1. Assessment of Pain Assessment and Management of Pain in Special Patient Groups
Dr Victor Mendis

2. Valid and reliable assessment of pain
- Pain management
- Clinical trials

3. CP assessment and its impact on physical,emotional and social functions
Multidimensional qualitative tools
Health related QOL instruments

4. Key components of an assessment
Direct enquiry about the presence of pain
including the use of alternative words to describe pain
Observation for signs of pain
especially in older people with cognitive/communication impairement
Description of pain
Measurement
Cause of pain

5. Description of Pain Sensory dimension - nature
- location and radiation
- intensity
Affective dimension
- emotional response to pain(fear,anxiety,depression)
Impact
- functional activities
- participation (work,social activities,relationships)

6. Measurement of Pain
Using standardised scales that is accesible to the individual

7. Pain Scales COMFORT – unconscious/ventilated children
CRIES ventilated neonates
MOBID Pts with severe cognitive impairement
ABBEY

8. Cause of Pain
Examination
Investigations

9. Assessment of Pain in Pts with Communication Problems/Dementia
UK – pain or discomfort in > 50% over 65 years
Higher prevalence in institutionalised older people % had at least one current pain problem

10. Communication Problems due to:
Language
Extremes of age
Critical illness
Dementia

11. Disorders that affect cognition
Neurodegenerative(Alzheimers, Parkinsons, Huntingtons)
Vascular (stroke, embolic disease)
Traumatic
Toxic (CO, adverse drug events)
Anoxic
Infections ( HIV, encephalitis)

12. Typical pain locations in the elderly
Degenerative spine disease, OA
Polyneuropathy/ PHN
Cancer pain

13. Particularities in elderly Pts (Even if adequate pain medication provided inadequate pain control)
Communication problems
Compliance (practical problems: impaired vision, motor skills, dry mouth, memory, > 1/5 fail task of opening drug packages, reduced + thinking )
Availability of opioids and risks of prescription
Comorbidity

14. Pharmacokinetic changes:
-reduction in P450
-reduction in plasma proteins
- dangerous drug interactions due to reduced renal function

15. Best Practices
Formalised approach to management, assessment and reassessment
Organisational standards for collaborative and interdiciplinary approaches
Pharmacological and non pharmacological strategies to alleviate pain
Individualised pain control plans

16. Pharmacological Mx Principles
When pain detected, institute treatment rapidly
Use scheduled rather than “as needed” dosing
Titrate Rx to pain levels and assess verbal, behavioural and functional response
Choose regimen that will mitigate common side effects

17. Non pharmacological Mx in Cognitive Impairement – “ integral part”
Physical exercise
CBT
Acupuncture
TENS
Manipulations
Heat, cold, massage
Distraction techniques
Appropriate pacing
Sensory calming and stimulating techniques

18. Important points AD does not affect the threshold for pain perception
Vascular dementia may heighten perception of pain
Potential of unrelieved pain is greater in those who cannot verbally express discomfort
Pain, depression, agitation can exacerbate one another
Side effects of pain Meds more prevalent in pts with dementia
Most important reason for inadequate Pain Mx is lack of assessment

19. Pearls of wisdom
No evidence that the elderly have less pain or need less analgesics
Pain is underdiagnosed in the elderly
Elderly pts act in a “socially acceptable” manner
NSAIDS/paracetamol first choice (Risk !!)
Opiods analgesics of choice for strong cancer pain

20. Coanalgesics in individually selected patients
Non pharmacological Rx strategies always be implemented if feesible
End of life decisions should respect the wishes of the patient
Start slow- go slow