Presented by Dr.Perry Fine at Pain Management for the Elderly Course, 2010. Scribe medical events Egypt. www.scribeofegypt.org

1. A Case-Based
Presentation of Pain
Management in an Older
Patient: From Diagnosis to
Death
Perry G. Fine, MD
Professor of Anesthesiology
Pain Research Center
School of Medicine
University of Utah
Salt Lake City, Utah

2. The Case of
Mrs. J:
An 82 Year
Old Woman
with
Osteoarthritis

3. 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)

4. Next Step(s)?
• Past Medical History and Medication Use
• Family History
• Psychosocial History
• Review of Systems

5. 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

6. Medications
• Glucosamine + Chondroitin Sulfate
• Alendronate
• Aricept 5 mg qd
• ASA 81 mg + multivitamin qd
• Occasional antibiotics for recurrent bronchitis
• Annual flu shot

7. 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

8. 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.

9. 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

10. 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

11. 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.

12. 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?

13. 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.

14. 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.

15. 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?

16. 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

17. 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.

18. 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

19. Provisional Diagnosis
• Drug seeking behavior?
• Tolerance to celecoxib?
• Exacerbation of osteoarthritis?
– YES, but….
• Neurogenic claudication.
– Probable spinal stenosis

20. 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”

21. 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?

22. 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?

23. 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?

24. 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

25. …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 really
needs them.”
What do you do now?

26. 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.

27. 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

28. 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.

29. 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.

30. 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.

31. …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.

32. 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