AMDA Clinical Practice

Guideline
(CPG) for Pain Management


For Medical Directors and
Attending Physicians
Introduction to Pain
Pain is common in the long-term care
setting.
Unrelieved chronic pain is not an inevitable
consequence of aging
Aging does not increase pain tolerance or
decrease sensitivity to pain
Most chronic pain in the long-term care
setting is related to arthritis and
musculoskeletal problems
Pain may be associated with mood
disturbances (for example, depression,
anxiety, and sleep disorders)
Introduction to Pain
The use of pain scales
Acute vs. chronic pain
Long-term care interventions
Pain in the Elderly
Definition of PainAn individuals
unpleasant sensory or emotional
experience
Acute pain is abrupt usually abrupt in
onset and may escalate
Chronic pain is pain that is persistent or
recurrent

Pain in the Elderly
The most common reason for
unrelieved pain in the U.S. is failure of
staff to routinely assess for pain
Therefore, JCAHO has incorporated
assessment of pain into its practice
standards
The fifth vital sign
Pain in the Elderly
Sources of pain in the nursing home
Source: Stein et al, Clinics in Geriatric Medicine: 1996
Condition causing pain Frequency (%)
Low back pain 40
Arthritis 37
Previous fractures 14
Neuropathies 11
Leg cramps 9
Claudication 8
Headache 6
Generalized pain 3
Neoplasm: 3
Pain in the Elderly
Degenerative joint
disease
Gastrointestinal
causes
Fibromyalgia
Peripheral vascular
disease
Rheumatoid arthritis
Post-stroke
syndromes
Low back disorders
Improper positioning

Conditions Associated with the Development of
Pain in the Elderly

Pain in the Elderly
Crystal-induced
arthropathies
Renal conditions
Gastrointestinal
disorders
Osteoporosis
Immobility,
contracture

Neuropathies
Pressure ulcers
Headaches
Amputations
Oral or dental
Pathology

Conditions Associated with the Development of
Pain in the Elderly

Pain in the Elderly
Different response
to pain
Staff training
Cognitive or
sensory
impairments
Practitioner
limitations
Social or Cultural
barriers
System barriers
Co-existing illness
and multiple
medications

Barriers to the Recognition of Pain in the
LTC setting:
Pain in the Elderly: Myths
To acknowledge pain is a sign of personal
weakness
Chronic pain is an inevitable part of aging
Pain is a punishment for past actions
Chronic pain means death is near
Chronic pain always indicates the presence
of a serious disease
Acknowledging pain will mean undergoing
intrusive and possible painful tests.

Pain in the Elderly: Myths

Acknowledging pain will lead to loss of
independence
The elderly especially cognitively
impaired have a higher pain tolerance
The elderly and cognitively impaired
cannot be accurately assessed for pain
Patients in LTC say they are in pain to
get attention
Elderly patients are likely to become
addicted to pain medications
Pain in the Elderly
Consequences of untreated pain:
Depression
Suffering
Sleep disturbance
Behavioral disturbance
Anorexia, weight loss
Deconditioning, increased falls

Pain in the Elderly
Inferred Pain Pathophysiology
6]

Nociceptive pain Explained by ongoing
tissue injury
Neuropathic pain Believed to be sustained
by abnormal processing in the peripheral or
central nervous system
Psychogenic pain Believed to be
sustained by psychological factors
Idiopathic pain Unclear mechanisms

AMDA Pain Management
CPGSteps

1. Recognition
2. Assessment
3. Treatment
4. Monitoring
Pain in the Elderly-
Recognition
Possible Indicators of Pain in MDS Version 2.0
Restlessness, repetitive movements (B5)
Sleep cycle (E1)
Sad, apathetic, anxious appearance (E1)
Change in mood (E3)
Resisting care (E4)
Change in behavior (E5)
Functional limitation in range of motion
(G4)
Change in ADL function (G9)

Pain in the Elderly-
Recognition
Possible Indicators of Pain in MDS Version
2.0
Pain site (J3)
Pain symptoms (J2)
Restlessness, repetitive movements (B5)
Sleep cycle (E1)
Sad, apathetic, anxious appearance (E1)
Change in mood (E3)
Resisting care (E4)



Pain in the Elderly-
Recognition
Possible Indicators of Pain in MDS Version 2.0
Loss of sense of initiative or
involvement (F1)
Any disease associated with pain (I1)
Pain symptoms (J2)
Pain site (J3)
Mouth pain (K1)
Weight loss (K3)
Pain in the Elderly-
Recognition
Possible Indicators of Pain in MDS
Version 2.0
Oral status (L1)
Skin Lesions (M1)
Other skin problems (M4)
Foot Problems (M6)
ROM restorative care (P3)

Pain in the Elderly
Recognition
Non-specific signs and symptoms suggestive
of pain:
Frowning, grimacing, fearful facial
expressions, grinding of teeth
Bracing, guarding, rubbing
Fidgeting, increasing or recurring
restlessness
Striking out, increasing or recurring
agitation
Eating or sleeping poorly
Pain in the Elderly
Recognition
Non-specific signs and symptoms suggestive
of pain:
Sighing, groaning, crying, breathing heavily
Decreasing activity levels
Resisting certain movements during care
Change in gait or behavior
Loss of function
Pain Management CPG
Recognition Steps

Is pain present?
Have characteristics and causes of
pain been adequately defined?
Provide appropriate interim treatment
for pain.
Pain Management CPG
Recognition
Pain Intensity Scales for Use with Older Patients Visual
Analogue Scale

No pain Terrible pain
l______l_____l_____l______l_____l______l_____l______l______l
1 2 3 4 5 6 7 8 9 10

Ask the patient:Please point to the number that best describes your pain
Scale has worst possible pain at a # 10
Pain Management CPG
Recognition
Documenting an Initial Pain Assessment
Pattern: Constant_________ Intermittent__________
Duration: __________
Location: __________
Character: Lancinating____ Burning______ Stinging_____
Radiating______ Shooting_____ Tingling______
Other Descriptors:________________________________
Exacerbating Factors:______________________________
Relieving Factors:_________________________________
Pain Intensity (None, Moderate, Severe)
1 2 3 4 5 6 7 8 9 10
Worst Pain in Last 24 Hours (None, Moderate, Severe)
1 2 3 4 5 6 7 8 9 10
Mood: ________________________________________
Depression Screening Score: ______________________
Impaired Activities: ______________________________
Sleep Quality: __________________________________
Bowel Habits: __________________________________
Other Assessments or Comments:__________________
______________________________________________
______________________________________________
Most Likely Causes Of Pain: _______________________
______________________________________________
Plans: ________________________________________
______________________________________________
Pain Management
Assessment Steps

Perform a pertinent history and physical
examination
Identify the causes of pain as far as
possible
Perform further diagnostic testing as
indicated
Identify causes of pain
Obtain assistance/consultations as
necessary
Summarize characteristics and causes of
the patients pain and assess impact on
function and quality of life
Pain Management
Assessment Steps

Pain History
[7]
Important Elements to
Include:
Known etiology and treatments
previous evaluation, pain diagnoses
and treatments
Prior prescribed and non-prescribed
treatments
Current therapies

Pain Management
Assessment Steps
Chronic Pain History
PQRST
Provocative/palliative factors (e.g., position,
activity, etc.)
Quality (e.g., aching, throbbing, stabbing, burning)
Region (e.g., focal, multifocal, generalized, deep,
superficial)
Severity (e.g., average, least, worst, and current)
Temporal features (e.g., onset, duration, course,
daily pattern)
Medical History
Existing comorbidities
Current medications
Source: Valley, MA. Pain measurement. In: Raj PP. Pain Medicine. St. Louis
MO. Mosby, Inc. 1996:36-46.
Pain Management
Treatment Steps

Adopt an interdisciplinary care plan
Set goals for pain relief
Implement the care plan
Pain Management
Treatment Steps

Provide a Comforting and Supportive
Environment
Reassuring words/touch
Topical or low-risk analgesic
Talk with patient/caregivers about pain
Back rub, hot or cold compresses
Whirlpool, shower
Comforting music
Chaplain services
Pain Management
Treatment Steps
Ethics and Pain

The old ethic of under-prescribing
just say no
it hurts so good
The new ethic
trust: believing what patients say
commitment: formalized mutual
agreement
standardized care: guidelines on
assessment and treatment
collaboration: working together

Source: Marino A. J Law, Med Ethics, 2001
Pain Management
Treatment

General Principles for Prescribing Analgesics
in the Long-Term Care Setting
Evaluate patients overall medical condition
and current medication regimen
Consider whether the medical literature
contains evidence-based recommendations for
specific regimens to treat identified causes
For example, acetaminophen for
musculoskeletal pain; narcotics may not help
fibromyalgia
In most cases, administer at least one
medication regularly (not PRN)
Pain Management
Treatment

General Principles for Prescribing Analgesics
in the Long-Term Care Setting
Use the least invasive route of administration
first
For chronic pain begin with a low dose and
titrate until comfort is achieved
For acute pain begin with a low or moderate
dose as needed and titrate more rapidly
Reassess/adjust the dose to optimize pain
relief while monitoring side effects

Pain Management
Treatment

Appropriateness of regular or PRN dosing:
Intermittent/less severe pain
Start with PRN then switch to regular if
patient uses more than occasionally.
Start with a lower regular dose and
supplement with PRN for breakthrough
pain.
Adjust regular dose depending on
frequency/severity of breakthrough pain.
Pain Management
Treatment

Appropriateness of regular or PRN dosing
More severe pain
Standing order for more potent, longer-
acting analgesic and supplement with a
shorter acting analgesic PRN

Severe/recurrent acute or chronic pain
Regular, not PRN dosage of at least one
medication
Start with low to moderate dose,
then titrate upwards

Pain Management
Treatment

Goal of treatment is to decrease pain,
improve functioning, mood and sleep
Strength of dosage should be limited only
by side effects or potential toxicity
Pain Management CPG
Treatment
Non-Opioid Analgesics Used in the Long-Term Care Setting

Pain Management CPG
Treatment

Opioid Therapy: Prescribing Principles
and Professional Obligations
[9]

Drug Selection
Dosing to optimize effects
Treating side effects
Managing the poorly responsive
patient
Pain Management CPG
Treatment
Opioid Analgesics Used in the Long-Term Care Setting
(Oral and Transdermal)

Pain Management CPG
Treatment

* Duration of effect increases with repeated use due to cumulative effect of drug
Pain Management CPG
Treatment
Oral Morphine to Transdermal Fentanyl

* NOTE : This table is designed to convert from morphine to transdermal
fentanyl and is based on a conservative equianalgesic dose. Using this
table to convert from transdermal fentanyl to morphine could lead to
overestimation of dose.
Treatment
Topical Analgesics

Counterirritants
(menthol, methyl
salicylate)
Supplied as liniments,
creams, ointments,
sprays, gels or lotions
May be effective for
arthritic pain (not multiple
joint pain)

Capsaicin cream
(0.025%) and (0.075%)
Derived from red peppers
Depletes substance P,
desensitizes nerve fibers
associated with pain
Main limitations are skin
irritation and need for
frequent application
Need to use routinely for
optimal effectiveness

Treatment
Analgesics of Particular Concern
in the Long-Term Care Setting

Chronic use of the following drugs are not
recommended:
Indomethacin
Piroxicam
Tolmetin
Meclofenamate
Propoxyphene

Meperidine
Pentazocine,
butorphanol and
other agonist-
antagonist
combinations
Treatment
Non-Analgesic Drugs Sometimes
Used for Analgesia

Neuropathic pain
Antidepressants
Anticonvulsants
Antiarrhythmics
Baclofen
Inflammatory
diseases
Corticosteroids
Osteoporotic
fractures
Calcitonin


Treatment
Factors to evaluate when considering
complementary therapies
Patients underlying diagnosis and co-
existing conditions
Effectiveness of current treatment
Preferences of the patient and family or
advocate
Past patient experience with the therapy
Availability of skilled experienced providers
Pain Management CPG
Monitoring Steps

Re-evaluate the patients pain
Adjust treatment as necessary
Repeat previous steps until pain is
controlled
Pain Management CPG
Monitoring
Opioid Therapy: Monitoring Outcomes
Critical outcomes: The Four As
Analgesia Is pain relief meaningful?
Adverse events Are side effects
tolerable?
Activities - Has functioning improved?
Aberrant drug-related behavior
Pain Management CPG
Monitoring

When patient is unresponsive to clinical
management consider referral to:
Geriatrician
Neurologist
Physiatrist
Pain clinic
Physician certified in palliative medicine
Psychiatrist (if patient has co-existing mood
disorder)
Dilemmas in Pain
Management

While addressing pain management, have
strategies in mind for common problems
Patient refusal of potentially beneficial
medication
Patient and family pressure to prescribe
certain drugs
Patient and family misconceptions about
illness
Unrecognized or denied psychiatric
disturbances
Reviewing the Physicians
Role

Prevention strategies
Communication with patients/families
Documentation
Participate in Quality Improvement
Follow policies and procedures

Summary

Views about management of pain in the
elderly have changed in recent years
It is an expectation that pain be managed
Pain can be effectively treated in the long-
term care setting
A culture of patient comfort should
permeate all aspects of facility operations