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No conflicts of interest

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Opinions are not that of VAMC or UA

ASSESSMENT AND TREATMENT OF PAIN AND DISTRESS FOR FRAIL AND DEMENTED OLDER ADULTS

A. LYNN SNOW, PHD ASSOCIATE PROFESSOR, UNIVERSITY OF ALABAMA CENTER FOR MENTAL HEALTH AND AGING & DEPT. OF PSYCHOLOGY; C LINICAL RESEARCH PSYCHOLOGIST, TUSCALOOSA VA MEDICAL CENTER

Pain is Associated with Poor Outcomes

 Under-treatment associated with: gait disturbances, falls, malnutrition, morbidity, mortality, functional disability, agitated behavior  Over-medication associated with: functional disability, increased falls, decreased activity, deconditioning, decubitus ulcers

Pain is Under-Treated

   In Homes In Hospitals In Nursing Homes

Barriers to Pain Control

 The health care system through regulation, lack of priority on pain treatment, cost-cutting measures, staffing issues.  The health care professional through misinformation, biased attitudes, fear of addiction, fear of disciplinary action, lack of knowledge and skill in pain management.

 The public/patients/families through fear (of addiction) misinformation, cultural beliefs, concern about side effects.

Older Adults Often Don’t Report Their Pain

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Belief that pain is a normal part of aging Fear of the cause Stoicism Fear of losing independence Don’t want to bother family or others Fear of addiction Fear of tolerance or side effects Impaired cognition

FEAR…What fears impact our ability to appropriately treat pain in frail and demented older adults?

    Addiction Delirium Side Effects Worse than the Pain Kill the Patient or Make Them Very Sick  Because they are more sensitive to drugs  Drug-drug interactions  Drug-disease interactions

Reality

  Delirium and Side Effects can be controlled through Starting Low and Going Slow, anticipating and proactively treating side effects, and good caregiver advocacy  Addiction versus  Physical Dependence  Tolerance A knowledgeable geriatrician and/or pain specialist, especially in collaboration with a pharmacist and good caregiver advocacy can avoid drug interactions

Dementia Pain Facts

  Pain thresholds are not altered, but pain tolerance is significantly increased Conclusion: demented individuals experience the same pain sensations as non-demented individuals,

but fail to interpret such sensations as painful

Huffman, J. C. & Kunik, M. E. (2000). Assessment and understanding of pain in patients with dementia. Gerontologist, 40, 574 – 581.

Persons with Dementia are at High Risk for Under-Diagnosis of Pain

  Self-report capacity is at least diminished  Memory, Language, & Abstract Thought Deficits Typically manifest pain through behaviors - but wide overlap with behaviors due to other etiologies (e.g., agitation, boredom, depression)  5 of 8 NH residents on psychotropics to control “difficult” behavior were successfully removed from the medications when placed on scheduled acetaminophen (Douzijan et al., 1998).

Dementia Patients are at High Risk for Under Treatment of Pain

 Patients hospitalized for hip fractures with advanced dementia received three times less the amount of opioid analgesics administered to cognitively intact patients (Morrison & Siu, 2000) .

 Several studies report that less than 25% of the demented individuals identified as in pain were receiving analgesics .

What is Pain?

Pain is



“… an unpleasant sensory and emotional experience which we primarily associate with tissue damage, or, describe in terms of such damage, or both.” (International Association for the Study of Pain)

Source: C. Kovach, U. Wis. Milwaukee

What is Pain?

McCaffery (Pasero, Paice, & McCaffery, 1999) says, "

Pain is whatever the experiencing person says it is, existing whenever he says it does".

But what if they can’t tell you?

Distress Behaviors

 Distress Expressions  Noises and words (“ow”, “ouch”, “that hurts”, “stop”, crying, moaning/groaning)  Facial expressions (grimacing)  Distress Movements (restlessness, guarding, bracing)  Other Distress Behaviors  Agitation, Aggression, Resisting care  Negative Affect (Depressed, Blue, Sad, Apathy)  Sleep and appetite disturbances  Change in activity level

Distress Behaviors are: Communications of Pain by Persons with Dementia

     Distress Expressions Noises and words (“ow”, “ouch”, “that hurts”, “stop”, crying, moaning/groaning) Facial expressions (grimacing) Distress Movements (restlessness, guarding, bracing)     Other Distress Behaviors Agitation, Aggression, Resisting care Negative Affect (Depressed, Blue, Sad, Apathy) Sleep and appetite disturbances Change in activity level

Distress Behaviors are: Communication of Other Unmet Needs by Persons with Dementia

     Distress Expressions Noises and words (“ow”, “ouch”, “that hurts”, “stop”, crying, moaning/groaning) Facial expressions (grimacing) Distress Movements (restlessness, guarding, bracing)     Other Distress Behaviors Agitation, Aggression, Resisting care Negative Affect (Depressed, Blue, Sad, Apathy) Sleep and appetite disturbances Change in activity level

CONCEPTUALIZATION: Number One Question:

WHY IS THIS HAPPENING?

What is causing the behavior?

CAUSATION THEORIES: Unmet Needs Model

 The behavior of persons with dementia represents efforts of the person with dementia to get unmet needs addressed

Algase, DL, Beck C, Kolanowski A, Whall A, et al. Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. Am J Alz Dis. 1996;11:12 –19.

Needs of All People With Dementia

      Physical Needs: Hunger, Thirst, Restroom, Pain/Discomfort, Rest Feel Safe and Secure Meaningful Positive Human Contact Meaningful Activity Feel That Are Contributing Have Success Experiences

CAUSATION THEORIES: Learning/Behavioral Models

 Problem behaviors have been inadvertently reinforced in the environment, or positive behaviors have not been reinforced.

 ABC Model:  Antecedent->Behavior->Consequence

 

CAUSATION THEORIES: Environmental Vulnerability /Reduced Stress Threshold Model

Dementia causes a lowered ability to cope with stimulation from the environment.

a Behaviors are due to person being overstressed/overstimulated.

Corollary: Under-stimulation is also problematic.

b

a Lawton MP, Nahemo L. An ecological theory of adaptive behavior and aging. In: Eiserdorfer C, Lawton MP, eds. The Psychoogy of Adult Development and Aging. Washington, DC: American Psychological Assocation; 1973:657-667.

b Kovach CR, Taneli Y, Dohearty P, et al. Effect of the BACE Intervention on Agitation of People With Dementia. Gerontologist. 2004;44:797-806.

CAUSATION THEORIES: Biological Models

 Neuropathology leads to neurotransmitter imbalances which lead to neuropsychiatric symptoms or disturbances in drives which lead to Behaviors.

Cause Models are Complementary and not Mutually Exclusive

 Implication: Nonpharmacologic interventions can be developed to address these causes, even for behaviors caused in large part by biological problems

Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia: a review, summary, and critique. AJGP. 2001;9:361-381.

Decisional Models

  A good decisional model is the cornerstone of developing effective nonpharmacologic treatment plans A decisional model provides a map to follow to decide how to approach treatment

       

Serial Trials Protocol

I DENTIFY the problem ASSESS  for all possible causes Unmet physical/functional needs  Understimulation/Overstimulation  Whose problem is it?

 Behavior/Learning Causes ADDRESS possible physical causes ADDRESS possible environmental causes ADDRESS possible behavior/learning causes Still a problem?  REASSESS  READDRESS Still a problem? REFER AND CONSULT (Geropsychiatry, Pain, etc.) DON’T GIVE UP…SERIAL trials…SERIAL!!! There Empirical Evidence that Persistence is Key to Success

15 Kovach CR, Logan BR, Noonan PE, Schlidt AM, Smerz J, Simpson M, Wells T. Effects of the Serial Trial Intervention on discomfort and behavior of nursing home residents with dementia. Am J Alzheimers Dis Other Demen. 2006; 21:147-55.

 You can never know that you have achieved an accurate pain assessment by observation alone...you can only develop a hypothesis based on the collected data...that hypothesis must then be tested through intervention trials and re-assessment

Use of analgesics for assessment

 Commonly done for other disease entities (such as Nitroglycerine for chest pain)  Christine Kovach RN PhD has conducted an RCT of this approach in Wisconsin, and shown it to be effective. Their nursing home state regulators know about her work and have approved of this use of pain meds.

 Usually the drug Kovach’s group starts with is acetaminophen extra strength BID.

Common Pain Beliefs

      I am familiar with the patient so I know if they are in pain or not…anyone not familiar with the patient will not know what their behaviors mean… There will be behavior change if pain is present If a person is on routine pain medications, they can’t be in pain The behavior is just part of dementia The resident just does that for attention Staff conceptualization/assessment of discomfort is different for verbal patients…their verbal reports are given more weight

Treating Pain

Non-pharmacologic Treatment

     

Basic Non-pharmacologic Pain Management

 Repositioning, hot packs, cold packs, cushions and pillows

Psychology

 Relaxation, Biofeedback, Cognitive retraining, Distraction/re interpretation Techniques, Sleep hygiene, caregiver training

Physical Therapy

 Reconditioning, Stretching, Exercise, Massage

Occupational Therapy

 Pacing skills, work simplification, body mechanics

Recreation Therapy

Meaningful and Pleasant Activities

Particularly for Persons with Dementia:

 Sensory Activities (touch, music, 1:1 attention)  Be Particularly Aware of Basic comfort needs

Use of Analgesics for Geriatric Pain

Source: C. Kovach, U. Wis. Milwaukee

WHO 3-Step Analgesic Ladder

Step 1 Mild Pain Step 2 Moderate Pain Weak opioids ± non-opioids (e.g. A/Codeine, A/Hydrocodone, A/Oxycodone, Tramadol) Step 3 Severe Pain Potent opioids ± non opioids (e.g. morphine, Oxycodone, Hydromorphone, Methadone, Fentanyl) ASA, Tylenol, NSAIDS+/ Adjuvants

2 Pitfalls:

 Over-aggressive Treatment  Treatment That’s Not Aggressive Enough

Treatment Considerations: Geriatric Physiological Changes

   

Near EOL, loss of muscle mass and body fat

 Altered volume of distribution for lipid-soluble drugs leading to prolonged half-lives (benzodiazepines, methodone, psychotropics)

In Older Adults, Renal clearance decreases

 Drugs like meperidine that rely on renal excretion become problematic

In Older Adults, Altered hepatic metabolism

 Elimination by Cytochrome oxidation affected  Elimination by conjugation not affected (morphine)

Dementia = Sensitivity to anticholinergic effects

Ferrell, Annals of

 antihistamines, tranquilizers, antiemetics

LTC, 2004, vol 12

Acetaminophen

    “Drug of choice for most elderly persons with mild-to-moderate musculoskeletal pain” Preferred in pts with gastric, renal, or hematologic disease (Marcus) “A common mistake is not giving enough..650 1000mg q6hrs or qid” Caution patients about acetaminophen in other prescription and OTC drugs, which might add up to a problematic dose

Ferrell, Annals of LTC, 2004, vol 12

Source: C. Kovach, U. Wis. Milwaukee

When is Tylenol Inappropriate?

   If a person is already on something stronger than tylenol, yet continues to have pain If they have an allergy or sensitivity to tylenol If someone has a high or chronic alcohol intake or has impaired liver function

Opioids

 “Opioids are effective for elderly patients with most pain types, and are probably underutilized in this population, and may be safer than NSAIDS or other drug strategies used in older persons”

Ferrell, Annals of LTC, 2004, vol 12

Why We Are Reluctant to Give Opioids: Opioid Side Effects

    Constipation (lactulose and senna) Nausea Somnolence and psychomotor retardation…

tolerance usually develops in a few days of reaching steady-state drug levels

Respiratory Depression…” for most patients opioid medications should never be held in the presence of severe pain and usually should not be held unless patients are poorly arousable and have a respiratory rate of less than 6 to 8 breaths per minute”

Ferrell, Annals of LTC, 20004, vol 12

Marcus DA. 2003. Clinical Geriatrics. Vol 11 (11); Caracci G. 2003. Clinical Geriatrics. Vol 11(11).

Opioid Side Effects

    Older adults have 10-25% higher risk of developing adverse drug reactions vs pts<30yrs old “Drug induced cognitive impairment accts for 11 30% of delirium in hospitalized pts and in 2-12% of those evaluated for suspected dementia” Patients with dementia are at higher risk of developing increased confusion with opioids

THESE ARE NOT REASONS TO AVOID OPIOIDS…these are issues to monitor and to prepare patients and family for

Caracci G. 2003. Clinical Geriatrics. Vol 11(11).

Opioids

 Avoid for chronic pain  Propoxyphene  Long half-life and metabolite norpropoxyphene is toxic  Meperidine  Its neurotoxic metabolite, normeperidine, causes tremor, irritability, cognitive changes, seizures  agonist-antagonist opioids (e.g., pentazocine, nalbuphin)  High incidence of delirium

Opioids

Caracci G. 2003. Clinical Geriatrics. Vol 11(11).

Ferrell, Annals of LTC, 2004, vol 12

     Morphine has most predictable metabolism Hydromorphone is a good alternative to morphine – more potent and better tolerated (Caracci) Oxycodone has fewer metabolites and side effects than codeine (Caracci) Methadone can be helpful, but should be prescribed by clinicians with expertise with its use or in closely monitored settings because of unpredictable pharmokinetics in older persons

Fentanyl can be difficult to titrate…don’t start with it…don’t use in opioid-naïve pts

Caracci G. 2003. Clinical Geriatrics. Vol 11(11).

Opioid dosing

 “Most studies on dosages of opioids in geriatric populations indicate an inverse relation between dosage used and age independent of other factors….[but]…focus on attempting to adapt the dose to the pt’s needs, rather than treating pain with fixed doses. This process calls for carefully monitored titration depending on the pt’s response and the emergence of side effects.”

Marcus DA. 2003. Clinical Geriatrics. Vol 11 (11).

Rules of Thumb

     Start low and go slow Start pt on low doses of short-acting opioids (oxycodone, morphine) Educate caregiver on side effects to watch for so if they appear they won’t become severe before you are alerted Once daily dose requirement established, switch to sustained-release formulation at scheduled intervals, with prn for rescue doses

Review prn admin regularly

…if rescue doses used regularly, the scheduled dose needs to change

Dose Escalation

Source: C. Kovach, U. Wis. Milwaukee

Done in percentages based upon the patient’s pain rating or prevalence/severity of behavioral symptoms. A guideline is: • Pain

mild

(or rated at 1 to 3/10), dose escalation is 25% of • Pain

moderate

(or rated as 4 to 6/10), dose escalation in 25% current dose to 50% of current dose • Pain

severe

(or rated as 7 to 10/10), dose escalation is 50% to 100% of current dose

To Appropriately Make Analgesic Dosage Decisions you Need to Know…

 What Quality Of Life Looks Like In…  The geriatric patient with serious chronic illness and disability  The patient with mild dementia  The patient with moderate dementia  The patient with severe dementia