EDUCATION
EDUCATION
Practical Pain Management in Older People- PERSONAL PRACTICE
Care UK Consultant Anaesthetist & Chair, Anaesthetists Group & Pain Group, North East London NHS Treatment Centre, near KGH, Ilford, Essex IG3 8YY. Member of Pain in Older Adults Special Interest Group of British Pain Society.
Neeraj Bhala MBChB, MRCP, MSc(Epi.), DLSHTM, FRSPH
Specialist Registrar in Gastroenterology and General Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, B15 2TH. MRC Health of the Public Fellow Clinical Trial Service Unit, University of Oxford, OX3 7LF.
cite as:
Bhala B, Bhala N. Practical Pain Management in Older People. The Physician
2012 1(1): 52-55
Introduction
Pain relief, whether acute, chronic or related to surgery, is an issue throughout the world. However, as a result of a changing population demographic in countries like the UK, the proportion of older patients is increasing, which poses
unique challenges when considering analgesia. We have a potential aging ‘time bomb’ and we need to prepare our services to meet the needs of this older age group ensuring their dignity and their well-being not compromised. Hence, five years ago the British Pain Society worked with the British Geriatrics Society & the Royal College of Physicians, reviewed the evidence and produced national guidance to help all practitioners in assessing pain in older people with a simple algorithm in October 20071 (Appendix 1).
The purpose was to provide professionals with a set of practical skills to assess pain as the first step towards its effective management. To put the effects of pain in the elderly in perspective, national UK statistics have indicated that pain or discomfort was reported by about half of those over 65 years old, and 56% of men and 65% of women aged 75 years and over. Higher prevalence estimates are obtained from samples of institutionalised older people, where 45–83% of patients report at least one current pain problem.
Pain Assessment
Compared to young adults some of the challenges are cognitive impairment, communication, language and cultural barriers. Box 1 in that report lists the key components like: direct enquiry, observations of signs, description (sensory, affective & its impact), measurement & cause of pain. Their table 1 & 2 describe the observational changes associated
with pain & various scales for assessing pain. Assessment of pain may be carried out by normal methods and conventional numerical or graphical methods work well. However, impairment of higher intellectual functions may mean that observational techniques may also be needed.
Key components of an assessment of pain include direct enquiry about the presence of pain and observation for signs of pain, especially in older people with cognitive / communication impairment. Description of pain should include the sensory dimension, the affective dimension (e.g. fear, anxiety or depression) and impact on the patient. Measurement of pain should ideally use standardised scales in a format that is accessible to the individual. Of course the aim of history,
examination and investigation is to establish the cause of pain, in order to effect treatment (Box 1). Observational changes associated with pain can also be more marked (or subtle) in the elderly, including autonomic changes, facial expressions and body movements. Aggressive verbalisations / vocalisations and altered interpersonal interactions can sometime be the presenting complaint of those with pain, especially if there is preceding cognitive impairment. Changes in activity patterns and mental status changes can sometimes also occur (Table 1).
Our experience at NELTC
We at NELTC have standardised the process along the entire surgical care pathway (from preassessment, through admission on the wards, theatre & recovery to discharge home and follow up) with a Coloured Visual
Analogue Scale (Appendix 2). Pain maps are sometimes used to get more details on localisation as in some patients with chronic pain (Appendix 3). Our numeric rating scale from 0 to 10 is used in those patients, with some difficulties, who are
able to use verbal descriptor 0 to 5 scale by converting it to 0 to 10 while recording it (Appendix 4). We found this standardisation to be very helpful in doing our routine recording of pain scores by our nurses on the wards, and also in the Pain & Sickness Audit carried out by us based on their records. This audit showed us excellent pain & sickness scores, with a high patient satisfaction rate, compared to world literature & was presented at various conferences in Birmingham (BAPIO), Wembley (BAOIA), Tel Aviv (ISA), Mumbai (ISA) & Granada (WSPC) and well received by the audience 2. We followed the recommendations of the National Guidelines which are summarised (Appendix 5) along with the algorithm (Appendix 1).
Management of Acute Postoperative Pain
Three years ago European Society of Regional Anaesthesia and Pain Therapy produced general recommendations and principles for successful pain management postoperatively3. Effective pain management is a very important part of modern surgical practice. The goals are to: improve quality of life, rapid recovery & early discharge with minimum morbidity. Listening to and believing in patient is the first step. Use of one scale within a hospital ensures that everyone in the team ‘speaks the same language’ of intensity of pain, from pre-assessments, wards, recovery to discharge time.
This also helps in adjusting drugs for better pain management4. Informed consent ensures detailed discussion about pain and its treatment. To keep realistic expectations of care patient participation is important and they need to know about ‘pain relief’, not a ’pain free status’. In addition to verbal information wall posters in the clinics / wards and patient leaflets are useful. As the mechanism of pain is multi-factorial these days multimodal analgesia is recommended for a balanced combination of analgesics, co-analgesics & local anaesthetic (LA) blocks or infiltrations. Surgeons routinely use local anaesthetics before or after (preferably both), with or without other form of anaesthesia to improve pain control. Using LA before incision means patient’s analgesic requirements & side-effects are reduced, especially in those older patients with multiple co-morbidities.
The elderly present special problems in the provision of analgesia. As a general rule, the elderly report pain less frequently and require smaller doses of analgesic drugs to achieve adequate pain relief. Many patients are anxious, which may be associated with increased pain postoperatively.
Commonest drugs in use are Paracetamol, NSAIDs, Gabapentin / Pregabalin, Codeine, Tramadol, Oxycodone, Morphine in
various combinations, through a step by step approach depending on the severity of pain & patient’s tolerance / intolerance of drugs. Drug dose for each drug prescribed needs to be tailored to patient requirements especially taking their age and agerelated metabolic changes in consideration. Coxib or NSAIDs are used with caution in older people usually with proton pump inhibitor and routinely monitored for drug interactions, gastrointestinal, renal & cardiovascular side effects. NSAIDs (e.g. diclofenac, ibuprofen and naproxen are amongst the most widely used medications globally for analgesia, particularly in patients with rheumatological conditions, but they can have serious side effects. Upper gastrointestinal disorders ranging from heartburn and dyspepsia are more common to peptic ulceration and gastrointestinal bleeding. Care should also be taken in patients with compromised hepatic or renal function. These drugs can also cause raised blood pressure, as well as leading to heart failure and myocardial infarction in high-risk patients,
first detected in studies of selective cyclo-oxygenase inhibitors.
Self-medication with opioids is not always wise in elderly patients and thus the role of patient-controlled analgesia may be limited. The elderly may be particularly sensitive to opioids and side effects such as confusion, sedation and respiratory depression assume greater importance. Because of changes in hepatic and renal function lower doses of opioids are needed and the expected length of action may be longer. Only one analgesic drug should be used at a time in the elderly. In general about half the normal adult dose, even less in very old, should be given at first, especially if the drug is being given intravenously. Small doses should be given regularly to anticipate pain where appropriate. When analgesic drugs are given they may not be absorbed as well or metabolised as efficiently. In practical terms, doses of drugs such as NSAIDs and opioids in the elderly should be reduced because of a decrease in liver metabolism. In addition, since the metabolites of drugs such as morphine and pethidine are excreted by the kidneys, any decrease in renal function may lead to accumulation with repeated doses. The elderly are more likely to be receiving more than one drug for underlying medical conditions and the possibility of drug interaction is also greater.
Spinal anaesthetic (LA + opioid) is now generally more popular than Epidural, and LA infiltrations are becoming more common than Nerve Blocks. For intra-articular LA infiltrations some adrenaline, NSAID & opioids maybe indicated
for better results than LA alone. Some of these drugs also help in reducing the incidence of the pain becoming chronic (beyond 3 months after surgery).
Nerve blocks are a most effective way of giving postoperative pain relief. Intercostal nerve block can aid pulmonary function after chest or upper abdominal surgery and pain below the waist can be abolished by epidural
blockade aiding the return of gastrointestinal function after surgery. However, blocks spread more widely in the elderly
and there may be compromise of respiratory function due to intercostal paralysis. In addition, a greater sympathetic block may occur with a consequent fall in blood pressure. With care, local anaesthetic blocks can be very useful in the elderly and give excellent pain relief whilst permitting mobilisation and rehabilitation by physiotherapists.
Non-pharmacological treatments like cold therapy with iced water bag on the joints seem to help reducing the swelling as well as pain. Fewer analgesic drugs are required, as we move towards enhanced recovery from surgery. We have regular meetings of Anaesthetists Group and Pain Group to continue to update and improve with latest evidence and mutual agreements. Daily multi-disciplinary ward rounds headed by an anaesthetist (with overall responsibility) have been valuable for some of the improvements in quality of life, reduced morbidity, rapid enhanced recovery and early discharges. Older patients in particular may need more time commitments and mutual co-operation from all staff in a multidisciplinary set up.
Management of Chronic Pain
Professor Schofield and colleagues produced a paper reviewing the main recommendations within the guidelines by the BPS & BGS4. Any pain beyond three months by definition is chronic. Prevalence of any pain in older persons is 0 to 93% by various estimates carried out, according to this joint report. Current pain ranged from 20-46% in the community& 28-73% in residential care. Chronic pain prevalence ranged from 25-76% in community & 83-93% in residential care. Women have a higher prevalence than men. The three most common sites of pain in older people were: back, lower limb and other joints. This shows that millions of people live with chronic pain as if it is ‘expected to be part of ageing’ that
they are ‘learning to live with’. In addition to the drugs for acute pain these patients might need the following, initially in lowest doses: Tricyclic antidepressants, anti-epileptics, gabapentin / pregabalin, with prophylactic anti-emetics and laxatives.
Interventional therapies showing benefits in well selected cases by Pain Clinicians include facet joint radiofrequency lesioning and intra-articular corticosteroids or hyaluronic acid injections. In acute herpes zoster & postherpetic neuralgia LA infiltration or nerve block with LA & corticosteroids is effective. In trigeminal neuralgia in older people percutaneous
procedures are preferred over microvascular decompression. Psychological approaches like cognitive behaviour therapy (CBT) has some role and maybe relaxation, meditation, mindfulness etc.
Ethical & Legal Aspects of Pain management
While assessing & managing pain in older people some important aspects of ethics and law need to be kept at the back of our minds 5 & 6 Firstly, it is now important that the consent is as informed as possible, with patients having rights to refuse. Consent in various situations and in different age groups, from cradle to grave, is discussed. 7 & 8 On the basis
of the Data Protection Act 1998, Confidentiality is considered along with express consent. Risk Management includes statutes such as the Medical Acts, NHS Acts and the Health & Safety at Work Act. It is suggested that we use Complaints Management from local resolutions to legal proceedings and ADR, in the light of Lord Woolf’s Reforms. Importance of good quality (Medical / Anaesthetic / ICU / Pain/ Clinic / Hospice / Hospital) records is stressed in medical defence of
any unfortunate incidents 9 & 10. From Bolam to Bolitho is the consideration on Clinical Negligence. Here the importance of practising within the issued guidelines from public authorities, like NICE, GMC, Royal Colleges or Boards, WHO, UN and international evidence based medical (EBM) practice, is stressed. Over 40 years of practice and experiences from the
USA, Canada, Europe, Balkans, Australia, New Zealand and India help us do a global comparison but we still need to tune into national guidelines, especially those drawn up by experts like BPS,BGS, RCP. If we visit a virtual courtroom to study civil, military and criminal cases and the law governing those Medical Witnesses and Medical Experts we will see various types and grounds of Discrimination including the latest developments in this highly prevalent, but preventable, area of Employment Law. An LLM project on ‘Race Laws in the NHS’, and experience in the BMA Medical Ethics Committee are briefly mentioned. A very significant shift in English Law, due to a European introduction (from October 2000) of the Human Rights Act 1998, is highlighted 11, 12 & 13.
With this knowledge we then try to predict the likely impact on the Pain Practice with all its sub-specialties. We will certainly be looking forward to any suggestions for tackling information overload while continuing to practice evidence-based, safe pain management, anaesthesia and critical care for our older patients! Let the Medical Law continue to evolve in the West and be lead by Ethics from the East, based on Bhagavad-Gita 14.
Recommendations & Conclusion
Based on our recent experience & developments locally we recommend that the following steps will help us move in the right direction for better pain management in older people:
• Institutions to have Strategic Pain Groups for those interested in the topic with a commitment for updates & continuous improvement leading to creating local champions everywhere.
• To standardise Pain Scales with Pain Maps for better assessing pain localization & pain intensity.
• On surgical side, to give more emphasis on acute pain management including safe use of LA in almost all patients & utilizing the skills of Anaesthetist colleagues.
• On Medical side, to use balanced analgesic combinations mainly, seeking expert advice from Pain Clinics in chronic or acute on chronic pains or from Psychologists in selected cases.
• Not to forget the Ethical & Legal issues in pain practice while using our National Guidelines.
In conclusion, ‘Sarve Bhavantu sukhinah, Sarve santu niramayaah’ meaning let everybody be happy, free of pain &
suffering. Let’s aspire to make the world of older people free of pain so we can all look forward to a long & happy retirement too!. ■
References
1. The assessment of pain in older people National Guidelines (October 2007) by RCP, BGS & BPS.
2. Bhala B & Kozma Z, Pain & Sickness Audit in Joint Replacement Surgery at NEL NHS TC, Ilford IG3 8YY. Presented at various conferences (2011).
3. Postoperative Pain Management – Good Clinical Practice, General recommendations and principles for successful pain management: by European Society of Regional Anaesthesia & Pain Therapy (2009).
4. Pat Schofield et al, Pain in older adults – guidelines for the management (Pain News, June 2012) by, Vol 10 No 2 p. 120-122.
5. Bhala B, Ethical & Legal Aspects of Pain Management presented at various updates & conferences (2011).
6. Giordano J. Moral Agency in Pain Medicine, Pain Physician 2006:9: 41-46
7. Meisel A. et al. Seven Legal Barriers to End-of-Life Care, JAMA 2000:284:19
8. Byock I. End of life decisions and quality of care before death, BMJ 2009:339:357
9. Shapiro R.S. Healthcare providers’ liability exposure for inappropriate pain management, Journal of Law, Medicine & Ethics 1996:24:360-4
10. Furrow B.R. Pain Management and Provider Liability: No more excuses, Journal of Law, Medicine & Ethics 2001:29:28-51
11. Brennan F. et al. Pain Management: A Fundamental Human Right, Anesth Analg 2007:105:205-221
12. Schatman M.E. Ethical Issues in Chronic Pain Management 2006
13. Blacksher E. Hearing from Pain, Pain Medicine 2001:2:169-175
14. BHAGAVAD-GITA (www.yatharthgeeta.com).
