1. Russell W. Lake, MD CPT MC USA Department of Family Medicine DD Eisenhower Army Medical Center 8 JUL 2009

2. What is pain?  The body’s way of telling you something is wrong  It can be good!  It is associated with emotions  Affects 25-50% of older adults living in the community  Affects 45-85% of older adults in long- term care facilities Pain Management in Older Adults 8 JUL 2009

3. What is pain?  Acute pain A signal to you that the body is injured Resolves when body heals Usually less than 3 months  Chronic pain Greater than 6 months after body heals Lower self-esteem Depression Anger Pain Management in Older Adults 8 JUL 2009

4. What is pain?  Nociceptive pain Stimulation of pain receptors Mechanical, chemical, thermal stimulation  Neurogenic pain Damage to central nervous system Peripheral neuropathy, phantom limb syndrome, neuralgia, strokes Pain Management in Older Adults 8 JUL 2009

5. Why pain? Diseases ○ Cancer ○ Arthritis ○ Migraines ○ Back problems ○ Diabetes Injury ○ Falls ○ Accidents ○ Surgery Pain Management in Older Adults 8 JUL 2009

6. Reports of pain  Some are reluctant to report pain Believe it is necessary or inevitable Fear of being judged Don’t want to be a “complainer” Not important compared to other problems  Some may be unable to report pain Hearing, speech, and/or visual impairments Cognitive impairments Pain Management in Older Adults 8 JUL 2009

7. How pain is described  Dull – slow or weak, not sudden or strong  Throbbing – surges, beats or pounds  Steady – does not change in intensity  Sharp – intense, causing mental or physical distress  Acute – lasts a short period of time  Chronic – present for long periods of time  Breakthrough – occurs between doses Pain Management in Older Adults 8 JUL 2009

8. What else should you tell your doctor?  Keep a diary  Date  Time  Pain scale rating  Type and dose of medication  Time pain medication was taken  How pain responded to medication  Other pain relief methods attempted* Pain Management in Older Adults 8 JUL 2009

9. How doctors diagnose pain  Physical examination  Imaging X-ray Computerized tomography (CT or “CAT scan”) Magnetic resonance imaging (MRI)  Pain scale  Stimulation tests Pain Management in Older Adults 8 JUL 2009

10. How is pain treated?  Acute pain Treat the cause ○ Infection, trauma NSAIDs Analgesics  Chronic pain Medications Nonpharmacologic treatment Pain Management in Older Adults 8 JUL 2009

11. How is pain treated?  Medications Given by ○ Mouth ○ Injection into muscle (IM) or under the skin (subcutaneous) ○ Through a needle into the vein (IV) ○ Through a catheter in the space around the spinal cord (epidural) ○ Through a patch ○ Implanted (pain pump) Analgesics (for mild to severe pain) Sedation (usually during a procedure) Anesthesia Topical anesthetics Pain Management in Older Adults 8 JUL 2009

12. How is pain treated?  NSAIDs  Non-narcotic analgesics  Narcotic analgesics  Anti-anxiety medication  Anticonvulsant medication  Antidepressants  Muscle relaxers  Sedatives  Steroids Pain Management in Older Adults 8 JUL 2009

13. How is pain treated?  NSAIDs Non-steroidal anti-inflammatory drugs ○ Traditional Aspirin Ibuprofen (Motrin ®, Advil ® ) Naproxen (Aleve ® ) ○ COX-2 inhibitors* Celebrex Reduce levels of a hormone-like chemical called prostaglandins Pain Management in Older Adults 8 JUL 2009

14. How is pain treated?  NSAIDs Side effects ○ Upset stomach, dyspepsia, ulcers, prevention of platelet clumping, kidney damage ○ Increased incidence of blood clotting* Who shouldn’t take ○ Cardiovascular disease* ○ People who are allergic to aspirin ○ If you have a bleeding disorder or take blood thinning medication (Coumadin, Plavix) ○ Liver or kidney disease ○ Stomach ulcer or GI bleeding ○ 3 or more alcoholic drinks per day Pain Management in Older Adults 8 JUL 2009

15. How is pain treated?  Acetaminophen (Tylenol ® ) Analgesic ○ Stops or reduces pain message from being received in brain Both over the counter (“OTC”) and prescription medications may contain acetaminophen Side effects ○ Liver damage Who shouldn’t take ○ If you are taking other medications with acetaminophen ○ If you have liver disease ○ If you have 3 or more alcoholic drinks per day Pain Management in Older Adults 8 JUL 2009

16. How is pain treated?  Narcotics From the Greek narkotikon: “making stiff or numb”  Opiod medications Block your body’s ability to communicate pain Side effects ○ Nausea, sedation, constipation ○ Tolerance, respiratory depression ○ Euphoria Pain Management in Older Adults 8 JUL 2009

17. What’s the big deal?  Tolerance Requires increasing dose for same effect ○ Applies to pain relief or euphoria ○ Does not apply to respiratory depression  Misuse Any use other than that agreed upon by you and your doctor  Physical dependence Withdrawal symptoms with cessation ○ Restlessness, muscle or bone pain, insomnia  Addiction Craving that drives a person to take a medication despite harm Pain Management in Older Adults 8 JUL 2009

18. How is pain treated?  Anti-anxiety medication  Anticonvulsant medication  Antidepressants  Muscle relaxers  Sedatives  Steroids Pain Management in Older Adults 8 JUL 2009

19. How is pain treated?  Special considerations in older adults Differing metabolism ○ Medications may take longer to be cleared from the body Medication interactions Pain Management in Older Adults 8 JUL 2009

20. How is pain treated?  Nonpharmacologic treatments Smoking cessation Education Hypnosis Comfort therapy Physical and occupational therapy Neurostimulation Pain Management in Older Adults 8 JUL 2009

21. How is pain treated?  Nonpharmacologic treatments Smoking cessation Education ○ Procedures ○ Expectations Hypnosis Comfort therapy Physical and occupational therapy Neurostimulation Pain Management in Older Adults 8 JUL 2009

22. How is pain treated?  Nonpharmacologic treatments Smoking cessation Education Hypnosis ○ Imagery ○ Distraction ○ Relaxation Comfort therapy Physical and occupational therapy Neurostimulation Pain Management in Older Adults 8 JUL 2009

23. How is pain treated?  Nonpharmacologic treatments Smoking cessation Education Hypnosis Comfort therapy ○ Exercise ○ Heat /cold ○ Lotions/massage therapy ○ Meditation ○ Music, art, and drama therapy ○ Pastoral counseling ○ Positioning Physical and occupational therapy Neurostimulation Pain Management in Older Adults 8 JUL 2009

24. How is pain treated?  Nonpharmacologic treatments Smoking cessation Education Hypnosis Comfort therapy Physical and occupational therapy ○ Aquatherapy ○ Tone and strengthening Neurostimulation Pain Management in Older Adults 8 JUL 2009

25. How is pain treated?  Nonpharmacologic treatments Smoking cessation Education Hypnosis Comfort therapy Physical and occupational therapy Neurostimulation ○ Transcutaneous electrical nerves stimulation (TENS) ○ Acupuncture ○ Acupressure Pain Management in Older Adults 8 JUL 2009

26. More information  familydoctor.org  ampainsoc.org  painfoundation.org