The AGS Foundation for Health in Aging



GERIATRIC EMERGENCY MEDICINE FACT SHEET: PAINPain is a common problem for older adults.Persistent pain is an issue for >50% of community dwelling older adults and 85% of nursing home residents.Pain has detrimental effects in older persons.Physical / functionalsleep disruptionappetite disturbanceweight losscognitive impairmentlimitations in performance of daily activitiesPain is under treated in older adults.Psychosocialdepressionsuicide riskanxietysocial isolationGlobal quality of lifepoorer health status use health care services likelihood of atypical pain presentationsPatients under-report painMisinterpretation of physical sensationsDifficulty using standard pain assessment scalesFalse beliefs about pain and its managementHealth care providersFail to believe patient’s pain; worry about addictionFail to use validated pain assessment toolsMistake aging for reversible and treatable disordersLack of education in the assessment & management of pain in the older adultJones JS, Johnson K, McNinch M. Age as a risk factor for inadequate emergency department analgesia. American Journal of Emergency Medicine. 1996; 14: 157–160.For acute pain, 66% of older adults received analgesia compared to 80% of their younger counterparts.more prolonged waiting time for delivery of pain medssignificant under dosing of pain medsreceived less opioid analgesicsHwang U, Richardson LD, Sonuyi TO, Morrison RS. The Effect of Emergency Department Crowding on the Management of Pain in Older Adults with Hip Fracture. Journal of the American Geriatric Society. 2006: 54; 270 275.Adults > 50yo with acute hip fracture 81.0% of patients complained of painmean time to pain assessment was 40 minutes (range 0–600)time to treatment was 141 minutes (range 10–525)Of those with pain 35.9% received no analgesia7.0% received non-opioids57.0% received opioidsPercentage of ED pain-related visits by adults in which any analgesic or an opioid was administered bypatient age in 5-year increments, NHAMCS 1999 to 2008.Platts-Mills TF, Esserman DA, Brown DL, Bortsov AV, Sloane PD, McLean SA. Older US Emergency Department Patients Are Less Likely to Receive Pain Medication Than Younger Patients: Results From a National Survey. Annals of Emergency Medicine, 2011, in press.Pain Assessment in the Older Adult:Nonspecific signs and symptoms indicating pain in the older adultFrowning, moaning, grimacing, fearful facial expressions, grinding of teethSighing, groaning, fearfulness, heavy breathing, withdrawalFidgeting / restlessness / agitationEating or sleeping poorlyMental status change / change in behaviorDecreasing activity levelsDepressed affectResistance to certain movements during carePaucity of interaction or speechLoss of function & lack of adaptation skillsPrinciples of pain managementAlways enquire about pain.Treat the underlying cause of the pain.Treat the pain meticulously.Treat the pain proportionately.Constantly reassess. the U.S., older adults consume greater than 30% of all prescription drugs. ~90% of older adults are on at least one medication> 40% of older patients use more than 5 drugs weekly ~ 12% of older adults are using more than 10 medications Increased risk of adverse drug reactions due to these multiple medications, greater severity of illness, multiple co-morbidities, sarcopenia, and changes in hepatic and renal metabolism. Patient 65 years and older comprise over 25% of all ED adverse drug events (ADE) visits, and are 2.4 times more likely to sustain ADEs when compared to their younger counterpartsFrom Ula Hwang, MD MPH – “GERIATRIC ANALGESIA” Optimal analgesic management for the geriatric patient requires the delicate balance of avoiding oligoanalgesia (inadequate analgesia) while taking into consideration aging-related changes with regards to medication metabolism, polypharmacy increased risk of adverse drug events, and drugs to avoid. First “do no harm”, initiating analgesia for mild pain with non-opioid analgesia (acetaminophen). For moderate to severe pain, progress to milder and then stronger opioids (hydrocodone, morphine, hydromorphone). Always start low and go slow with routine re-assessment of pain severity and titration of medications with a preference for shorter-acting drugs and lower doses. If using opioids, always remember to also use laxatives and stool softners to curtail the adverse effect of constipation.Analgesics NOT recommended and considered inappropriate (per Beers Criteria) CodeineIndomethacin (Indocin)Meperidine (Demerol)Pentazocine (Talwin)Propoxyphene (Darvon)Toradol (Ketorolac)muscle-relaxantslong-acting benzodizaepineshigh-doses of short-acting benzodiazepinesBibliography / Resources: AGS Clinical Practice Guideline: Pharmacological Management of Persistent Pain in Older Persons. Barkin RL, Barkin SJ, Barkin DS. Pharmacotheraputic Management of Pain with a Focus Directed at the Geriatric Patient. Rheumatic Disease Clinics of North America. 2007; 33: 1-31.Beers MH. Explicit criteria for determining potentially in appropriate medication use by the elderly. An update. Archives of Internal Medicine. 1997; 157: 1531-1536.Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: Results of a US Consensus Panel of Experts. Archives of Internal Medicine. 2003; 163: 2716-2724.Hohl CM, Dankoff J, Colacone A, Afilalo M. Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Annals of Emergency Medicine. 2001;38(6):666-671.Hwang U, Richardson LD, Harris B. Morrison RS. The Quality of Emergency Department Pain Care for Older Adult Patients. Journal of the American Geriatrics Society. 2010; 58:?2122–2128.Hwang U, Richardson LD, Sonuyi TO, Morrison RS. The Effect of Emergency Department Crowding on the Management of Pain in Older Adults with Hip Fracture. Journal of the American Geriatric Society. 2006: 54; 270 275.Jones JS, Johnson K, McNinch M. Age as a risk factor for inadequate emergency department analgesia. American Journal of Emergency Medicine. 1996; 14:157–160.Platts-Mills TF, Esserman DA, Brown DL, Bortsov AV, Sloane PD, McLean SA. Older US Emergency Department Patients Are Less Likely to Receive Pain Medication Than Younger Patients: Results From a National Survey. Annals of Emergency Medicine, 2011, in press.Terrell KM, Heard K, Miller DK. Prescribing to older ED patients. The American Journal of Emergency Medicine. 2006;24(4):468-478. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download