Managing Pain in the Older Patient Part 4

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Challenges in Medicating the Senior Patient

Choosing an appropriate dosage form of analgesic drug is essential to successfully manage pain in the older patient. Beyond the clinical recommendations, the pharmacist can be instrumental in providing information on products that will optimize pain relief in this patient population. Swallowing difficulties secondary to other medical conditions, such as Parkinson’s disease, dementia, or stroke, may preclude the use of large tablets or sustained-release medications that cannot be crushed. Liquid medications provide an acceptable alternative for administering analgesics. Unfortunately, few analgesic preparations are available in liquid form. Ibuprofen and naproxen suspensions are the few NSAIDs available as liquids for the relief of mild to moderate pain. For moderate to severe pain, fentanyl patches provide continuous pain relief and are suitable for patients who cannot swallow sustained-release preparations, are tube-fed, or who have difficulty remembering to take their medication. The 72-hour administration interval also reduces the burden of administering medication by nursing staff in long-term care facilities or caregivers at home. The initial dose of the patch may be increased after the first three days of therapy. Additional dose increases should only occur after two cycles of patches have been applied. Morphine sulfate controlled-release capsules may be opened and the pellets mixed in applesauce or administered via a gastrostomy tube without loss of continuous pain relief. Patient controlled analgesia (PCA) through the use of a pump has not been as widely used in elderly patients, particularly those with cognitive impairment, since successful use requires active involvement by the patient.

The older patient may be taking numerous medications, some of which may induce similar side effects as pain management therapy. Constipation is frequently a side effect of narcotic analgesic administration, particularly as the dose increases, placing the patient at risk for fecal impaction. Patients may also be taking calcium supplements and psychoactive agents, which can contribute to constipation. A review of bowel management therapy is advised at the time of prescribing narcotics.

According to the World Health Organization guidelines, the basis for current pain management practices, senna is the laxative of choice for managing opiate-induced constipation. Normal peristaltic movement is inhibited by opiates, preventing movement of fecal material through the colon. Irritant laxatives, such as senna, can help stimulate bowel evacuation. Docusate or psyllium-containing products may be of additional benefit to prevent straining or to add bulk. Adequate fluid intake is essential to prevent possible bowel obstruction associated with the use of bulk-forming laxatives.

Health Care Financing Administration (HCFA) Interpretive Guidelines also influence the process of selecting drug therapy for pain management. The use of tricyclic antidepressants, especially amitriptyline and doxepin, is discouraged in elderly patients due to their increased sensitivity to adverse effects, particularly anticholinergic effects and heart rhythm abnormalities. If a tricyclic agent is to be used, particularly for neuropathic pain, nortriptyline is preferred at low doses with careful titration and monitoring. Patients currently receiving amitriptyline should be considered for conversion to nortriptyline in equipotent doses. Documentation of efficacy and absence of adverse effects should be readily available. During medication pass and meal observation, surveyors are instructed to determine whether NSAIDs are administered with a meal. If they are administered on an empty stomach, it is calculated into the facility’s medication error rate.

Analgesics that are considered unnecessary drugs with a high potential for significant adverse effects and should be avoided include pentazocine and oral meperidine. Both drugs have an increased risk of respiratory depression or central nervous system adverse effects, including seizures with meperidine, in patients over 65 years of age. Alternative agents with less serious adverse effects are readily available.

Conclusion

Successful chronic pain management in the senior patient requires the active involvement of the pharmacist in the community as well as the institution. Regulatory requirements have established a framework for a comprehensive approach to pain management and a fundamental right of patients to adequate relief of pain. Overcoming the barriers to adequate pain relief is only one of the challenges facing the patient and the clinician. Multiple opportunities exist for enhancing patient quality of life. The pharmacist can help educate patients, families and staff about pain management, provide the clinical expertise necessary to manage pain, recommend dosage forms and adjunct medications that will enhance therapy, and measure outcomes of pain management programs.