Geriatrics Chapter 13: Comfort and Pain Management

Comfort

A state of physical, emotional, social, and spiritual well-being

-Defined as to release from suffering, free from pain

Pain

Defined as “an unpleasant sensory and emotional experience”

Subjective, relying on the patient’s perception and report

-Greatest threat to comfort

Prevalence of pain in older adults

1 in 4 suffer day-long bouts of pain

3 of 5 patients aged 65+ experience pain lasting longer than 1 year or more

Low back pain is most common along with migraines or severe headaches, joint pain (knee), aching, stiffness

Severe joint pain increased with age

Nociceptive Pain

Mechanical, thermal, and chemical stimuli to A-delta and C fiber nociceptors found in fasciae, muscle joints, deep tissues

Somatic Pain

Bone or soft tissue masses; localized; throbbing or aching

-Type of nociceptive pain

Visceral Pain

Disorders that cause generalized or referred pain; deep and aching

-Type of nociceptive pain

Referred Pain

Pain located away from source

-type of nociceptive pain

Neuropathic Pain

Abnormal processing of sensory stimuli by central or peripheral nervous system

-Sharp, stabbing, tingling, burning; onset of high intensity

-Phantom limb pain, diabetic neuropathy, post-herpetic neuralgia, and other insults to the nervous system

Pain Perception

Role of age in pain perception is unclear

Pain threshold: the same in all healthy individuals

Pain tolerance: varies with each person

Effects of unrelieved pain

Limited mobility, develop pressure ulcers, pneumonia, constipation, poor appetite; lack of motivation to eat/drink, malnutrition and dehydration, spiritual distress, and social isolation

Assessment: Medical History

Acute/chronic conditions

Cognitive status

Surgeries

Medications

Significant recent events (fall, relocation, death of a spouse)

Assessment: General Observations

Grimacing, crying, moaning, clutching fists, limitations of movement, shifting position, favoring or rubbing of a specific body part, discoloration, swelling, agitation, or depression

Assessment: interview

Frequency, duration, characteristics?

Is it related to any medical problems, injuries?

What factors worsen & alleviates?

What meds do you use for pain including dose, frequency, effect?

Assessment: Physical examination

ROM, sensitivity to touch, guarding

Weakness, numbness, bruises, cuts, inflammation, temperature of area

Pain Assessment

-Open-ended questions

-Detailed pain history

-Physical examination

-Need for ongoing assessment

-Cultural factors

-Cognitive impairment

Pain Assessment Instruments

Numeric rating scales (0-10)

Visual analog scales (FACES)

Acupressure

Use of pressure over joints

Acupuncture

Placement of needles under skin at acupooints

Aromatherapy

Uses scents from essential oils of plants to create physiological and emotional effects

-Lavendar, rose, sandalwood scents to calm

Biofeedback

Ability to bring specific bodily functions under voluntary control

-Blood pressure and heart rate

Chiropractic

Manipulation and adjustment of spine and joints to correct misalignments that can be causing dysfunction and pain

Electrical Stimulation

Electrical current administered to skin and muscles via electrodes

Exercises

Gentle stretches and range of motion

Guided Imagery

Suggesting images that can create specific reactions (calm)

Heat and Cold Therapies

Hot or cold pads, packs, dips (paraffin), baths, massage, environments (sauna)

Herbal Medicine

Use of plants for therapeutic benefit

Hypnosis

Guiding person into trance-like state, increasing receptivity to suggestions

Meditation

Using deep relaxation to calm body and mind and focus on the present moment

Progressive Relaxation

Series of exercises that help the body achieve a state of deep relaxation

Supplements

Use of specific nutritional products (B-complex vitamins) to enhance function of nervous system

-Fish oils, ginger, turmeric, devil’s claw= reduce inflammation

-Topical capsaicin = blocks pain signals

-Vitamin B2 = migraines

Dietary Changes

Vitamin B deficiency: Green leafy vegetables

Anti-inflammatory: omega-3 fatty acids

• Cold water fish (salmon, tuna, sardines, halibut) and their oils

-Flaxseed oil

-Garlic, ginger, turmeric

Flavonoids: red, purple, blue fruits

• Berries (blueberries, raspberries)

-Black or green tea or red wine

-Chocolate, cocoa

Foods to AVOID to prevent inflammation

Animal products, high-fat dairy products, egg yolk, beef fat, corn, soybean, peanut oils, white flour, sugars

Medication

Medication management can be complicated in older adults

Risk of adverse effects is higher

Trial nonopioids prior to opioids

Adjuvant medications may benefit

Use narcotics cautiously

START LOW, GO SLOW

Examples of Meds

Acetaminophen: most commonly used with older adults

NSAIDS: ibuprofen, naproxen, aspirin

Opioids- moderate to severe pain: oxycodone, hydrocodone, codeine

Opioids- severe pain: morphine, fentanyl patches, naloxone (Narcan)

*Meperidine (Demerol) is contraindicated in older adults*

Comforting

Give the patient undivided attention regardless of the length of the interaction

Listen attentively, encouraging the patient to speak and demonstrate interest through body language and feedback

Explain procedures, changes, and progress

Touch: gentle rubbing the patient’s back or shoulders, massaging the feet, holding a hand

Perceive: watch for signs of distress; tear-filled eyes, sighing, flat affect