Pain Treatments for Geriatric Patients

Pain is a complex and multidimensional experience targeted for improvement by healthcare organizations because of inadequate pain control. Poorly managed acute or chronic pain has a negative effect on patients and is often the root cause for a worsening condition, reduced quality of life, and decreased patient satisfaction with increased health care cost. Clinicians can take many directions to redesign approaches for improved pain management to meet evolving standards of care. “In the Western hemisphere, the elderly population has increased rapidly over past decades. For example, between 1960 and 1999 the proportion of the European population aged 60 years rose from 16% to 21%, while the proportion aged 80 years doubled or even tripled in virtually every country. This growth is expected to continue; across the 27 European Union member states, the European Commission predicts that almost a quarter of the population will be more than 65 years of age by 2035. In the USA, people reaching 65 years of age can expect to live another 18.6 years. Globally, approximately 10% of the world’s population is currently aged 65 years, but this is forecast to exceed 16% by 2050” (Kress et al., 2014). In geriatric patients how effective is nonpharmacological pain-relief interventions compared to pharmacological pain therapies in improving patient pain interventions and follow-up.

Syn


opsis of the problem

Patients are admitted to the hospital in an acute state of illness and sometimes diagnosed with a disease that requires lifelong treatments. Chronic diseases require lifelong treatment to prevent the disease from worsening and to treat the symptoms. Age influences the pain experience. It is important to consider how a painful event affects patient development. Pain is not an inevitable part of aging, or pain perception does not decrease with age. However, older adults have a greater likelihood of developing pathological conditions, which are accompanied by pain. Older adults experience numerous physical and psychological changes as they age. These changes not only increase their educational needs but also create barriers to learning unless adjustments are made in nursing interventions. Older adults learn and remember effectively if the nurse pace the learning properly and if the material is relevant to the learner’s needs and abilities. Although many older adults have slower cognitive function and reduced short-term memory, the caregiver facilitate learning in serval ways to support behaviors that maximize the individual’s capacity for self-care. Serious impairment of functional status often accompanies pain in older patients. It potentially reduces mobility, ADLs, social activities, and activity tolerance. The presence of pain in an older adult requires aggressive assessment, diagnosis, and management.

The ability of older patients to interpret pain is sometimes complicated. They often suffer from multiple diseases with symptoms that affect similar parts of the body. The nurse must make a detailed assessment when the source of pain is not clear. Pain management should be patient-centered, with nurses practicing patient advocacy, empowerment, compassion, and respect. Caring for patients in pain requires recognition that pain can and should be relieved. Effective communication among the patient, family, and professional caregivers is essential to achieve adequate pain management.

“Many older adults have different types of pain simultaneously (eg, nociceptive and neuropathic, acute and persistent) and may have other conditions that complicate pain treatment (eg, dementia, kidney, and cardiovascular disease)” (Hogan, 2017). The challenges of health promotion and disease prevention for older adults are complex and affect health care providers as well. Pain management is further complicated by age-related physiologic changes that alter gastrointestinal drug absorption, distribution, liver metabolism, and renal excretion (Hogan, 2017). Pain perception is the conscious awareness of pain, which occurs primarily in the reticular and limbic systems and the cerebral cortex.  Pain threshold is defined as the lowest intensity of pain that a person can recognize and in an older person that threshold may be lower. Behavioral responses the individual responses vary and may be influenced by the presence of chronic diseases and decline in renal, intestinal, hepatic, cardiovascular, and neurologic function, individuals with cognitive impairment may demonstrate changes in behavior (combative or withdrawn, and increased confusion).  The nurse’s role is to focus interventions on maintaining adequate pain level, promoting patients’ function, and overall quality of life.                                                                                                   Review of the Literature

Nurses have a key role to play in the pharmacological management of pain, both in the administration and monitoring of drugs, but also increasing authority for the suitably qualified nurse to independently prescribe non-controlled drugs. Anatomical and physiological changes in the heart, liver, kidneys, and other body systems that all have the potential to impact upon drug concentrations and metabolism and as a result there may be increases side effects and risk of toxicity. American Geriatric Society guidelines on the management of pain in older people paid particular attention to pharmacology. Analgesics are the common and effective method of pain relief. However, health care providers and nurses still intend to undertreat patients because of insufficient knowledge about pain management, incorrect drug information, concerns about addictions, exaggerated concerns about opioid analgesic safety, and administration of less medication that was ordered. However, NSAID use in an older patient is not recommended because it is associated with more frequent adverse effects (gastrointestinal bleeding and renal insufficiency). “The


AGS guidelines


recommend acetaminophen as the initial (first-step) and ongoing pharmacotherapy for pain management; opioids are recommended for the treatment of moderate-to-severe pain, and adjunctive analgesics are to be used for patients with specific pain types, such as neuropathic pain. The guidelines recommend that analgesics such as NSAIDs, corticosteroids, and TCAs be avoided due to their potential to cause AEs and worsen certain disease states” (Bettinger et al., 2017). According to the American Geriatrics Society (AGS< 2009), opioids are probably not used enough with older people. The AGS suggest a “start-low” (dose) and “go-slow” (upward dose titration) philosophy. Careful use of multiple drugs together can be seen as potentially helpful. The elderly require special considerations because age-related changes and increased frailty lead to less predictable drug responses, including increased drug sensitivity, and the severity of side effects. “ Opioid can cause a drop in blood pressure upon standing, causing dizziness and imbalance. While no direct cause and effect could be proven, the findings indicate a strong association between falls and narcotic analgesic intake” (DukeMedicine, 2013). Despite these concerns, elderly patients should not be deprived of opioid therapy when needed to treat pain.

Additional non-pharmaceutical pain management strategies need to be developed alongside the use of medication in order to deliver the best possible pain management in older people. Research suggests that non-pharmaceutical interventions may be useful for patients who cannot tolerate pain medication, those who wish to reduce multiple, medications, and those who are seeking alternative methods of relieving chronic pain. Nonpharmacological interventions can be used alone or in combination with pharmacological measures. Nonpharmacological interventions include cognitive-behavioral and physical approaches. Cognitive-behavioral interventions change patient’s perceptions of pain, alter pain behavior, and provide patients with a greater sense of control. Distraction, prayer, relaxation, guided imagery, music, and biofeedback are examples. An evidence-based practice protocol for pain management in older adults recommends using these guidelines for nonpharmacological therapies: tailor nonpharmacological techniques to the individual, cognitive behavioral strategies may not be appropriate for the cognitively impaired, physical pain-relief strategies focus on promoting comfort and altering physiological responses to pain and are generally safe and effective.

Encourage older adults to maintain physical exercise and activity. The primary benefits of exercise include maintaining and strengthening functional ability and promoting a sense of enhanced well-being. Other benefits include improvement of cardiovascular functions, increases metabolic rate, increase gastrointestinal transit, prevent a depressive illness, and improved sleep quality. “ In the presence of strong evidence linking physical inactivity to chronic health conditions and increased physical activity to lower mortality and morbidity in older adults, it is imperative to develop a strong commitment to improving physical activity levels in older adults. Governments around the world have begun to produce national guidelines for physical activity and health for older adults. The main challenge is to find effective ways to support older adults to increase their physical activity and then to develop habitual physical activity behaviors. Individual health practitioners have an important role in discussing and making recommendations on physical activity” (Taylor, 2013).

Decision-Making


Tool

Patient medication adherence is a collaborative team effort between administration, the nursing manager, the patient and family, the staff such as the floor nurse, charge nurse and the doctor. In order for a team to work effectively, discussion and brainstorming are necessary to achieve the best outcome. Decision-making is a critical component of an effective leader and manager. As the nurse manager, it is important to make sure the team is staying on topic and working together efficiently, to do this the manager must choose the correct tool to generate questions in an organized comprehensive way. The best way to achieve this is by using the starburst tool, which creates questions that can be answered into future detail and allows the team to collaborate with one another.

Proposed Solution

The proposed solution for improving pain intervention should be the first critical thinking in planning nursing care. Part of the planning process is selecting nursing interventions by setting realistic goals and outcome for the patient. Realistic goals give the patient a sense of hope. To establish realistic goals, assess the resources of a patient, health care facility, and family. Be aware of the patient’s physiological, emotional, cognitive, and socio-cultural potential and the economic cost and resources available to reach expected outcomes in a timely manner. During planning nursing team select interventions designed to help a patient move from the present level of health to the level described in the goal and measured by the expected outcomes. Choosing suitable nursing interventions involves applying the best evidence for a patient’s health problems and using good clinical judgment. It is important to remember that a successful plan of care requires a therapeutic relationship with a patient and family to focus on a relevant education plan.

When setting priorities in pain management, consider the type of pain the patient is experiencing and the effect that it has on various body functions. Work with the patient to select interventions that are appropriate. For example, if an analgesic is relieving acute pain, turn the attention to how the pain is affecting the patient’s activity, appetite, and sleep.

References

Kress, H.-G., Ahlbeck, K., Aldington, D., Alon, E., Coaccioli, S., Coluzzi, F., … Sichère, P. (2014). Managing chronic pain in elderly patients requires a CHANGE of approach.

Current Medical Research & Opinion

,

30

(6), 1153–1164.

https://doi-org.zeus.tarleton.edu/10.1185/03007995.2014.887005

Pain Management in Older Adults

Author links open overlay panel

Ann L.HorgasRN, PhD, FGSA, FAAN

Show more

https://doi.org/10.1016/j.cnur.2017.08.001

1. Review article
3. Full text access

Pain



Management in



Older


Adults

1. 
   
   Nursing Clinics of North America
   
   
   ,
2. Volume 52, Issue 4,
3. December 2017,
4. Pages e1-e7

Pain Management in the Elderly: Focus on Safe Prescribing

Choosing pain medications for elderly patients requires a broad knowledge of polypharmacy, drug-drug interactions, and pharmacokinetics.

By






Jeffrey J. Bettinger,




PharmD








,






Erica L. Wegrzyn, PharmD






and






Jeffrey Fudin, PharmD, DAIPM, FCCP, FASHP

Pain Management in the Elderly: Focus on Safe Prescribing

Choosing pain medications for elderly patients requires a broad knowledge of polypharmacy, drug-drug interactions, and pharmacokinetics.

By






Jeffrey J. Bettinger,




PharmD








,






Erica L. Wegrzyn, PharmD






and






Jeffrey Fudin, PharmD, DAIPM, FCCP, FASHP

Use of opioids to control arthritis pain under scrutiny: increase in falls, fractures in older adults attributed to narcotic painkillers, such as oxycodone, vicodin or percocet. (2013, May).

Duke Medicine Health News

,

19

(5), 7. Retrieved from

http://link.galegroup.com.zeus.tarleton.edu:82/apps/doc/A329607263/HRCA?u=txshracd2559&sid=HRCA&xid=e989b368

Physical activity is medicine for older adults

1. Denise Taylor

Taylor D

Physical activity is medicine for older adults

Postgraduate Medical Journal 2014;90:26-32.

Publication history

• Received January 19, 2013
• Revised June 4, 2013
• Accepted July 1, 2013
• First published November 19, 2013.