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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

Pain Management in the Elderly

A series of clinical vignettes provides insight into assessment and management of pain in the geriatric patient population.

With the elderly segment of the population quickly becoming the fastest growing in the world, and aging baby-boomers increasing the healthcare burden in the United States, pain clinicians are encouraged to familiarize themselves with relevant pain issues affecting the aging and to be ready to face the challenges ahead. This review enumerates some of the physical and mental changes that occur in those age 65 and over through clinical examples and offers recommendations for assessment and management of comorbid pain conditions in this population. For the purposes of this article, pathophysiologic and pharmacologic modalities will not be discussed.

Source: 123RFAssessing and treating pain the elderly, or geriatric, patient population requires unique considerations.

Pain Assessment and Evaluation

Geriatric pain assessment is different from that conducted in other age groups. Several factors are responsible for this distinction, including biology, culture, religion, ethnic background, cognitive function, and attitudinal barriers.1 Multiple studies and literature reviews have addressed these aspects. Biologically, elderly patients are frail, have poorer circulation, have multiple comorbidities and more coexisting pain types, such as somatic pain and neuropathic pain at the same time, and recover slower than other age groups. Culturally, assessment of pain in the elderly is influenced by psychologic, physiologic, spiritual, social, behavioral, and physical factors. Elderly tend to be more religious and spiritual than other age groups as they near the end of their journey and seek a “pain free” remainder of their lives.

Elderly individuals, for instance, may have biased pain perception and modified threshold. Many may feel they have to “just deal with the pain,” that reporting pain is a sign of “weakness,” or presume that pain medications will lead to addiction.1 In older age groups, pain may be masked by an inability to communicate or dementia. Evidence shows that pain is under-recognized, underestimated and undertreated in patients 65 or older. However, in the authors’ clinical experience, the older the patient, the more common these trends tend to be.

 

As shown in Table I, several reliable methods exist for assessing pain in the elderly. A recent literature review found that, in cognitively normal patients, the Numeric Rating Scale, Visual Analog Scale (VAS), Face Pain Scale, and Verbal Descriptor Scale are valid for assessment.2 In older patients with cognitive impairment, however, the Abbey Pain Scale, Doloplus-2, Pain Assessment in Advanced Dementia Scale, Pain Assessment Checklist for Seniors with Limited Ability to Communicate, Checklist of Nonverbal Pain Indicators, Pain Assessment for the Dementing Elderly rating tool, and the Clinical Utility of the Certified Nursing Assistant Pain Assessment Tool (CPAT) may be more appropriate. Many of these tests may be administered by a family member or a caregiver.

Pharmacokinetic and Pharmacodynamic Changes in this Population

Clinicians may need to adjust medication selection and dosage for elderly patients compared to younger patients, and should be mindful of changes in homeostasis as well as underlying conditions. For example, renal drug excretion typically declines at age 65 and over, and out of caution, the elderly should be considered renally insufficient. Therefore, pain providers should pay special attention to all medications the elderly are taking, whether prescribed or over-the-counter. Many of these medications may linger in the body for many days and affect multiple vital systems including the heart, kidneys, circulation, cognition, coherence, balance, and even breathing patterns with possible respiratory depression. Medications that have high hepatic extraction (ie, blood flow-limited metabolism) usually have reduced metabolic clearance.

However, the metabolism of medications with low hepatic extraction (ie, capacity-limited metabolism) is not usually affected.3 Elderly individuals often have decreased water content and muscle mass, and increased fat content. Therefore, the distribution volume of hydrophilic drugs may be reduced whereas lipophilic drugs increase.3

Decreased serum albumin in this population may increase the amount of free drug availability, especially in chronic disease states and if malnutrition is present. A drug’s half-life is increased for many medications if there are coexisting kidney and liver diseases.4 Age alters hepatic Phase I reactions that involve hydrolysis, reduction, and oxidation more so than Phase II conjugation, such as acetylation, glucuronidation, sulfation, and glycine conjugation.4 In addition, Cytochrome P-450 function declines with age and, along with polypharmacy, may lead to potential drug toxicity and side effects in this population.4 Table II reviews some of these changes.

 

CLINICAL VIGNETTES

 

Case #1: 69-Year-Old Male Veteran with Chronic, Low Back Pain, Kidney Disease, and Vitamin D Deficiency

A 69-year-old African American veteran was referred to the pain clinic with chronic recurrent low back pain with left leg paresthesia. His past medical history (PMH) is significant for DM-II, hypertension, hyperlipidemia, CAD s/p 3 stent placements about 3 months ago, chronic kidney disease, GERD, and Vitamin D deficiency. His medications include Metformin, Januvia, Lisinopril, Metoprolol, Plavix, Aspirin 325 mg qd, Gabapentin 100 mg tid, Oxycodone 5 mg 2 tablets qid prn, Lipitor, and Omeprazole. His surgical history is significant for right inguinal hernia repair and appendectomy. He is widowed, has three adult children who live in a different state. He lives alone. He is a former smoker and drinks vodka on a nightly basis to “relax.”

His low back pain is located across the posterior lower lumbar spine and radiates to his buttocks and down to the posterolateral left leg, all the way to his left ankle. He has tried chiropractic care but did not complete more than 6 sessions of physical therapy as they “hurt.” The patient has not tried injections for the back pain. Upon further discussion, he was found to be a kind, soft-spoken man, who did not talk or complain much. He seemed to under-estimate his complaints and repeated the phrase “not a big deal” frequently. His vital signs were all normal except for a BP of 171/76 and heart rate of 101. He rated his pain score at “3/10” but it was unclear if he understood the rankings.

Upon physical examination, the patient demonstrated significant lumbar tenderness, mild thoraco-lumbar scoliosis, tenderness over the SI joints, positive SLR on left at 55, right at 75. The rest of the exam was unremarkable, including normal heel/toe walking but he was a little wobbly upon standing and taking the first few steps. A recent MRI (ordered 3 months prior by his PCP, who had been treating the patient’s pain) showed multilevel facet arthropathies, multilevel degenerative disk disease, multi-level posterior disk bulges with multilevel moderate foraminal stenosis. He had no spinal stenosis.

Discussion

In the clinic’s experience, we have observed that many older veterans under-report their pain scores at the expense of their own health. In this case, the patient seemed unlikely to complain of pain as he seemed to feel embarrassed by the condition, but his pain was evident from the high systolic BP and tachycardia. He is on low-dose Metoprolol.

Our initial approach with this patient would be to evaluate his cognition with an office-based Mini-Mental Status Examination. Since he is drinking on a nightly basis, a CAGE questionnaire is also in order. Our task would be to establish an honest and transparent relationship with him upfront, and upon gaining his trust, talk more directly about his pain and expand treatment to involve a multidisciplinary team. Educating the patient on pain scores and pain generators will be crucial, as is a discussion about alcohol use, especially as he is taking pain medications.

Compliance with the prescribed Oxycodone should be emphasized and the patient should be educated on the pros and cons of narcotics. We recommend minimizing the amount and number of tablets the patient is taking and enforced that with regular urine drug testing. Optimizing his dose of gabapentin by increasing it slowly and gradually over the course of weeks may also be considered, but it is important to be mindful of the patient’s chronic kidney disease.

Evaluation and addressing the Vitamin D3 should also be carried out. Elderly patients on Metformin and Omeprazole may be clinically deficient on Vitamin B12, although blood levels may appear within normal. Our experience, especially in patients with neuropathic pain, has been to optimize Vitamin B12 via intramuscular injections. Since this patient is only 3 months out of stent placement, it may be difficult to have his cardiologist agree to stop the Plavix and aspirin to perform interventional pain procedures. But injections remain a valid option for him once he becomes candidate. Other modalities that may be encouraged include physical therapy, Tai Chi, acupuncture, relaxation, meditation, and psychotherapy. The patient’s psychological and mental wellness may be assessed and screened for possible depression. He is possibly lonely and his living environment should be evaluated by involving a social worker.

Case #2: 78-Year-Old Obese Female with Severe Thoracotomy-Related Pain, Hypertension, and Breast Cancer History

A 78-year-old was referred to our clinic for evaluation. She states her PCP no longer wants to give her pain medications and that she is “here just to pick up a prescription.” Her psychiatric-mental-health examination (PMH) includes obesity, hypertension, hyperlipidemia, Hx multiple TIAs, GERD, depression, DM-II, Hx smoking (she smoked for 30 years and quit 20 years ago), and Hx breast cancer treated with right radical mastectomy 15 years ago followed by chemoradiation. She also underwent right lobectomy for an isolated focal lung metastasis. She is in remission and there is no evidence of active disease on a recent follow-up. Her pain is located around the right thoracotomy surgical scar and radiates above and below that area in a band-like fashion. She never had shingles. Her pain is “always severe” and she rates it at “12/10” on VAS.

Her medications include Norvasc, Aspirin, Metoprolol, multiple inhalers, Lovastatin, Omeprazole, Morphine Sulphate ER 60 mg q6h ATC, Oxycodone 10 mg qid prn pain, and Cymbalta 20 mg qd. She is also taking Naproxen 220 mg, four to five tablets a day over-the-counter, and Ibuprofen 200 mg–about 8 tablets a day. She is married to a former policeman and has four adult children who live on their own. She weighs about 240 pounds and is 5’3.” She states the Morphine and Oxycodone are not doing much and she is taking them to avoid going into withdrawal as she has been on these medications for 5 years. Upon reviewing her medical records, it was noted that another pain clinician discharged her for having Tramadol in her urine.

Physical examination is normal except for sensitivity to touch in the right chest surgical scar. She denies pain or tenderness around the mastectomy area. Her BP is 189/110 and her HR is 88 to 95, and is irregular. She has bipedal edema. While conversing with her, she was noted to jerk a lot in a non-voluntary manner. There is no recent blood work.

Discussion

This patient presents a fairly complex, multi-faceted case that must be addressed in a systematic way. Addressing this case in an interdisciplinary fashion would be best. In the authors’ opinion, her irregular HR has to be addressed immediately as she may be in Atrial Fibrillation (AFib). She is taking multiple NSAIDs a day, which may be contributing to her Hx TIAs, high BP, and possible AFib. An ER visit is warranted and educating the patient on NSAIDs should be a priority (NSAIDs may contribute to morbidity and mortality in elderly, including cardiovascular accidents, myocardial infarction, gastrointestinal bleeds, liver and kidney disease, and hypertension). In addition, large doses of Tylenol should be avoided and used judicially.

The patient’s pain should be thoroughly assessed. Education on pain scores and rating is essential. In our experience, when patients rate pain over “10/10”, they are seeking immediate attention to their complaints as they might have experienced poor patient–provider interaction in the past. This patient seems to have had difficult challenges and may be depressed. Addressing these issues with the help of a mental health professional is paramount.

The patient had multiple TIAs and was a smoker. She may have chronic ischemic brain changes and possible dementia. Evaluation by a neurologist may be warranted and may change the course of treatment. Other modalities should be explored, such as increased activity, Tai Chi, acupuncture, relaxation, meditation, and psychotherapy. In addition, consultation with a social worker may be helpful as well as with a dietitian to educate the patient on healthy eating and weight loss.

As the United States and world population ages, pain management practitioners bear a huge burden in understanding and dealing with a new subset of pain: pain in the elderly. (Source: 123RF)

The patient may have hyperalgesia from Morphine metabolite accumulation, namely M3G and to a lesser extent, M6G. This neurotoxicity is evidenced by the patient repeated myoclonus. Opioid rotation should be considered in a controlled and safe manner, possibly addressed while her AFib is treated as inpatient. Oxymorphone should be considered as it is metabolized in a non-cytochrome P-450 pathway and avoids much of the drug-to-drug interaction often seen in the elderly.4 Similarly, changing the patient’s Oxycodone preferably to Oxymorphone and starting at 25 to 50% lesser dose of the equianalgesic dose based on calculation of the MEDD would be beneficial. Other than a low dose of Cymbalta, the patient is not on any adjuvants for pain medications. It is therefore either wise to slowly and gradually increase her Cymbalta as tolerated or to switch her to anther agent, such as gabapentin or Lyrica to address the post-thoracotomy syndrome, which has a strong neuropathic pain component. Although used infrequently as an adjuvant, since the patient is obese, the authors’ experience has been successful with the use of Topiramate, to avoid weight gain and water retention as seen with gabapentin or pregabalain.

Considering topical creams, such as clonidine, gabapentin, ketoprofen, and even ketamine, in this patient may also offer benefit as her pain is localized.

Case #3: 86-Year-Old Nursing Home Resident with Pain and Dementia

A middle-aged man presented to the clinic holding the arm of his 86-year-old father who lives in a nursing home. He was referred for “pain–related issues.” The patient is unable to talk and has a soothing smile on his face. He is well-groomed and looks pale and skinny. When asked about his pain, he repeatedly looked at his son in a monotonous way. He was not blinking and did not say a word throughout the conversation. His son stated, “I know my dad, he is in pain.” Upon review of the provided medical record, it was found that the patient was diagnosed with dementia about 7 years ago and has been in the nursing home for the past 5 years. His son, who has power of attorney, lives in another state and comes to check on his father every 3 months.

PMH includes dementia, atherosclerosis, macular degeneration (dry type), prostate cancer treated with local radiation about 15 years ago, and Hx TIA about 6 months ago. His medications include Memantine, baby aspirin, Lutein supplements, and he is on Bactrim for a recurrent UTI. He weighs 118 pounds and is 6’1”. His BMI is 15.6. His BP is 86/45 and his HR is 90. His son tells us that his father has diarrhea, likely from the Bactrim. Other than ulnar deviation of the hands at the wrist joints, and anteflexed shuffled gait, the patient did not appear to be in distress or in pain.

Discussion

This case highlights the importance of adequate history taking, assessment, and thorough evaluation. The son has power of attorney and seems to be quite confident of his father’s pain. While it is essential to gather input from family caregivers, it is equally important to communicate with those who work with the patient regularly for relevant clinical information. In this case, it is very important to contact the nurse manager and the nurse at the nursing home to obtain in-depth details about this patient’s complaints, pain, pain reaction and behavior, and how he expresses himself. If there is no neurologist on board, it may be useful to consult one to help differentiate between full-fledged Alzheimer’s versus vascular dementia, frontotemporal dementia, or dementia of Lewy Body Disease; these subtypes differently affect the pain experience.5

This patient demonstrated hampered sensory perception as evidenced by his possible blindness secondary to macular degeneration, severe nutritional deficiencies and possibly malnutrition, possibly reversible anemia as reflected by his pallor and hypotension, and possible confusion related to his UTI and dehydration from diarrhea related to antibiotic use.

The unfortunate lack of ability to communicate with this patient poses a barrier to adequate diagnosis and management. The systematic study of facial expressions through computerized system has successfully identified core features that are highly specific to pain.6 These observational-behavioral instruments are considered highly reliable and valid in patients with dementia.6 As is typical for other elderly with poor functionality and mobility, major obstacles to daily activities include attention, speed of information processing, memory learning, and executive functions.7 All of these characteristics seem to apply in this case. Involving a psychologist may be warranted, but otherwise, we have to accept our clinical limitation.

In this case, it is recommended that the patient’s nutritional status be fine-tuned to allow him to contribute to his amelioration. This may include daily physical training and reconditioning, and possibly supervised aquatherapy. Building muscle mass and optimizing his albumin/protein level may improve his care, strengthen his stamina, and potentially decrease his pain. Mild pain Step I agents as recommended by the WHO ladder, such as Tylenol, may go a long way for this patient and others in similar conditions in this age group.

Conclusion

As the United States and world population ages, pain management practitioners bear a huge burden in understanding and dealing with a new subset of pain: pain in the elderly. With these times of measured patient encounters and limited resources, clinicians should commit themselves to better evaluating, assessing, and managing our elderly patients. Clinicians may better serve elderly patients by spending more time assessing their pain, relying on more than a valid assessment tool as discussed, involving an interdisciplinary team, and consulting with other specialists, if needed. Moreover, as always, there is no substitute for compassion, empathy, and kindness.

Last updated on: November 28, 2018
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