Dr. Corcoran, MD, discusses palliative approach to pain management in older patients

1. Palliative Approach
to Pain Management
in the Older Adult
Amy M Corcoran, MD CMD FAAHPM
Associate Professor
Geriatric and Palliative Medicine
Milton S Hershey Medical Center
College of Medicine, Penn State University

2. Disclosure
• Speaker has no conflict of interest,
financial agreement, or working affiliation
with any group or organization.

3. Objectives
• Define palliative approach
• Describe pain assessment tools,
including those utilized for cognitively
impaired and nonverbal patients
• Create case-based pain management
plans for older adults

4. Palliative Care
• Holistic patient-centered care
• Focus on symptom management –
physical, psychosocial, spiritual
• Interprofessional team approach
http://www.who.int/cancer/palliative/definition/en/

5. Review Major Types of Pain
Type Somatic Visceral Neuropathic
Characteristics -well-localized
-dull or achy
-poorly-localized
-deep, squeezing,
pressure-like
-associated with nausea,
vomit, sweating
-severe
-burning or vise-like
-occasionally
shooting
Patho-physiology
-arises from
cutaneous or
deep tissues
(i.e. post-op
pain or bone
mets)
-arises from organ
infiltration, compression,
or stretching (i.e. MI,
cholecystitis, bowel
obstruction)
-arises from traumatic
or ischemic injury to
PNS or CNS or other
nerve damage

6. Review Pain Assessment
• Requires repeat comprehensive
assessments
• Older adults under-report pain”normal
aging”
• How is it affecting function and daily life?
• How do you pick what scale to utilize?
AGS Panel on Pharmacologic Management of Persistent Pain in Older Persons. JAGS 57:1331-1346, 2009

7. 0 1 2 3 4 5 6 7 8 9 10
No pain
Worst
pain
imaginable
Numerical Scale

8. 0
Very happy, no
hurt
2
Hurts just a little
bit
4
Hurts a little
more
6
Hurts even more
8
Hurts a whole lot
10
Hurts as much as
you can imagine
(don't have to be
crying to feel this
much pain)
Whaley L, Wong, D. Nursing Care of Infants and Children, ed 3, p. 1070. ©1987 by C.V. Mosby
Company. Research reported in Wong D, Baker C. Pain in children: Comparison of assessment
scales. Pediatric Nursing 14(1):9-17, 1988.

9. Other Components to Assess
• Spiritual
• Psychosocial
• Depression/anxiety
• Misc

10. Scenario
90 year-old patient with advanced dementia.
She is non-ambulatory, non-verbal, and
requires assistance with all basic ADLS.
Her nursing aide is concerned that she is
in pain.
What types of questions would you ask her
aide to assist with assessing her for pain?

12. Scenario
Her aide reports that she scores a 5/10
on the PAIN-AD. She makes facial
grimaces with personal care and any
movement. She is sometimes
moaning and inconsolable.
Given her history of osteoarthritis, what
would be the best choice for her pain
management?

13. Overview of Nonopioid Analgesics:
Appropriate for MILD Pain
• Acetaminophen
• NSAIDs
• COX-2
• Tramadol

14. Given her age, what types of
pharmacological concerns do you
have when choosing your
medications?

15. Review of Geriatric
Pharmacotherapy
• Kidney
• Liver
• CNS
• Protein Binding
• Body Composition
• Drug-drug Interactions

16. Scenario
78y/o in the hospital with recently diagnosed
with metastatic breast cancer. Although
NSAIDs have given her some relief with
the pain, she feels pain “in her bones”.
She is still experiencing 5-8/10 constant,
sharp pain. She has normal renal and
hepatic function.
Her primary physician gave her Percocet
and she reports taking 4-6/day.

17. Do you have any concerns
about NSAIDS in older adults?

18. She is still experiencing 5-8/10 constant,
sharp pain. She has known bone
metastases causing his pain.
What are your options for treating bone
pain?

19. Bone Pain
• Bone Mets
– NSAIDS
– Bisphosphonates—pamidronate, zalendronic
acid
– Radiotherapy (XRT)—strontium-89, samarium-
153-lexidronan
– Steroids
• Acute Fracture
– Bisphosphonates
– Calcitonin
• Paget’s Disease
– Bisphosphonates

20. Her cancer doctor gave her percocets and
she reports taking 4-6/day. She is still
experiencing 5-8/10.
How long does it take for opioids to take
affect given the route of administration?

21. Review of the Opioid Basics
• Morphine
• Hydromorphine
• Oxycodone
• Fentanyl transdermal
• Methadone

22. What type of regimen
would you start?
• Her cancer doctor gave her percocet
(10/325) and she reports taking 4-6/day.
Taking into account that his pain is
moderate-severe (5-8/10) could
increase dose by 50-100%.
• Approximately 50mg
oxycodone/dayincrease by 50% to
75mg/day
• Oxycontin (long-acting) 40mg bid with
oxycodone (short-acting) 10mg
q3hours/prn

23. What type of preventive medications or
measures should you always consider
when prescribing opioids?
• Bowel regimen (senna at a minimum!)
• Nausea prophylaxis?

24. She expresses concern about
addiction or fear of tolerance
– now what do you do?
• What is addiction?
• What is tolerance?
• What is dependence?

25. She agrees to start the regimen and then
develops diffuse itching after about 3 days
of the regimen….what do you do next?

26. What if there is a
neuropathic pain component
or mixed-pain?

27. Neuropathic Pharm Review
• Tricyclic antidepressants
(TCAs)
• Anticonvulsants
• NSAIDs
• Steroids

28. Scenario
70 year-old with stage IV lung cancer. He is
comfortable on a continuous infusion of
morphine at 6mg/hr IV on home hospice.
However, he is experiencing “jerking, shock-like
movements” and “moderately severe”
cramping pain.
What is happening? What are your
management options?

29. What are some non-pharmacological
methods to treat pain?
• Hypnosis
• Hyperstimulation analgesia
– Ice massage
– Acupuncture
– TENS (transcutaneous electrical nerve stimulation)
• Dry heat
• Hydrotherapy
• Orthotic devices
• Trigger point injections with lidocaine or steroid

30. Common Pitfalls in Older Adults
• Not using a quantitative pain scale
• Not prescribing opioids for patients whose pain
levels are moderate to severe
• Not providing aggressive bowel regimen
• Not discontinuing medications that contribute to
sedation
• Not scheduling around the clock medications
• Not re-assessing clinically for effectiveness of
pain regimen
• Not utilizing the interprofessional team

31. Which of the following are
non-verbal pain indicators?
A. Facial grimace
B. Restlessness
C. Tachycardia
D. All of the above

32. Which of the following are
common pitfalls in palliative pain
management of the older adult?
A. Inconsistent use of a pain assessment
tool
B. Forgetting to discontinue medications that
could be contributing
C. Forgetting to order a bowel prophylaxis
regimen
D. Not re-evaluating the effectiveness of the
regimen
E. All of the above

33. Helpful References
• AGS Panel on Pharmacologic Management of Persistent Pain in Older
Persons. JAGS 57:1331-1346, 2009
• AGS Clinical Practice Committee: Management of cancer pain in older
patients. JAGS. 1997 (45): 1273-76.
• Cafiero, Angela C. PharmD, CGP. Geriatric Pharmacotherapy. Geriatric
Secrets. 3rd Edition. Henly and Belfus, Inc. 2004; 29-35.
• Feldt, Karen PhD RN. The Checklist of Nonverbal Pain Indicators (CNPI).
Pain Management Nursing. March 2000; 13-17.
• Hadjistavropoulus T., et al. An Interdisciplinary Expert Consensus
Statement on Assessment of Pain in Older Persons. Clinical Journal of
Pain. January 2007 Supplement. Volume 23 (1):S1-43.
• Kapo, Jennifer MD and Janet Abrahm, MD. Pain Management. Geriatric
Secrets. 3rd Edition. Henly and Belfus, Inc. 2004; 87-94.
• Mercadante, S. and Fabio Fulfaro. Management of Painful Bone
Metastases. Current Opinion in Oncology. 2007 (19):308-314.
• Pavlakis N. et al. Bisphosphonates for Breast Cancer (review). Cochrane
Review. John Wiley and Sons. 2007.
• Upton et al. Population pharmacokinetic modelling of subcutaneous
morphine in the elderly. Acute Pain. 2006 (8);109-116.