Page 285 Guide to Pain Management in Low-Resource Settings

Pain in Old Age and Dementia 273

iii) Write down your orders in big letters for pa- all dose increases should be done slowly and in small
tients with impaired vision. stepwise increments.
iv) Always provide patients with written infor-
mation on what to take, when to take it, and Pharmacotherapy in older patients
eventually, what side eff ects to expect.
v) Avoid mentally overloading the patient; gen- What special considerations are
erally not more than one major topic should there for analgesic pharmacotherapy
be discussed per consultation, and directions in the elderly patient?
should be repeated several times. NSAIDs have a variety of pharmacological interac-
vi) Anticipate pain, and treat accordingly. tions. One of the most relevant is the potential increase
vii) Use nonpharmacological techniques where of gastrointestinal side eff ects with the comedication of
applicable, such as positioning, counterirrita- steroids. Also, blood sugar reduction is increased if the
tion (using ice, external alcoholic herbal lo- patient is taking oral antidiabetics. Other interactions
tions, etc.). are the reduction of the comedication’s eff ect, e.g., with
viii) Use reassurance for anxiety-associated be- diuretics (reduced urine output) or ACE (angiotensin-
havior. converting enzyme) inhibitors (less blood pressure re-
ix) Don’t use “cookbook dosing schemes,” but in- duction). Other interactions with unexpected serum lev-
stead titrate doses individually from very low el changes might result from concomitant therapy with
initial doses. NSAIDs and alcohol, beta blockers, methotrexate, selec-
x) For general assessment of the patient, fi tness is tive serotonin reuptake inhibitors (SSRIs), or quinine.
a better guideline than chronological age.
xi) Pain management in general may be accom- Why are NSAIDs of special importance
plished in the outpatient setting; inpatient regarding unwanted eff ects?
treatment for the sole reason of pain control is Elderly patients may experience a typical complication
indicated only in selected patients. spiral with the prescription of long-term NSAID medi-
2) Assessment cation. For example, painful arthritis is often the prima-
i) Ask the patient, who might not reveal infor- ry cause for prescribing a NSAID. Longer intake (more
mation spontaneously for certain reasons. than 5 days of regular intake), higher doses, and con-
ii) For patients with impaired communication, comitant steroid medication may cause gastrointestinal
one of the suggested scores is the BESD (Beur- ulcers. Repetitive ulcer bleeding then may be the cause
teilung von Schmerz bei Demenz [Assess- for anemia. In an older patient with reduced cardiac
ment of pain in dementia]). For fi ve observa- function, anemia may cause cardiac insuffi ciency, which
tions, 0–2 points may be allocated depending is then followed by diuretics as therapy. Although that
on their nonexistence, medium presence, or medication is reasonable in normal instances, the di-
strong presence. Th e observations are: uretics might cause renal dysfunction and consequently
a) Breathing rate (normal/high/hectic) renal failure!
b) Vocalizations (none/moaning/crying)
Can opioids have unwanted eff ects, too?
c) Facial expression (smiling, anxious, gri-
macing) Opioids may also interact with other medications.
d) Body position (relaxed/agitated/tonic) Watch out especially for all drugs that have a CYP2D6-
e) Consolation (not necessary, possible, im- inhibiting eff ect, and expect higher than usual plasma
possible) levels, for example cimetidine, quinidine, paroxetine,
iii) Starting with a total of 5 points, this scoring fl uoxetine, methadone, antihistaminic drugs, and halo-
system forces the therapist to start analgesic peridol. Other important direct interactions for mor-
therapy. phine with other pharmacotherapies are ranitidine and
3) Pharmacotherapy. Th e basic principle of phar- rifampicin; for fentanyl ketoconazole and clarithromy-
macotherapy in the elderly patient is “start low and go cin; for methadone cimetidine, quinidine, paroxetine,
slow,” meaning that initial doses of all analgesics should fl uoxetine, antihistamines, and haloperidol; and for tra-
be reduced compared with normal adult doses and that madol quinine and SSRIs.