Pain Management in Elderly Persons Case Studies UCLA Multicampus Program of Geriatrics and Gerotontology

Case Study #1 A graceful and delicate lady, 69 years old, has pain under her left arm. She first noticed it two days ago while trying on a new dress. Yesterday the pain became worse. She describes "sharp, like lightening" pain near her shoulder blade and traveling under her left arm and breast. It hurts when she raises her arm.

Case #1 Today, the pain is so severe she could not put on her bra or pull her dress over her head. She states she has never had anything like this. Her neighbor told her she probably has shingles.

1. What is the most likely cause of this patient’s pain (differential diagnosis)? 2. What is the physiologic mechanism of pain in this condition? 3. What is the natural history of pain in this condition? Case #1

4. What is the appropriate treatment in this case? A. Treatment for underlying disease? B. Pain Management strategy? Case #1

One month later, she returns. She is depressed, looks disheveled, and tired. She is still unable to wear a bra or dress. The pain remains intense. She now complains of extreme sensitivity of the skin over the healed rash. Anything that touches the skin "sets me on fire!".

Case #1 5. What are your recommendations now?

Case #1 The patient has been taking oxicodone 5mg (Percocet), two tablets every 6 hours. She describes good pain relief just after taking each dose, but it doesn’t last very long. She wakes from sleep with pain every night. Moreover, she describes breakthrough pain every four hours after she takes her usual dose. She has experienced no drowsiness, cognitive impairment, nausea or constipation as long as she drinks her prune juice every morning.

Case #1 6. What are your pharmacologic options to improve pain management at this time? 7. What issues should be considered in the initiation of sustained released opioid medications? 8. What is the equi-potent analgesic dose of sustained release oxycodone for this patient?

Equianalgesic Conversion A cancer patient is taking 2 Percocet every 4 hours. Calculate the initial starting dose of MS Contin based on equivalent analgesic potency. A cancer patient is taking 2 Percocet every 4 hours. Calculate the initial starting dose of MS Contin based on equivalent analgesic potency.

Equianalgesic Conversion First: Calculate the 24 hour dose of Percocet (2 tabs) (5mg) ) (6 doses/24 hr) = 60mg oxycodone/24hr Second: Calculate the 24hr oral morphine equivalents from potency table: 20mg oxicodone = 30mg oral morphine (60mg oxicodone/24hr) (30mg morphine / 20mg oxidodone) = 90mg oral morphine/24hr Third: Calculate the divided 24 hour dose for sustained release morphine 90mg / 2 = 45mg MS Contin q12h