Pain Management in the Geriatric Population
Pain Management in the Geriatric Population
in the Geriatric Population
Ali R. Rahimi,MD,FACP,AGSF
Professor of Medicine
Mercer University School of Medicine
University of Georgia School of Pharmacy
a : usu. localized physical suffering associated with a bodily
disorder; also : a basic bodily sensation induced by a noxious
stimulus, received by naked nerve endings, characterized by
physical discomfort (as pricking, throbbing, or aching), and
typically leading to evasive action
b : acute mental or emotional distress or suffering
What happens when you reach into the blender to dislodge a
stuck icecube without unplugging it first.
Pain & elderly
Pain is what many people say they fear most about dying.
Pain is undertreated at the end of life
Older patients are likely to have a increased pain threshold
but to be less toleant to severe pain.
PAIN IS MC REASON FOR INDIVIDUALS
TO SEEK MEDICAL CARE
• Addiction: Psychological dependence on a drug.
• Physical Dependence:
Development of physical
withdrawal reaction upon discontinuation or antagonism of a
• Tolerance: Need to increase amount of drug to obtain the
• Pseudoaddiction: Behavior suggestive of addiction
occurring as a result of undertreated pain
Pain can be assoc w/:
Psychologic and physical disability
a source of individual suffering
Pain in nursing home patients
30% reported daily pain
26% of these patients received no analgesia
Only 26% of them received strong opioids
What predicted inadequate pain management?
Advanced age: >85 years old
Poor cognitive function
Bernabei (1998), N = 13,625 cancer patients
Obstacles of geriatric pain
Accessibility to treatment
Ex- NSAID use in pt w/ HTN or heart disease
Ex- Acetominophen use in Liver dz pt
Interactions with the current meds
Pts with cognitive impairments
The assumption that pain is normal party of aging
Practitioner’s bias (pain seeker..)
fear of legal repercussions…
It’s a risk factor!
bc of pain
INJURIES from falls
Types of pain:
Nerves responding appropriately
to a painful stimulus
results from NS dysfunction,
and may originate centrally or
originates in the skin, bones, myo, and
connective tissue, and usually is
originated in internal body structures
and organs, and is located more
Set off by unusual stimuli, light touch, wind on skin, shaving
Electric, burning, tingling, pins & needles, shooting (system
isn’t working right)
Easier to treat than
Worse with stress, pressure
Responds better to opioids, NSAIDs
Sharp, dull, stabbing, pressure, ache, throbbing
Occasionally radiates (less well-defined), but not along an
obvious nerve distribution
Differentiating between somatic, visceral, and neuropathic pain is
ESSENTIAL to proper tailoring of pain treatments
determining the presence and cause of pain
identifying exacerbaing comorbidities
reviewing beliefs, attitudes and expectations regarding
Overall: to decrease pain and increase function and
quality of life!
Common pain syndromes in elderly
Degenerative disk dz
Osteoporosis & Fxs
Central poststroke pain
Radicular pain secondary to degenerative disc dz
Aging takes a toll…
In the PNS:
Loss of myelinated and unmyelinated fibers
Axonal atrophy common
Nerve conduction and endoneural blood flow are reduced w/ age
Less nerve regeneration observed
progressive loss of serotonergic and noradrenergic neurons in the
superficial lamina of the spinal dorsal horn, and bc serotonin and
norepineph have important roles in the descending inhibitory
control pathways, such a loss may upset the natural endogenous
Therefore, pain treatment of the elderly obviously
differs from that of young patients!
Models of the prevalence of pain
1- Pain increases with age and then decreases at older ages (ie, 70 and
beond). They suppose that this pain typically has a mechanical etiologic
component and possibly is assoc with the occupational envioroment
2- pain increases with age. This has a mechanical etilogic component but
also an assoc with increasing prevalence of degenerative dz, particulary at older
3- age-independent pain that (obviously) lacks a mechanical etiologic
component. (ie- risk factors that are constant throughout the life course)
4- A decrease in pain prevalence at older ages. It is not clear whether
the trajectory is caused by age-related changes in pain and pain perception, or
by changes in pain reportin.
Effect of age on human (via clinical
Clinical observation examples:
increased incidence of silent MI in elderly patients
atypical presntation of an inflamed appendix, (absence of RLQ
Study example: (pg 208)
Yunis compared elderly and young patients with
fibromyalgia. They found that chronic head aches,
anxiety, tension, mental stress and poor sleep were all
less common in the elderly patients w this condition.
Lonliness and pain
The comorbidity of pain and psychological distress is WELL
DOCUMENTED The feeling of lonliness is the single most important predictor
of psychologic state of distress in older persons.
A study by Eisenberger supported the
hypothesis that Pain distress and social
distress share neurocognitive substrates
Study on page 193
Sleep and pain
Multiple studies have demonstrated the comorbidity of pain and
Pain is among the best predictors of sleep disturbances among
Thus, it appears that improved pain leads to improved
sleep, and impoved sleep leads to
Study =pg 193
HOW TO QUANTIFY THE PAIN?
Troubleshooting pain assessment:
Have to look for:
Agitation, agressiveness, etc.
Pain control vs quality of life
to abolish pain with minimal adverse effects.
Ex- Patient with COPD and pain:
o Cant treat their pain too vigorously bc we will exacerbate the
Treating the pain:
Anti-inflammatory agents (asa, NSAIDS, cyclooxygenase
[COX-2] inhinitors, steroids)
Antielileptic drugs (AEDs)
Cultural healing rituals
How to choose an analgesic?
Moderate to severe:
Use in combo with opioids
Mild to Moderate pain:
Analgesic, antipyretic, anti-inflammatory and anti-rheumatic activity.
Inhibits prostaglandin synthesis producing analgesic.
antiplatelet effect by inhibiting the production of thromboxane
Much higher levels needed for anti-inflammatory effect than for anti-platelet, anti-pyretic
and analgesic effects.
Metab: Gut & plasma (ASA); liver (salicylate)
Can cause: GI irritation and bleeding.
Use w caution in ppl with hx of gastric or peptic ulcercs.
analgesic and antipyretic agent
Inhibits central prostaglandin synthesis with minimal inhibition of peripheral
Antipyretic effect by direct action on the hypothalamic heat-regulating center
No gastric mucosa effects
No effect on platelet aggregation
Metab by liver
Excretion: urine (metabolites can accumulate w renal impairment)
Can take 500-1000mg orally q 6hr
Older pts and Pts with liver dz: do not exceed 2g/day
Antipyretic, analgesic and anti-inflammatory
Reduce central and peripheral prostaglandin synthesis but they do not
inhibit the effects of the prostaglandins already present, resulting
in analgesia, followed by relatively delayed anti-inflammatory
1.5 times higher risk of GI bleeding
Hepato and nephrotoxicity
(more so in the elderly)
Concurrent use of PPI for prevention
18 available in the US
All NSAIDS have similar mechanism of action BUT differ in:
Time to onset
Response among patients
Painful chronic conditions (ex- OA)
Benefit more notable when used in combo w an opiod.
Opiod SEs like sedation, n/v decreased when used w NSAID
COX 2 NSAIDS:
Purpose in pharmacology unclear
Only available: celecoxib
Cox2 and NSAIDS are CI in pts with cardiac disease!
estimated to be responsible for up to 20 percent of hospital admissions for congestive heart failure.
BY INCREASING SYSTEMIC VASCULAR RESISTANCE
and REDUCING RENAL PERFUSION
a chemical that works by binding to opioid receptors, which
are found principally in CNS and the GI.
Hence, the GI Ses
decreased perception of pain
decreased reaction to pain
increased pain tolerance
Cornerstone of the analgesic regimen for mod-sev pain
• MC ones:
• Transdermal fentanyl
3 Main Opioid receptors:
Mu, delta and kappa receptors.
affect numerous body systems
influence mood & reward behavior
not a lot on market
may cause less resp depression and miosis
psych effects, can produce dysphoria
Opioids LACK the adverse renal, and hematologic
effects of NSAIDs
MU-receptor agonists are MC used
although drugs may interact with more than one type of receptor.
Ex- the mu receptor antagonist and kappa receptor agonist
drugs were deigned to cause less respiratory depression.
Pharmacokinetic properties of an opioid can dictate the
circumstance which they are appropriate in:
Ex- Lipid-soluble drug such as fentanyl, which diffuse rapidly acros the BBB, are preferable if
analgesia is required immediately before a short, painful procedure.
Elimination half life very short:
So, steady state reached in a day or less!
Thus, you can adjust the dose daily knowing we are seeing it’s
1. Respiratory depression
Caused by directly acting on respiratory center
Naloxone is specifically used to counteract life-threatening
depression of the central nervous system and respiratory system
Therapeutic doses of morphine can affect:
Resp rate, minute volume tidal exchange
Although, tolerance to this effect is usually achieved
with repeated doses of opioids.
Avoid/Monitor in pts with:
Imparied resp function
Or bronchial asthma
Not common if
begin with low
dose and titrate
2. Nausea and vomiting
Likely due to changing blood serum levels , not problem @
The freq of nausea and vomiting is higher in ambulaory
patients (vestibular component?)
Antiemetics (metoclopramide or droperidol) can be used
along with the opioid.
Acts on receoptors of GI tract and spinal cord
to produce decrease in peristalsis and intestinal secretions
Tolerance to this effect is not common Result- prescribe prophylactic laxatives
… use stood softener AND a stimulant laxative.
4. Urinary retention
causes increased smooth muscle tone
increases sphincter tone
Mechanism not fully known~
Hypot: related to the release of histamine from mast cells.
If itching is with rash- consider allergy.
Can use an antihistamine to treat this
Morphine = standard of opioids
BUT if pt doesnt respond well, they may switch to an
equianalgesic dosage of:
If pt has diminished renal function, they may benefit from:
Oxycodone or hydromorphone (bc these don’t have clinically
significant active metaolites)
Full opioid agonists:
Typically combined with
acetaminophen or an NSAID
Acetaminophen con Codeine
Low regulatory control
10% cannot convert codeine to morphine
Many drugs interfere with conversion
Acetaminophen with Oxycodone,
• Oxycodone combination contains 325 mg acetaminophen
• Hydrocodone combination contains 500 mg acetaminophen
• No clear advantage between the two
Three mu=receptor agonist to avoid
whenever possible!! ..
Low potency relative to morphine
A short duration of action – so have to dose it more frequently
And a toxic metabolite (normeperidine)
Ex- meperidine 75mg = 5-7.5 mg of morphine
can cause irritability and seizures
2. Propoxyphene (DARVOCET)
treat mild to mod pain
Toxicities assoc with it’s primary metabolite: norpropoxyphene
can cause cardiotoxicity and pulmonary edema
Half life: 6-12 hour;Metabolite half life 30-36 hours
Pts with Dec Renal function or pts getting repeat doses: higher risk
Puts geriatric pts at higher risks of falls (d/t CNS effects)
study found that propoxy users have twofold higher risk for hip frature compared with nonusers of analgesics
ALSO, it has no clinical advantage over nonopioid analgesics
such as acetominaphen
Must be converted to morphine by means of the cytochrome
P-450 pathway to provide analgesia.
Lots of Caucasians are poor metabolizers of this isoenzyme
-thus cant make the conversion!
So, they do not get any of the codeine’s benefit but still suffer
the Side effects.
Principles of opioid use:
No ceiling effect
Dose to pain relief without side effects
Give orally when possible
Sub-cutaneous administration is basically equivalent to
intravenous (and preferable)
Treat constipation prophylactically
Full opioid agonists are best choice for severe pain..
Where to start?
Treating Chronic pain:
Basal pain medicine plus a different therapy for spikes:
Predictable spikes - Short-acting agent prior to event
Unpredictable spikes - Short-acting agent readily available (prn)
Treating Neuropathic Pain;
Opioids and NSAIDS less effective
Classes of Agents
Tricyclic for dysesthetic pain
2. Anticonvulsants for shooting pain
Steroids to decrease peri-tumor edema
Tricyclic for dysesthetic pain
Dysesthesia is pain not experienced by a normal nervous
Eg- neuropathic burning from chemotherapy
Considered "Dante-esque" pain.
Anticonvulsants for shooting pain
Steroids to decrease compression
Nerve infiltration by tumor or spinal cord compresion:
*Usu used for pts near end of
Life bc of detrimental SE of
Long term steroid use.
Opioid analgesics available in US
Kappa agonist/mu antagonist
Mu partial agonist/kappa
When to refer:
Pain not respsoning to opoiods at typical doses
Neuropathic pain not responding to first line treatments
Comples methadone management issues
Intolerable side effects from oral opioids
Severe pain from bone mets
For a surgical or anesthesia-based procedure, intrathecal
pump, nerve block, or rhizotomy
When to admit:
For severe exacerbation of pain that is not responsive to
previous stable oral opioid around-the-clock plus
Pateints whose pain is so severe that they cannont be cased
for at home
Uncontrollable side effects from opioids, including nausea,
vomiting, and altered mental status
Good to know..
Older individuals tend to be more sensitive to
benzodiazepines and opiods.
Pain from bone mets more susceptible to NSAID pain relief
The 1998 guidelines recommended earlier use of narcotics
than is typical for treatment of younger patients because of
the significant toxicities assoc with NSAIDS.
Characterized by: severe, unilateral facial pain described as
lancinating electrics shock-like jolts in one or more
distributions of the trigeminal nerve.
Maxillary and Mandibular divisions = MC
Careful clinical evaluation and MRI is recommended
Follows outbreak of Herpes zoster
Allodynia (wind against skin hurts, sheet on area hurts etc)
Post stroke pain
An underrecognized consequence following storke
May present as shoulder pain in the paretic limb or present as
central poststroke pain.
Characterized as pain that is severe and persistnet w
accompanying sensory abmomalities
Ex- the guy from Oceanside.
Metastatic bone pain
Bone pain that is worse at night, when laying down or not
assoc with acute injury
Pain that gradually but rapidly increase in intensity or with
weight-bearking or activity.
Hips, vertebrae, femur, ribs, and skull
More than 95% of TA are ppl >50
New onset headache, malaise, scalp tenderness and jaw
PE: indurated temporal arterly that is tender with a diminihed
or abent pulse
Irreversible bliness is consequence of untreted.. So timely
assesment and tx is
Pain perception in rats:
When nociception is tested in mice using an electrical
current, it seems that there are age related changes in
The graphic representaion of electical thresholds needed to
induce a vocal reponse was of a U-shap pattern. (high pain
tolerance in young and old- lower in the middle aged)
Effect of age on human experimental
50 studies total
21 concluded an increase in pain threshold with advancing age
3 reporeted a decrease
17 noted no change
Temporal vs Spatial summation:
It was fround that temopral summation to a heat pain stimulus, for
example, is more pronounced in the elderly as compared with
younger subjects. Whereas spatial summation is not significantly
influenced by age.