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Medical care of older persons in residential aged care facilities (Silver Book)

Pain management

Assessment
Management
Nonmedication therapy
Medication

Acute pain has a prevalence of approximately 5% across all age groups, whereas the prevalence of chronic pain increases with age. The prevalence of chronic pain in aged care home residents is as high as 60-83%. Consequences of chronic pain include increased confusion, sleep disturbance, nutritional alterations, impaired mobility, depression, social isolation, worsening pain, slowed rehabilitation, and increased risk of falls.206

Assessment207

Pain can be acute (<3 months) or chronic (>3 months). Acute pain may occur concurrently with chronic pain, and should be investigated and treated. For chronic pain, identification of pain patterns helps to establish a treatment regimen. Baseline pain is experienced constantly for more than 12 hours per day. Breakthrough (intermittent) pain is transient periods of increased pain. Incident pain flares up during an activity (eg. turning in bed).

Diagnosis of the cause of pain impacts on treatment and choice of analgesia. Nociceptive pain results from somatic and visceral stimulation/injury. Neuropathic pain results from injury to the nervous system. The most common type of pain seen in aged care home residents is nociceptive pain, often resulting from pathologies related to ageing such as arthritis, osteoporosis and vascular disease. Types of nociceptive and neuropathic pain are presented in Table 10.


Table 10. Types of pain and their causes 208

Characteristic of pain

Nociceptive superficial

Nociceptive deep somatic

Nociceptive visceral

Neuropathic

Origin of stimulus

Skin, subcutaneous tissue; mucosa- mouth, nose, sinuses, urethra, anus

Bone joints, muscles, tendons, ligaments; superficial lymph nodes; organs and capsules, mesothelial membranes

Solid or hollow organs, deep tumour masses, deep lymph nodes

Damage to nociceptive pathways

Examples

Pressure ulcers, stomatitis

Arthritis, liver capsule distension or inflammation

Deep abdominal or chest masses, intestinal, biliary ureteric colic

Tumour related brachial, lumbosacral plexus or chest wall invasion, spinal cord compression; nontumour related: postherpetic neuralgia, postthoracotomy syndrome, phantom pain

Description

Hot, burning, stinging

Dull, aching

Dull, deep

Dysesthesia (pins and needles, tingling, burning, lancinating, shooting)
Allodynia; phantom pain, pain in numb area

Localisation to site of stimulus

Very well defined

Well defined

Poorly defined

Nerve or dermatome distribution

Movement

No effect

Worsening pain
Resident prefers to be still

May improve pain

Nerve traction provokes pain,eg. sciatic stretch test

Referral

No

Yes

Yes

Yes

Local tenderness

Yes

Yes

Maybe

Yes

Autonomic effects

No

No

Nausea,vomiting, sweating, BP and heart rate changes

Autonomic instability: warmth, sweating, pallor, cold, cyanosis (localised to nerve pathway)


Consider assessment of pain on admission of resident to the facility, after a change in medical or physical condition, and as symptoms arise. Assessment includes input from resident, family, and RACF staff. Regular reassessment is required to determine changes and the effect of interventions.

Self reporting of pain is the usual method of assessment of location, duration and intensity, however the subjective nature of pain makes quantification difficult. Asking about pain in the present (rather than in the past) is a reliable method of assessment for residents whose communication skills are compromised by illness or cognitive impairment.

Pain is often expressed through behavioural symptoms, even in residents whose verbal communication skills are intact, by:

  • aggression, resistance, withdrawal, restlessness

  • facial expression: grimacing, fear, sadness, disgust

  • verbalisations: self reports of pain, requests for analgesia, requests for help, sighing, groaning, moaning, crying, and unusual silence.

Physiological changes with pain include:

  • raised heart rate, pulse, temperature, respiratory rate, blood pressure or sweating

  • abnormal colour of skin, discharge from eyes, nose, vagina or rectum

  • lesions to oral or rectal mucosa, skin

  • distension of the abdomen, swelling of limbs, swelling of body joints

  • abnormal results on testing urine (eg. presence of blood, leucocytes, glucose)

  • functional decrease in mobility, range of movement, activity, endurance, and increase in fatigue

  • changes in posture-standing, sitting, reclining.

Multidimensional pain assessment scales have been developed specifically for use in older people. The Abbey Pain Scale (see Tool 7) is suitable for residents with dementia who cannot verbalise their pain, and may also be useful for cognitively intact residents who aren't willing or cannot talk about their pain. The Resident's Verbal Brief Pain Inventory (see Tool 8) is suitable for residents able to verbalise their pain. The same scale/s selected for the individual resident should be for reassessment.

Management209

Establish treatment goals with the resident (or representative),taking into account their culture, beliefs and preferences. The aim may be to eradicate the pain and/or reduce it to tolerable levels so that mobility and independence can be restored or maintained. For example, chronic nociceptive pain due to degenerative arthritis requires a balance between pain relief and the maintenance of function, whereas residents in the terminal stage of a disease may require complete pain relief, even though mental and physical function is compromised.

Effective pain management relies on care planning to manage baseline pain and future pain episodes. Regularly reassess pain,and review management if pain scores are repeatedly high and breakthrough strategies are used more than twice in 24 hours.

Nonmedication therapy

Nonmedication and complementary therapies (eg. aromatherapy, guided imagery[not usually suitable for cognitively impaired people],acupuncture or music)may be used by themselves or in conjunction with medication. Emotional support for residents in pain can be therapeutic when offered by their GP, RACF staff and relatives/carers. Diversional therapies may help, as well as offering nutrition and fluids, ensuring the resident is warm and comfortable, and reducing lighting and surrounding noise.

Physiotherapists trained to evaluate nociceptive and neuropathic pain can assist choosing nonmedication therapies to enhance medication. Physical therapies include TENS, walking programs, strengthening exercises and massage. Heat or cold packs need to be used with care to avoid burns or hyperalgesia. Cognitive behavioural therapies (CBT) are beneficial for older patients, including residents who have mild dementia. Patients will often benefit from a clear explanation about the cause of their pain, as well as behaviours and positive thoughts to enhance their own capacity to manage pain.

Medication

Choice of medication is based on pain severity. Begin with a mild analgesic such as paracetamol, and build up stepwise to opioids for severe unrelieved pain. Regular medication for baseline pain, that maintains a therapeutic blood level, is more beneficial than administering analgesia when residents ask for it or as staff consider it necessary. Treat breakthrough and incident pain with additional analgesia. Analgesia can be given 30 minutes before activities such as pressure area care, dressings, physiotherapy,and hygiene procedures.

Paracetamol is the preferred analgesic for older people and is effective for musculoskeletal pain and mild forms of neuropathic pain. Lower doses should be used in patients with hepatic or renal impairment. Aspirin is not recommended for use as an analgesic in older people because of the risk of gastrointestinal bleeding.

Codeine has a short half life and is suitable for incident pain or predictable mild to moderate short lasting pain. About 10% of people lack the enzyme that converts codeine to the active opioid form; therefore they will have no analgesic benefit.

Tramadol is a centrally acting analgesic that also weakly acts on opioid receptors and as an inhibitor to noradrenaline and serotonin reuptake. It is a useful medication in a significant minority of older people with chronic noncancer pain, but should be used with caution because of the high incidence of side effects (up to one-third experience nausea, vomiting, sweating, dizziness or hallucinations) and medication interactions (eg. SSRIs). Low doses are recommended initially (25-50 mg per day for the first 3 days) with careful titration and monitoring. Patients over 75 years of age should not have more than 300 mg per day.

Opioids should not be withheld if pain is moderate to severe and unresponsive to other interventions. In general, commence with low doses of short acting opioids and titrate the dosage slowly. More rapid dosage escalation is appropriate in very severe pain, cancer pain and palliative care. In these situations, increase titration by 25% of the prescribed dose until pain ratings are 50% less, or the patient reports satisfactory relief.

When changing the route of administration of opioids, adjust the new dose accordingly. Tolerance to opioids may develop necessitating an increase in dose or decreased interval of administration to achieve the same pain relief. Long acting opioid agents can be used in conjunction with short acting opioids to treat incident pain. In moderate to severe noncancer pain, dosage increments are usually less frequent and the target degree of pain relief may need to be modified, maintaining function and other patient defined goals. Apart from codeine, the main opioids are morphine, oxycodone and fentanyl.

Morphine is suitable for the treatment of severe pain in older people, and is available in forms for most routes of administration. Starting doses for severe acute pain are 10-30 mg 3-4 hourly orally, 2.5-5.0 mg 4-6 hourly intramuscularly, 2.5-10.0 mg 2-6 hourly intravenously, and 2.5-10.0 mg 2-6 hourly subcutaneously. In chronic severe pain, unresponsive to other interventions, after 24 hour dosage needs are established, long acting morphine (MS Contin)can be introduced.

Oxycodone is available in immediate release (endone, oxynorm) and sustained release form(oxycontin)for oral administration. Endone or oxynorm (immediate release) may be used for the initial establishment of tolerance and dosage needs, and later for breakthrough pain. Oxycontin (sustained release) is recommended for chronic pain with the recommended dose of 5-20 mg twice per day.

Transdermal fentanyl is used for ongoing severe pain. It is potent and long acting and the risk for delirium and respiratory depression is high. It should be used only when the resident has had opioids previously and high dosage needs are established. Fentanyl is metabolised in the liver and is suitable for patients with renal failure. Its adverse effects are similar to those of morphine but with a lower incidence of constipation and confusion.

To change the type of opioid medication or route of administration, convert dose to equivalent dose of oral morphine, as shown in Table 11 and Table 12. Conversion doses are only approximate, if drowsiness occurs reduce the dose, if pain increases, increase the dose.


Table 11. Opioid conversion 210

Opioid

Conversion factor from oral morphine

Approx. equivalent dose to 10 mg oral morphine

Codeine

x 10

100 mg

Fentanyl (IV/SC)
(100 mcg/2 mL amps)
(500 mcg/10 mL amps)

x 6.5-7.0 for mcg dose
(x 0.0065-0.007 [in mg])

65-70 mcg (approx. 50-100 x more potent than morphine)

Fentanyl Transdermal Patch

see Table 12

see Table 12

Hydromorphone (oral)
(1 mg/mL in 473 mLs)

x 0.15-0.2

1.5-2.0 mg
(approx. 5.0-7.5 x more potent than morphine)

Hydromorphone (SC/IV)
(2 mg/1 mL amps)
(10 mg/mL 1 or 5 mL amps)

x 0.067

0.67 mg
(approx. 5 x more potent than morphine)

Morphine (rectal)

x 1

10 mg

Morphine (IV/SC)

x 0.33

3.33 mg
(approx. 3 x more potent than oral)

Oxycodone (oral)

x 0.5

5 mg
(approx. 2 x more potent than morphine)

Pethidine (oral)

x 8

80 mg

Pethidine (IV/SC/IM)

x 2.5

25 mg

Sufentanil (SC/IV)
(250 mcg/5 mL amps)

x 0.5 for mcg dose
(x 0.00045/0.0005 [in mg])

5 mcg (mcg daily dose equiv.)
(approx.15 x more potent than fentanyl)


Where a fentanyl patch is substituted for another opioid, the total daily dose of the opioid should be first converted to mg per day of morphine. Table 12 gives data on ranges for conversion, as fentanyl patches may have variable rates of delivery (eg. sweaty skin, hot climates). Patches produce a reservoir in the underlying skin and consequent continued absorption and are usually changed every 3 days. In some patients, breakthrough needs may increase on the third day and the patch may need to be changed more frequently (eg. every 2 or 2.5 days). After the patch is removed the half life of fentanyl in the blood is 15-20 hours.211


Table 12. Dose conversion of transdermal fentanyl patches to morphine

Patch strength (mg)

Delivery rate (mcg/hour)

Parenteral morphine dose equivalent(mg/day)

Oral morphine dose equivalent (mg/day)

2.5

25

30-40

60-100

5.0

50

60-80

120-200

7.5

75

90-120

180-300

10

100

120-160

240-400


Adjuvant medications used in pain management are medications not primarily used for pain treatment but that have analgesic properties. They may be given alone or in conjunction with analgesics. Types of adjuvant medications:

  • Low dose tricyclic antidepressants are suitable for use in neuropathic pain (eg. painful diabetic neuropathy, postherpetic neuralgia, central poststroke pain) or fibromyalgia syndromes. Start with 10 mg nocte, and titrate over 3-7 days to between 30-50 mg. Amitriptyline is the best researched agent. Nortriptyline may be better tolerated. Side effects include: anticholinergic properties, postural hypotension, sedation, constipation, urinary retention, exacerbation of cardiac conditions

  • Anticonvulsants (eg. carbamazepine) are suitable for trigeminal neuralgia but require careful titration over 1 month to reduce adverse effects

  • Gabapentin may be as effective and better tolerated than anticonvulsants and tricyclics but does not have PBS approval for pain management

  • Corticosteroids for inflammatory conditions such as rheumatoid arthritis

  • NSAIDs for nociceptive pain that accompanies musculoskeletal disorders. Caution should be exercised because of the risk of gastrointestinal bleeding and ischaemic heart disease

  • Glucosamine sulphate (1500/mgday) has been shown to relieve pain and improve function in knee and hip arthritis. It is well tolerated, however as it is made from shellfish, it should not be taken by those with an allergy to seafood

  • Complementary and alternative medicines other than glucosamine (eg. herbs, foods, vitamins) have been shown to be effective for pain relief in rheumatoid arthritis (omega-3 oils 4-6 gm/day) and osteoarthritis (eg.chondroitin, topical capsaicin, topical stinging nettle, ginger [Zinger officinale], devil's claw [Harpargophytum procumbens] ). Significant drug interactions have been identified between some herbal products and conventional medicines.212

It is preferable to use a minimum number of medications to maintain a simple regimen,promote adherence and minimise adverse effects. However,sometimes using small doses of medications from different classes in combination will provide a therapeutic benefit that cannot be achieved with a larger dose of a single medication. For example, it may be possible to maintain a resident with postherpetic neuralgia on controlled release morphine 5 mg twice per day plus nortriptyline 10 mg nocte, whereas a higher dose of either morphine or nortriptyline alone may not provide pain relief or may cause intolerable adverse effects.

Older people have lower muscle mass, increased adipose tissue and reduced glomerular filtration. Therefore they have greater sensitivity to the therapeutic and adverse effects of opioid analgesics and many adjuvants, eg. central adverse effects of somnolence,sedation,poor concentration and confusion,are particularly common with opioids, tricyclic antidepressants,carbamazepine and other antiepileptics. NSAIDs can cause confusion and fluid retention, which can precipitate heart failure and acute renal failure. Medication interactions are common, eg. warfarin interacts with NSAIDs and carbamazepine.

The route of administration of a medication is preferably the least invasive and safest for patients. The oral route is the least invasive and is effective in most cases. Percutaneous endoscopic gastrostomy (PEG) tubes may be used to administer oral medications where they can be crushed or given in liquid form. The sublingual or rectal route may be a good alternative for patients unable to tolerate oral medication. The subcutaneous route, using a 'butterfly needle' may be indicated where the patient is nauseated or vomiting. Intramuscular injection should be avoided if patients are on warfarin because of the risk of haematoma. Topical applications, (eg. NSAIDS) are often perceived as beneficial by patients.

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