ADVERTISEMENT
Managing Chronic Pain in Older Adults: A Long-Term Care Perspective
Affiliations:
1Lisa Byrd Healthcare Inc, Bolton Family Clinic, Bolton, MS
2School of Nursing, University of Mississippi Medical Center, Jackson, MS
3School of Nursing, University of South Alabama, Mobile, AL
Abstract: Chronic pain is a common problem among nursing home residents that is often difficult to manage, mismanaged, or not managed at all. Yet uncontrolled pain or suboptimal pain management can decrease residents’ quality of life and lead to worsening of other medical conditions and increase the risk of immobility, falls, and other complications. Every resident deserves appropriate pain management, and healthcare providers must be adequately prepared with the knowledge and information to meet their residents’ needs. This review presents information on common types of pain in older adults, describes how to assess pain, and discusses options for management, including nonpharmacologic therapies and medication management with mild analgesics and opioid-based therapies.
Key words: Chronic pain, nursing home, mild analgesics, pain management, opioid therapy.
______________________________________________________________________________________________________________________________________________
Chronic pain is a major issue among older individuals, especially those residing in long-term care facilities. The prevalence of chronic pain among geriatric nursing home residents is estimated to be between 45% and 80%, with the majority of these elders experiencing pain on a daily basis.1-3 The prevalence of chronic pain increases with age, as the most common pain reports are those associated with increased joint pain and neuralgias, which occur frequently among elderly persons.4,5 Although chronic pain is common, research shows that 25% of individuals experiencing pain on a daily basis received neither analgesic medications nor nonpharmacologic treatments for their pain.6 Another study reported that between 25% and 40% of older individuals with a diagnosis of cancer experienced pain on a daily basis.7 Among these patients, 21% who were aged 65 to 74 years, 26% who were aged 75 to 84 years, and 30% who were older than 84 years received no pain medication.7
There are many factors that complicate and decrease the appropriate management of pain in older adults, including a high prevalence of dementia, sensory impairment, and disability. Other issues that may exacerbate the problem are erratic staffing patterns, high turnover of nursing and administrative staff, and limited presence of a physician.8 Yet the consequences of poor pain management are significant for residents, and may include sleep deprivation, anorexia, depression, anxiety, agitation, increased behavioral problems, cognitive decline, increased debility and falls, decreased activity and functional status, delayed healing, lower overall quality of life, and polypharmacy.4,9,10 These consequences can also place an increasing burden on nursing home staff, who now have to deal with an even more complex clinical picture.
In addition to resident and staff consequences, uncontrolled and poorly controlled pain can be quite costly. In 2003, the Journal of the American Medical Association put the direct economic cost at $61.2 billion annually in elders with chronic pain, and this number is projected to continue increasing substantially as the elderly population continues to increase its numbers.11 In 2010, the Institute of Medicine estimated the annual value of lost productivity for an individual with pain and/or a family member caring for a person with pain to be between $297.4 billion and $335.5 billion.12,13
Having a good understanding of pain can enable nurses and other healthcare providers to develop an individualized plan of care for their elderly patients who experience pain, ensuring more optimal pain management. What follows is an overview of pain, its types, and how it should be assessed and managed.
Understanding Pain
By definition, pain is an unpleasant sensation that is both a sensory and emotional experience associated with an actual and/or potential tissue injury. The type of pain that the patient is experiencing will dictate what medications and interventions will be the most helpful in managing that pain. The many different types of pain include muscle pain, such as fibromyalgia and myofascial pain; inflammatory pain commonly associated with acute pain, such as follows surgery or an injury; chronic inflammatory pain, including arthritis; mechanical pain created by pressure or stretching and resulting in complications such as a fracture or dislocation and compression of tissue by bony structures; and psychological pain, such as depression, anxiety, personality disorders, somatization disorders, and posttraumatic stress disorder. Other types of pain include headaches, low back pain, cancer pain, arthritis pain, and neurogenic pain resulting from damage to the nerves.
Pain can be present even when a person cannot communicate it, such as in the case of late-stage dementia or when there is expressive aphasia following a stroke. In addition, pain can be acute or chronic. Acute pain is defined as pain lasting fewer than 6 months.14 It may be mild and last only a short period of time (minutes) or a longer period of time (hours, weeks, or even a few months), during which time it might wax and wane in severity. In most cases, acute pain usually disappears when the underlying cause of the pain resolves. Any acute pain that is not resolved may lead to chronic pain.
Chronic pain is defined as pain lasting longer than 6 months or pain that continues despite the cause of the pain being resolved.14 It may wax and wane or be constant. Chronic pain can lead to other problems, including muscle tension, limited mobility, fatigue, changes in appetite or sleep, depression, anxiety, and fear of re-injury, which can affect a person’s daily life.
Assessing Chronic Pain
Assessment and proper diagnosis of chronic pain depends on the use of accurate historical and clinical information, along with physical evidence derived from an appropriate direct examination; see the tip sheet that directly follows this article for more information. During the direct examination, attention is paid to the patient’s self-report, observation of the patient’s physical symptoms (eg, guarding, mobility), and the patient’s behavioral symptoms (eg, agitation, restlessness, resisting care). The patient’s perception of pain is the most important factor to consider, and it can be determined through verbalization or use of a variety of pain scales, such as a numerical self-rating scale or the faces pain rating scale. For example, when using a numerical scale, a report of 0 or 1 usually is equivalent to having no pain, while a report of 10 is equivalent to the worst pain the patient has ever experienced. Healthcare providers may question the utility of using pain scales in their patients with cognitive impairment; however, one study showed that healthcare providers should not underestimate the ability of these patients to properly express their pain.15 In this study, which included 129 older adults with severe dementia, 61% of participants demonstrated comprehension of at least one pain scale, with comprehension rates being significantly better for the verbal and the faces pain scales.15
While examining a resident reporting pain, the healthcare provider should assess the characteristics of this individual’s pain and how much is known about the pain, including the frequency or chronicity of pain and any precipitating and alleviating factors. Knowledge of any current and previous pain management approaches is essential to properly develop a plan of care.
Developing a Plan of Care
When developing a plan of care, if the patient’s pain is excruciating, it is sometimes necessary to treat his or her pain before all relevant information has been gathered or the cause has been identified. Caution should be used when doing this, however, as medications administered to alleviate pain may mask the cause of the pain and may lead to not accurately identifying its etiology. In such cases, it may be important to have the patient assessed by his or her primary care provider and, possibly, by a pain management or neurological specialist, particularly when the goal remains to identify the cause of pain so that an appropriate treatment plan can be developed.
Goals of a person-centered approach to developing a plan of care should be based on an individual’s preferences; knowledge of the pain’s location, characteristics, and causes; and knowledge of the patient’s condition, prognosis, risk factors, comorbidities, and existing medication regimen. It is important to establish realistic expectations regarding pain relief or pain management/tolerance. The healthcare provider should also determine whether there are any underlying causes of pain that can be alleviated without the use of medications. The healthcare provider should put the plan of care into action, set a time frame for re-evaluating the patient’s pain management, and monitor the patient for complications and side effects of pain medications.
Managing Chronic Pain
It is essential to make individual, patient–specific decisions when managing a resident’s pain. As previously noted, healthcare providers should first determine the cause of the pain and attempt to alleviate that cause and/or modify the resident’s activity and environment, focusing on nonpharmacologic management strategies, including lifestyle interventions. Thereafter, medications can be used, starting with over-the-counter (mild) pain medications and then progressing to stronger prescription-strength medications, if needed. Throughout this process, it is imperative for healthcare providers to periodically re-evaluate the resident’s pain management to determine whether the plan needs to be revised to optimize pain management.
Starting With Nonpharmacologic Management
Some general principles should be followed when starting pain management. First and foremost, reassurance, comfortable positioning (especially in bed/chair-bound individuals), and a comfortable, supportive environment should be provided. A quiet place, for instance, may make pain more tolerable. Overstimulation that can occur from bright lights or loud, noisy places should be avoided. Therefore, during such times, patients may fare better spending time in their room or other quiet areas, rather than more noisy common areas. Ensuring that the environment is not too hot or too cold may also assist in decreasing pain. The healthcare provider should consider recommending the use of cold packs and/or warm compresses to help minimize the patient’s pain. Cold packs can help numb areas of pain and are particularly beneficial when there are strains, sprains, or bruising, as cold can help prevent or reduce bleeding, swelling, muscle pain/spasms, and inflammation.16 In contrast, heat is generally best for sore muscles and older injuries (those sustained at least 48 hours earlier), as it promotes blood flow and can reduce inflammation.16,17
In addition, lifestyle management needs to be encouraged, including getting adequate sleep, eating a balanced diet, drinking plenty of water, limiting caffeine intake, stopping smoking, and performing appropriate exercises and physical activities. Although patients should avoid or limit the activities that cause or exacerbate their pain, nonaggravating regular exercise can help these patients maintain or develop balance, strength, and stamina, preventing injuries that can worsen pain or lead to new pain. As a safety measure, all exercises should be performed on an even level to avoid overexertion and prevent injury. Exercises should always be tailored to the patient, but one type of exercise that is often used for individuals with pain is stretching. This is because stretching can make the patient’s muscles stronger around the injured area, alleviating the pain. Yoga can serve as a good stretching exercise for some patients with chronic pain, as it also promotes good posture and provides relaxation, which can assist in diminishing pain intensity. When moving a particular part of the body does not aggravate pain and contractures are not present, healthcare providers should consider physical therapy to increase circulation and prevent deconditioning, muscle atrophy, and fatigue, all of which can worsen pain.18
Finally, relaxation techniques should be promoted and encouraged, as they can also enhance mood and provide a sense of well-being. For example, a long warm bath may help calm the patient and enable his or her muscles to relax. Massage, aromatherapy, acupuncture, and hypnosis are other nonpharmacological techniques that can help relieve pain and assist in relaxation.19 Interestingly, laughter has been shown to be beneficial in aiding relaxation, as it can enable a person to let go of negative feelings and emotions (eg, stress, anger, fear, depression, hopelessness), while having positive physical effects.20 For example, laughter may help a person experiencing pain to take deep breaths, while lowing blood pressure and causing the brain to release endorphins, which can decrease pain perception. In addition, a positive attitude, which laughter can bring on, may help decrease pain. Interventions that are less relaxing but may provide pain relief include spinal cord stimulation and transcutaneous electrical nerve stimulation (TENS); however, these therapies may be better suited to managing certain types of pain (eg, TENS for neuropathic pain).21
After the cause of pain has been determined and attempts have been made to remove that cause, nonpharmacologic measures should be initiated and continued even when medications are deemed necessary, as the concomitant use of these measures and pharmacotherapy can increase the efficacy of pain management. Although the aforementioned nonpharmacologic measures may bring substantial relief and reduce the need for analgesics, they may sometimes be insufficient to control a patient’s pain. In such cases, healthcare providers need to consider pharmacologic management options.
Continued on next page
Progressing to Pharmacologic Management
Pain medications have different mechanisms of action, but many pain medications work by blocking pain signals traveling to the brain or by changing how the brain interprets pain signals. The World Health Organization (WHO) has recommended a three-tier “stepladder” approach to pain management using analgesics.22 Although these guidelines were specifically developed for patients with cancer, the principles are the same in managing noncancer pain and can be applied to the elderly. The following are the most commonly prescribed classes of medications for pain, listed in the order in which they should be prescribed per the WHO.
• Nonopioid analgesics. These analgesics work by changing the way the body senses pain, and they can also reduce inflammation and lower the body’s temperature to normal range in the setting of fever. These agents are generally used to relieve mild to moderate pain and inflammation, including from headaches, muscle injuries, colds, and fever. Commonly used mild analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, and aspirin. A variety of stronger, prescription preparations are also available (eg, prescription ibuprofen in strengths of 400 mg, 600 mg, and 800 mg). When these agents are ineffective in optimizing pain control or pain increases, a mild opioid can be added.
• Mild opioids. These agents are full µ-opioid receptor agonists and have relatively low analgesic efficacy on their own; thus, they are often administered as fixed-dose combination products with aspirin or acetaminophen to control mild to moderate pain.22 When using these products, the toxicity of the nonopioid generally limits the dose of the opioid that can be administered daily. Examples of mild opioids include codeine and oxycodone, and examples of combination agents include hydrocodone and acetaminophen, hydrocodone bitartrate and acetaminophen, and oxycodone and acetaminophen. When these agents are used, they need to be administered on an around-the-clock/routine basis, with additional “as needed” booster doses used to control breakthrough pain.22 If this treatment fails to optimize pain control or pain increases, these agents can be replaced with strong opioids.22
• Strong opioids. Also called major opioids, strong opioids are µ-opioid receptor agonists that have high analgesic efficacy,22 making them the strongest pain medications available. These agents are used for moderate to severe pain, such as cancer pain, postoperative pain, or pain from other medical procedures. Examples of this type of medication include morphine, fentanyl, and methadone. Among these agents, morphine is considered the gold standard for pain relief in terminally ill patients, but it should be used cautiously in elderly persons since it can cause hallucinations in certain individuals. For severe pain, consider using an extended-release (ER) form, such as a patch, which can provide 72 hours of pain relief.
In addition to analgesics, a variety of other medications are sometimes used in conjunction with or in place of these agents; these medications include antianxiety medications, antidepressants, antispasmodics, and steroids (Table 1).19,22-25 In addition, when the etiology of the pain is clear, common treatments for the underlying condition may also be used to alleviate the pain. For example, pain caused by unresectable metastatic cancer may be treated with chemotherapy or radiation therapy if these agents may help shrink the tumors that are causing the pain, whereas pain caused by swelling from infections may be treated with antibiotics or antiviral medicines to reduce the swelling and alleviate the pain.
Regardless of which medications are used to control pain, prescribers should use the least amount of medication as possible at the lowest doses possible to manage the patient’s pain. In addition, the patient should be closely observed for adverse effects (eg, falls, aspiration, sedation, constipation) and any impairment in balance or gait. It is important to remember that all medications, including mild analgesics, have benefits and risks that may vary and that could interact with a patient’s current medication regimen. Therefore, healthcare providers need to closely consider any other medications their patients are taking, along with their patients’ current diagnoses. Using medications correctly and vigilant monitoring can reduce the risk of adverse effects and events, including death in patients experiencing any type of pain.24 What follows is an overview of some adverse effects of several of the most commonly prescribed analgesics, including nonopioid and opioid medications (Table 2).19,22,24-27
Continued on next page
Nonopioid analgesics. Because nonopioid medications are the mildest analgesics, healthcare providers may have fewer concerns regarding any adverse effects; however, there are still many factors that need to be considered. One of the most commonly prescribed agents for managing persistent pain in older adults is acetaminophen. This is not surprising given that the American Geriatrics Society (AGS) Clinical Practice Guidelines: Pharmacological Management of Persistent Pain in Older Persons, which were published in 2009, recommend that acetaminophen be considered as initial and ongoing pharmacotherapy of patients with mild to moderate musculoskeletal pain.28 However, when prescribing acetaminophen, healthcare providers need to remember that many other medications, including pain and cold medications, contain this agent. In fact, the US Food and Drug Administration (FDA)reports that more than 600 medications contain acetaminophen.29 Currently, the maximum daily dose of acetaminophen should not exceed 4000 mg daily; however, many experts are recommending limiting intake to 3000 mg daily to prevent accidental overdose as well as decrease complications associated with its use.30 Dosing that exceeds these recommended levels can cause liver damage. In addition, acetaminophen use has recently been linked to serious and potentially fatal skin reactions, including Stevens-Johnson syndrome, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis, all of which can occur at any time during treatment, including upon initiation.31 Therefore, all patients receiving acetaminophen in any of their medications should be closely observed for skin rashes and flu-like symptoms.31
Compared with acetaminophen, the AGS guidelines recommend that nonselective NSAIDs and COX-2 selective inhibitors be considered rarely, with caution, in highly selected individuals,28 and they are included as an inappropriate medication in the AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.32 Yet NSAIDs continue to be used in elderly patients, often as a treatment for osteoarthritis, rheumatoid arthritis, gout, and chronic pain.33 Although avoiding NSAIDs may be preferable, when they are prescribed, healthcare providers need to exercise caution and employ protective measures.
All NSAIDs tend to irritate the stomach’s lining, increasing the risk of digestive upset (ie, heartburn, indigestion, nausea, bloating, diarrhea, and stomach pain), peptic ulcers, and gastrointestinal bleeding; however, administering NSAIDs with food and providing antacids may help prevent patients from developing stomach irritation. In addition, concomitant use of proton pump inhibitors (ie, omeprazole) or histamine-2 (H2) blockers (ie, famotidine) can help prevent stomach problems.
With the exception of coxibs, all NSAIDs also interfere with the clotting tendency of platelets and lead to an increased risk of bleeding, especially in the digestive tract when there is irritation of the stomach’s lining. In addition, NSAIDs can cause swelling in some patients, and the regular use of NSAIDs may increase the risk of developing a kidney disorder, sometimes resulting in kidney damage and kidney failure. Recent studies suggest that all NSAIDs (except aspirin) may increase the risk of myocardial infarction, stroke, and blood clots in the legs.26 The risk appears to be increased with higher doses and longer use of these drugs. The risk is also higher with some NSAIDs than with others. For example, indomethacin seems to be quite toxic, whereas etoricoxib and diclofenac are moderately toxic and ibuprofen and naproxen are only mildly toxic.26 These agents’ toxicity levels may be related directly to their effect on clotting or indirectly to the small but persistent increase in blood pressure that they cause.
Coxibs (also known as COX-2 inhibitors), such as celecoxib, may be less likely to irritate the stomach and cause bleeding than traditional NSAIDs. These agents differ from traditional NSAIDs in that traditional NSAIDs block the two enzymes COX-1 (involved in the production of prostaglandins that protect the stomach and play a crucial role in blood clotting) and COX-2 (involved in the production of prostaglandins that promote inflammation), whereas COX-2 inhibitors block only COX-2. However, healthcare providers need to keep in mind that the risk of irritating the stomach and causing bleeding are just as likely in patients taking these agents if they are also taking aspirin.
Mild and strong opioid analgesics. More aggressive pain management may involve the use of opioid analgesics, also referred to as narcotics, which are the most powerful analgesics available and also have the highest risks. They are often used in the treatment of severe acute pain and chronic pain due to cancer and other serious disorders. Opioid agents decrease the patient’s perception of pain and reaction to pain, while increasing his or her pain tolerance. Opioids are effective at controlling pain because they are chemically related to morphine (a natural substance extracted from poppies but that can also be manufactured in a laboratory). The dose of an opioid should be started low and then increased gradually until the pain is relieved or the opioid’s side effects cannot be tolerated. Because the effects of strong opioids, such as long-acting and ER opioid products, are so powerful, the FDA has issued class-wide labeling changes emphasizing that these drugs be prescribed in patients for whom pain is severe enough to require daily, around-the-clock relief and for whom other treatments (eg, nonopioids) are ineffective or not well tolerated.34 This statement by the FDA reaffirms that strong opioid analgesics should be prescribed as the last step in controlling pain, rather than the first step.
Side effects of opioid drugs are more likely to occur in people with certain conditions, such as kidney failure, liver disease, chronic obstructive pulmonary disease, dementia, or another brain disorder.35 Potential problems with the use of opioid agents include drowsiness or sedation, respiratory depression, constipation, confusion, agitation, falls, nausea, vomiting, itching, and even death.35 The only opioid included in the AGS Beers Criteria as an inappropriate medication is pentazocine due to its higher risk of causing adverse central nervous system effects, including confusion and hallucinations.28 If a healthcare provider needs to initiate opioid therapy or switch the patient to another agent due to ineffectiveness, cost, or issues with insurance coverage, Practical Pain Management offers an online calculator (opioidcalculator.practicalpainmanagement.com) for healthcare professionals to calculate opioid doses.
Conclusion
Older patients often experience chronic pain and deserve appropriate management to improve their health and quality of life. Developing an individualized plan of care begins with accurate assessment and evaluation of the patient, use of nonpharmacologic management strategies, and initiation of pharmacologic therapy as needed. Patients should always be started on the lowest dose and mildest medication that works. The dose can be gradually increased when needed, but upon initiation and titration of these therapies the patient must be carefully monitored for adverse effects. The WHO recommends that patients start with nonopioid analgesics and be moved to mild opioids and strong opioids only if needed. Healthcare professionals have a lot of intervention options at their disposal; thus, pain can be made tolerable in many individuals if healthcare providers make use of all appropriate nonpharmacologic strategies while remaining cognizant of proper medication and dosing strategies.
References
1. Cavalieri T. Managing pain in geriatric patients. J Am Osteopath Assoc. 2007;107(suppl 4):ES10-ES16.
2. Lapane KL, Quilliam BJ, Chow W, Kim MS. Pharmacologic management of non-cancer pain among nursing home residents. J Pain Symptom Manage. 2013;
45(1):33-42.
3. Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am Geriatr Soc. 1990;38:409-414.
4. Kaye AD, Baluch A, Scott JT. Pain management in the elderly population: a review. Oschner J. 2010;10(3):179-187.
5. Badley EM, Tennant A. Changing profile of joint disorders with age: findings from a postal survey of the population of Calderdale, West Yorkshire, United Kingdom. Ann Rheum Dis. 1992;51(3):366-371.
6. Won AB, Lapane KL, Vallow S, Schein J, Morris JN, Lipsitz LA. Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. J Am Geriatr Soc. 2004;52(6):867-874.
7. Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA. 1998;279(23):1914-1915.
8. Jones KR, Fink R, Pepper G, et al. Improving nursing home staff knowledge and attitudes about pain. Gerontologist. 2004;44(4):469-478.
9. Herr K. Chronic pain: challenges and assessment strategies. J Gerontol Nurs. 2002;28(1):20-27.
10. Teno JM, Kabumoto G, Wetle T, Roy J, Mor V. Daily pain that was excruciating at some time in the previous week: prevalence, characteristics, and outcomes in nursing home residents. J Am Geriatr Soc. 2004;52(5):762-767.
11. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. JAMA. 2003;290(18):2443-2454.
12. The cost of pain to business and society due to ineffective pain care. American Academy of Pain Management Website. www.painmed.org/patientcenter/cost_of_pain.aspx. Accessed July 5, 2013.
13. Institute of Medicine of the National Academies Report. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press, 2011.
14. Volochayev R. Pain management: acute and chronic. National Institute of Health Website. https://clinicalcenter.nih.gov/ccc/nursepractitioners/pdfs/pain_management_slid.pdf. Accessed October 8, 2013.
15. Pautex S, Michon A, Guedira M, et al. Pain in severe dementia: self-assessment or observational scales? J Am Geriatr Soc. 2006;54(7):1040-1045.
16. Ice packs vs. warm compresses for pain. The University of Chicago Medicine. www.uchospitals.edu/online-library/content=P00918. Accessed November 14, 2013.
17. Ice and heat treatment for injuries. Patient.co.uk Website. www.patient.co.uk/health/ice-and-heat-treatment-for-injuries. Accessed November 14, 2013.
18. Kleinpell RM, Fletcher K, Jennings BM. Reducing functional decline in hospitalized elderly-Chapter 11. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. www.ahrq.gov/qual/nurseshdbk. Accessed December 4, 2013.
19. Byrd L. Top 10 Geriatric Syndromes: Clinical Management Strategies. Eau Claire, WI: PHC Publishing Group; 2011.
20. Hassed C. Mind-body therapies—use in chronic pain management. Aust Fam Physician. 2013;42(3):112-117.
21. Transcutaneous electrical nerve stimulation. American Cancer Society Website. www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/manualhealingandphysicaltouch/transcutaneous-electrical-nerve-stimuation. Accessed November 28, 2013.
22. WHO’s pain ladder for adults. World Health Organization Website. www.who.int/cancer/palliative/painladder/en. Accessed October 8, 2013.
23. Parveen S, Javed MA. Stevens Johnson Syndrome associated with lamotrigine. Pak J Med Sci. 2013;29(6):1450-1452.
24. Levenson S. Pain needs to be managed one step at a time. AMDA: Caring for the Ages. 2007;8(5):14-15.
25. Monthly Prescribing Reference Website. www.empr.com. Accessed July 5, 2013.
26. McGettigan P, Henry D. Cardiovascular risk with non-steroidal anti-inflammatory drugs: systematic review of population-based controlled observational studies. PLoS Med. 2011;8(9):e1001098.
27. US Food and Drug Administration. Fentanyl patch can be deadly to children. www.fda.gov/forconsumers/consumerupdates/ucm300803.htm. Accessed December 4, 2013.
28. American Geriatrics Society. AGS Clinical Practice Guideline: Pharmacological Management of Persistent Pain in Older Persons. www.americangeriatrics.org. Accessed November 14, 2013.
29. US Food and Drug Administration. Careful: Acetaminophen in pain relief medicines can cause liver damage. www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/SafeUseofOver-the-CounterPainRelieversandFeverReducers/UCM234275.pdf.
Accessed November 14, 2013.
30. McNEIL-PPC. Acetaminophen dosage for adults. https://bit.ly/188HUTS. Accessed November 14, 2013.
31. US Food and Drug Administration. FDA Drug Safety Communication: FDA warns of rare but serious skin reactions with the pain reliever/fever reducer acetaminophen. www.fda.gov/Drugs/DrugSafety/ucm363041.htm. Accessed November 14, 2013.
32. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631.
33. Liantonio JJ, Simmons BB. NSAIDs and the geriatric patient: a cautionary tale. Clinical Geriatrics. 2013;21(5). www.clinicalgeriatrics.com/article/nsaids-geriatric-patient-cautionary-tale. Accessed November 14, 2013.
34. FDA announces safety labeling changes and postmarket study requirements for extended-release and long-acting opioid analgesics [press release]. Silver Spring, MD: US Food and Drug Administration; September 10, 2013. www.fda.gov. Accessed November 21, 2013.
35. The Merck Manual for Health Care Professionals. www.merckmanuals.com/professional/search.html?qt=pain&start=1&context=%2Fprofessional. Accessed November 28, 2013.
Disclosures: The author reports no relevant financial relationships.
Address correspondence to: Lisa Byrd, PhD, P.O. Box 217, Bolton, MS 39041; LByrd@ByrdHealthcare.com
