Additional Material

Pre/Post Test Questions

Question 1

True or False : Older adults do not require special dosing considerations for  opioid or non-opioid analgesics.

Question 2

Pain affects ________  of community dwelling older adults and  _______ of older adults residing in long term care

Question 3

Which of the following are reasons that older adults are at increased risk for adverse drug reactions? There may be more than one correct answer.

Question 4

True or False : The Numeric Rating Scale (NRS) for pain assessment is not appropriate for verbal older adults who are cognitively intact.

Question 5

A bowel protocol should: Select all that apply.

Question 6

What question(s) is/are important to include when obtaining a pain history?

Background Education on Older Adults

Students are encouraged to read:

Gagliese, L. & Melzack, R. (2006). Pain in the elderly. In S. B. McMahon & M. Koltzenburg (Eds.), Wall and Melzack’s textbook on pain (pp. 1169-1179). Philadelphia: Elvsevier.

Older Adult Population is Growing

2010 Census report highlighted the shifting trends in the U.S. older adult demographic
This demographic shift in older adults has been dubbed the ‘Silver Tsunami’

http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf

Older Adults and Health

The typical older adult comes to a health care encounter with:

• Multiple morbidity and 2 – 5 prescription medications dail^y1
• Reduced lean-body mass¹
• Reduced hepatic size and blood flow^1,2
• Reduced renal blood flow^1,3

Given this, older adults have greater potential for toxic drug levels, as well as adverse drug-drug interactions and drug-disease interactions.

The Scope of Pain

• Leading presenting symptom⁴
• Costs for pain management exceed $100 billion per annum⁵
• Associated with anxiety, depression, stress⁶
• Chronic musculoskeletal pain increases risks for falls in older adults⁷

Myths Related to Aging & Pain

• Pain is a normal part of the aging process and nothing can be done about it
• As people get older, they lose the ability to feel pain, so it isn’t as bad
• Pain is okay

Pain Statistics in Older Adults

• > 60% of community-dwelling older adults report pain in at least 1 site⁷
• 40 – 80% of older adults in nursing homes have pain⁸
• 67% of hospitalized older adults reported pain; 49% of those who reported pain actually received adequate analgesics⁹
• > 2/3 of hospitalized older cancer pts who are given opioid analgesics continue to report moderate to severe pain¹⁰

What Might Contribute to Poor Pain Management in Older Adults?

• Impaired ability to communicate
  • aphasia
  • impaired cognitive status
  • being on a ventilator
  • English as a second language
• Cultural differences
  • stoicism
  • meaning of pain
  • perception that pain is deserved
  • language used to describe pain ~ achy, uncomfortable
• Health Care System Barriers
  • reluctance to treat due to fears of addiction or overdose)

Common Causes of Pain in Older Adults^11,12

• Osteoarthritis in joints 
• Lower Back Pain
• Complications of Diabetes Mellitus
• Cancer
• Post Stroke
• Ischemia
• Post Herpetic Neuralgia
• Surgery
• Infection
• Trigeminal Neuralgia
• Psychological stressors
• Medical procedures and tasks of care
  • nasogastric tube insertion
  • dressing change/wound debridement
  • lumbar puncture
  • phlebotomy
  • cough and deep breathing after surgery
  • ambulating after surgery

Consequences of Unrelieved Pain^{7,13,14,15,16}

• Depression
• Poor sleep
• Reduced mobility
• Reduced quality of life
• Increased sympathetic nervous system activity
• Falls
• Decreased functioning
• Impaired immune function 
• Hyperglycemia
• Increased protein breakdown
• Hypercoagulation
• Impaired GI function 
• Delirium
  • this is a medical emergency with up to 20% mortality

Unrelieved Pain & Delirium¹⁶

Unrelieved pain is a risk factor for delirium
Among frail older adults admitted for elective surgery for hip fracture:

• Receipt of < 10 mg parenteral morphine equivalents/day -> 5-fold increased risk for delirium
• Cognitively intact with severe pain post-op -> 9-fold increased risk for delirium
• Meperidine vs. other opioids -> 2-fold increased risk for delirium

Pain and Sleep Disturbance

• Older adults at increased risk for disturbed sleep
  • Prevalence of older adults with poor sleep 28%¹⁷ 
  • Common sleep disturbances include obstructive apnea, restless legs syndrome, reduced sleep efficiency
• There is a bi-directional association between poor sleep and increased pain^18,19
  • Pain interferes with sleep
  • Poor sleep results in increased subsequent day pain

Pain Assessment – Verbal Older Adult

• Older adults may not use the term “pain”
• Use open ended questions: “Tell me about your pain, aches, soreness or discomfort”
• Ask for descriptions: Burning, aching, dull, throbbing, stabbing, crushing…
• Location(s): Localized vs. flare
• What is the meaning of this pain to you?

Pain Assessment – Numeric Rating Scale

• Cognitively intact, verbal older adults can use the NRS for rating pain severity
  • 0 (no pain) – 10 (worst pain imaginable)
• Some like to have a ‘pain anchor’ to help them rate their pain
• Ask about a past pain experience
• Ask person “compared to that pain, how do you rate this pain’s severity

Opioid Analgesics and Constipation

• A commonly reported and unintended effect of opioid analgesics
  • Older adults are prone to constipation, due to increased transit time and reduced thirst drive
  • Persons diagnosed with hypothyroidism, diabetes mellitus, multiple sclerosis, or irritable bowel syndrome are at increased risks for constipation
  • Initiating a bowel protocol can help older adults maintain adequate bowel function while taking an opioid analgesic

Bowel Protocol

• Hydration
  • 6-8, 8 oz glasses of water daily
  • Older adults may need more frequent reminders to drink water
• Increase fiber in the diet
  • High fiber foods, whole grains, bran
  • Prunes, prune juice
  • Fresh fruits and vegetables
• Bulk forming laxatives
  • Psyllium 
• Stool softeners
  • Docusate sodium

If no bowel movement in 24 hours, call the physician or nurse practitioner for guidance.