1. The Management of Persistent Pain in Older Persons
Presented By Dr. Saeed Al_gahtani

2. Persistent Pain
A painful experience that continues for a prolonged period of time
May or may not be associated with a recognizable disease process
Terms “persistent” and “chronic” often used interchangeably
“persistent pain” is abetter label

3. Comprehensive Pain Assessment
Evaluation of present pain complaint (self-report)
Impairments in physical and psychosocial function
Analgesic history
Attitude and beliefs/knowledge
Effectiveness of past pain-relieving treatments
Satisfaction with current pain treatment/concerns

4. Comprehensive pain assessment
Careful exam of site, referral sites, common pain sites
Focus on musculoskeletal and neurological systems (may necessitate consultation(e.g PT,OT, Physiatry)
Establish definitive diagnosis if possible
Observation of physical function

5. Assessing pain in mild to moderate cognitive impairment
Direct query of older adults
Surrogate report only if patient cannot reliably communicate
Use terms synonymous with pain
Use standard pain scale, if possible
Ask about present pain
Ask and observe for verbal and non verbal pain-related behaviors and changes in usual activities/functioning

6. Verbal Descriptor Scales
Most intense pain
Very severe pain = no pain
Severe pain = mild
Moderate pain = discomforting
Mild pain = distressing
Slight pain = horrible
No pain = excruciating

7. Assessing Pain In Non Verbal And/Or With Moderate to Severe cognitive Impairment
Direct observation or history from caregiver for evidence of pain- related behaviors(during movement,not just at rest)
Facial expression for pain(grimacing),less obvious rapid blinking,sad /frightened face,any distorted expression
Vocalization (crying,moaning,groaning)
Body movements

8. Changes in interpersonal interactions
Combative/ aggressive
Resisting care
Decreased social interactions
Disruptive
withdrawn

9. Changes in activity pattern routines
Sudden cessation of common routines
Increased wondering
Difficulty sleeping
Refusing food/appetite change

10. Changes in mental status
Irritability or distress
Increased confusion
Agitation
Crying or tears

11. Specific Recommendations
All older patients with functional impairment or diminished quality of life as a result of persistent pain are candidates for pharmacologic therapy.
There is no role for placebos in the management of pain…use is unethical.
The least toxic means of achieving pain relief should be used.When systemic medications are indicated, non-invasive routes should be considered first.

12. Specific Recommendations
Acetaminophen should be the first consideration in the treatment of mild to moderate pain of musculoskeletal origin.
Traditional (nonselective) NSAIDs should be avoided in patients who require long-term daily analgesic therapy.The COX-2 selective agents or non- acetylated salicylates are preferred for older persons who require NSAIDs.

13. Specific Recommendations
Opioid analgesic drugs may help relieve moderate to severe pain,especially nociceptive pain.
Opioid for episodic (non-continuous) pain should be prescribed as needed.
Long-acting or sustained-release analgesic preparation should be used for continuous pain.

14. Specific Areas of Concern
Constipation and opioid-related GI effects.
Sedation.
Nausea.
Acetaminophen toxicity in fixed-dose combination products.

15. Monitoring
Frequent evaluation during titration and subsequent dose adjustments.
Reassessment on a regular basis (function,mental status,sleep,mood….etc)
Watch for signs of inappropriate medication use (e.g., use of opioid for depression,anxiety,insomnia)
Prevent “ opiophobia”.

16. Non Pharmacological Intervention
Physical and psychological components.
Active patient involvement = self reliance& control over pain.
Integral part of the approach to management of any persistent pain problem.

17. Physical Activity
Strong evidence that participation in regular physical activity reduces the pain and enhances functional capacity for older adults.

18. A physical activity program should be considered for all older patients
Physical activities should be individualized to meet the needs and preferences of each patient.
For some older adults with severe physical impairments,a trial of supervised rehabilitation therapy is appropriate, with goals to improve range of motion and to reverse specific muscle weakness or other physical impairment associated with persistent pain.

19. For healthy individuals who are currently sedentary or deconditioned , referral should be made to a group exercise program for a moderate program of physical activity.
For those who are incapable of strenuous training, initial training should be conducted over 8 to 12 weeks and should be supervised by a professional with knowledge of the special needs for older adults.

20. Moderate levels of physical activity should be maintained.
Any physical activity program for older patients should also include exercises that improve flexibility,strength,and endurance.

21. Patient Education Programs are integral components of the management of persistent pain syndromes
Should include information on :
-disease process
-goals of treatment
-treatment options
-expectations of pain management
-medication use

22. Focused patient education should be provided prior to special treatments or procedures.
Patients should be encouraged to educate themselves by using available local resources.

23. Patient Education
Should be modified to patients’ needs and levels of understanding.
Sources of the patients information should always be ascertained.

24. Cognitive Behavioral Strategies
Cognitive strategies =
distraction methods to divert attention from pain.
Mindfulness methods to enhance acceptance of pain.
Behavioral strategies =
- help control pain by pacing activities, increasing involvement in pleasurable activities ,and using relaxation methods.
Cognitive strategies + behavioral strategies =
cognitive behavioral therapy
- typically combined with pharmacological therapy.

25. Formal cognitive-behavioral therapies are helpful for many older adults with persistent pain
should be conducted by a professional as a structured program
A plan for coping with pain exacerbations should be part of this therapy
Spouses or other partners should be part of this therapy

26. Recommendations continued
Other modalities (e.g., heat,cold,massage,acupuncture,and transcutaneous electrical nerve stimulation ) often offer temporary relief and can be used as adjunctive therapies.

27. Quality Assurance / Quality Improvement
Importance of QA/QI related to pain :
ambulatory care facilities
Hospitals
Nursing home
Assisted-living facilities
Home-care agencies
Indicators:
structure (screening procedures,chart options)
Process (assessment,referrals)
Outcomes( pain severity,appropriate medication use +/- satisfaction )

28. MY RECOMMENDATIONS
Think of pain any time you see afunctional change in older person.
Patient education of great importance to improve overall pain management.
Consistently recommend physical activity to improve pain symptoms and overall health.
Improve health care system for geriatrics.

29. Eliminate financial barriers by integration and collaboration of other sectors.
Education in pain management for all health care professionals should be improved at all levels {certification ,continuous education }
Health care financing systems should extend resources for geriatrics care.

30. We need a better quality of geriatric centers regarding { medical care , service , equipments , rehabilitation , and recreation}
At least 1-2 visits /week of a family physician to geriatric centers.
We are in great need for ideal geriatric centers in the main cities of the kingdom.

31. We should encourage family medicine postgraduate to sub specialized in geriatrics to fill up the gap.
Common problems in geriatrics should be given intensively during introductory course of family medicine program.
At least one month rotation in R3 of family medicine program to include geriatric.

32. Bottom Line Pain is not a normal part of aging
Pain has significant negative impact on function and quality of life
Pain is eminently treatable
WE NEED TO DO ABETTER JOB

33. Thank you