Management of Pain

Introduction

Pain assessment in elderly people provides very unique challenges. The doctor assessing the pain must rely on his skill and perception as well as verbal and nonverbal expressions of patients and caregivers for a comprehensive assessment.

Assessment of pain in the elderly may at times be difficult and frustrating task because of:

  • unusual presentation,
  • multiple concurrent disease and multiple sources of pain,
  • disability with sensory deprivation from poor hearing and vision,
  • cultural barriers where there are tendency to under-report pain experienced both by patients and caregivers.
  • decreased cognitive capacity for example in patients with dementia making expression of pain unclear.

Symptoms / Signs

One simple way to assess pain is to use GOLD CARTS as a mnemonics to help cover all aspect of patient’s pain. The assessment should cover the followings:

G: Goals of care and expectations of patients and caregivers
O: Onset – acute onset of pain as compared with gradual type of pain
L: Location of the pain with / without radiation of pain
D: Duration of pain i.e. recent onset or longer duration (chronic or longer duration of pain)
C: Characteristics – the quality of pain and the type of pain including incidental pain and breakthrough pain
A: Aggravating factors to the pain
R: Relieving factors for the pain
T: Treatments – previously tried treatment need evaluation:

  • Response- what was the previous response?
  • Dose and / or duration of the treatment used
  • Why was the treatment discontinued?

S: Severity Pain Scales: 0 – 10; Visual Analogue Scale (VAS) are score regularly and they are helpful to quantify pain objectively

Pain Maps or Body Pain Charts are drawn with (or by) the patient as a communication tool to make pain “visible”. They are very useful for initial assessment and for monitoring of progress of pain symptoms

These Pain scales (e.g. VAS and body pain chart etc) are usual for charting severity of pain and monitoring the pain progress

After the above detail assessment have been done, clinician will have a clearer idea of the followings:

  • Type of pain i.e. soft tissue, bone pain, neuropathic nerve pain etc
  • Severity of Pain
  • Probable cause of pain
  • Options for pain relief

The above assessment using the GOLD CARTS mnemonics will help assess patient’s needs and then matched the type, severity and probable cause and mechanisms of pain to the specific non pharmacological and analgesics drugs available.

Treatment

Principles of Pain Management are as follows

  1. Communication with the patient and /or caregivers about the treatment goals and priority is utmost important.
  2. Clarify the goals:
    1. Improved Quality of Life
    2. Improved function
  3. Educate patients and caregivers about the most appropriate pain medication matched for the most appropriate type of pain or severity
  4. Clinicians must balance the risks of side effects of analgesic with the benefits of being pain free. The key is flexibility and creativity in prescribing these various types of analgesics.
  5. Review! Review! Review! Regular review and careful monitoring; pay attention to details and progress of the improvement of pain is very important.
  6. If cognition is in question, we must have more appropriate assessment. Remember that Alzheimer’s Disease diagnosis does not mean individual cannot partake in their treatment decisions.

Factors affecting most appropriate choice of analgesic drug includes:

  • Coexisting disorders
  • Interactions with other drugs used for concomitant conditions
  • Tolerability of the drug
  • Cost of the drug

When prescribing, consider the following

  • Pain killers must be given orally (by the mouth), regularly (by the clock) and via the WHO ladder of 3-step model to guide the most appropriate pain killer’s choice depending on the severity of the patient’s pain.
  • For mild pain use antipyretics (e.g. paracetamol) plus adjuvants (e.g steroids, amityptyline etc); whilst for moderate severe pain we must consider using mild opioids with adjuvant. In patients with severe pain use strong opioids (e.g. morphine) plus adjuvants.
  • Drugs for mild to moderate pain are NSAIDs, acetaminophen, tramadol. Anticipate problems with the non-selective NSAIDs and use them cautiously and sparingly in elderly as they have a higher risk of adverse drugs events with NSAIDs .
  • Use opioids for moderate to severe pain. Morphine is the prototype. Expect increased sensitivity to opioids in elderly patients because of age-related changes in the pharmacokinetics of these drugs
  • Match the severity of pain to the strength of the analgesic i.e. strong analgesics for severe pain.
  • Always consider adjuvant analgesics. Examples are antidepressants, anticonvulsants, local anesthetics and steroids. Other adjuvant analgesics to consider are Bisphosphonates and or Calcitonin; and for disease specific therapies; radiation, chemotherapy and even surgery may have to be considered
  • Do not use placebos as they are unethical in clinical practice and they don’t work. They are not helpful in diagnosis and worse they destroy trust.

Prevention / Education

PATIENT AND CAREGIVER EDUCATION is very important and the following should be discussed

  • Diagnosis, prognosis, natural history of underlying disease
  • Communication and explanation of the nature and mechanism of pain after a careful assessment of the pain
  • Explanation of drug strategies
  • Management of potential side-effects
  • Explanation of non-drug strategies
Last Review : 20 June 2014
Writer : Dr. Yau Weng Keong
Reviewed : Dr. Ungku Ahmad Ameen bin Ungku Mohd Zam