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Q: What specific tools do you recommend or advice can you give about assessing pain among older persons who have severe dementia or who are nonverbal (i.e. aphasic due to CVA for example)?

Response:
To assess pain in older persons with severe dementia that are noncommunicative, the patient should be observed for nonverbal behaviors and changes in activity and function suggestive of pain. The Persistent Pain Guideline provides examples of behaviors and activities that can be used for assessment, as well as an algorithm that guide the screening process for patients that are noncommunicative. There are no clear recommendations of specific tools to assess pain in the severely demented older adult and this is an area of ongoing research. Two tools or approaches that are being refined and tested for use in this population are the Checklist of Nonverbal Pain Indicators developed by Karen Feldt and the Assessment of Discomfort in Dementia Protocol developed by Christine Kovach and colleagues. It is important to note that the presentation of pain behaviors, particularly in those with dementia, can be quite variable. For example, one patient might present with increased irritability and pacing, while another presents with withdrawal and refusal to eat. Thus, it is very important to determine the patient's baseline activities and behavior and then monitor for changes over time that indicate the possibility of a pain problem. Regarding the stroke patient with aphasia, if it is determined that the patient can understand and respond to directions, use of one of the standard pain intensity scales that do not require a verbal response, such as the 0-10 Numeric Rating Scale, the Verbal Descriptor Scale or Pain Thermometer or the Faces Pain Scale. If unable to use any of these approaches, observation for pain-related behaviors is being the priority assessment approach.

Q: If you were developing a protocol for assessment of pain and had already established pain as the 5th vital sign), what makes sense for the frequency of reassessment of pain in an inpatient. (medical unit) setting?

Response:
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommends establishing a frequency of assessment that is appropriate for a given unit and population of patients. For assessment of pain on an inpatient medical setting routinely assessing all patients for pain every shift would be reasonable. If the patient is reporting pain, assessment should occur as often as needed to monitor response to intervention (e.g. one hour after oral analgesics) until the pain intensity is at or below the patient's goal (often a 3 on a 0-10 scale) and then every four hours while awake, until the pain is resolved or the patient is discharged.

Q: What is the best way to communicate these guidelines of management of persistent pain in older persons to the physicians if they have not seen these guidelines and are resistant to changing their beliefs? And if the physician's pain management is inadequate, how does a nurse manage this?

Response:
Several approaches can be taken to address the challenge of changing physician practice behavior. First, provide a copy of the Persistent Pain Guidelines with the suggestion that your team might wish to review them and discuss how your organization's current practices are in line with national recommendations for improving the care of older adults. Another effective approach to motivating physicians to examine their behavior is to gather baseline information on their practices and on patient outcomes. For example, review the care of a selected group of older adults with pain problems and document when and how pain is assessed, what is documented related to presence of pain, its severity and its impact, what pharmacologic interventions are prescribed and administered, how effective are current treatment approaches at decreasing pain severity and increasing function and quality of life, and determine patient and family satisfaction with the older adult's pain management. If a review of current practices suggests there is room for improvement, the guidelines can be used to help establish assessment and management approaches to address the needs of older adults with persistent pain. If there are particular areas of resistance, it might be helpful to access articles related to the recommendations and share these with the physician. Another helpful approach is to find a physician colleague that practices good pain management and ask him to help champion practice changes on your unit.

If a physician's pain management is inadequate, the nurse manager can use the well-being of the patients as primary motivation to effect change on your unit. It is often the nurse manager and her one-on-one interactions with the physician that have the most impact in changing practices. Physicians are often open to suggestions for treatment strategies that the nurse recommends based on her experience and knowledge of the patient and of current best practice evidence. Prepare yourself with all the information needed to demonstrate a thorough assessment and appropriateness of nonpharmacological and pharmacologic interventions for each patient. With successes in improving patient outcomes, physicians should be more receptive to updating their practice behavior.

Q: The pain management associated with neuropathy of the feet in a non-diabetic. It seems that the only thing that works is the use of painkillers that have undesirable side effects. And long-term use is not what should be done. Is there any other pain management process etc. that will make like more livable?

Response:
The first line treatment for the pain associated with peripheral neuropathy has become gabapentin. It is critical that this medication be used in adequate doses (up to 3600 mg per day) in order to determine its efficacy. The practitioner should also be aware that doses must be adjusted for patients with renal insufficiency, and titrated slowly in frail older adults. Typically the starting dose is 300 mg at bedtime, and the drug should be titrated by approximately 300 mg per day every 7 days (e.g., 300 mg bid, then 300 mg tid). It has no drug-drug interactions, and is quite well tolerated in most cases. The rate limiting side effect, most commonly, is a sensation of dizziness or unsteadiness.

If gabapentin is ineffective, then a tricyclic antidepressant should be tried. First, obtain an EKG to make sure there is no prohibitive QT prolongation, and if there are no other contraindications, then begin desipramine (it has the lowest anticholinergic side effects of all the tricyclics) at 10 mg at bedtime, and titrate by an additional 10 mg at bedtime every 7 days. I typically titrate to about 40-50 mg. If you are also treating depression, then use nortriptyline, as serum levels can be measured with accuracy. Titrate at the same rate as with desipramine.

If gabapentin and tricyclics are not effective, then long-term opioids are appropriate. Their potential for addiction is quite low, and neuropathic pain can be extremely disabling.

If none of these approaches are effective, then referral to a pain specialist should be considered.

Q: How can pain be managed in a frail 89 year old woman with hx of multiple old compression # of spine and history of delirium (secondary to CHF and multiple medication). She is presently on Fentynal patch125 mg q 3 days but still finds she has to lie down frequently to relieve back pain. Other medications: Paxil 20 mg o.d., NitroDur 0.6 mg o.d. Norvasc 10 mg o.d. Lasix 40 mg o.d Palvix 75 mg od. Respiridone 0.25 mg q hs, Metoprolol 100 mg b.i.d. Codeine and morphine have caused confusion and hallucination in the past She continues to have some tactile hallucination -feels someone tapping on her leg or shoulder at night She is high risk for falls She has had physiotherapy for several months. TENS wasn't successful -she became frustrated and anxious as home care support to apply TENS wasn't started.

Response:
In order to most effectively treat the pain associated with vertebral compression fractures, the source of the pain should be determined. Often refractory pain is related to paraspinal spasm. Pain from this source is better treated with local modalities such as heat, massage, and/or interferential current administered by a physical therapist. With regard to her pharmacologic therapy, the fentanyl may be wearing off before the 3 day interval, so take a careful pain history and determine whether this is the case. If so, she may do better with a q48 hour regimen. On what dose of morphine was delirium experienced? I recommend that patients be started on 2.5 mg every 4 hours. A 4 week trial of capsaicin tid-qid could also be considered. Sometimes combining a nonopioid analgesic with an opioid limits the dose of the opioid required. You could try adding salsalate 500-750 mg bid with meals. Complementary modalities such as cognitive behavioral therapy and alternative modalities such as acupuncture should also be considered.

Q: Delirium post surgery- what can be done to minimize risk of delirium in the elderly without compromise to the pain control I understand this problem is not limited to the elderly.

Response:
Post-operative delirium may be caused by poorly treated pain as well as medications. Other risk factors for delirium should be addressed, such as poor lighting, sensory deprivation, etc. Studies have been done in younger individuals that demonstrate improved cognitive function with increasing doses of opioids and decreasing pain intensity.

Q: What can be done for the patients with severe interstitial cystitis?

Response:
There are urologic medications available that should be prescribed by a urologist. They work by coating the bladder mucosa. I have also had success with tricyclic antidepressants and acupuncture. Chronic opioid therapy for these patients is also appropriate. There was an excellent review of interstitial cystitis recently published in Pain Medicine.

Q: What about the caveats for use of amitriptyline in the elderly for pain? Is it not true that most adverse effects are dose dependent and not a problem at low dose.?

Response: It is true that adverse effects are dose dependent for the tricyclics antidepressants, but there is still potential at the lowest doses for anticholinergic side effects. Amitriptyline has the greatest potential for anticholinergic side effects of all of the tricyclic antidepressants, so it is not recommended for use in older adults since effective alternatives exist. Desipramine has the lowest risk of anticholinergic side effects, so it is preferred for the treatment of neuropathic pain. If the patient needs to be treated for pain and depression, nortriptyline is the drug of choice, since serum levels can be accurately monitored.