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Specific populations and Pain (2.1.10 & 2.2.10 - 2.2.12)

Updated: Mar 7, 2022


 

Aboriginal and Maori populations




- General factors

  • Patients should all be asked if they identify as an Aboriginal or Torres Strait Islander person

  • Confidentiality should be assured

  • Respectful discussion recognises cultural values and traditions

  • Open questions help guide understanding "What do you understand you need to do next?"

  • A conversational or 'yarning' style may be beneficial

  • Recognise partnerships with other Aboriginal/other providers

  • Recognise there may be mistrust

- Cultural and social context

  • Be flexible with appointments if possible

  • Consider literacy and health literacy

  • Consider affordability and accessibility of suggested management

  • The gender of the clinician may be important

  • Understand the role of Elders and members

  • Understand the impact of community events such as death, sickness, celebrations

- Culturally sensitive pain management

  • Reluctance to express or manage pain and associated shame may be a barrier

  • They may not express things like back pain as 'illness'


Children

Pain is common in children and adolescents with estimates from 20 - 46% affected by chronic pain

The nociceptive system functions by the 20th week of gestation

Pain in children effects their physical, psychological and social wellbeing.

It particularly affects family, friends, and schooling

It may predispose the child to ongoing problems in adulthood

While similar biological and maladaptive coping strategies may persist in childhood, there are extra factors to consider. These include:

  1. Schooling

  2. Anxiety and depression

  3. Social limitations such as loss of outings and recreation

  4. Loss of physical interaction/activity leading to further poor health

  5. Impacts upon self esteem

  6. Maladaptive interactions between parents and child

  7. Attachment issues with parents may either contribute or develop

  8. Scoring systems and grading pain is more difficult

  9. Microglia are likely 'primed' by childhood noxious stimuli leading to reactivation in later life

  10. Descending pain modulation systems are not fully developed in children

  11. Myelination can occur later in childhood - slowing, but not stopping, pain signals

  12. The number of nociceptors per square meter is higher in children than adults

  13. Signal of pain often is more severe and can last longer


Reference:


Landry, B. W., Fischer, P. R., Driscoll, S. W., Koch, K. M., Harbeck-Weber, C., Mack, K. J., Wilder, R. T., Bauer, B. A., & Brandenburg, J. E. (2015). Managing Chronic Pain in Children and Adolescents: A Clinical Review. PM & R, 7(11), S295–S315. https://doi.org/10.1016/j.pmrj.2015.09.006


Pancekauskaitė, G., & Jankauskaitė, L. (2018). Paediatric Pain Medicine: Pain Differences, Recognition and Coping Acute Procedural Pain in Paediatric Emergency Room. Medicina (Kaunas, Lithuania), 54(6), 94. https://doi.org/10.3390/medicina54060094


 

Older Persons

Pain prevalence increased until 85 years and then decreased

Poorly controlled pain can lead to:

  1. Decreased ambulation

  2. Activity avoidance

  3. Decreased social participation

  4. Shifts in family dynamics

  5. Depression

  6. Sleep disturbances

  7. Increased risks of falls

  8. Secondary worsening of comorbid illness

Risk factors include:

  1. Female gender

  2. History of heavy labour

  3. Multiple traumas

  4. Lower socioeconomic status

  5. Tobacco use

  6. Depression and anxiety

Barriers to appropriate pain relief include:

  1. Personal beliefs

  2. Stoicism

  3. Misconceptions about pain

  4. Fears associated with pain

  5. Fear of medications, side effects and addiction

  6. Fear of change in family dynamics

  7. Cognitive and comorbid illness worries

  8. Physician fears, biases, lack of education, legal concerns with opioids, lack of guidelines/protocols

Difficulties in management for older persons

  1. Polypharmacy

  2. Multiple comorbidity

  3. Lack of research upon this age group

  4. Lack of clear guidelines

Physiological changes in the elderly with respect to pain and analgesia:


General: Increased body fat, less water, less muscle --> Delayed elimination of drugs, increased drug side effects, and careful dose adjustments required


MSK: Degenerative joints, decreased muscle mass --> increased falls, decreased mobility


GI: Decreased secretions, decreased mobility, altered absorption --> Altered drug pharmacokinetics, GI intolerance of medications, increased risk of GI ulcers


Kidney: Decreased renal clearance (6-10% per decade after 30yo) and more UTIs --> decreased drug elimination, increased risk of renal toxicity, medication dose adjustments


Liver: Decreased liver metabolism, increased risk of hepatotoxicity --> Decreased drug metabolism, increased serum levels of protein-binding drugs, dose adjustment


Nervous system: Decreased neuronal cells, altered neurotransmitter balance, decreased opioid receptor sensitivity/density/binding, altered gait --> Altered response to pain, sensitivity to pain medications, increased risk of depression, cognitive dysfunction, increased risk of falls

 

Cognitively impaired (non dementia)

Depending on the cause, cognitive-evaluative, motivational-affective, and autonomic responses to pain can be affected

They express pain differently - nonverbal indicators are highly subjective, not easily recognised.

Varied communication and physical abilities have made pain assessment tools difficult to standardise and apply to heterogenous cohorts

Atypical reactions may occur - laughing when in pain, or same sounds when excited and when in pain


Scores that can be trialled in young persons can be the r-FLACC, or Indiviualised Numeric Rating Scale


Scores in adults include: Pain and discomfort scale (PADS), Disability distress assessment tool (Dis-Dat).


Whichever score is used, baseline values in this patient group are crucial to be able to assess changes


Certain conditions may be more prevalent:

  1. Dental problems

  2. Fractures

  3. GORD

  4. Self-injurious behaviours

Physician bias may lead to subtherapeutic doses of analgesic mediation being given due to fear of the drugs consequences


Interaction with other medications also needs to be considered e.g. CP450 system in antiepileptic drugs


Reference:

Pain in Cognitive Impairment, not Dementia-Related: Management - IASP 2019

 

Neurocognitive disorders (Dementia)

Pain in dementia is very prevalent and has unique challenges in its assessment

In the community, more than half of the patients with dementia experience daily pain

In nursing homes, this number rises to 60-80%. 30% report severe pain. Nociceptive is the most common followed by mixed neuropathic and nociceptive.


Dementia causes confusion, memory loss, neuropsychiatric symptoms and sometimes physical challenges

The DSM-5 now uses the term neurocognitive disorders and lists these as mild/moderate based upon impairment on daily functioning

Alzheimers disease (AD) is the most common subtype

Self-report instruments may not be suitable and behavioural observational instruments have their own inherent difficulties including underrating a persons pain.


Patients with alzheimers have been shown in fMRI studies to experience a more profound reaction to pain than those without


Vascular dementia may lead to increased central pain syndromes


Pain impact upon dementia behaviours. It will worsen -

  • Verbal abuse

  • Wandering

  • Agitation

  • Aggression

Assessment

Self report is the gold standard. A suggested minimum MMSE of 18 is required for appropriate self-report - however each patient needs to be individually assessed.

Numerical scales or simply yes or no should be used - not VAS.


Observer ratings are necessary in moderate/severe dementia

These are usually based upon

  • Facial expressions

  • Vocalisation

  • Body movements and/or posture

Problems with these scales include:

  • Poor/unproven reliability

  • Lack of evidence for validity

  • Untested sensitivity to change

  • Implementation and utilisation is more difficult

Machine learning algorithms are to be attempted - but none are currently verified


Management

Unfortunately many patients with dementia are excluded from pain trials


Nonpharmacological treatments include:

  1. Exercise - Choice of exercise needs to be considered in the setting of comorbidities

  2. Psychological - Impaired memory, executive function, visuospatial skills, impact upon ability to perform mindfulness and CBT training

  3. Music therapy may be of assistance particularly in behavioural difficulties

  4. Reiki and reflexology

  5. Heat therapies

  6. Rocking chair therapy

Pharmacological treatments include:

  1. Paracetamol - Very commonly used but evidence is limited. Harms are likely low so less risk.

  2. NSAIDs - These should be avoided in the elderly due to high risks of complications including increased risks of bleeding, cardiac events etc.

  3. Opioids - Buprenorphine is commonly used. Benefits as a patch and reduced respiratory depression. The difficulty is some of the side effects from opioids are similar to behavioural symptoms of depression and this may make recognition more difficult

  4. Adjuvant analgesics - their efficacy is not known.

Summary: No guidelines currently exist for analgesic therapy for people with dementia


Reference:

Achterberg, W., Lautenbacher, S., Husebo, B., Erdal, A., & Herr, K. (2020). Pain in dementia. Pain reports, 5(1).


Communication impairments


In patients who are deaf or mute, there are several further factors to consider:

  1. Thorough timely assessment should be completed

  2. Clinical objective measures may be useful

  3. Sign language experts specifically clinical if possible should be used

  4. Family members should be used as much as possible if suitable

  5. Minimise sedatives and hypnotic medications as this will further impair communication

  6. Avoid postoperative delirium and psychosis

  7. Effective pain protocols should be instigated

Reference:

Chowdhry, V., Padhi, M., Mohanty, B. B., & Biswal, S. (2016). Perioperative challenges in management of a deaf and dumb patient posted for high-risk cardiac surgery. Annals of cardiac anaesthesia, 19(3), 564–567. https://doi.org/10.4103/0971-9784.185567

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