A Case-Based

Presentation of Pain

Management in an Older

Patient: From Diagnosis to

Death

Perry G. Fine, MDProfessor of Anesthesiology

Pain Research Center

School of Medicine

University of Utah

Salt Lake City, Utah

The Case of

Mrs. J:

An 82 Year

Old Woman

with

Osteoarthritis

Findings

• Multifocal pain: hips, knees, ankles, shoulders for many years

• Occasional use of nonselective NSAIDs (ibuprofen, naproxen) used to be sufficiently helpful--- but no longer.

• Increasing dyspepsia with regular use of NSAIDs

• Counseled by PCP to d/c NSAIDs…concerned about GI bleeding, ulcer

• Pain intensity with activity 6/10 (0-10 scale)

Next Step(s)?

• Past Medical History and Medication Use

• Family History

• Psychosocial History

• Review of Systems

Medical History

• Osteoporosis with DDD, no vertebral fx

• Type II DM, managed with diet alone

• Mild COPD, non-smoker

• No allergies

• Hysterectomy for fibroids; no HRT

Medications

• Glucosamine + Chondroitin Sulfate

• Alendronate

• Aricept 5 mg qd

• ASA 81 mg + multivitamin qd

• Occasional antibiotics for recurrent bronchitis

• Annual flu shot

Family History

• Mother and father died of “old age”; she remembers her mother, especially, being in considerable pain “all bent over” for many years. Father used cane and had trouble walking from “arthritis”.

• Sister died uterine ca

• Brother had CABG surgery age 57, died from a CVA age 68

Psychosocial History

• Husband died suddenly 8 years ago AMI

• No ETOH

• Finished teaching college; taught until motherhood

• One daughter who lives close by, good health

• Two children live out of state

• No living will or written advanced directives

• Modest fixed income from husband’s savings; basic living expenses are covered adequately…not much left over.

Review of Systems

• Progressive short-term memory loss and occasional confusion

• Increasing difficulty with routine tasks

• No chest pain, dyspnea at rest, melena, hemoptysis

• Sleep, mood, bowel/bladder: OK

Physical Examination

• Well groomed; no obvious distress; O x 4; unable to subtract “serial 7’s”; cannot reliably recall 3 objects named after several minutes

• Vision, hearing, gait, balance OK

• Heart, lungs, pulses, peripheral perfusion OK

• Kyphosis, no localized tenderness or TPs

• Limited ROM spine and joints due to pain and mechanical restriction; no erythema or swelling

What Next?

• Sustained-release morphine, 15 mg bid ?

• Meperidine with promethazine 75/25 PO qid?

• Evaluate pain more thoroughly?– Pain is dull and constant.

– Sharp exacerbation of pain in the low back, knees and

hips with walking, bending, or prolonged standing.

– There is pain in the shoulders with abduction, similar

to her knee pain.

– No radicular complaints, no report of burning,

paresthesias, loss of grip strength, loss of bowel or

bladder control.

What Next?

• Begin sustained-release morphine 15 mg PO bid

– Why? Why not?

• Begin acetaminophen 1000 mg PO q 6 h?

– Why? Why not?

• Refer Mrs. J to Physical Therapy?

• Other non-pharmacological therapies?

Interim Phone Call

• The addition of acetaminophen has helped decrease her pain at rest to 1-2/10 and her activity has increased, with pain that is “tolerable”, rated at 3-4/10.

• Mrs. J is reluctant to participate in a structured PT program.

• Warm baths do feel good and help her to sleep.

Two Months Later

• Pain has increased to 8/10 with activity.

• Using medication as directed.

• Poor sleep: “ I can’t get comfortable.”

• Mood disturbance: “I don’t care about anything anymore.”

• Difficulties with self-care.

What Next?

• Consult rheumatologist?

– Tests? Drugs?

• Consult orthopedic surgeon?

– Tests? Surgery?

• Consult pain management specialist?

– Tests? Drugs? Injections?

• Begin NSAID therapy with COX-2 inhibitor?

Interim Call

• Mrs. J was started on celecoxib 200 mg q day.

• Two weeks later she states her pain is better, but it still keeps her from being as active as she’d like. “I feel like a potted plant.”

– No apparent AE’s

• Her daughter states Mrs. J seems better:

– Mood, sleep, energy, self-care, general appearance, but cringes with activity

What Next?

• Start propoxyphene/acetaminophen?

• Add a long-acting opioid with an immediate release opioid for breakthrough pain?

• Switch from NSAID to corticosteroid?

• Increase the dose of celecoxib to 400 mg q day + proton pump inhibitor for GI protection

– Pain is tolerable: walking, shopping.

One Year Later

• Minimal pain at rest.

• Moderate to severe pain, especially with walking.

– Pain in low back, hips, lower extremities rated “real bad” after 50 feet

– “My legs feel like rubber…like they’re someone else’s”

• Physical examination:

– Good tissue perfusion and pulses

– No focal neurologic signs; no atrophy; no TPs

Provisional Diagnosis

• Drug seeking behavior?

• Tolerance to celecoxib?

• Exacerbation of osteoarthritis?

– YES, but….

• Neurogenic claudication.

– Probable spinal stenosis

Further Evaluation

• Sleeping well

• Stiff all over in the morning

• Exerts all her time and energy on basic ADLs

• Blood pressure remains high normal

• 1+ ankle edema (no notable change)

• Daughter reports: “more confusion, occasional disorientation; worried about ability to care for self; forgetful about medicine”

What Is a Valid Conclusion?

• Pain perception in an aging person such as Mrs. J will be decreased as time goes on, so no further therapy is indicated.

• Progressive dementing illness in a patient like Mrs. J will make pain assessment more difficult over time.

– What is indicated?

What Will You Recommend?

• Immediate referral to a specialist:

– Rheumatology

– Neurology

– Surgical Consult

– Pain Clinic

• Add low-dose corticosteroid for inflammatory pain.

• Review options and goals of therapy:

– Burdens versus benefit “analysis”.

– Is there a role for chronic opioid therapy?

What Drug Would You

Recommend

• No allergies or sensitivities, but “bad constipation” with codeine in the past.

• Long-acting vs. short-acting opioid?

• How about oxycodone + acetaminophen (5/325) one half hour before pain-precipitating activity?

Anything Else?

• Don’t forget the bowels!!!

– Diet

– Fluids

– Discontinue bulking agents (e.g., Metamucil), at least for a while.

– Motility agent (e.g., Senakot; bisacodyl)

– Stool softener as needed

– Review bowel function at every follow-up

– Remind daughter to check on adherence

…But Guess What Happens?

As you discuss the prescription with Mrs. J and

her daughter, Mrs. J exclaims:

“ I don’t want to be a drug addict!”

And her daughter concurs, stating:

“ Maybe we should save narcotics for when she reallyneeds them.”

What do you do now?

Next Steps

• Double up on the celecoxib and add amitriptyline?

• Start gabapentin…isn’t it good for pain?

• How about acupuncture or a TENS unit?

• Counsel Mrs. J and her daughter regarding opioid therapy.

– Your brilliant and empathic approach creates such trust that the issues are well-understood and appreciated. They agree to give it a try, and a follow-up visit is scheduled for two weeks later.

Two Months Later

• Things were going well for a while. “Incident pain” has been well-controlled, but she has started to have constant, unremitting pain:

– Low back, 5-6/10

– Non-radiating

– No problems with bowel/bladder function

– No sensory disturbances or changes in muscle strength

– She’s now taking 10 tablets of oxy./acet. per day

What to Do?

• Recommend increasing the dose of oxy./acet. to 10/325, up to 2 ever 4 hours prn?

• Bring up the possibility of drug-seeking behavior with Mrs. J’s daughter?

• Switch to sustained-release oxycodone, 20 mg PO bid with oxy./acet. 7.5/500 for breakthrough pain.

One Year Later

• Over the first few months of long-acting opioid therapy, she had been doing well over the last few months, rating her pain on average as 3/10, but gradually required dose increases to maintain this level of pain control and function.

• Currently taking oxycodone SR 40 mg q 8h but seems to be forgetting doses frequently, with exacerbations in pain, leading to problems with self-care…a vicious cycle is setting up. Her daughter worries that Mrs. J will take too little and suffer, or take too much and overdose.

What to Recommend?

• On examination, Mrs. J is losing memory, and appears increasingly frail. Simple tasks are difficult.

• This is a good time to discuss and review advance directives, short- and long-term goals of therapy, living situation, what to expect as Alzheimer’s progresses.

• Review importance of pain evaluation and control.

• Discontinue oxycodone, start transdermal fentanyl 25 mcg q 72 h. Have Mrs. J’s daughter evaluate her mother’s verbal and behavioral responses to activity and supplement / “pre-treat” with oxycodone IR as needed.

…The Rest of the Story

• After 3 weeks: average of 60 mg oxycodone IR per day to control pain 50 mcg fentanyl patch.

– Breakthrough Pain: Mrs. J’s daughter leaves one 10 mg oxycodone/325 mg acetaminophen tablet available to her…checks on her throughout the day to determine if she has needed it, and replaces it.

• Several months later, Mrs. J moves in with her daughter. Hospice care is initiated when her Alzheimer’s disease progresses to FAST 7. Pain control is continued with transdermal fentanyl, and oral morphine concentrate for breakthrough pain.

D i s e a s e M a n a g e m e n t / P a l l i a t i v e H e a l t h c a r e

Disease Modifying Interventions*

Interventions with Curative

Capacity*

Palliative Interventions

Bereavement

Diagnosis of a

serious or chronic

condition

Prognosis of

foreseeable

limited life

expectancy or

end-stage disease

Death

Adapted from: Fine PG, Davis M. Fine PG, Davis M: 2006. Hospice:

comprehensive care at the end of life. Anesthesiol Clin;24(1):181-204.

Consumer Education, “Coaching”, Empowerment

AL = Assisted Living LTC = Long Term Care * until no longer meeting medically specified outcomes or patient’s goals

Late Stage Advanced

Illness

H o s p i c e