Treatment of pain in older patients

Comparison of paracetamol and diclofenac prescribing preferences for adults in primary care

INTRODUCTION

The most frequently prescribed analgesic drugs in primary care centers in Turkey are diclofenac and paracetamol, respectively. In this study, we aimed to compare paracetamol-included prescriptions (PIP) and diclofenac-included prescriptions (DIP) generated for adult patients in primary care.

METHODS

In this cross-sectional study, PIPs (n = 280 488) and DIPs (n = 337 935) created for adults by systematic sampling among primary care physicians working in Istanbul in 2016 (n = 1431) were examined. The demographic characteristics, diagnoses, and additional drugs in PIPs and DIPs were compared.

RESULTS

Women constituted the majority in both groups (69.8% and 67.9%, respectively; P < 0.05), and mean age at PIP (52.6 ± 18.8 years) was lower compared to DIP (56.3 ± 16.1 years), (P < 0.05). In single-diagnosis prescriptions, 11 of the 15 most common diagnoses in PIP were respiratory tract infections (47.9%); three pain-related diagnoses formed 4.6% of all these prescriptions. In DIP, the number of pain-related diagnoses, mostly of musculoskeletal origin, was eight (28.5%); four diagnoses (7.8%) were upper respiratory tract infections. While hypertension was the third most common diagnosis in PIP (6.1%), it was ranked first in DIP (8.0%). The percentage of prescriptions with additional analgesic (14.0% versus 18.3%, P < 0.001), proton-pump inhibitor (13.8% versus 18.4%; P < 0.001), and antihypertensive (22.0% versus 24.8%, P < 0.001) was lower in PIP compared to DIP. However, the percentage of prescriptions with antibiotics (31.3% versus 14.7%, P < 0.001) was higher in PIP.

CONCLUSION

Paracetamol appears to be preferred mostly in upper respiratory tract infections compared to the preference of diclofenac rather in painful/inflammatory musculoskeletal conditions. The presence of hypertension among the most commonly encountered diagnoses for these analgesic drugs points to challenges in establishing the diagnosing-treatment match and indicates potential irrational prescribing practice, especially for interactions.

Assessing Knowledge and Attitudes Regarding Pain Management Among Nurses Working in a Geriatric Hospital in Vietnam

Background

Nurses play a pivotal role in pain management. Knowing more about nurses’ knowledge and attitudes regarding pain is important as we develop multidisciplinary pain services. Therefore, this study aimed to assess knowledge and attitudes regarding pain management among nurses in a geriatric hospital and its associated factors.

Subjects and Methods

A survey was conducted of nurses worked at the National Geriatric Hospital over a 3-month period. The Knowledge and Attitudes Survey Regarding Pain (KASRP) was utilized to assess nurses’ knowledge and attitudes toward pain management. Four domains were defined based on KASRP, included cancer-related pain, pain assessment, pharmacology and substance abuse and physical dependence. Knowledge and attitudes regarding pain were classified as poor, fair, or good (≤50%, 50% - 75%, or ≥75% of the KASRP score). Multivariate Tobit regression models were applied to identify factors associated with the knowledge and attitudes regarding pain management.

Results

Of 154 participants completed the survey, 72.2% (111 participants) had poor knowledge and attitudes regarding pain management. The participants had a correct mean score of 45.2% (SD = 2.2). Nurses’ knowledge of pain assessment was poor, with the proportion of correct answers to nine questions ranging from 2.6% to 50%. 44.8% of nurses reported never or rarely using pain assessment tools. Nurses who had previous training regarding pain at medical universities had significantly higher scores of knowledge and attitudes compared to those without training. Nurses who often use pain assessment tools had a significantly higher level of knowledge and attitudes than those who never or rarely use them.

Conclusion

This study highlights significant deficits of knowledge and negative attitudes regarding pain management among nurses. The subject of pain management should be applied and enhanced in the nursing undergraduate curriculum. Nurses’ active participation in pain management should be encouraged by healthcare providers for older patients.

Morphine responsiveness to thermal pain stimuli is aging-associated and mediated by dopamine D1 and D3 receptor interactions

Morphine actions involve the dopamine (DA) D1 and D3 receptor systems (D1R and D3R), and the responses to morphine change with age. We here explored in differently aged wild-type (WT) and D3R knockout mice (D3KO) the interactions of the D1R/D3R systems with morphine in vivo at three different times of the animals' lifespan (2months, 1year, and 2years). We found that: (1) thermal pain withdrawal reflexes follow an aging-associated phenotype, with relatively longer latencies at 2months and shorter latencies at 1year, (2) over the same age range, a dysfunction of the D3R subtype decreases reflex latencies more than aging alone, (3) morphine altered reflex responses in a dose-dependent manner in WT animals and changed at its higher dose the phenotype of the D3KO animals from a morphine-resistant state to a morphine-responsive state, (4) block of D1R function had an aging-dependent effect on thermal withdrawal latencies in control animals that, in old animals, was stronger than that of low-dose morphine. Lastly, (5) block of D1R function in young D3KO animals mimicked the behavioral phenotype observed in the aged WT. Our proof-of-concept data from the rodent animal model suggest that, with age, block of D1R function may be considered as an alternative to the use of morphine, to modulate the response to painful stimuli.

Pain in the Elderly

Pain management in the elderly has increasingly become problematic in the USA as the aged population grows. The proportion of the population over 65 continues to climb and may eclipse 20 % in the next decade. In order to effectively diagnosis and treat these patients, a proper history and physical exam remain essential; pain assessment scales such as the Verbal Descriptor Scales (VDS), the Numerical Rating Scales (NRS), and the Visual Analogue Scales (VAS) often but not always prove beneficial. The conditions most frequently afflicting this population include osteoarthritis, diabetic neuropathy, post-herpetic neuralgia, and lower back pain which include spondylosis and radiculopathies. While the normal aging process does not necessarily guarantee symptoms of chronic pain, elderly individuals are far more likely to develop these painful conditions than their younger counterparts. There are many effective treatment modalities available as potential therapeutic interventions for elderly patients, including but not limited to analgesics such as NSAIDs and opioids, as well as multiple interventional pain techniques. This review will discuss chronic pain in the elderly population, including epidemiology, diagnostic tools, the multitude of co-morbidities, and common treatment modalities currently available to physicians.

Analgesia enhancement and prevention of tolerance to morphine: beneficial effects of combined therapy with omega-3 fatty acids

Objectives

Recent evidence associates omega-3 fatty acids (O3) with pain reduction. The aim of this work was to evaluate the antinociceptive effect of O3, either alone or in combination with morphine after acute and chronic administration in rats. As well, a new pharmaceutical mixture that allows the concomitant administration of O3 and morphine as an oral solution was developed.

Methods

Animals were fed on a control or an experimental diet supplemented with O3. They were subjected to the hot-plate test to assess analgesic effect and tolerance to the analgesic effect of morphine. The open-field test was carried out to determine if the differences in the response latency can be related to non-specific sedative effects.

Key findings

O3 dietary supplementation increased the response latency compared with the control group. Acute treatment with morphine in these groups resulted in an additive antinociceptive effect not related to locomotor activity. Chronic coadministration of morphine with O3 attenuated the development of tolerance. Oral administration of the new pharmaceutical mixture showed analgesic activity with a subtherapeutic dose of morphine.

Conclusion

This finding suggests a role for O3 as adjuncts to opioids in pain therapy and might contribute to the reduction of the occurrence of morphine side-effects.

[Use of methadone in the elderly with cancer pain: a systematic review]

OBJECTIVE

To identify the clinical use of methadone as an analgesic in the management of cancer pain in elderly patients.

MATERIAL AND METHODS

We performed a systemic review of the literature on the specific use of methadone in elderly with cancer pain in MEDLINE, COCHRANE DATABASE and SCOPUS. A second search was conducted in MEDLINE to look for clinical trials and systematic review of the use of methadone in cancer pain, selecting only those in which the mean age of patients was ≥ 65 years old.

RESULTS

Four articles were obtained in the first search, and from the second 7 clinical trials, none of them specific to methadone use in elderly patients with cancer.

CONCLUSIONS

There are insufficient data on the use of methadone as an analgesic in the elderly with cancer. Given its pharmacological characteristics it must be used by trained personnel. Several recommendations are proposed for its use as an analgesic in the treatment of cancer pain in the elderly.

Pain management in older adults

BACKGROUND

Chronic pain is prevalent among older adults but is underrecognized and undertreated. The approach to pain assessment and management in older adults requires an understanding of the physiology of aging, validated assessment tools, and common pain presentations among older adults.

OBJECTIVE

To identify the overall principles of pain management in older adults with a specific focus on common painful conditions and approaches to pharmacologic treatment.

METHODS

We searched PubMed for common pain presentations in older adults with heart failure, end-stage renal disease, dementia, frailty, and cancer. We also reviewed guidelines for pain management. Our review encompassed 2 guidelines, 10 original studies, and 22 review articles published from 2000 to the present. This review does not discuss nonpharmacologic treatments of pain.

RESULTS

Clinical guidelines support the use of opioids in persistent nonmalignant pain. Opioids should be used in patients with moderate or severe pain or pain not otherwise controlled but with careful attention to potential toxic effects and half-life. In addition, clinical practice guidelines recommend use of oral nonsteroidal anti-inflammatory drugs with extreme caution and for defined, limited periods.

CONCLUSION

An understanding of the basics of pain pathophysiology, assessment, pharmacologic management, and a familiarity with common pain presentations will allow clinicians to effectively manage pain for older adults.

Treatment of Metastatic Breast Cancer in Women Aged 65 Years and Older

Breast cancer is a disease of aging and the incidence of breast cancer increases dramatically with increasing age. In spite of major advances in prevention, screening and treatment approximately 40,000 Americans still die of metastatic breast cancer every year – the majority being women aged 65 years and older. Metastatic breast cancer remains incurable regardless of age and the goals of treatment are to reduce symptoms when present and to provide the patient with the best quality of life for as long as possible. Cornerstones of treatment to control metastases include endocrine therapy, chemotherapy and radiation therapy. Supportive care that includes psychosocial support and treatment of pain is also a key component of management. This review focuses on the issues related to the care of older women with metastatic breast cancer.

Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them

OBJECTIVE

There has been a growing recognition of the need for better pharmacologic management of chronic pain among older adults. To address this need, the National Institutes of Health Pain Consortium sponsored an "Expert Panel Discussion on the Pharmacological Management of Chronic Pain in Older Adults" conference in September 2010 to identify research gaps and strategies to address them. Specific emphasis was placed on ascertaining gaps regarding use of opioid and nonsteroidal anti-inflammatory medications because of continued uncertainties regarding their risks and benefits.

DESIGN

Eighteen panel members provided oral presentations; each was followed by a multidisciplinary panel discussion. Meeting transcripts and panelists' slide presentations were reviewed to identify the gaps and the types of studies and research methods panelists suggested could best address them.

RESULTS

Fifteen gaps were identified in the areas of treatment (e.g., uncertainty regarding the long-term safety and efficacy of commonly prescribed analgesics), epidemiology (e.g., lack of knowledge regarding the course of common pain syndromes), and implementation (e.g., limited understanding of optimal strategies to translate evidence-based pain treatments into practice). Analyses of data from electronic health care databases, observational cohort studies, and ongoing cohort studies (augmented with pain and other relevant outcomes measures) were felt to be practical methods for building an age-appropriate evidence base to improve the pharmacologic management of pain in later life.

CONCLUSION

Addressing the gaps presented in the current report was judged by the panel to have substantial potential to improve the health and well-being of older adults with chronic pain.

Managing pain in the elderly population: pearls and pitfalls

While pain is a common symptom among older adults, it often is underdiagnosed and undertreated. Aging-related physiological changes, misperceptions about the use of pain medications by both patients and providers, and the lack of evidence-based clinical research on pain management in older adults are some of the reasons why pain in older adults is mismanaged. Using extrapolated evidence from pain research in younger patients, consensus statements, and best practice guidelines, this article summarizes and highlights areas of geriatric pain assessment and management that need special consideration. Some highlighted areas include 1) pain assessment in cognitively impaired patients; 2) medication choice and initiation doses; 3) duration of adequate medication trials; and 4) common medication side effects and suggested management.

The prevalence and management of current daily pain among older home care clients

The aim of this cross-sectional study was to examine the prevalence and correlates of pharmacotherapy for current daily pain in older home care clients, focusing on analgesic type and potential contraindications to treatment. The sample included 2779 clients aged 65+years receiving services from Community Care Access Centres in Ontario during 1999-2001. Clients were assessed with the Resident Assessment Instrument-Home Care (RAI-HC). Prescription and over-the-counter (OTC) medications listed on the RAI-HC were used to categorize analgesic treatment into two groups (relative to no analgesic use): use of non-opioids (acetaminophen or non-steroidal anti-inflammatory drugs only); and, use of opioids alone or in combination with non-opioids. Associations between client characteristics and analgesic treatment among those in current daily pain were examined using multivariable multinomial logistic regression. Approximately 48% (n=1,329) of clients had daily pain and one-fifth (21.6%) of this group received no analgesic. In multivariable analyses, clients aged 75+years and those with congestive heart failure, diabetes, other disease-related contraindications, cognitive impairment and/or requiring an interpreter were significantly less likely to receive an opioid alone or in combination with a non-opioid. Clients with congestive heart failure and without a diagnosis of arthritis were significantly less likely to receive a non-opioid alone. A diagnosis of arthritis or cancer and use of nine or more medications were significantly associated with opioid use. The findings provide evidence of both rational prescribing practices and potential treatment bias in the pharmacotherapeutic management of daily pain in older home care clients.

Holistic assessment of chronic pain among elders

This pilot study assessed pain using 7 dimensions of pain (physiologic, behavioral, sensory, affective, cognitive, sociocultural, and spiritual) to better understand and identify patterns of elder response to chronic pain within a holistic framework. Previously validated instruments were used to assess 150 cognitively intact subjects, aged 65 years and older, with chronic pain. Thirteen patterns were identified reflecting distinct patterns of pain response. Two patterns comprised 85% of the responses: (1) high spiritual well-being, low physiologic pain, and high perceived independent functioning; and (2) high spiritual well-being, low physiologic pain, and lower perceived independent functioning. The 11 other patterns of pain response also varied in their responses to the pain experience. These responses reflect the unique and holistic experience of chronic pain among older adults. Holistic assessment enhances the understanding of the pain specific to the individual. Self-perceived functional dependence and the spiritual component significantly influence chronic pain experiences.