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Geriatrics > Pain > Flashcards

Pain Flashcards

1
Q

When can APAP be used in elderly patients?

A

OA

Low back pain

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2
Q

APAP is considered first line over what other group?

A

NSAIDs as it has a better safety profile

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3
Q

When should we particularly use caution when using NSAIDs?

A

Low CrCl
Gastropathy
CV disease
Intravascularly depleted states (CHF)

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4
Q

If NSAIDs are used, how should they be used?

A

Short term, at low doses

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5
Q

Which type of NSAIDs have improved GI safety over others?

A

Nonacetylated

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6
Q

What is an alternative to oral agents of NSAIDs?

A

Topical
No long term studies
Potentially less effective than oral agents

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7
Q

What type of NSAID should be used if that patient has gastropathy?

A

COX II inhibitor - but should be used with caution in patients with CV risks

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8
Q

If a long term NSAID therapy is chosen, what do we give with it?

A

Gastroprotective agents (H2RAs, PPIs)

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9
Q

What may be necessary for chronic, severe pain in elderly adults?

A

Opioids

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10
Q

What are the pros of APAP in pain therapy?

A 
Effective for mild-moderate pain
Cheap
Readily available
Antidote available
Limited DDIs
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11
Q

What are the cons of APAP therapy?

A

Potential for confusion with combination products and OTC, liver consideration

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12
Q

What is the max dose of APAP?

A

4g daily

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13
Q

How do we reduce APAP in hepatic insufficiency?

A

50-75%

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14
Q

What are the pros for NSAID therapy?

A

Effective - especially for mild-moderate pain associated with inflammation
Cheap
Availability of topical agents which can limited ADRs

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15
Q

What are the cons for NSAID therapy?

A 
Renal insufficiency
GI bleed
CV events
Edema
Elevated BP
Avoid in CKD and CHF
Avoid chronic use
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16
Q

If a patient is taking ASA and wants to being an NSAID, what should be considered?

A

Adding H2RA/PPI

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17
Q

What can be added to celecoxib therapy for CV protection?

A

ASA

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18
Q

What is the preferred NSAID if the patient has a h/o GI bleed/ulcer?

A

Celecoxib

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19
Q

What is the preferred NSAID overall?

A

Salsalate

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20
Q

What is the non-preferred NSAID?

A

Diclofenac - may have the highest risk of CV effects

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21
Q

What NSAIDs are avoided in pain management in the elderly?

A

Indomethacin

Ketorolac

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22
Q

What are the pros of using opioids in pain of the elderly?

A

Effective for moderate to severe pain of various types
Multiple options for ROA
May be preferred over NSAIDs in stepwise therapy

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23
Q

What are the cons of opioids in pain of the elderly?

A 
Constipation
Respiratory depression
Sedation
Elderly more sensitive to effects
Risk of falls increased
Consideration of organ function
(morphine: hepatic for metabolism, renal elimination; meperidine: renal for toxicity)
Risk for allergies
Potential for addiction
Development of tolerance to effects of time
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24
Q

How should opioids be given in elderly with cognitive impairment?

A

Fixed/schedules dosing

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25
Q

Who should be in charge of dosing and conversions of methadone and fentanyl?

A

Those familiar with pharmacology - may take longer for elderly to reach ss

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26
Q

What are secondary amine TCAs?

A

Desipramine

Nortiptyline

27
Q

What are tertiary amine TCAs?

A

Amitriptyline
Doxepin
Imipramine

28
Q

What are the pros for TCA use for pain in the elderly?

A

Effective agents for depression & sleep
Can be used for other indications (HA)
Indicated for neuropathic pain

29
Q

What are the cons for TCA use for pain in the elderly?

A 
Anticholinergic effect
Sedating
Orthostasis
Caution in CV disease
Increased risk of falls
30
Q

How do we dose TCAs?

A

Cautiously, unlikely to go to max doses

31
Q

What are the preferred TCAs?

A

Secondary amines

32
Q

Which TCAs should be avoided?

A

Tertiaty - higher risk for potent anticholinergic properties, sedating, and potential for orthostatic hypotension

33
Q

What are the pros of SNRIs in pain for the elderly?

A

May be beneficial for neuropathic pain

Can also help with hot flashes

34
Q

What are the cons of SNRIs in pain for the elderly?

A 
May increase BP
May affect cognition
Cause dizziness
Increased risk of falls
DDI (duloxetine)
Increases in HR (venlefaxine)
Caution in renal insufficiency and dose adjust if CrCl < 30 (milnacipran)
35
Q

What is the non preferred agent of SNRIs?

A

Milnacipran - cost, ADEs (nausea, constipation, hot flashes, hyperhidrosis, palpitations, dry mouth, HTN)
Avoid in narrow angle glaucoma

36
Q

What are the SNRIs?

A

Duloxetine
Venlefaxine
Desvenlafaxine
Milnacipran

37
Q

What are the pros of anticonvulsants?

A

Can be helpful for neuropathic and fibromyalgia

38
Q

What are cons of anticonvulsants?

A 
Sedation
Ataxia
Edema
Carful dose titration
Consideration of renal function with dosing - several dose adjustments (may not be ideal for fluctuating renal function)
39
Q

What is the non-preferred anticonvulsant?

A 
Carbamepine
Monitor drug level
Auto inducer
Several DDIs
Serum lab monitoring
40
Q

What labs are monitored with carbamazepine?

A 
CBC
LFTs
Cr
BUN
Electrolytes
41
Q

What are the pros of corticosteroids?

A 
Inflammation related pain (often gout, immune disorders - RA, etc)
Cancer related bone pain
Infiltration related pain
Compression of nerves
HA d/t intracranial pressure
42
Q

What are the cons of corticosteroids?

A

Lots of AEs
Adrenal insufficiency - requires tapering off
ADEs limit use to last line typically
Try to use lowest effective dose for short amounts of time

43
Q

What are corticosteroids AEs?

A 
Glucose elevation
Edema
Increased BP
Leukocytosis
Bone demineralization
Fat redistribution
Psychosis/delirium in elderly
44
Q

What are the pros of muscle relaxants?

A

Slight potential for efficacy in musculoskeletal pain - risks outweigh benefits

45
Q

What are the cons of muscle relaxants?

A

ADEs similar to TCAs
Often ineffective
Concerns for abuse (carisprodol)
May relieve muscle pain but not by relaxing muscles
In true muscle spasms, BZDs or baclofen are better options
Increased risk of falls

46
Q

What are the pros of BZDs?

A

Muscle spasms
Pain related anxiety
Low doses, short term or end of life

47
Q

What are the cons of BZDs?

A 
Elderly have increased sensitivity
Cognitive impairment
Delirium
Falls
Fractures
MVAs
48
Q

What are the pros of calcitonin/bisphosphonates?

A

Bone pain (metasteses)
Potentially second line for neuropathic conditions
Postosteoporotic fracture pain (calcitonin)
Great in those with OP

49
Q

What are the cons of calcitonin/bisphosphonates?

A

Calcitonin (nausea, calcium/phosphate abnormalities)

Complicated administration

50
Q

What are issues with taking bisphosphonates?

A

Attention to renal function

Must be able to sit upright, cost, ONJ, nausea, calcium abnormalities

51
Q

What are the topical analgesics?

A

Lidocaine
Capsaicin
NSAIDs

52
Q

What are the pros of topical analgesics?

A

Local effects
Lidocaine - neuropathic pain, ease of use, low risk of toxicity, no DDIs
Capsaicin - neuropathic pain
NSAIDs - some efficacy, systemic absorption minimal at recommended doses

53
Q

What are cons of topical analgesics?

A 
Skin irritation (esp w/capsaicin)
Confusion with Lidoderm dosing potential problems
Lidoderm CI in liver failure
Capsaicin - burning
54
Q

Should treatment be withheld out of fear of addiction or AEs?

A

No

55
Q

How should dosing be considered in pain?

A

Initiated at low doses, titrated carefully, and monitored closely, but not withheld

56
Q

What medications are elderly patients sensitive to for pain?

A

Opioid analgesics

57
Q

What route of administration is preferred?

A

Oral - ease of dosing and predictable PK parameters

58
Q

Why is IV therapy not preferred in elderly patients?

A

Rapid with a short half-life, but labor and cost intensive

59
Q

Why are SQ and IM not preferred in elderly patients?

A

Wide fluctuations in absorption and do not last as long as oral medications

60
Q

What route may be useful in patients with swallowing difficulties?

A

TD
Rectal
Transmucosal

61
Q

What kind of regimen is recommended for chronic pain with cognitive impairment?

A

Scheduled

62
Q

What type of medications should be used for breakthrough pain?

A

Short acting medications

63
Q

What is the goal of pain therapy?

A

Acceptable QOL

Unrealistic to completely eliminate pain

Geriatrics (15 decks)

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