Pain is the most common reason people seek care in Emergency Departments. In addition to diagnosing the cause of the pain, a major goal of emergency physicians (EPs) is to relieve pain. However, medications that treat pain can have their own set of problems and side effects. The risks of treatment are particularly pronounced in older adults, who are often more sensitive to the sedating effects of medications, and are more prone to side effects such as renal failure. EPs frequently have to find the balance between controlling pain and preventing side effects. Untreated pain has large personal, emotional, and financial costs, and more effective, multi-modal pain management can help reduce the burden that acute and chronic pain place on patients.1 There is evidence that older adults are less likely to receive pain medication in the ED.2,3 The first step to improving, is being aware of the potential tendency to under-treat pain in older adults. Here are 5 tips to help you effectively manage pain in older adults on your next shift.
1. Know the risks of the medications we use and which patients will be at highest risk.
a) IV opioids. Morphine, hydromorphone, and fentanyl are commonly used in the ED to control moderate to severe pain. They come with the risks of sedation and respiratory depression, particularly when combined with other sedating medications such as benzodiazepines. Older adults, particularly those who have lower body mass and who have more underlying frailty, are at risk for respiratory depression with smaller doses than younger, healthier patients.
b) PO opioids: PO versions are less sedating than IV opioids, and are usually used on discharge for patients who will continue to have pain, such as from a fracture. In older adults they can increase the risk of falls4 and also cause constipation, which can lead to abdominal pain and additional ED visits.
c) NSAIDs: Older adults are more prone to renal failure, which can be triggered by NSAIDs. This can occur even with a short course of NSAIDs.5 In terms of long term treatment, GI bleeding and cardiovascular risks are also potential complications. They should certainly be avoided in patients who have known underlying renal failure.
d) Acetaminophen: This is relatively safe in older adults. It is a great go-to, first line med for mild pain, or as an adjunctive for moderate pain.
e) Gabapentin: For neuropathic pain, gabapentin is great, and has few side effects. It can also be used in combination with morphine, and can help reduce the dose of each medication needed while improving pain scores.6
2. Be attuned to signs of pain, and ask if the patient needs more treatment.
If the patient is able to answer questions then ask if they are in pain and if they want pain medications. A rookie mistake I have made in the past is asking a patient if they are in pain, and then assuming that they want medications. Some patients will opt to not take any medications while the pain is manageable. So asking specifically if they want medication is helpful and saves nursing time so that they do not have to pull the med and then restock it. When reassessing, it also more helpful to ask whether they want more pain medications, rather than to just ask if they still have pain. Most pain medications will not completely remove their pain. The goal is to reduce it to a level that is tolerable, without causing dangerous side effects.
For patients who are nonverbal or who have cognitive impairment, assessing pain can be more challenging than simply asking the patient. Most hospitals use numeric 1-10 pain scales to help assess a patient’s need for medications. However, these scales can fail patients who have cognitive impairments, or have difficulties expressing themselves due to aphasia, prior strokes, or who are acutely ill and delirious. There are scales that have been created to assess pain in patients with cognitive impairment using clues such as patient posturing, facial expressions, negative vocalizations, and vital signs.7 However, for general practice, if the patient appears uncomfortable, is moaning, has unexplained tachycardia, is grimacing, or curled up in a ball, those can all be signs of pain! Family members and caregivers who are used to the patient’s baseline can also help give input as to whether the patient appears uncomfortable or if their positioning and facial expression is at their baseline. If nonverbal patients appear uncomfortable, it is important to treat their pain. Ongoing pain can contribute to delirium as well as suffering.
3. Start low and go slow.
For patients with mild pain, try non-opioid medications. Try acetaminophen first, or in very healthy patients, you can consider an NSAID. For moderate or severe pain, opioids are appropriate, but consider a lower dose than younger adults, and place patients on a monitor to pick up any respiratory depression or hypoxia. While in younger, healthier adults, a typical starting dose of morphine is 4-8 mg IV, in frail or very elderly adults, 2-4 mg IV may be more appropriate. However it is very important to reassess frequently! If 2 mg of morphine is not providing adequate pain relief 15 minutes after administration, then another 2 mg can be given. This concept also applies to procedural sedation in older adults.
4. Try alternative pain control methods and involve other specialties.
- Topicals: Topical NSAIDs are useful for mild joint aches (particularly knee pain) from osteoarthritis, with little systemic absorption. Topical lidocaine, such as a lidocaine patch, is helpful and has a good side-effect profile for musculoskeletal back pain, or for post-herpetic neuralgia.
- Regional Anesthesia: Femoral nerve blocks and fascia iliaca compartment blocks are commonly used to reduce pain associated with hip and femoral fractures, and reduce the risks associated with IV opioid administration. Though femoral nerve blocks are the most frequent block used8, there are many different nerve blocks that can be safely performed in the ED, including blocks or regional anesthesia for joint dislocations, upper extremity and lower extremity fractures, rib fractures and facial or dental injuries or lacerations. These can provide both pain control and anesthesia to allow repair of lacerations or reductions.9–12
- Outpatient referral for physical therapy, or an evaluation by physical medicine and rehab for certain musculoskeletal pains could help the patient long-term, to provide therapy to prevent or help alleviate the pain when it recurs. For patients with chronic pain, a pain clinic referral may help them get the regular care and monitoring they need, and prevent the need for future ED visits.
5. Have a safe discharge plan.
It is important to carefully explain the new medications that you are prescribing, and to write out your instructions for the patient or their caregiver to review later. For example, for a patient with a fracture explain the plan for them to take scheduled acetaminophen and then oxycodone if needed every 8 hours. Avoid using medical terms like “PRN”. Explain that the medications can make them dizzy or sleepy which could put them at risk for falls. Finally, explain the need for Senna and Colace for constipation. Without a good explanation of the discharge plan, patients may simply add their PRN opioid to their scheduled box of medications, and end up taking it even if they don’t need it.
It is also a good idea to have an early follow up plan. If you are able to make an appointment for the patient to see their regular physician, that is best. If not, then encourage them to do so. It is important to have early follow up to reassess the original cause of the pain, as well as the effectiveness of the pain medication, and any side effects that may have arisen.