Special Concerns in Caring for the Elderly AdultPain ManagementViolence and Elder Mistreatment

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Scenario….• S. T. is a 68 year old female who comes alone to your E.R..• She complains of shortness of breath.• Vitals: Ht. 65” Wt. 101 lbs BP 155/84 Pulse 88• When electrodes are placed for an EKG, you notice bruising

across her chest.• Her son comes in and states, “You fell down the stairs, again,

didn’t you, Mom?”

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What is pain?• Pain is an unpleasant feeling often caused by noxious or

injurious stimuli• Pain usually prompts the person to withdraw from the cause

of the pain and avoid it in the future• Most pain resolves promptly once the cause is removed • Other types of pain continue (chronic)• At times pain occurs without any recognizable cause• In the United States, pain complaints prompt the majority of

all doctor visits• Pain is costly• Pain can negatively affect a person's quality of life• Psychological and social factors can affect the nature of pain 3

Persistent pain in the elderly is associated with…• Functional impairment • Falls• Slow rehabilitation• Depression• Anxiety• Decreased socialization• Sleep disturbance• Increased healthcare utilization and costs• The Joint Commission on Accreditation of Healthcare

Organizations has mandated pain screening noting pain “the fifth vital sign.”

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Importance in the care of the elderly• Painful conditions are common in this population• Undertreatment is common• Patients with dementia may not express pain effectively• Fear of “addiction” is common• Some believe unrelieved pain is to be expected• Lack of routine pain assessment• Ineffective methods of assessment

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Duration of pain• Acute pain—resolves quickly• Chronic pain definition is arbitrary…• More than 30 days• 3 months• 6 months

• Some say the transition from acute to chronic pain occurs at 12 months

• Chronic pain is sometimes classified as:• Cancer pain, or,• Benign pain 6

Types of pain

Nocioceptive (tissue

trauma)

Neuropathic (damage to

CNS)

Visceral (internal organs)

Diabetic neuropathy

Somatic (muscles &

joints)

Post-herpetic neuralgia 7

Nocioceptive pain• Nocioceptors are nerve cell endings that initiate the sensation

of pain• They respond to stimuli that threaten to cause harm to the

individual• Examples are • Heat• Cold• Crushing or tearing• Chemical injury

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Neuropathic• Pain caused by injury to the nervous system itself• Described as • Burning• Tingling• Electrical• Stabbing• Pins and needles

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Phantom pain

• Pain experience a part of the body that is no longer• Type of neuropathic pain• Common in amputee patients

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Psychogenic pain• Pain affected by • Mental,• Emotional,• Behavioral factors

• Sometimes include specific situations with no other identifiable cause…• Headache• Back pain• Stomach pain

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Breakthrough pain• Pain that “breaks through” a patient’s normal pain

management dosing• Comes on suddenly• Common in patients managed for cancer pain• Alternating pain medicine dosing sometimes helpful

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Incident pain• Episodic increase in pain intensity• Can come from a specific activity• Or, not related to any activity• Arthritic joint• Bumping an injured site

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Acute pain in older adults• Similar to acute pain in other populations• Also due to exacerbations of chronic conditions• Situations to which they are more at risk:• UTI• Decubitus ulcers• Pneumonia• Constipation • Injury due to diminished protective mechanisms

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Chronic pain in older adults• 1 in 5 patients age 65 or older• Generally lasting >3-6 months• All are candidates for pharmacological therapy• Exacerbated by depression• Can create a vicious cycle

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Pain causes among older adults• Osteoarthritis and rheumatoid arthritis• Spinal stenosis• Peripheral neuropathy• Post-herpetic neuralgia• Fibromyalgia• GERD• Peripheral vascular disease• Headache• Post-surgical pain• Pressure ulcers• Angina, cardiac disease• Cancer pain, pain of treatment

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Process of hyperalgesia (increased sensitivity to pain)

Pain is left untreated

Nociceptors more responsive

Increased sensitivity to pain

Exaggerated pain response

Further complaints may be ignored17

Assessing pain in the older adult

• Pain intensity (0-10)• Pain frequency• Pain location (use the “one finger” rule)• Duration• What makes it better?• What makes it worse?• What are the effects on his or her functional level?• Continue to assess until acceptable level of relief has been

achieved• Assessment must be documented to be complete

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Special cases…the patient with dementia• Need to rely on cues other than verbal communication,

including…• Facial expression• Vocalizations• Body movements• Change in person-person interaction• Change in activity patterns• Mental status changes

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Pain management plans• Include both acute and chronic pain• Include both pharmacological and nonpharmacological

interventions• Must be individualized• Must be titrated, i.e., provided based on the level of pain

reported or the level of pain assessed if the patient is nonverbal

• Start with smaller doses to avoid toxicity• Consider oral route first• Often involves “rational polypharmacy”• 2 or more drugs in combination with• Complementary therapy 20

Pharmacological management

Analgesics

Non-opioids Opioids

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Opioid use in the older adult• Great efficacy in moderate to severe pain• No maximum dose• Can be used for long periods of time• Minimal organ damage

• Some are inappropriate for the elderly adult: Meperidine—confusion, seizures Propoxyphene—delirium, ataxia, dizziness (withdrawn) 22

Adverse side effects of opioids• Constipation

• Sedation

• Respiratory depression

• Nausea and vomiting

• Myoclonus

• Pruritis 23

Considerations in opioid use• Titrate slowly• Bowel regimen to prevent constipation• Watch for signs of sedation and protect patient• Monitor for respiratory depression, provide O2 if necessary• Antiemetics for nausea/vomiting• Use antihistamines cautiously for pruritis

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Definition of elder abuse• The physical or psychologic mistreatment, neglect, or financial

exploitation of the elderly.”• Several types of abuse are common• Each type may be intentional or unintentional• Perpetrators are usually spouses or adult children• May be other family members• Paid or informal caregivers

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Physical abuse• “The use of force that results in physical or psychological

injury.”• Includes striking, shoving, shaking, beating, restraining and

improper feeding• May include sexual assault, i.e., any form of sexual intimacy without consent or by force or threat of force

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Psychologic abuse• The use of words, acts, other means that cause emotional

stress or anguish• Includes threats (e.g. of institutionalization), insults and harsh

commands• Remaining silent• Ignoring the person• Infantilization: encouraging the victim to become dependent on the abuser

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Neglect• Failing to provide essentials• Food• Medicine• Personal care

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Financial abuse• The exploitation of or inattention to a person’s possessions or

funds• Includes swindling• Pressuring a person to distribute assets• Managing a person’s money irresponsibly

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Healthcare fraud and abuse• Duplicate billings for the same medical service or device• Evidence of overmedication or undermedication• Evidence of inadequate care when bills are paid in full• Problems with a care facility• Poorly trained, poorly paid or insufficient staff• Crowding• Inadequate responses to questions about care

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Epidemiology of elder abuse• True incidence is unclear• Appears to be a growing public problem in the USA• One large study showed 3.2% of individuals ≥ 65 years were

victims of physical abuse, psychologic abuse or neglect• Study did not include financial abuse

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Risk factors for elder abuse (1)• Chronic disease and or functional impairment of the victim• The elder person’s ability to escape, seek help and defend himself

is reduced• Social isolation of the victim• Abuse of isolated persons is less likely to be detected and stopped

• Cognitive impairment• Persons with dementia may act aggressively and disruptively, precipitating abuse 32

Risk factors for elder abuse (2)• Substance abuse• Alcohol or drug abuse

• Psychiatric disorder• Schizophrenia, other psychoses• Patients discharged from an inpatient facility may return to their elder parents’ home for care• These younger patients may become violent at once at home

• History of violence• History of violence in a relationship and outside the family may

predict abuse• Violence is a learned response to life challenges

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Risk factors for elder abuse (3)• Dependence of abuser on victim• Financial support, housing, emotional support• Family member’s attempts to obtain resources from elderly

person can result in abuse• Dependence can produce resentment

• Stress affecting abuser• Chronic financial problems• Death in the family• Responsibilities of caregiving

• Shared living arrangements• Opportunities for tension and conflict are greater

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Difficulty of diagnosis• Many signs are subtle• Victim often unwilling or unable to discuss the abuse• Shame• Fear of retaliation• Desire to protect the abuser

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Failure of healthcare• “Ageist” response from nurses, doctors, others• Dismiss complaints of abuse as:• Confusion• Paranoia• Dementia

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Social isolation and identification of abuse• Abuse tends to increase the isolation• Abuse limits the victim’s access to the outside world• Denies visitors• Refuses telephone calls

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Obtaining the history• If abuse suspected, client should be interviewed alone for at

least part of the time• Others may be interviewed separately• Include general questions about feelings of safety• If offered, note nature, frequency and severity of abusive

events• “Do you have family or friends who are willing to nurture, listen, and assist you?”• (More practicable) “Do you feel safe at home?”

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Interview with family members

• Avoid confrontation• Explore if caregiving responsibilities are burdensome • Acknowledge the caregiver’s difficult role• Are there any recent stressful events?• Interview patient, family member separately

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Situations suggesting elder abuse (1)

• When there is a delay between the injury or illness and the seeking of medical attention

• When the accounts of the patient and the caregiver do not agree

• When the severity of the injury does not fit the explanation given by the caregiver

• When the explanation of the patient or caregiver is implausible or vague• When visits to the emergency department for chronic disease are frequent despite appropriate care and adequate resources

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Situations suggesting elder abuse (2)

• When a functionally impaired patient presents for care without a designated caregiver in attendance

• When laboratory findings are inconsistent with the history• When the caregiver is reluctant to accept home health care or

to leave the elderly person alone with a health care practitioner

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Signs of elder abuse (1)• Behavior—withdrawal by the patient infantilization of the

patient by caregiver; caregiver insists on giving history• General appearance—poor hygiene, inappropriate dress• Skin/mucous membranes—signs of dehydration, multiple skin

lesions, bruises, pressure ulcers, deficient care for skin problems

• Head and neck—traumatic alopecia

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Signs of elder abuse (2)• Trunk—bruises, welts (shapes may suggest implement)• Genitourinary area—rectal bleeding, vaginal bleeding,

pressure sores, infestations• Extremities—wrist or ankle lesions suggesting restraints or

immersion to burn• Musculoskeletal—occult fracture, pain, gait disturbances• Mental and emotional health—depression, anxiety

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Roles of nursing and social work

• Members of interdisciplinary team• May be appointed as coordinator to ensure pertinent data are

recorded correctly• Relevant parties are contacted and informed• Necessary care is available 24 hours per day• Inservice education on elder abuse

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Reporting elder abuse• Reporting of suspected or confirmed abuse is mandatory in all

states if abuse occurs in an institution• Mandatory in most states if it occurs at home• Adult protective services• Burden of proof does not rest on the reporter• Reporting suspected abuse without claim of abuse• May be anonymous

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Formal evaluation• What is your nursing diagnosis for S. T.?• What is your desired outcome?• What steps will you take?• What are your appropriate interventions?

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