C h a p t e r 3 5
Somatosensory Function, Pain, and Headache
877
Pain Management
When prescribing pharmacologic and nonpharmacologic
methods of pain management for the older population,
care must be taken to consider the cause of the pain, the
person’s health status, concurrent therapies, and mental
status. In the older population, where the risk of adverse
reaction to drugs is higher, the nonpharmacologic options
are usually less costly and cause fewer side effects.
Common nonpharmacologic interventions include
application of cold (which suppresses the release of
products from tissue damage) and heat (which pro-
motes the release of endogenous endorphins).
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The role
of mental focus and anxiety is important, and relaxation
techniques, massage, and biofeedback may be useful.
Physical therapy and occupational therapy bring a vari-
ety of modalities, including the use of braces or splints,
changes in biomechanics, and exercise, all of which have
been shown to promote pain relief.
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Although efficacy is important when considering
the use of pharmacologic agents for pain relief in the
elderly, safety must also be considered. The elderly may
have physiologic changes that affect the pharmacoki-
netics of medications prescribed for pain management.
These changes include decreased blood flow to organs,
delayed gastric motility, reduced kidney function, and
decreased albumin related to poor nutrition.
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Also, the
elderly often have coexisting health problems requir-
ing medications. On average, a 70-year-old takes seven
different medications.
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The addition of analgesics to a
complex medication regimen may cause drug interac-
tions and complicate compliance; however, these con-
siderations should not preclude the appropriate use of
analgesic drugs to achieve pain relief. Non-opioids are
generally the first line of therapy for mild to moder-
ate pain, and acetaminophen is usually the first choice
because it is relatively safe for older adults.
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Opioids
are used for more severe pain and for palliative care.
As with younger persons, adjuvant analgesics are effec-
tively used for treatment of pain in older adults. The
use of some assessment tool to evaluate the level of pain
and effectiveness of treatment is essential. Monitoring
for side effects is also critical.
R E V I EW E X E R C I S E S
1.
A 25-year-old man is admitted to the emergency
department with acute abdominal pain that began
in the epigastric area and has now shifted to the
lower right quadrant of the abdomen. There
is localized tenderness and guarding or spasm
of the muscle over the area. His heart rate and
blood pressure are elevated, and his skin is moist
and cool from perspiring. He is given a tentative
diagnosis of appendicitis and referred for surgical
consultation.
A.
Describe the origin of the pain stimuli and the
neural pathways involved in the pain that this
man is experiencing.
B.
Explain the neural mechanisms involved in the
spasm of the overlying abdominal muscles.
C.
What is the significance of his cool, moist skin
and increased heart rate and blood pressure?
2.
A 65-year-old woman with breast cancer is
receiving hospice care in her home. She is
currently receiving a long-acting opioid analgesic
supplemented with a short-acting combination
opioid and nonnarcotic medication for
breakthrough pain.
A.
Explain the difference between the mechanisms
and treatment of acute and chronic pain.
B.
Describe the action of opioid drugs in the
treatment of pain.
C.
Define the term
tolerance
as it refers to the use
of opioids for treatment of pain.
3.
A 42-year-old woman presents with sudden,
stabbing-type facial pain that arises near the right
side of her mouth and then shoots toward the right
ear, eye, and nostril. She is holding her hand to
protect her face because the pain is “triggered by
touch, movement, and drafts.” Her initial diagnosis
is trigeminal neuralgia.
A.
Explain the distribution and mechanisms of the
pain, particularly the triggering of the pain by
stimuli applied to the skin.
B.
What are possible treatment methods for this
woman?
SUMMARY CONCEPTS
■■
Children experience and remember pain, and
even fairly young children are able to accurately
and reliably report their pain. Recognition of
this has changed the clinical practice of health
professionals involved in the assessment of
children’s pain. Pharmacologic (including opioids)
and nonpharmacologic pain management
interventions have been shown to be effective in
children. Nonpharmacologic techniques must be
based on the developmental level of the child and
should be taught to both children and parents.
■■
Pain is a common symptom in the elderly.
Assessment, diagnosis, and treatment of pain
in the elderly can be complicated.The elderly
may be reluctant or cognitively unable to
report their pain. Diagnosis and treatment can
be complicated by comorbidities and age-
related changes in cognitive and physiologic
function.
