The Management of Persistent Pain in Older Persons

[Dave ARNP]

AGS Clinical Practice Guideline:

The Management of Persistent Pain in Older Persons

Executive Summary

Persistent pain, defined as a painful experience that continues for a prolonged period of time, is prevalent in older adults. The terms persistent and chronic are often used interchangeably in the medical literature. Unfortunately for older persons, chronic pain has become a label that often conjures up negative images and stereotypes associated with longstanding psychiatric problems, futility in treatment, malingering, or drug-seeking behavior. The term persistent pain may foster a more positive attitude for patients and professionals for the many effective treatments that are available to help alleviate suffering.

The American Geriatrics Society disseminated a clinical practice guideline for the management of chronic pain in older adults in 1998. Since then, important advances in pharmacology and strategies for the assessment and management of pain in older persons have emerged. The recommendations presented in this updated guideline, The Management of Persistent Pain in Older Persons, are meant to revise, refine and update the previous work. They represent the consensus of a panel of pain experts and were derived from a synthesis of the literature combined with clinical experience in caring for older adults with persistent pain. Important new information provided in this document includes recommendations for pain assessment in cognitively impaired persons, the use of new COX-2 selective nonsteroidal anti-inflammatory medications, the unethical use of placebos, and many other contemporary issues in persistent pain management. In focusing on issues unique to the geriatric population and areas that have been omitted or less well developed in previous work,the new guideline will be helpful to clinicians as well as to researchers and policy makers. Ultimately, we hope the beneficiaries of this work will be those patients who require effective pain management to maintain their dignity, functional capacity and overall quality of life.

The recommendations are divided into four sections: Assessment of Persistent Pain, Pharmacologic Treatment, Nonpharmacologic Strategies, and Recommendations for Health Systems That Care for Older Persons. For each section, general principles are discussed, followed by the panel's specific recommendations for improving the clinical assessment and management of persistent pain in older persons.

This guideline was developed and written under the auspices of the AGS Panel on Persistent Pain in Older Persons, approved by the AGS Board of Directors on April 8, 2002, and published in the June 2002 supplement issue of the Journal of the American Geriatrics Society under the title "The Management of Persistent Pain in Older Persons". The following organizations with special interest and expertise in the management of pain in older persons provided peer review of a preliminary draft of the guideline: American Academy of Family Physicians; American Academy of Home Care Physicians; American Academy of Orthopaedic Surgeons; American Academy of Pain Medicine; American Academy of Physical Therapy; American Academy of Physical Medicine and Rehabilitation; American College of Clinical Pharmacy; American Medical Association; American Occupational Therapy Association; American Society of Anesthesiologists; American Society of Clinical Oncologists; American Society of Consultant Pharmacists; Hospice and Palliative Nurses Association; Oncology Nursing Society.

Summary of Key Recommendations

• The key to effective treatment of persistent pain lies in comprehensive assessment. All older persons should be screened for persistent pain on initial evaluation, on admission to any health care service, and periodically thereafter. Any persistent pain that has an impact on physical function, psychological function, or quality of life should be considered a significant problem
• The verbally administered zero to ten scale is a good first choice for assessment of pain intensity; however, other scales such as word descriptor scales, faces scales, or pain thermometers may be more appropriate for some patients.
• For those with moderate to severe cognitive impairment, assessment of behaviors and family or caregiver's observations are essential.
• The use of placebos in clinical practice is unethical and there is no place for their use in the management of persistent pain.
• Acetaminophen should be the first drug to consider in the treatment of mild to moderate pain of muskuloskeletal origin.
• Traditional (i.e., nonselective) nonsteroidal anti-inflammatory drugs (NSAIDS) should be avoided in those who require long-term daily analgesic therapy. The selective NSAIDs, i.e., the COX-2 inhibitors, are preferable.
• Opioid analgesic drugs are effective, associated with a low potential for addiction, and overall may have fewer long-term risks than other analgesic drug regimens in older persons with persistent pain. As with all medication, careful monitoring for the development of adverse side effects is important.
• An individualized program of physical activity should be designed to improve flexibility, strength, and endurance, and should be maintained indefinitely.
• Patient and caregiver education is an essential component in the management of persistent pain.
  
• Health care facilities that care for older patients should routinely conduct quality assurance and quality improvement activities to enhance pain management.
  

SOURCE: AGS Panel on Persistent Pain in Older Persons. The Management of Persistent Pain in Older Persons. American Geriatrics Society. J Am Geriatr Soc 2002; 50;6:1-20

The development of this guideline was supported by unrestricted educational grants from Janssen Pharmaceutica, McNeil Consumer & Specialty Pharmaceuticals, a Division of McNeil-PPC, Inc.; Ortho-McNeil Pharmaceutical, Inc.; Pharmacia Corporation; and Purdue Pharma L.P.

http://www.americangeriatrics.org/education/executive_summ.shtml

[adrienurse, LPN]

Dave, I got floated last night to a subacute unit and I'm telling you it wasn't pretty. I don't know what the heck is the problem of that unit but the pain control!!!! Disheartening to say the least the amount of crying and moaning I heard throughout the night from people with pain no where near being controlled. A man with ca in his neck (with a tumor the size of a walnut) and nothing to give him but prn tylenol!!!!! That's just one example. The nurse I was working with commented "well the doctor here runs the place like a boot camp, he wants people to be motivated to going back home and get independent again". Who thinks like that??? :stone

[Dave ARNP]

If the doc had but to walk one day in that poor mans shoes.....

The order for pain meds would be enough to kill an elephant.

-Dave

Dave, I got floated last night to a subacute unit and I'm telling you it wasn't pretty. I don't know what the heck is the problem of that unit but the pain control!!!! Disheartening to say the least the amount of crying and moaning I heard throughout the night from people with pain no where near being controlled. A man with ca in his neck (with a tumor the size of a walnut) and nothing to give him but prn tylenol!!!!! That's just one example. The nurse I was working with commented "well the doctor here runs the place like a boot camp, he wants people to be motivated to going back home and get independent again". Who thinks like that??? :stone

[NRSKarenRN, BSN, RN]

Now that you know there is pain mangement issues on this unit, what so you plan to do about it???

My suggestion:

1. Write up your concern, send to Administrator, risk management, Medical director.

2. Empower patients with pain info.

3. Give them the name of ombudsman for your facility....maybe even call them

yourself, if no change indicated

4. Send pain info to doc

5. If over time no change: report to outsider Quality organization, including medical board

[sharann, BSN, RN]

It seems as if those that need the most protection are given the least. I too take exception to untreated pain in both the geriatric and pediatric populations. We often recieve babies post surgery of hernia repair or circumsion and are told "don't give narcotics, use a tylenol supp. Well, acetaminophen may be hepful, but not directly post op! They scream(and rightly so). The elderly deserve the best pain control, well, I suppose we all do.

[GLORIAmunchkin72]

It seems as if those that need the most protection are given the least. I too take exception to untreated pain in both the geriatric and pediatric populations. We often recieve babies post surgery of hernia repair or circumsion and are told "don't give narcotics, use a tylenol supp. Well, acetaminophen may be hepful, but not directly post op! They scream(and rightly so). The elderly deserve the best pain control, well, I suppose we all do.

I work at a nursing home and we are told that some of these residents are just plain addicted to the medicine and they ask for it whether they need it or not. This one resident in particular is ALWAYS telling me how much pain she is in all the time. I cannot say it's all in her head. I heard she is getting everything in the book including morphine and if they give her much more she will be totally out of it. What's an aide to do?

[teeituptom, BSN, RN]

The elderly should be given whatever is necessary for pain control

[GLORIAmunchkin72]

That is the way that I feel but I really have no sayso

[teeituptom, BSN, RN]

Thats a pity

[aimeee, BSN, RN]

I work at a nursing home and we are told that some of these residents are just plain addicted to the medicine and they ask for it whether they need it or not. This one resident in particular is ALWAYS telling me how much pain she is in all the time. I cannot say it's all in her head. I heard she is getting everything in the book including morphine and if they give her much more she will be totally out of it. What's an aide to do?

Perhaps she really IS in pain all the time even though she is getting "everything in the book" because they haven't actually prescribed a medication regimen that is effective for her pain. As an aide your job is too report your observations and the resident's complaints of pain to the nurse. You may also use other interventions to help the patient be more comfortable such as repositioning, active listening, distraction (helping her to become involved in other activities so she doesn't focus on her discomfort) etc.

[GLORIAmunchkin72]

What I did was, besides listening to her, do research online and download a list of pain centers in our area complete with telephone numbers. Her son was supposed to check into this, but didn't because he believed that she was already "overmedicated". Her eyes do look "haggard".

[caffine addict]

Thanks Dave for the Great post,

I ran across it the other night while surffing but forgot where I saw it.

Now I can print it out for work.

We are trying to develop a more efficient pain program based on State Guidelines. I think the AMA had a good publication too but I don't have membership there. Left my hard copy at last job.

Booo