Syed Hasan Abbas Rizvi

What is Pain?
 Pain is an unpleasant sensory and emotional experience.
 The International Association for the Study of Pain (IASP)
defines pain in terms of both actual or potential tissue
damage and the emotional experiences associated with
pain.
 Acute Pain is often limited, warns of tissue damage.
Often with signs of autonomic nervous system activation
Intensity of pain indicates severity of injury or disease
 Chronic persistent ( > 3 months) - pain no longer signals
tissue damage.
Autonomic signs are often absent.
IASP website
Hix M.D. Pain Management in elderly patients, Journal of pharmacy Practice, 20:49-63, 2007
 Types of pain:

– Nociceptive pain- Nerves responding appropriately

to a painful stimulus

• Neuropathic pain- results from NS dysfunction,

and may originate centrally or
peripherally

• Somatic pain- originates in the skin, bones, myo,

and connective tissue, and usually
is located specifically.

• Visceral pain- originated in internal body

structures and organs, and is
located more genearlly.
 Multiple Types of Pain
Examples
A. Nociceptive Noxious • Strains and sprains
Peripheral
Stimuli • Bone fractures
• Postoperative

B. Inflammatory • Osteoarthritis
Inflammation • Rheumatoid arthritis
• Tendonitis

• Diabetic peripheral
C. Neuropathic neuropathy
Peripheral Nerve • Post-herpetic neuralgia
Multiple Mechanisms
Damage • HIV-related polyneuropathy

D. Noninflammatory/ • Fibromyalgia
Nonneuropathic • Irritable bowel syndrome
No Known Tissue or
Abnormal Central Processing Nerve Damage
• Patients may experience
Adapted from Woolf CJ. Ann Intern Med. 2004;140:441-451. multiple pain states
1. Chong MS, Bajwa ZH. J Pain Symptom Manage. 2003;25:S4-S11. simultaneously1
 Neuropathic pain:

• Origin:
–Nerve damage
• Palliates/potentiates:
–Set off by unusual stimuli, light touch, wind on
skin, shaving (trigeminal neuralgia)
• Quality:
–Electric, burning, tingling, pins & needles,
shooting (system isn’t working right)
• Radiation:
–Nerve-related pattern
 Nociceptive Pain:
Easier to treat than
Neuropathic!!
• Origin:
–Tissue damage
• Palliates/potentiates:
–Worse with stress, pressure
–Responds better to opioids, NSAIDs
• Quality:
–Sharp, dull, stabbing, pressure, ache, throbbing
• Radiation:
–Occasionally radiates (less well-defined), but not
along an obvious nerve distribution
 Vicious Cycle of Uncontrolled Pain

Avoidance
Behaviors Decreased
Pain Mobility

Social Altered
Limitations Diminished Functional
Self- Status
Efficacy
Pain in Geriatric Population
FACT: 50% of hospitalized older adults
experience severe pain
MYTH: Pain is a normal part of aging

FACT: Pain is under-treated in the older adult

population
MYTH: PRN = pain relief

FACT: Treatment of pain at the end of life is the

RIGHT of the patient, and the MORAL DUTY &
LEGAL OBLIGATION of the clinician.
MYTH: Patient will become addicted to pain
medication if they take it too regularly.
 Pain in Geriatric Population
BARRIERS:
• Inadequate or inconsistent assessment
• Lack of education
• Poor communication
• Normal part of aging process
• Fear of addiction to/ dependence
• Pt. is branded” drug –seeking behavior”
• Symbol of weakness
• Health care provider discouragement/frustration
• Fear of repercussions

FACT:
• Chronic pain is common in older persons
• Emotional factors often contribute to pain perceptions
• Any older person taking >4 drugs is a high risk for falls
Pain in Geriatric Population

CONSEQUENCES OF PERSISTENT PAIN

– Depression
– Anxiety
– Insomnia
– Delirium
– Atelectasis
– Pneumonia
– Thromboembolism
– Slow Recovery

FACT: Pain in older adults impacts function

 Age related changes:

 Reduction in number and function of

peripheral nociceptive neurons.
 Sensory threshold for thermal and vibratory
stimuli increase with age.
 Pain receptors: 50% decrease in Pacini's
corpuscles,10%-30% decrease in
Meissner's/Merkle's disks
 Diminished endogenous analgesic response
(endorphins)
in the older patients.
 Age related changes:
Peripheral nerves :
Myelinated nerves
 Decreased density
 Increase abnormal/degenerating fibers
 Slower conduction velocity
Unmyelinated nerves
 Decreased number of large fibers (1.2-1.6
mm
 No change in small fibers (0.4 mm)
 Substance P content decreased
 Age related changes:
Central nervous system
 Loss in dorsal horn neurons
Altered endogenous inhibition, hyperalgesia
 Loss of neurons in cortex, midbrain, brainstem
18% loss in thalamus
Altered cerebral evoked responses
Decreased catacholamines, acetylcholine,
GABA, serotonin
Endogenous opioids: mixed changes
Neuropeptides: no change
 Prevalence of pain in Elderly

 1 in 5 elderly have pain

• 18% above 65 are taking pain medications
regularly
• One-fifth of adults 65 years and older said they
had experienced pain in the past month that
persisted for more than 24 hours.
• Almost three-fifths of adults 65 and older with
pain said it had lasted for one year or more.
• Women report severely painful joints more
often than men (10 percent versus 7 percent).
Factors affecting perception of pain

 Pain affects quality of life far beyond the

local region of injury
 Feeling of loneliness is predictor of
psychological distress
 Lack of intimate relationships, dependency,
and loss increase loneliness
 Loneliness has been shown to lower pain
threshold
 Loneliness is a risk factor for depression
Factors affecting the perception of pain
 Depression: lack of energy, avoidance of
diversional activities, decreased
engagement in treatment
 Anxiety: may inhibit participation in rehab
efforts
 Sleep disturbance: pain is best predictor of
sleep disturbance.
 Increased health care needs
 Isolation and reduced independence:
Involvement with family and friends can
provide pleasurable experience
Factors affecting perception of pain
 Focusing one's attention on pain makes the
pain worse.
 Patients who have low levels of pain remember
it as being worse than they originally reported.
 Pain can be a learned response, rather than a
purely physical problem.
 Psychosocial issues like patient’s belief about
their pain , their coping skills, their involvement
in the “sick role”, all have an impact on how
much pain patients feel, and how it affects
them.
 Factors contributing to Pain
– Attributed to physical injuries/trauma
– Stem from a range of disease states
– Persistent pain in older patients is commonly associated with:
• Depression
• Anxiety
• Impaired ambulation
• Sleep disturbances
• Decreased socialization
Principles of Pain Management in the
Elderly
• Pain in Frail (weak) older adults
– Less likely to report pain
– No words/behavior presented
– More likely to suffer pain
– Compounded in cognitively impaired person
causing pain undetected/untreated
– Physiologic changes and circulatory function
predispose the elder to adverse analgesic
effects also complicates pain management
– Attitudes of the healthcare providers
• Frail elders are typically people over age 75 with
multiple medical conditions, weakness, and or
social isolation.
Principles of Pain Management in the
Elderly
• Acute pain management after surgery is worse
than for the general population.

• Delirium often accompanies injury,

hospitalization, surgery, and anesthesia in frail
elders, placing them at risk for poor pain
management underlying causes of delirium
should be investigated. Lowering the dose or
changing an alternate analgesic may be better
if analgesic is thought to contribute to the
delirium.
Principles of Pain Management in the
Elderly
GOALS:
• Adequate pain management
• Restoration of both physical and social
function

• LISTEN, Assess, TREAT, Reassess often

• Dosing: start low, increase slowly
• Combine pharmacological with non-
pharmacological modalities
 Multimodal Treatment

Pharmacotherapy
Opioids, nonopioids, adjuvant
analgesics
Physical Medicine and Interventional
Rehabilitation Approaches
Injections,
Assistive devices, electrotherapy
neurostimulation
Strategies for Pain
and Associated
Disability
Complementary and Psychological Support
Alternative Medicine Psychotherapy,
Massage, supplements group support

Lifestyle Change
Exercise, weight loss

Fine PG, et al. J Support Oncol. 2004;2(suppl 4):5-22.

Portenoy RK, et al. In: Lowinson JH, et al, eds. Substance Abuse: A Comprehensive Textbook. 4th ed.
Philadelphia, PA: Lippincott, Williams & Wilkins; 2005:863-903.
Challenges of pain assessment in older patients

 Myths that having pain is “natural” with

aging
 Fears about addiction to pain medications
 Sensory and cognitive impairments
 Under-reporting
 Co-morbidities complicating the clinical
picture and caregivers' beliefs and the
reliability of patients' pain.
 Lack of congruence between patients' and
caregivers' perceptions of pain
 Caregiver may misinterpret pain perception
 Pain Assessment
Unidimensional Scales: A single item that
usually relates to pain intensity alone.
Advantages: Easy to administer and require
little time or training to produce
reasonably valid and reliable results
Disadvantages: Some require vision,
hearing and attention, pencil and paper
Pain Thermometer

Pain as bad as it could be

Extreme pain
Severe pain
Moderate pain
Mild pain
Slight pain

No pain
(Herr and Mobily, 1993)
 Pain Assessment
Obtain history of pain:
 Ask about onset, pattern, duration,
location, intensity, and characteristics of
the pain,
 Find out aggravating or palliating factors,
and the impact on the patient.
Evaluate psychological state of patient
 Screen for depression
 Anxiety
 Assess social networks and family
 Pain Assessment Scales

Multidimensional scales evaluate pain in

multiple domains ( McGill Pain
Questionnaire).
Advantage: looks at pain in terms of
intensity, affect, sensation, location, and
several other domains that are not
evaluable with a single question.
Disadvantage: long, time consuming and
difficult to administer.
Pain Assessment in Dementia

 Patients’ self report are still reliable

 Reports from caregivers/family members
are also reliable if they are familiar with
patient.
 Behaviors exhibited may indicate pain
 Facial pain scale
 Do not use pain scales and ask to recall
information from past.
Pain assessment in advanced dementia
The Pain Assessment in Advanced Dementia
(PAINAD) scale
 Assess breathing independent of
vocalization
 Negative vocalization
 Facial expression
 Body language
 Consolability
Each behavior is scored 0 to 2,higher the
score more severe the pain.
Pain assessment in nonverbal patients

Checklist of Nonverbal Pain Indicators (CNPI):

 Nonverbal vocal complaints (sighs, gasps, moans,
groans, cries)
 Facial grimacing
 Bracing (clutching or holding onto furniture,
equipment)
 Rubbing (massaging affected area)
 Restlessness
 Verbal vocal complaints such as “ouch” or “stop”
Feldt K S., Pain Manag Nurs 1(1):13-21,2000.
Barriers to Effective Pain Management

Study of 805 chronic pain sufferers, >50%

changed physicians due to lack of
physician’s:
1)Willingness to treat the pain aggressively,
2)Failure to take the pain seriously,
3)Lack of knowledge about pain management

Chronic pain in America: roadblocks to relief. Survey conducted for the American Pain Society, The America
Academy of Pain Medicine, and Janssen Pharmaceutica. Hanson, NY: Roper Starch Worldwide, 2000.
Patient related barriers to effective pain
management

Communication: Patients with

communication problems with care giver
had worse pain control.
Psychological: Anxiety, distress, depression,
anger, and dementia, all of which can
complicate assessment by masking
symptoms.
Attitudinal issues: Fear of addiction,
tolerance, and side effects, belief that pain
was inevitable.
 References

• AGS Panel on Persistent Pain in Older Persons (2002). The

management of persistent pain in older persons. Journal of
American Geriatric Society, 50, 205-224.
• Goldstein, N.E., & Morrison, R. S., (2005). Treatment of pain in
older patients. Critical Reviews in Oncology/Hematology, 54,
157-164.
• Herr, K., Titler, M.G., Schilling, M.L., Marsh, J.L., Xie, X., Ardery,
G., Clarke, W.R., & Everett,L.Q., (2004). Evidence-based
assessment of acute pain in older adults: current practices and
perceived barriers. Clinical Journal of Pain, 20(5), 331-340.
• Panda, M. & Desbiens, N. (2001). Pain in elderly patients: how
to achieve control. Consultant.1597-1604.
 References

• Joan Luckmann, MA. RN (1997).Caring for people in pain.

Saunders Manual of Nursing,338-362, 577
• Literature Reviews
– Gregory M. Martin, MD/Thomas S. Tornhill, MD (2007) Total knee
arthroplasty. Licensed to Baylor College Of Medicine. Official reprint
from Up To Date www.uptodate.com
– McGarry Logue, Rebecca MSN, APRN, BC.(2002).Self-Medication and
the Elderly [Features]: How Technology Can Help. AJN American of
Nursing. Volume 102 (70), July 2002,pp 51-55
– Steven D. Passik, PhD (2007).Pain management and addiction. Licensed
Baylor College of Medicine. Official reprint from Up To Date
www.uptodate.com
– Carol A. Miller, RNC, MSN. Cardiovascular Drugs: Reasons for Promise
and Vigilance. Drug Consult. Geriatric Nursing (2002) Volume 23.
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