Published by the Missouri Association of Long-Term
Multifacility Medical Director, St. Louis MO
Care Physicians and the Pain is common at the end mood disturbances can increase and Department of life, due to the prevalence of compound untreated pain. Dimin- of Family & arthritis, circulatory disorders, ished ambulatory status from pain Community immobility, cancer, neuropathy, and can result in decreased socialization Medicine similar age-related processes. and increased healthcare utilization. Functional impairment and de- Many Facility Quality Indicators University of creased quality of life may occur in are affected by chronic pain: Missouri- 45 to 80% of patients.1 Unfortu- Columbia nately, many elders, families and
s Prevalence of behavioral symp- staff accept pain as an inevitable toms affecting others of Medicine part of age and disease, and do not
s Prevalence of symptoms of accurately report it. Some residents depression may not report pain for fear of
s Prevalence of bladder or bowel being labeled as complainers. Fear incontinence of addiction and accelerated decline
s Prevalence of weight loss may hinder acceptance of pain Minimum Staffing
s Prevalence of bedfast residents Levels Update medication. Some may see com-
s Decline in late loss ADLs plaints of pain as attention seeking
s Prevalence of antipsychotic use in and manipulation. Others mistak-
·Tougher Surveys the absence of psychotic related enly believe geriatric residents don’t conditions sense pain as well as younger
s Prevalence of anti-anxiety/
·Pain Assessment & persons. Mood disorders and hypnotic use Basic Management dementia may cause pain to present
s Relevance of hypnotic use more in non-classic manners, making than twice in the last week symptom reporting and assessment
s Prevalence of daily restraint use difficult. Staff turnover and lack of
s Prevalence of little or no activity training may hinder recognition
s Prevalence of skin ulcers and appropriate treatment of pain. Some staff feel they don’t have the Pain can be addressed only time to manage pain well. through a stepwise multidisciplinary approach. Assessment, intervention, Untreated pain can lead to and reevaluation are all needed to many unintended consequences. manage pain for the individual Depression, agitation, and other resident. General Assessment of pain in elderly residents. Pain can be quanti- Pain may need to be indirectly fied by several measures. observed by behaviors (de- RNs and LPNs, in addition scriptive indicators) such as:2 to MDs, should ask resi- dents to describe their pain, Furrowed brow Eyes shut tight keeping these descriptors in Grimacing Yelling out Weight loss Intensity. A standardized pain Published quarterly by the scale should be used to ensure Teeth clenching Eyes kept wide open Missouri Association of Long- consistency. Simple verbal Warding off care Term Care Physicians and the scales (mild, moderate, severe) Guarding body parts Depatment of Family and may not be as helpful as Loss of appetite Sleep disturbance Community Medicine at the combined visual analog- Withdrawal University of Missouri- numeric scales. Pain scales Repetitive facial movements Columbia School of Medicine, should be easily accessible. Respective body movement Sudden change in behavior Columbia MO 65212. Phone Facial expression and number Sudden social changes (573) 882-4991. Fax (573) scales can be used to measure Sudden change in function 882=9096. pain by all team members. Physical or verbal agitation Assessments can easily be made Repetitive verbal behaviors and recorded during medication If there is a question passes and vital signs. Certain Steven Zweig, MD of whether pain is present in a residents may need individual- Editorial Board: resident, a careful history of ized assessments (e.g., dementia David Mehr, MD how pain was shown in the Larry Lawhorne, MD patients, or those who are vision past should be sought from Michael Hosokawa, EdD impaired). friends and family. Changes in Marilyn Rantz, RN, PhD Managing Editor: Quality. Ask the patient what resident status as shown above Susan Kauffman the pain is like (e.g., burning, may be indicators for a trial of aching, sharp, etc.), and whether scheduled (not prn) pain Missouri Association of Long- it changes with time (e.g., new/ management. This could be Term Care Physicians old, frequency/duration). for a limited time period, and President: Charles Crecelius, MD, PhD would require frequent reas- Location. Determine the specific sessment of descriptive or generalized location of all Vice-President: indicators. The patient and David Cravens, MD, MSPH sites, and whether it radiates. family should be involved and Columbia in agreement with the pain/ Secretary-Treasurer: Aggravating and Precipitating Cary Bisbey, DO Factors. Ask what makes the comfort care plan. Springfield pain better or worse. Time of Board of Directors: day, movement, position; use of Jeffrey Kerr, DO, Rolla heat/cold, medications, massage MDS Version 2.0 and Pos- Babu Dandamudi, MD, St Louis are all examples. Paul Schoephoerster, MD, Fayette sible Pain Indicators Steven Zweig, MD, Columbia The Minimum Data Effect. Ask both how effective Set has several components current treatments are, and the which may directly or indi- effect the pain has on the rectly measure pain. These resident’s life. could be helpful in finding or Atypical Presentations of tracking pain in nursing home residents.3 Many residents don’t Sleep cycle (E1) show pain in normal ways. Change in mood (E3) Complaints, mobility, medica- Sad, apathetic, anxious appearance tions used, sleep and vital Resisting care (E4) signs aren’t reliable indicators Change in behavior (E5) Long-Term Links Page 2 Spring 2002 Functional change in range of motion (G9) worse with pressure or move- Footnotes Change in ADL function (G9) ment. Examples include Pain symptoms (J2) 1. Stein WM, Ferrell BA. Pain in the Mouth pain (K1) cancer, metastatic to bone, nursing home. Clin Geriatr Med Oral status (L1) fractures, and very severe 1996; 12(3):601-13. Other skin problems (M4) 2. Hurley ACVolicer BJ, Hanrahan PA, Range of motion restorative care osteoporosis. NSAIDS and Houde S, Volicer L. Assessment of opiates work well. Loss of sense of initiative/ discomfort in advanced Alzheimer involvement (F1) patients. Res in Nurs & Health Any disease associated with chronic Neuropathic. This non-nocicep- 1992; 15:369-77. pain (I1) tive pain results from injury to 3. Chronic Pain Management in the Pain site (J3) Long-Term Care Setting, Clinical Weight loss (K3) central or peripheral nerves. Skin lesions (M1) Practice Guideline 1999. American Pain is perceived (nerves Medical Directors Association. Foot problems (M6) discharge) without a normal (nociceptive) stimulus. Pain is Types of Pain normally described as burn- Pain can be divided ing, aching, stabbing, tingling, into two types -- nociceptive pins and needles, or shock-like. and neuropathic. Each has Neuropathic pain may show characteristics which help hyperesthesia (hypersensitiv- guide therapy. Nociceptive HHS Secretary Tommy ity to any stimulus), allodynia pain can be subdivided into Thompson announced a new (pain to non-painful stimulus), three types -- somatic, visceral, proposal in April to improve or sensitization (surrounding and bone. the quality of care for nursing tissue becomes sensitive). home residents by allowing for Examples include diabetic Somatic. This nociceptive pain trained assistants to help neuropathy, post-stroke pain, comes from skin, muscle and residents eat and drink. phantom limb pain after connective tissue. It tends to “Allowing trained feeding amputation, and cancer be well-localized, sharp to dull, assistants will mean better metastatic to nerve plexus. may be constant, achy or care for residents, especially at Simpler pain medications and intermittent, and tends to be mealtimes, which can be the opiates often don’t work well. worse with any movement or busiest times in nursing touch. Examples include homes,” Secretary Thompson See Insert for treat- sprains, headaches, cuts, and said. “Trained feeding assis- ment principles and sugges- most arthritic pains. Most tants will free nurses and aides pain medications will help. to focus on residents’ other health care needs. The result Ancillary Methods Visceral. This nociceptive pain will be that residents will Environmental sup- comes from internal organs. It receive better nutrition and port and a positive, focused tends to be poorly localized care.” attitude toward pain relief and even referred to other sites, shouldn’t be underestimated. more constant and dull, and Under the CMS Music and other relaxation/ less affected by ovement or proposal, individuals would be distraction techniques can be position. Examples include required to complete a state- helpful. Local balms, thermal appendicitis, gastritis or ulcer approved course to qualify as (ice and heat) and massage pain, and angina. Stronger trained feeding assistants. therapy can be helpful for pain medications in general “Feeding residents is often a arthritic and musculoskeletal will be needed to treat these slow process and competes pain. Occupational therapy with more complex tasks, such can help with difficult position- as bathing, toileting and ing, and physical therapy with Bone. This nociceptive pain dressing changes, as well as mobility and safety issues. comes from very sensitive urgent medical care,” CMS Setting realistic goals and nerve fibers on the outer administrator Tom Scully said. providing psychologic and surface of bone. It tends to be psychiatric services as needed
Ifrom Missouri Association of constant, more intense, and should not be forgotten. Homes for the Aging Hotline Long -Term Links Page 3 Spring 2002
President, Missouri Association of Long-Term Care Physicians
I Surveys are Tougher and Families are Finding Out
Your instincts are potential problems with both facilities having four or more correct if you feel surveyors sites. Much of the data may actual harm violations in the are handing out more deficien- be old or incomplete, and not last four years. Fort Wayne cies. The average number of indicative of current efforts IN and Detroit MI were deficiencies per nursing home and performance. Survey data second and third. Twenty-two survey jumped from 2.7 in is slow to be updated, and cities made the worst cities list, 1996 to 6.3 in 2001. In the complaint surveys are not defined as 40% or more actual last 12 months, 32% of nurs- considered by the CMS harm violations in the same ing homes had at least one website. HealthGrades’ four-year period. Nashville deficiency involving actual rankings used weighting TN was the best, with 57% of harm to a resident. Fifteen factors on a variety of selected homes having no actual harm percent of nursing homes had indicators to arrive at general violations in four years. Baton more than five formal com- groups (top 30%, next 40%, Rouge LA and Jacksonville FL plaints filed in the last year, etc.) Importantly, neither were numbers 2 and 3. resulting in 9% more com- completely address surveyer plaint-based surveys. variability, case-mix consider- While consumers are ations, plans of correction entitled to information to help Families can easily outcomes, or historical pat- them select a home for their access not only general infor- loved one, it isn’t clear that an mation such as that above, but answer has been found. Physi- also facility-specific informa- Barring these consid- cians should know their tion. Two websites can supply erable concerns, the Health- facilities’ “report cards” and be survey-related data that may Grade website recently made able to respond meaningfully be interesting, but perhaps not widespread news coverage to current and prospective truly informative. The gov- when it listed the best and family concerns. Knowledge ernment offers Nursing Home worst cities for nursing home of the population served, Compare through CMS’s care. They used four years of quality indicator coneerns and website (www.medicare.gov). survey results in cities with 20 interventions, current deficien- HealthGrades Inc. offers a or more nursing homes, and cies, implementation of plans proposed “report card” through calculated the percentage of of corrections and trends in its website, listing both facil- violations involving actual survey results and quality ity- and city-specific data harm as a marker of poor indicators can better detail (general ratings free, complete care. Wichita KS topped the your facilities’ quality than a reports for a fee, at www. “worst” list, with 80% of simple grading system. healthgrades.com). There are ment of Health and Human The long-awaited contained the major points. Services Secretary Tommy second half of the Department The report does not support Thompson noted that other of Health and Human Services mandatory staffing levels. issues such as the importance (HHS) report on minimum This is in good part because of training and management, staffing levels in nursing of the high costs of funding staff shortages, and staff mix homes, ordered by Congress in the increased staff proposed, make using the suggested 1990, was released on March estimated at $7.6 billion a staffing ratios “improper” as 19, 2002. The draft version year, or 8% over current costs, was leaked a month earlier and with no mechanisms for Continued at bottom of Page 5 --> providing this money. Depart- Long-Term Links Page 4 Spring 2002 AMDA’s presence was ing clinical situations that are continues to work on this heard on a recent CMS confer- beyond their scope of practice. issue, he believes that surveyor ence call for the Skilled Nurs- Moreover,” continued Dr. guidance is reasonable. “CMS ing Facility/Long Term Care Isaacs, “patients in long-term does not prohibit the states’ Open Door Forum. Fred care are complex, multi- use of physicians as consult- Isaacs, MD, CMD, past presi- diseased people, and the ants to the survey process,” dent of the Michigan Medical decision-making that goes into said Mr. Pelovitz. “In addition, Directors Association, ex- treating these patients is very CMS has made it a priority for pressed concern that most complex.” their regional offices to have states do not have physicians physicians on staff.” involved in the survey process. Steve Pelovitz, CMS “Since many surveyors are Director of Survey and
I from AMDA’s nurses and pharmacists,” Dr. Certification Group, responded Health Policy Advisor Newsletter, Isaacs said, “they are evaluat- by saying that while CMS March 2002 Staffing Levels Update (continued) standards. However, the below HHS suggested levels. The National Citizens report does recommend a new Coalition for Nursing Home provider requirement to The HHS report did Reform (NCCNHR) has electronically submit accurate find a “pattern of incremental already stated that it will press data on the number of nursing benefits” of higher staffing to a Congress to adopt minimum staff employed. This would be certain point, beyond which a staffing levels, and has almost shared with consumers, who threshold of little further 90,000 signatures from 49 could use nursing home benefit was seen. These states to support the cause. staffing levels as part of their thresholds varied on the The staffing crisis is well selection criteria. In theory facility case mix, and are: recognized by all professional Nursing aides: this would promote increased groups. The American Health 2.4-2.8 hrs/resident/day staffing by public demand and Care Association has noted Licensed staff: market forces. Currently, the staffing problems are indica- 1.15-1.3/hrs/resident/day only federal staffing standard Registered nurses: tive of chronic underfunding for nursing facilities that .55-.75 hrs/resident/day of Medicaid and Medicare. participate in Medicare or The American Medical Direc- Medicaid is rather subjective: According to the tors Association acknowledges to provide licensed nursing report, fewer than one of 10 the need for more and better- coverage 24/7 (including an nursing homes currently meet supported staff, but has stated RN for eight consecutive hours these standards. While no it could not support simplistic a day) and to have sufficient mandatory levels have been levels derived only on staff-to- nurses and staff to ensure that recommended, the report does resident ratios, not taking into residents attain their highest call for further study of the account resident acuity. Unfor- practicable level of well-being. costs and quality improvment tunately, what could be ideal While most states have some potential of the proposed levels may fall victim to stark form of minimum levels, the staffing levels. financial, political and majority are significantly workforce realities. Long-Term Links Page 5 Spring 2002
Pain Assessment and Basic Management by CNAs
Everyone experiences Other misconceptions include:
s Loss of ADLs pain differently. Because it
s Sadness, anxiety or depression cannot be measured like blood
s Signs of pain will be obvious.
s Difficulty in walking or transfer- pressure or temperature, we Some people mistakenly believe ring; can become bedbound must rely on the patient to tell pain will manifest itself in us where the pain is and what typical signs like moaning, a What Can Cause Pain? it’s like. Severe pain to one change in vital signs, or lack of Illness or disease. Often person may feel like almost appetite. But people can adapt when we think of pain, we even to severe pain, and show no nothing to another. Health- think of cancer, but almost care workers sometimes take it any disease can cause pain. upon themselves to determine Even if the healthcare worker People with arthritis, decubitus if the patient is telling the doesn’t believe what the resident ulcers, heart disease, stroke, truth. But according to pain is saying about their pain, try to pneumonia (and the list goes experts, the patient’s self set aside your personal beliefs on!) all can have pain. report of pain is the single and accept the report of pain. most reliable indicator. How- Immobility can cause ever, some residents and
s Anxiety always makes pain pain, and pain can cause families simply accept pain as worse. Anxiety and pain often go immobility. If it hurts when a together, but it is not proven that an inevitable part of disease, person moves, of course they anxiety causes pain. Pain often and don’t report it regularly. don’t want to move. If they does cause anxiety. don’t move, they are at high Everyone’s role is
s Pain is a normal part of aging. risk for contractures and important in helping residents Often residents themselves decubitus ulcers, which can in pain. Caregivers spend believe this. They may be afraid cause more pain. more time with the resident to say they’re in pain because than anyone else. Doctors and they think they may become External factors. This charge nurses may have more addicted to pain medications, or could be as simple as an control over pain medications, because they want to be “brave” undergarment that is fastened but they don’t see residents as and “not bother the staff.” too tight or a wheelchair leg often. Sometimes a patient can rest with a rough edge. Look appear pain-free when they What Happens if Pain Isn’t around the resident for easily are still, but caregivers see the Properly Treated? corrected things that could pain when they help them There are many effects cause pain. Also, a room that move or do ADLs, or patients of poorly treated pain. Not is too cold or hot, a bright may share information with only can it make the patient light, or loud noises can all caregivers during personal miserable, but it can make make pain harder to tolerate. care. It is especially important their care more difficult. It can that CNAs watch for signs of certainly affect Facility Quality Emotional factors. Pain pain and report them to the Indicators and survey findings does increase anxiety, and charge nurse. anxiety may increase pain. Other effects can be: While treating anxiety helps, it
s Poor appetite and weight loss Misconceptions shouldn’t be treated only with Sleep disturbance A common misconcep- medicines. A warm bath, soft Withdrawal from social activities, tion about pain is that the or even talking music, hand-holding, hugs, and person caring for the patient is
s Development of skin ulcers just listening all can decrease the best judge of that person’s
s More likely to become inconti- anxiety. Letting the resident pain. It is the patient who know you believe their pain is best knows their own pain.
s More likely to use restraints real and that you want to help is also extremely important Long-Term Links Page 6 Spring 2002 and helpful. Facility staff should rigidity, rubbing, holding body consider some guidelines when Assessing Pain assessing those with dementia Vocalizations: moaning, repeated or communication problems: phrases, yelling, loud breathing General. Social: sleepless, agitated, Everyone in
s Ask the resident if he/she is having combative, crying, trying to get the nursing home is respon- pain. You might be surprised at attention, refusal to go to activi- sible for finding and describing what he understands and the ties, loss of appetite. pain in residents. Doctors, response you get. Residents with significant cognitive impairment nurses, aides, and even admin- can often understand a simple What Everyone Can Do for istrators, dietary staff and question about pain and respond housekeepers should know the to it. You might want to use a While it is the role of basics of identifying pain. It term other than “pain.” Try hurt, the doctor, nurse, therapist and helps to assess pain if you can discomfort, uncomfortable, aching or family to determine pain soreness. treatment (medicine, whirl- pools, braces, ultrasound or
s What seems to bring on the pain.
s Consider the disease condition and massages), there are very Movement, position, meals, procedures that might cause pain. A important things that anyone family visits, urination or bowel skin tear from a wheelchair’s movements are all possibilities. rough edge, a fractured hip, an elbow bruise from a fall, daily
s Show that you care. A kind, Where is the pain and what does physical therapy goals for ambu- reassuring word and a soft touch go a it feel like? Is it dull, achy, lation would be reasons to medi- long way. sharp, or stabbing? Is it constant cate for pain. If you were the or occasional? How many areas resident, would you want
s Tell the resident what you are going hurt and exactly where are they? something for pain? to do, even if they don’t understand. Talk to, not around the resident.
s What makes the pain worse?
s Use proxy pain reporting. Families Remember, hearing is the last sense Sitting up in a chair, putting on a often report to the nurse that their brace or dressing, a change in loved one is in pain. Housekeep- room temperature, or time of ers, maintenance workers, social
s Make the room pleasant. A comfort- services, activity aides and able temperature, soft lighting, soft music and noise control can all dietary staff observe the resident increase pain tolerance. What makes the pain better? throughout the day and should be Can you calm the patient with encouraged to report pain.
sTake care of the basics. Reposition- touch or verbal reassurance? ing, eyeglasses and hearing aids, dry Does prescribed medicine really
s Be alert for behaviors that may clothing, a comfortable bed or chair, help? What about heat, cold, or indicate pain. Actions may speak toileting, food and fluids are often massage? louder than words. Pay attention more important to the resident than to physical or verbal aggression, any pill. facial expressions, restlessness, Assessing Pain in Residents resistance to caregivers. When
s Communicate with your team. Let others know what works best for the with Dementia or Communi- implementing a facility behavior resident. cation Difficulties intervention program, start by considering the pain assessment
s Always report pain to the charge While a resident’s of each resident. Any of these nurse or team. Pain is not a normal actions may signal pain: report of pain is the best part of aging, and everyone should method for assessing it, some have treatement for it! Facial expression: frown, grimace, residents are unable to report. fearful, sad, clenched teeth, eyes
s Understand the care plan for pain. Those with dementia or other wide open or shut tight. Not all pain can be cured, but it can cognitive disabilities will have Physical movements: restlessness, be treated in a thought-out, effective difficulty communicating their fidgeting, slow, cautious or no fashion. A care plan for any resident pain symptoms. movement, guarding, rocking, with problem pain should have a team approach. Long-Term Links Page 7 Spring 2002 In a recent hearing, pharmacists with geriatric The report, Medical Sen. John Breaux, Chairman of training. The need to better Never-Never Land: 10 Reasons the Senate Special Committee recruit and train these Why America’s Not Ready for on Aging, urged his colleagues healthcare professionals is the Coming Age Boom, focuses to take immediate action to growing ever more dire as 77 on ten barriers that preclude remedy the coming shortfall in million baby boomers begin to America’s health professionals the numbers of geriatric- reach retirement age. from being adequately pre- trained healthcare profession- pared for the coming age The Alliance for Aging boom. The report can be Research released a new report accessed online at Sen. Breaux called the at the hearing, which high- www.agingresearch.org. hearing to illustrate how lights the lack of formal elderly patients suffer from a training in geriatric care in
I from AMDA’s lack of doctors, nurses, social many healthcare professions. Health Policy Advisor workers, psychologists and Program will include presentations on:
s The Role of the Consultant Pharmacist Pneumonia and dementia Falls Assessment
s Parkinson’s Disease
s Quality of Care and Staffing
s Diabetes Medications for the Elderly
s Chronic MRSA in Nursing Home Residents
s Evaulation and Managementof the Im-
s Drug Therapy for Alzheimer’s Disease paired Older Adult Driver
s Update of Federal Regulations and the
s Geriatric Dermatology Survey Process
s Depression and Panic in the Elderly
s Treatment of Venous Ulcers
s A Closer Look at the Strengths and Gifts of
s PACE (Program for All-Inclusive Care of the Persons with Alzheimer’s Disease Elderly)
s Spirituality Among Alzheimer’s Patients
s Community Options for Long-Term Care -
s Furthering Education for Nurses Who Care Lessons from the VA for the Elderly Sponsored by: s University of Missouri Health Care s Department of Family and Community Medicine s MU Sinclair School of Nursing Special Preconference Workshop:
s MU School of Health Professions Dying in the Nursing Home
s Missouri Association of Long-Term Care Physicians s Mid-Missouri Area Health Education Center Conference information and registration can be found online at www.muhealth.org/~cme.frail or call (573) 882-0366 Long-Term Links Page 8 Spring 2002 What You Can Do Now An important factor influencing a nursing home’s performance is the degree of involvement by the medical director. The medical director, with strong support from administration, can serve as the leader of change by assuming greater authority and responsibility for the type of care provided by the facility. Most successful change comes through strong leadership. There are several things the medical director can do to prepare for this initiative: 1. Support quality improvement efforts in your individual facility. In effecting change, the medical director can assist facility staff both in reviewing current clinical practices and in making changes to better meet residents’ clinical needs. Securing the support of other physicians who care for residents in the facility is essential to effecting change in care practices. The medical director is the perfect liaison for recruiting physicians’ support. 2. Give us your feedback. When this initiative is rolled out nationally, MissouriPRO will select up to five of the measures on which to focus our statewide quality improvement efforts. They would like you to tell them what measures you are interested in, as well as what types of assistance you believe would be most beneficial to your efforts. A “needs assessment” was mailed to a randomly selected group of nursing home admin- istrators. If your facility received this survey, encourage administrators to complete and return it to us. Or you can give your feedback by filling out a short survey on the website -- www.mpcrf.org/MU/files/nursing_home_survey.html. CMS’s Pilot Nursing Home Project Quality Measures Late loss ADL decline Prevalence of infections Weight loss prevalence Inadequate pain management Pressure ulcer prevalence Use of physical restraintsPost-Acute Care Prevalence of delirium Inadequate pain management Improvement in walking Pain Treatment Principles and Guidelines General Treatment Basic principles of pain management should always be considered. To summarize:
s Use the lowest effective dose by the simplest (e.g. oral) route.
s Start with the simplest single agent, and maximize its potential before adding other drugs. If combination therapy is necessary, use complementary medication to potentiate effectiveness.
s Use scheduled, long-acting pain medications for constant/frequent pain, with prn, short-acting medication available for breakthrough pain.
s Treat breakthrough pain with one-third the 12-hour scheduled dose.
s If three or more prn doses are used in a day, increase the scheduled dose.
s Treat or prevent side effects of pain medications, such as constipation and nausea. Change meds as necessary.
s Use the WHO stepwise approach described below.
s Reevaluate and adjust medications at regular intervals and as necessary.
s Do not stop pain medications in terminal patients. Change the route if needed. WHO (World Health Organization) Ladder. Three-step ladder approach appropriate for all nociceptive pains. Step 1: Mild Pain Acetaminophen Advantages: lack of toxicities, good relief of simple pain, opioid sparing, and easily available. Disadvantages: ceiling effect (4 grams in younger patients. For the elderly, some have suggested maximum dose between 2.5 and 4 grams daily). NSAIDS (non-steroidal anti-inflammatory drugs) Advantages: broad indications in mild or moderate pain, opioid sparing, and complementary to other drugs. Disadvantages: caution in renal, cardiac, GI and anticoagulated patients. Step 2: Mild to Moderate Pain Combination analgesics (opioid combinations) Advantages: simple mixture of low dose opioid and acetaminophen, and relative good tolerance. Disadvantages: ceiling effect due to acetaminophen, and mild opioid side effects. Hydrocodone and oxycodone preparations are preferred. Propoxyphene (Darvocet, Darvon), codeine (Tylenol #3) and butalbital (Fiorcet or Fiorinal) are in general more likely to have CNS, GI and/or liver/kidney side effects. Tramadol (Ultram) Advantages: non-controlled status, relatively low risk for abuse, analgesic efficacy to Tylenol #3. Main disadvantage -- expense. Adjuvant medication can be added to the above, as described on the other side. Step 3: Moderate to Severe Pain Opioid (narcotic) analgesics. Advantages: No ceiling effect, wide dosage forms (pills, elixir, suppositories, patches), availability of short- and long-acting formulations. Disadvantages are mainly dose-related, but can be anticipated and treated. Respiratory depression and sedation are normally transient with tolerance occuring in a few days. Nausea and vomiting are more constant with tolerance occuring slowly, but can be treated with anti-emetics if needed. Tolerance doesn’t occur with constipation, which requires stimulant laxatives (e.g., Senekot, Miralax). Confusion usually requires dose reduction or change in medication. Myoclonus normally results from metabolite accumulation, and can be treated with benzodiazepines or change of opioids. Adjuvant medication can be added, as described on the other side. Specific Opioids Morphine. Inexepensive, popular with hospice due to flexible dosing. IM dosing is painful and unnecessary given efficacy of high concentration oral solutions. MS Contin (12-hour efficacy) and Kadian (24-hour efficacy) are popular brands. Oxycodone More expensive, available in rapid release (Oxyfast), short-acting (OxyIR) and long-acting (Oxycontin) formulations. Fentanyl More expensive transdermal patch system, convenient for resident, but harder to titrate quickly due (Duralgesic) to slower peak effect. Absorption may vary depending on fever and body fat. (continued on other side) Specific Opioids (continued) Hydromorphine Oral, IV and rectal doses may be helpful. A sustained release product will be available soon. (Dilaudid) Opioids not recommended Meperidine (Demerol) more likely to cause nausea/vomiting, has toxic metabolites that can cause tremor, seizures and confusion. Federal regulations strongly discourage the use of Demerol. Pentazocine (Talwin), butorphanol (Stadol), and buprenorphine (Buprenex) have partial or mixed agonist effects that are undesirable and have a ceiling effect. Adjuvant Medications Tricyclic Amitryptiline (Elavil), nortryptiline (Pamelor) and desipramine (Norpramin) suppress signals from antidepressants damaged neurons, can augment nociceptive pain relief, and be used as primary treatment for neuropathic pain. Effective at low doses (1/8 to 1/2 doses to treat depression). Can have significant side effects: dry mouth, constipation, postural hypotension, confusion. Should be used with caution and appropriate documentation according to federal regulations. Mirtazapine (Remeron) and venlafaxine (Effexor) have been reported to have adjuvant pain properties. antidepressants SSRI antidepressants seem to have less utility in this regard. Anticonvulsants Carbamazepine (Tegretol) gabapentin (Neurontin), and valproate (Depakote) also can be used for nociceptive and neuropathic pain. Doses should be started low and titrated carefully. Serum drug levels don’t correlate with clinical effectiveness, useful mainly to investigate suspected toxicity. Corticosteroids Prednisone, prednisolone, and dexamethasone all decrease spontaneous neuronal discharge and inhibit edema, lessening pain. Can also help nausea and appetite. Have obvious long-term side effects, should be used at lowest doses possible. Clonidine Useful primarily for regional complex pain syndromes such as reflex sympathetic dystrophy and causalgia (sympathetically modulated pain). Not useful for nociceptive pain. Lidocaine patch FDA approved for post-herpetic neuralgia, uncertain utility in nociceptive pain. Has minimal (Lidoderm) systemic absorption, can be cut to size, should be left off half the time to prevent skin irritation. Capsaicin Useful for neuropathic and arthritic/musculoskeletal pain. Acts via substance P, a pain modulator. (Zostrix) Can cause burning, should not be used on irritated skin. Low strength (0.25%) is over the counter. Co-analgesics Lorazepam (Ativan), alprazolam (Xanax) and diazepam (Valium) can be cautiously used to augment pain and nausea relief. Can potentate sedation. Use of Valium in particular should be well docu- mented given federal regulations. Hyperstimula- TENS units and acupuncture can both treat nociceptive pain; indications and long-term efficacy are tion Analgesics uncertain. Strontium-90 Useful for bone pain from bony metastasis, given by radiation oncologist. Can only be used every 90 (Metastron) days, with possible initial flare of pain and delayed onset of pain relief (10-21 days). Radiation therapyUseful for control of oncologic pain if tumor is radiosensitive. Nerve blocks Local anesthetic blocks performed by anesthesiologists or pain experts can help local nerve induced pain syndromes for up to several months. Success rates variable, may require repeated injections to assess initial results. Neurosurgical Reserved for localized intractable pain, these pemanent procedures (e.g., rhizotomy, cordotomy, procedures deep brain stimulators) are infrequently used in long-term care patients, but should be considered in difficult cases.
Alphabetische Auflistung der in den UZL News erschienenen Artikel UZL Geschäftsstelle Gesicherter Elektronischer Datenaustausch mit den UZL-Institutionen – November 2001 Ihr rascher Zugang zu aktuellen InformatiOptimierte externe Befundübermittlung – Mai 2001 Sicherer Austausch von Patientendaten (Befundübermittlung) mit externen Auftraggebern – April 2004 Start des Interdiszi
Normas generales I Pontificia Universidad Católica Argentina Unidad 6: Actos administrativos singulares: normas comunes (cánones 35-47) El Título IV es el más largo de todo el Libro I. tiene 59 cánones, distribuidos en cinco Capítulos. En él se retoman algunas materias que ya estaban presentes en el Código de 1917, modificándolas en mayor o en menor medida, en algunos