Pain management in geriatric
The case involved an 80-year-old woman from an assisted-living seniors’ building with a 24-hour health centre. She had been suffering from chronic pain for the past two years in one of her legs. She had diabetes, an unsteady gait that put her at risk for falls, moderate cognitive impairment which was affecting her short-term memory, and exhibited wide fluctuations in emotions. She was a frequent visitor to the health centre during the day and was prone to increased confusion and agitation late in the day.
Sleep disturbance led to frequent calls to the night nurse and her children with discussions focusing on her pain. She could not remember receiving her pain killers and regularly insisted to nurses and her family that no one was helping her. She was withdrawing from her dining room meals and social programs in the building. She expressed feelings of abandonment with her son traveling on business and daughter living out of town, which caused her family much stress and worry. They in turn would place urgent calls to different staff on the care team, pleading for help for their mother and questioning the pain treatment she was receiving.
The patient continued to express great discomfort in her leg, even after assessments in Baycrest’s Geriatric Assessment and Treatment Unit and with an outside pain clinic. Attempts at medication changes resulted in episodes of mental confusion termed delirium and a subsequent return to her previous drug regimen. The case was perplexing the health-care team which included a primary care physician, nurses, social worker, occupational therapist, pharmacist and psychiatrist. The team never doubted that the patient’s pain was real, but the treatment plan, which mainly involved prescribed pain medication, was not providing an effective outcome. The patient was topping up with over-the-counter anti-inflammatory drugs.
“Although persistent pain is common in the elderly due to chronic medical problems, it should not be interpreted as a normal part of aging,” says Marjorie Hammond, clinical nurse specialist in pain management at Baycrest. “With the appropriate assessment and a correct management plan, it can and should be controlled.”
Hammond became involved with this patient case last fall. She acknowledged that older persons often have multiple medical problems which, when combined with dementia, can make pain assessment and management more challenging, as well as time and resource intensive.
Hammond, in collaboration with the care team, embarked on a comprehensive multi-domain assessment. The approach involved: a cognitive assessment (Mini Mental State Exam or MMSE) to determine the patient’s cognitive status and ability to self-report pain (can she reliably evaluate changes in her pain after interventions?); a medication review to determine the most optimal drug regimen; a psycho-social review of her interaction with her family, health-care staff, hired companion and other residents in the apartment building; and assessment for depression, impact on quality of life and physical functioning. An environmental assessment was also conducted of her apartment unit to reduce the risk of falls and other injury.
The MMSE showed short-term memory impairment. In order to generate a report of changes in pain level after different drug and non-drug interventions were tried, the team trained the hired companion to use a pain rating scale, keep a daily pain record, and monitor behavioural changes day and night. The companion was a critical component to the evaluation process.
The patient was switched to a slow-release opiate that was more aligned with the intensity and persistent nature of her pain. She was prescribed an additional breakthrough medication for times when her pain would spike. She was found to be self medicating with additional over-the-counter medications that were subsequently stopped. It was expected that the medication changes would cause some temporary delirium. After being informed of the risk, the family supported having an additional private companion to provide crucial overnight supervision and monitoring. It was identified that having a companion at night reduced the number of requests for breakthrough medication and that this medication did not always change her pain intensity reports. To help the patient sleep at night, a sedative was administered (providing she had overnight supervision).
The patient did, however, found benefit putting on topical pain creams and massage to the painful area – a behaviour that was encouraged by staff and supported with assistance by her companion. She was also encouraged to attend recreational pool sessions twice weekly if the companion could go with her.
The psychosocial evaluation indicated that increasing social isolation (not attending dining room meals and other on-site activities), and even certain routine behaviours in family and health staff when interacting with the patient (in person or by phone), were exacerbating the patient’s pain experience. Staff and family were asked to refrain from constantly asking the patient how her pain was and encouraged to steer conversation to positive topics unrelated to pain. The private companion reported that encouraging social interaction with friends (during meals and other activities) proved an effective distraction from pain and the client appeared happier during these occasions.
Interviews revealed her expectations regarding her pain – she wanted to live pain free without medication, not have to use a walker, and return to being socially and physically active as in her younger life. Much effort was placed on transitioning her and the family’s thinking toward how well her pain was managed. She reported that her medication was very helpful and she could do more activities (observations supported by staff and her companion). She continued on her slow-release medications, and her breakthrough medication remained available to her. It was found that long walks to the dining room were triggers for breakthrough medication, so a scheduled dose of pain medication one hour before the journey was initiated.
The family was kept well informed and partnered with the pain management team. A family conference was held and written resources about pain in older persons were provided to them. One person on the care team (in this case the social worker) was appointed the primary contact for the family, providing regular updates on their mother’s health status and taking their calls.
“In developing a pain management strategy, it sometimes takes several tries until we find what works best,” says Hammond. “The keys to successful pain control are identifying all the complex issues that account for a person’s pain and subsequent suffering.