychological evaluation and evaluate the functional status, adherence to medicines, nutrition and fitness to drive Check renal and liver function, metabolic status, vitamin B12, vitamin D and folate Undertake a thorough medication review and ask about side effects and complementary/herbal medicine use Pain history and assessment of Mr XY: What the pain means to him Where the pain is, when it occurs, how long it lasts The symptoms Effect on sleep What prescribed and self-prescribed treatment he has tried and their effectiveness Whether he has had any falls Undertake a thorough foot assessment and neurological review of both feet Consider other cause of neuropathic pain such as alcohol-induced vitamin B12 deficiency Observing the person is an important part of the assessment to note functional capacity, gait etc that could be affected by the pain Pain rating scales such as PAIN AD, M-RVBPI, Abbey Pain scale can be used to determine the severity of Mr XY’s pain but should be interpreted in context including cultural context and other factors operating at the time the assessment is undertaken. See http://wwwbritishpainsociety/pub_professional.htm#assessmentpop for details about pain assessment Many older people regard pain as a normal part of aging and often become very stoical about the severity of the pain and under-report the severity of the pain, thus careful probing questions are important. In addition, older people with diabetes under-report the sensory and affective components of pain e.g. the so called ‘silent’ pain associated with myocardial infarction. Feet should be checked for trauma and infection and blood tests might be required to detect infection e.g. CPR, ESR and wound swabs if a lesion is present. Neurological foot check includes: nerve conduction studies X-Ray/MRI to detect Charcot’s changes Reflexes, but these are not reliable in older people Response to pin prick and light touch 10gm monofilament Check foot wear and ask about foot self-care

Management plan The management plan should be developed with Mr XY and his wife to ensure their goals are met Unnecessary or ineffective medication should be stopped. Analgesics should be prescribed while considering Mr XY’s renal and liver status as well as the risks and benefits to Mr XY of relevant analgesic medicines and potential interactions with his existing medicines. Pain management strategy: Start with simple analgesia and/or recommended first line tricyclic, anticonvulsive or NSAIDs e.g. Gabapentin 300-600 mgs/day Generally avoid medicines with a long half life Taking medicines on a regular dose schedule often results in better analgesia than taking analgesics ‘as needed’ Consider non-medicine option instead of/in addition to analgesics Exercises within Mr XY’s capacity It may be impossible to totally eliminate Mr XY’s pain He may worry about becoming dependent, having to stop driving and going into a nursing home or becoming a burden on his wife The risks and benefits of analgesic and other medicines and non-medicine pain management strategies must be carefully consider and explained to Mr XY and his wife Non-medicine options might enable lower doses of conventional medicines to be used, which improves medicine safety e.g.: Hydrotherapy Cognitive Behavioural therapy (CBT) Transcutaneous electrical nerve stimulation (TENS) Tai chi Yoga Exercise e.g. tai Chi, walking, yoga within the individual’s limits The home environment might need to be modified to improve safety e.g. reduce the risk of falls IV antibiotics might be required if infection is present and surgery might also be indicated

Management plan Refer Mr XY to a podiatrist for advice about appropriate foot wear and to a diabetes educator for foot self-care education Plan to manage any concomitant conditions such as depression and anxiety Consider whether testosterone replacement could improve energy and wellbeing Review blood glucose targets. Mr XY’s last HbA1c was 75mmol/mol, reducing it to around 64mmol/mol could contribute to pain management and help improve mood as well as reduce the risk of infection. Consider Mr XY’s need for support and determine whether any community services are likely to be beneficial Mr XY may need to stop driving OR develop a proactive plan to stop driving Develop a plan for regular foot assessment and metabolic review Depression is often associated with chronic pain and exacerbates the pain as well as leading to suboptimal self-care Educate Mr XX and his wife about how to manage his medicines and possible side effects, what to do if side effects occur e.g. Explain possible medicine side effects, when to report them and how to manage e.g. Tricyclics –dry mouth, confusion, postural hypotension and risk of falling, urine retention, and exacerbate glaucoma Gabapentin – dizziness, lethargy and peripheral oedema

Key points for clinical practice Pain is common in older people but the causes and consequences of pain are complex Likewise, pain assessment and management is complex and must be personalised and holistic Peripheral neuropathy and other neuropathies are common causes of pain in older people Pain is likely to have more than one underlying cause Chronic pain may cause/exacerbate depression and reduce quality of life and sleep quality Advanced care planning should be considered