Pain Management In the Nursing Home
Robert S. Stall, MD, Medical Director, Kresge Residence
Hospice Association of Western New York
Presented at the NYS Hospice Association Conference
Advanced Pain Management:  A Clinical Update
October 18, 1996
I.   Brainstorming
     A.   What are the Important Elements of Geriatric Pain Assessment?
     B.   How do you Identify Opportunities to Alleviate dis-EASE?
     C.   What Strategies can be Used to Improve a Resident's Quality of Life and Functional Ability?
II.  Demographics/Statistics
     A.   Currently approx. 12% of population >65 yrs, compared to 4% in 1900
     B.   By 2030, >20% of population will be >65 yrs
     C.   The old-old (>75 yrs):  29% in 1900, 38% in 1970, 44% by 2000
     D.   Currently approx. 16,000 nursing homes in U.S.A. with 1.9 million beds
     E.   53 nursing home beds for every 1000 >65 yrs
     F.   Probability of nursing home placement:  17% (65-74), 60% (>85)
     G.   Chance of spending some time in a nursing home for ages >65:  43% (>20% will spend at least a year)
     H.   Prevalence of pain in nursing home residents (29% none, 47% intermittent, 24% constant)
III. Key Concepts
     A.   Concept of Disease Threshold and Functional Reserve (click
here for chart--35K .gif file)--use holistic approach to maximize "Total Body" functional reserve and functional ability
          1.   Mind (Cognitive Ability, Mood)
          2.   Body (Physical Ability, Pain)
          3.   Spirit (Hope, Love, Connectedness, Goals, Sense of Purpose)
     B.   Atypical Symptoms and Atypical Presentation of Disease 
     C.   Ageism and Other Barriers to Effective Treatment
IV.  Examples of Acute Pain In Nursing Home Residents
     A.   Arthritic exacerbations
     B.   Trauma-related
     C.   Skin conditions
     D.   Constipation
     E.   Herpes zoster
V.   Examples of Chronic Pain In Nursing Home Residents
     A.   Arthritic syndromes (57% prevalence >75 yrs)
     B.   Post-herpetic neuralgia
     C.   Gastroesophageal reflux disease (GERD)
     D.   Chronic sinusitis (11% prevalence >75 yrs)
VI.  Treatment Approaches
     ("What ONE thing can I do to best improve this patient's quality of life?")
     A.   Team Approach
     B.   Comprehensive Initial Evaluation, Frequent Reevaluation
     C.   Choose the Approach that will Best Relieve dis-EASE and Preserve (or Enhance) Functional
          Ability (e.g. drugs, physical therapy, topical treatments, massage, education, "being there")
     D.   Use of Drugs ("Start Low and Go Slow")--Watch Out for Drug Interactions and Side Effects
          1.   Discontinue any unnecessary medications ("When In Doubt, Leave It Out").
          2.   Use the step-ladder approach--maximize each step of the analgesia ladder before moving on.
          3.   Use regular dosing to PREVENT pain--avoid prn except for breakthrough dosing or if resident able to express a preference(e.g. acetaminophen 325mg qid, capsaicin .025% tid).
          4.   Start with longer dosing intervals--e.g. consider q6h or qid dosing instead of q4h dosing.
          5.   Start with lower doses--e.g. consider Darvocet N-50 (50/325) instead of Darvocet N-100 (100/650), T&C#2 (15/300) instead ofT&C#3 (30/300), Motrin 200mg instead of 400mg, amitryptiline 10mg instead of 25mg, morphine 5mg (or lower) as starting dose instead of 10mg.
          6.   Use drugs with fewer potential adverse side effects--e.g. consider desipramine instead of amitryptiline, ibuprofen instead of diclofenac (Voltaren).
          7.   Use shorter acting drugs first--go to longer acting cautiously.
          8.   Consider local treatments when possible (e.g. lidocaine 5% ointment applied topically to painful pressure sores qshift).
VII. Meeting the Challenge--Knowledge, Teamwork, Creativity and Persistence!
     A.   Where are you in the "Zones of Quality"(click
here for chart--29K .gif file)?
VIII.     References
     A.   Clinics in Geriatric Medicine, August 1996 (Pain Management)
     B.   Merck Manual of Geriatrics, Chapter 12 (Pain)
     C.   New England Journal of Medicine, October 10, 1996, "Pharmacologic Treatment of Cancer Pain", pp. 1124-1132.
     D.   On-Line Resources:  Internet/World Wide Web (WWW)
          1.   Roxane Pain Institute--http://www.roxane.com/
          2.   Dr. Stall's WWW home page--http://www.acsu.buffalo.edu/~drstall/
          3.   Administration on Aging home page--http://www.aoa.dhhs.gov/aoa/
     E.   Working With Your Older Patient:  A Clinician's Handbook (available free from the National Institute on Aging--800 222-2225)

Feel free to contact me by phone (716 636-7531) or E-mail (drstall@acsu.buffalo.edu)
if you have any questions!
Robert S. Stall, M.D.