The journal of pain : official journal of the American Pain Society
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Review
Pharmacological management of persistent pain in older persons: focus on opioids and nonopioids.
Managing persistent pain is challenging, particularly in older adults who often have comorbidities and physiological changes that affect dosing and adverse effect profiles. The latest guideline issued by the American Geriatrics Society in 2009 is an important clinical resource on prescribing analgesics for older adults. This guideline helps form an evidence-based approach to treating persistent pain, along with other current endorsements, such as the relevant disease-specific recommendations by the American College of Rheumatology, the European League Against Rheumatism, and Osteoarthritis Research Society International, as well as opioid-specific guidelines issued by the American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards of the United States, and the American Society of Interventional Pain Physicians. ⋯ Combining analgesics that have multiple mechanisms of action with nonpharmaceutical approaches can be beneficial in providing pain relief. Nontraditional analgesics are also considered on a case-by-case basis, and a few of these options are weakly recommended. Therapies should be initiated at the lowest possible dose and slowly titrated to effect, while tailoring them to the therapeutic and side-effect responses of the individual.
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The prevalence of pain and pain undertreatment in older persons, along with the many potential detrimental consequences of undertreated pain, pose a substantial burden to the individual, their family, and society. An accurate pain assessment is the foundation for treating pain; yet, thorough pain assessments and regular reassessments are too often neglected. Older adults typically present with multiple pain etiologies, making it all the more imperative that a comprehensive assessment is conducted. ⋯ Following an unsuccessful attempt at self-report from a nonverbal older adult, the potential causes of pain should be explored. Direct observation can then be used to identify behaviors suggestive of pain, and the patient's response to an analgesic trial can be observed. A pain behavior tool can also provide useful information suggesting the presence of pain.
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Drugs without a strong evidence base and outside of recommendations are too often prescribed for older adults. Established guidelines such as Beers criteria have identified both specific medications and certain drug classes as inappropriate for older adults, primarily due to adverse effects. Age-related physiological changes in distribution, metabolism, and elimination often alter the effects of pharmacotherapies in older adults. ⋯ The NNT is a measure describing the number of patients who require treatment for every 1 who reaches the therapeutic goal, and the NNH describes the number of participants who manifest side effects; these can further be segregated into numbers who withdraw from studies due to intolerable side effects. These parameters, along with a patient's comorbidities and concomitant medications, should be considered when selecting an analgesic and dose regimen. In addition, practitioners should avoid prescribing multiple-drug therapies that have overlapping pharmacodynamics or that may have an adverse pharmacokinetic interaction.
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The aim of this study was to create a psychometrically sound short form (PPPM-SF; scored 0‑10) of the Parents' Postoperative Pain Measure (PPPM; scored 0-15). Data from previously published studies were pooled and analyzed to identify the best 10 PPPM items for the short form. Criteria for item selection were: corrected item-total correlation, response distribution, and correlation with a child self-report measure of pain intensity on 2 days after surgery. The sample comprised 264 children aged 7 to 12 years (55.3% male) and their parents. The PPPM-SF correlated r = .98 with the PPPM. Similar internal consistency was found for the PPPM and the PPPM-SF, Cronbach's alpha = .85 for both. Item content was found to cover functional interference (5 items) and pain behavior (5 items). A preliminary indication of validity was provided by significantly lower PPPM-SF scores on the second than the first postoperative day. Consistent with the PPPM, there were no significant sex or age differences in PPPM-SF scores. Validation of the PPPM-SF in independent samples including younger children is a necessary next step. Adaptation of the PPPM to the standard 0-10 metric should enhance its utility for research and clinical practice. ⋯ The Parents' Postoperative Pain Measure-Short Form, scored on the standard 0-10 metric for pain intensity scales, shows promise as a useful observational tool in research and clinical care for postoperative pain in children at home.
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The purpose of this study was to determine the types of nonverbal cues that informal family caregivers use to evaluate pain in loved ones with dementia. Moreover, we sought to determine the extent to which caregiver characteristics such as mood, empathy, and sex are associated with caregiver ratings of patient pain. Long-term care home residents with dementia were filmed while at rest and while they were engaging in discomforting movements (eg, routine transfers). Informal caregivers (ie, family members) observed the videos of their loved ones and rated the amount of pain that the patients were expressing. Contrary to expectations, caregiver ratings of pain were not related to any specific pain behaviours, suggesting that nonverbal pain cues were either disregarded or not noticed by the caregivers. The total number of pain behaviors expressed by patients was related to caregiver ratings of pain intensity only among caregivers who spent relatively more time with the patient each week. Caregiver empathy, mood, sex or other demographic characteristics were not predictive of caregiver ratings. Instead, it appears that caregivers relied on context in making the pain determinations. ⋯ Informal caregivers (ie, family members) of persons with dementia who reside in long-term care facilities do not generally take into account specific pain behaviors when evaluating pain in their loved ones. Interventions designed to help caregivers become more attentive to specific pain cues might be important to pursue.