AMDA Clinical Practice
Guideline
(CPG) for Pain Management
For Medical Directors and
Attending Physicians
Introduction to Pain
 Pain is common in the long-term care
setting.
 Unrelieved chronic pain is not an inevitable
consequence of aging
 Aging does not increase pain tolerance or
decrease sensitivity to pain
 Most chronic pain in the long-term care
setting is related to arthritis and
musculoskeletal problems
 Pain may be associated with mood
disturbances (for example, depression,
anxiety, and sleep disorders)
Introduction to Pain
 The use of pain scales
 Acute vs. chronic pain
 Long-term care interventions
Pain in the Elderly
 Definition of Pain—An individual’s
unpleasant sensory or emotional
experience
 Acute pain is abrupt usually abrupt in
onset and may escalate
 Chronic pain is pain that is persistent or
recurrent
Pain in the Elderly
 The most common reason for
unrelieved pain in the U.S. is failure of
staff to routinely assess for pain
 Therefore, JCAHO has incorporated
assessment of pain into its practice
standards
 “The fifth vital sign”
Pain in the Elderly
Sources of pain in the nursing home
Source: Stein et al, Clinics in Geriatric Medicine: 1996
Condition causing pain
Low back pain
Arthritis
Previous fractures
Neuropathies
Leg cramps
Claudication
Headache
Generalized pain
Neoplasm:
Frequency (%)
40
37
14
11
9
8
6
3
3
Pain in the Elderly
Conditions Associated with the Development of
Pain in the Elderly
 Degenerative joint
disease
 Gastrointestinal
causes
 Fibromyalgia
 Peripheral vascular
disease
 Rheumatoid arthritis
 Post-stroke
syndromes
 Low back disorders
 Improper positioning
Pain in the Elderly
Conditions Associated with the Development of
Pain in the Elderly
 Crystal-induced
arthropathies
 Renal conditions
 Gastrointestinal
disorders
 Osteoporosis
 Immobility,
contracture
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
Neuropathies
Pressure ulcers
Headaches
Amputations
Oral or dental
Pathology
Pain in the Elderly
Barriers to the Recognition of Pain in the
LTC setting:
 Different response
to pain
 Staff training
 Cognitive or
sensory
impairments
 Practitioner
limitations
 Social or Cultural
barriers
 System barriers
 Co-existing illness
and multiple
medications
Pain in the Elderly: Myths
 To acknowledge pain is a sign of personal
weakness
 Chronic pain is an inevitable part of aging
 Pain is a punishment for past actions
 Chronic pain means death is near
 Chronic pain always indicates the presence
of a serious disease
 Acknowledging pain will mean undergoing
intrusive and possible painful tests.
Pain in the Elderly: Myths
 Acknowledging pain will lead to loss of
independence
 The elderly – especially cognitively
impaired – have a higher pain tolerance
 The elderly and cognitively impaired
cannot be accurately assessed for pain
 Patients in LTC say they are in pain to
get attention
 Elderly patients are likely to become
addicted to pain medications
Pain in the Elderly
Consequences of untreated pain:
 Depression
 Suffering
 Sleep disturbance
 Behavioral disturbance
 Anorexia, weight loss
 Deconditioning, increased falls
Pain in the Elderly
Inferred Pain Pathophysiology 6]
 Nociceptive pain – Explained by ongoing
tissue injury
 Neuropathic pain – Believed to be sustained
by abnormal processing in the peripheral or
central nervous system
 Psychogenic pain – Believed to be
sustained by psychological factors
 Idiopathic pain – Unclear mechanisms
AMDA Pain Management
CPG—Steps
1.
2.
3.
4.
Recognition
Assessment
Treatment
Monitoring
Pain in the ElderlyRecognition
Possible Indicators of Pain in MDS – Version 2.0
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



Restlessness, repetitive movements (B5)
Sleep cycle (E1)
Sad, apathetic, anxious appearance (E1)
Change in mood (E3)
Resisting care (E4)
Change in behavior (E5)
Functional limitation in range of motion
(G4)
 Change in ADL function (G9)
Pain in the ElderlyRecognition
Possible Indicators of Pain in MDS – Version
2.0
 Pain site (J3)
 Pain symptoms (J2)
 Restlessness, repetitive movements (B5)
 Sleep cycle (E1)
 Sad, apathetic, anxious appearance (E1)
 Change in mood (E3)
 Resisting care (E4)
Pain in the ElderlyRecognition
Possible Indicators of Pain in MDS – Version 2.0
 Loss of sense of initiative or
involvement (F1)
 Any disease associated with pain (I1)



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Pain symptoms (J2)
Pain site (J3)
Mouth pain (K1)
Weight loss (K3)
Pain in the ElderlyRecognition
Possible Indicators of Pain in MDS –
Version 2.0
 Oral status (L1)
 Skin Lesions (M1)
 Other skin problems (M4)
 Foot Problems (M6)
 ROM restorative care (P3)
Pain in the Elderly–
Recognition
Non-specific signs and symptoms suggestive
of pain:
 Frowning, grimacing, fearful facial
expressions, grinding of teeth
 Bracing, guarding, rubbing
 Fidgeting, increasing or recurring
restlessness
 Striking out, increasing or recurring
agitation
 Eating or sleeping poorly
Pain in the Elderly–
Recognition
Non-specific signs and symptoms suggestive
of pain:
 Sighing, groaning, crying, breathing heavily
 Decreasing activity levels
 Resisting certain movements during care
 Change in gait or behavior
 Loss of function
Pain Management CPG—
Recognition Steps
 Is pain present?
 Have characteristics and causes of
pain been adequately defined?
 Provide appropriate interim treatment
for pain.
Pain Management CPG—
Recognition
Pain Intensity Scales for Use with Older Patients – Visual
Analogue Scale
No pain
Terrible pain
l______l_____l_____l______l_____l______l_____l______l______l
1
2
3
4
5
6
7
8
9
10
Ask the patient:“Please point to the number that best describes your pain”
Scale has worst possible pain at a # 10
Pain Management CPG—
Recognition
Documenting an Initial Pain Assessment
Pattern: Constant_________ Intermittent__________
Duration: __________
Location: __________
Character: Lancinating____ Burning______ Stinging_____
Radiating______ Shooting_____ Tingling______
Other Descriptors:________________________________
Exacerbating Factors:______________________________
Relieving Factors:_________________________________
Pain Intensity – (None, Moderate, Severe)
1 2 3 4 5 6 7 8 9 10
Worst Pain in Last 24 Hours (None, Moderate, Severe)
1 2 3 4 5 6 7 8 9 10
Mood: ________________________________________
Depression Screening Score: ______________________
Impaired Activities: ______________________________
Sleep Quality: __________________________________
Bowel Habits: __________________________________
Other Assessments or Comments:__________________
______________________________________________
______________________________________________
Most Likely Causes Of Pain: _______________________
______________________________________________
Plans: ________________________________________
______________________________________________
Pain Management–
Assessment Steps
 Perform a pertinent history and physical
examination
 Identify the causes of pain as far as
possible
 Perform further diagnostic testing as
indicated
 Identify causes of pain
 Obtain assistance/consultations as
necessary
 Summarize characteristics and causes of
the patient’s pain and assess impact on
function and quality of life
Pain Management–
Assessment Steps
Pain History [7] – Important Elements to
Include:
 Known etiology and treatments –
previous evaluation, pain diagnoses
and treatments
 Prior prescribed and non-prescribed
treatments
 Current therapies
Pain Management–
Assessment Steps
Chronic Pain History
“PQRST”
 Provocative/palliative factors (e.g., position,
activity, etc.)
 Quality (e.g., aching, throbbing, stabbing, burning)
 Region (e.g., focal, multifocal, generalized, deep,
superficial)
 Severity (e.g., average, least, worst, and current)
 Temporal features (e.g., onset, duration, course,
daily pattern)
 Medical History
 Existing comorbidities
 Current medications
Source: Valley, MA. Pain measurement. In: Raj PP. Pain Medicine. St. Louis
MO. Mosby, Inc. 1996:36-46.
Pain Management–
Treatment Steps
 Adopt an interdisciplinary care plan
 Set goals for pain relief
 Implement the care plan
Pain Management–
Treatment Steps
Provide a Comforting and Supportive
Environment –
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Reassuring words/touch
Topical or low-risk analgesic
Talk with patient/caregivers about pain
Back rub, hot or cold compresses
Whirlpool, shower
Comforting music
Chaplain services
Pain Management–
Treatment Steps
Ethics and Pain
 The old ethic of under-prescribing
 “just say no”
 “it hurts so good”
 The new ethic
 trust: believing what patients say
 commitment: formalized mutual
agreement
 standardized care: guidelines on
assessment and treatment
 collaboration: working together
Source: Marino A. J Law, Med Ethics, 2001
Pain Management–
Treatment
General Principles for Prescribing Analgesics
in the Long-Term Care Setting
 Evaluate patient’s overall medical condition
and current medication regimen
 Consider whether the medical literature
contains evidence-based recommendations for
specific regimens to treat identified causes
 For example, acetaminophen for
musculoskeletal pain; narcotics may not help
fibromyalgia
 In most cases, administer at least one
medication regularly (not PRN)
Pain Management–
Treatment
General Principles for Prescribing Analgesics
in the Long-Term Care Setting
 Use the least invasive route of administration
first
 For chronic pain – begin with a low dose and
titrate until comfort is achieved
 For acute pain – begin with a low or moderate
dose as needed and titrate more rapidly
 Reassess/adjust the dose to optimize pain
relief while monitoring side effects
Pain Management–
Treatment
Appropriateness of regular or PRN dosing:
 Intermittent/less severe pain –
 Start with PRN then switch to regular if
patient uses more than occasionally.
 Start with a lower regular dose and
supplement with PRN for breakthrough
pain.
 Adjust regular dose depending on
frequency/severity of breakthrough pain.
Pain Management–
Treatment
Appropriateness of regular or PRN dosing
 More severe pain
 Standing order for more potent, longeracting analgesic and supplement with a
shorter acting analgesic PRN
 Severe/recurrent acute or chronic pain
 Regular, not PRN dosage of at least one
medication
– Start with low to moderate dose,
then titrate upwards
Pain Management–
Treatment
 Goal of treatment is to decrease pain,
improve functioning, mood and sleep
 Strength of dosage should be limited only
by side effects or potential toxicity
Pain Management CPG–
Treatment
Non-Opioid Analgesics Used in the Long-Term Care Setting
Pain Management CPG–
Treatment
Opioid Therapy: Prescribing Principles
and Professional Obligations [9]
 Drug Selection
 Dosing to optimize effects
 Treating side effects
 Managing the poorly responsive
patient
Pain Management CPG–
Treatment
Opioid Analgesics Used in the Long-Term Care Setting
(Oral and Transdermal)
Pain Management CPG–
Treatment
* Duration of effect increases with repeated use due to cumulative effect of drug
Pain Management CPG–
Treatment
Oral Morphine to Transdermal Fentanyl
* NOTE : This table is designed to convert from morphine to transdermal
fentanyl and is based on a conservative equianalgesic dose. Using this
table to convert from transdermal fentanyl to morphine could lead to
overestimation of dose.
Treatment
Topical Analgesics
 Counterirritants
Capsaicin cream
(0.025%) and (0.075%)
(menthol, methyl
salicylate)
 Derived from red peppers
 Supplied as liniments,
 Depletes substance P,
creams, ointments,
desensitizes nerve fibers
sprays, gels or lotions
associated with pain
 May be effective for
 Main limitations are skin
arthritic pain (not multiple
irritation and need for
joint pain)
frequent application
 Need to use routinely for
optimal effectiveness
Treatment
Analgesics of Particular Concern
in the Long-Term Care Setting
Chronic use of the following drugs are not
recommended:
 Meperidine
 Indomethacin
 Pentazocine,
 Piroxicam
butorphanol and
 Tolmetin
other agonist Meclofenamate
antagonist
 Propoxyphene
combinations
Treatment
Non-Analgesic Drugs Sometimes
Used for Analgesia
 Neuropathic pain
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
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Antidepressants
Anticonvulsants
Antiarrhythmics
Baclofen
 Inflammatory
diseases
 Corticosteroids
 Osteoporotic
fractures
 Calcitonin
Treatment
Factors to evaluate when considering
complementary therapies
 Patient’s underlying diagnosis and coexisting conditions
 Effectiveness of current treatment
 Preferences of the patient and family or
advocate
 Past patient experience with the therapy
 Availability of skilled experienced providers
Pain Management CPG–
Monitoring Steps
 Re-evaluate the patient’s pain
 Adjust treatment as necessary
 Repeat previous steps until pain is
controlled
Pain Management CPG–
Monitoring
Opioid Therapy: Monitoring Outcomes
Critical outcomes: The “Four A’s”
 Analgesia – Is pain relief meaningful?
 Adverse events – Are side effects
tolerable?
 Activities - Has functioning improved?
 Aberrant drug-related behavior
Pain Management CPG–
Monitoring
When patient is unresponsive to clinical
management consider referral to:
 Geriatrician
 Neurologist
 Physiatrist
 Pain clinic
 Physician certified in palliative medicine
 Psychiatrist (if patient has co-existing mood
disorder)
Dilemmas in Pain
Management
While addressing pain management, have
strategies in mind for common problems
 Patient refusal of potentially beneficial
medication
 Patient and family pressure to prescribe
certain drugs
 Patient and family misconceptions about
illness
 Unrecognized or denied psychiatric
disturbances
Reviewing the Physician’s
Role
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Prevention strategies
Communication with patients/families
Documentation
Participate in Quality Improvement
Follow policies and procedures
Summary
 Views about management of pain in the
elderly have changed in recent years
 It is an expectation that pain be managed
 Pain can be effectively treated in the longterm care setting
 A culture of patient comfort should
permeate all aspects of facility operations
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AMDA Clinical Practice Guideline (CPG) on Pain …