Assessment of pain in older adults

1. StopLookListen
Painassessment

2. Specific considerations
Assessment
Pharmacological interventions
Non-pharmacological interventions
Scenarios

3. Specific considerations
Assessment
Pharmacological interventions
Non-pharmacological interventions
Scenarios

6. •Communication
•Culture
•Exposure
•Structure/Function
•Time
•Complexity

7. Specific considerations
Assessment
Pharmacological interventions
Non-pharmacological interventions
Scenarios

10. The Cerebral Signature for Pain Perception
and Its Modulation
Irene Tracey and Patrick W. Mantyh Neuron 55, August 2, 2007
Interpretive framework for the place of
tissues in somatic symptoms
•Source?
•Cause?
•Stage?
•Epiphenomenon?

11. acute on chronic

12. acute on chronic

13. acute on chronic

14. Affective
Sensory
Impact

15. •Autonomic signs in acute situations (pallor
breathing sweating BP pulse)
•Facial expressions
•Guarding and behaviours (rubbing, pressing)
•Utterances (grunting, sighing..) Change in
interactions
•Mental status
•Observe during activities if you can

17. Sullivan, M Toward a Biopsychomotor Conceptualization of Pain Implications for Research and Intervention
Clin J Pain Volume 24, Number 4, May 2008i

18. • Communications
model
• Encoding and
decoding an
experience
• Self-report and
expression as sources
• Interpretation
Hadjistavropoulos, T., K. D. Craig, et al. (2011). "A biopsychosocial formulation of pain communication." Psychological Bulletin.
Transaction
Interaction
Action

19. Mood
Sleep
Mobility
Function

20. Specific considerations
Assessment
Pharmacological interventions
Non-pharmacological interventions
Scenarios

22. Start low
Go slow
Longer dosing interval

24. Elderly populations
• Due to age-related physiological changes in renal, hepatic and cardiovascular
function, elderly patients are at risk of underdosing and overdosing
medication. This means analgesic medications should be individually titrated
and monitored. As a general rule, the initial dose should be reduced by 25%
and should be slowly titrated, based on clinical response and side-effects.
• TCAs, especially tertiary amines, should be used with caution in elderly due to
their adverse cardiovascular and anticholinergic side-effects, e.g. worsening
prostatic symptoms in men, and potential drug interactions.
• Gabapentinoids are probably better because they induce fewer of the side-
effects associated with TCAs, although gabapentinoids can increase the risk of
sedation. However, where possible, topical agents should be used because of
their lack of systemic side-effects.

25. Kurita, G. P., et al. (2012). "The burden of chronic pain: A cross-sectional survey focussing on diseases, immigration, and
opioid use." PAIN 153(12): 2332-2338.

28. Property Duloxetine Venlaflaxine
Dose 30-120 mg/day 37.5-225 mg/day
Titration Start at 30 mg/day, increase to
60 mg after the first week
then a maximum 60 mg twice
a day
Start at 37.5 mg once or twice
a day, increase by 75 mg every
week until a maximum 225
mg/day is achieved
Therapeutic effect 3 days 3-4 weeks
Duration of adequate trial 4-6 weeks 4 weeks
Side-effects Nausea, somnolence,
insomnia, dizziness. Nausea is
worse at beginning of
treatment but usually settles
in a week and is better
tolerated if duloxetine is
started at a lower dose of
30 mg/day
Nausea, precipitate glaucoma,
miscarriage, pulmonary
hypertension, increase blood
pressure, heart rate and
cardiac conduction
abnormalities including
prolonged QT interval

29. Property Pregabalin Gabapentin
Onset of therapeutic
response
3-5 days 4 weeks
Therapeutic effect 3 days 3-4 weeks
Duration of adequate trial
4 weeks 3-8 weeks for dose
titration, 2 weeks at
maximum dose of at least
1800 mg/day
BNF recommended dose Up to 600 mg/day Up to 3600 mg/day
Titration
Start at 50-75 mg twice a
day, increase by 25-75
mg/day every 3-7 days,
as tolerated
Start at 100-300 mg 1-3
times a day, increase by
100-300 mg 3 times a day
every 1-7 days, as
tolerated

33. Specific considerations
Assessment
Pharmacological interventions
Non-pharmacological interventions
Scenarios

37. Boyers D, McNamee P, Clarke A, et al. Cost-effectiveness of self-management methods for the treatment of chronic pain in an aging adult population: A systematic review of the
literature. Clinical Journal of Pain 2013;29(4):366-75.
Kroon FP, van der Burg LR, Buchbinder R, et al. Self-management education programmes for osteoarthritis. Cochrane Database Syst Rev 2014;1:Cd008963.

39. ADAMS, K., GREINER, A. C. & CORRIGAN, J. M. 2004. 1st Annual Crossing the Quality Chasm Summit: A Focus on Communities, Washington, The National Academies Press.
“Self-management is defined as the
tasks as an individual must undertake
to live with one or more chronic
conditions. These tasks include the
confidence to deal with medical
management, role management and
emotional management of their
conditions”

40. Jones A, Silva PG, Silva AC, et al. Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee osteoarthritis: a
randomised controlled trial. Annals of the Rheumatic Diseases 2012;71(2):172-79.

41. William Cullen 1710-1790 Edinburgh
“I prescribed therefore in
pure placebo, but I make it
a rule even in employing
placebos to give what
would have a tendency to
be of use to the patient.”

42. Carvalho, C., et al. (2016). "Open-label placebo treatment in chronic low back pain: a randomized controlled trial." PAIN 157(12): 2766-2772.

43. Specific considerations
Assessment
Pharmacological interventions
Non-pharmacological interventions
Scenarios

45. NICE (2014). Osteoarthritis - Care and management in adults Clinical guideline CG177 Methods, evidence and recommendations Clinical guidelines, National Clinical Guideline Centre: 505.
Do no harm !
Do no harm !
Do no harm !
Do no harm ! Do no harm !

46. “Targeted
attention with
good
intention”

47. SHAW, S. E. & ROSEN, R. 2013. Fragmentation: a wicked problem with an integrated solution? Journal of Health Services Research & Policy, 18, 61-64.

48. Yinan zabing