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:
Schooling
Anxiety and depression
Social limitations such as loss of outings and recreation
Loss of physical interaction/activity leading to further poor health
Impacts upon self esteem
Maladaptive interactions between parents and child
Attachment issues with parents may either contribute or develop
Scoring systems and grading pain is more difficult
Microglia are likely 'primed' by childhood noxious stimuli leading to reactivation in later life
Descending pain modulation systems are not fully developed in children
Myelination can occur later in childhood - slowing, but not stopping, pain signals
The number of nociceptors per square meter is higher in children than adults
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:
Decreased ambulation
Activity avoidance
Decreased social participation
Shifts in family dynamics
Depression
Sleep disturbances
Increased risks of falls
Secondary worsening of comorbid illness
Risk factors include:
Female gender
History of heavy labour
Multiple traumas
Lower socioeconomic status
Tobacco use
Depression and anxiety
Barriers to appropriate pain relief include:
Personal beliefs
Stoicism
Misconceptions about pain
Fears associated with pain
Fear of medications, side effects and addiction
Fear of change in family dynamics
Cognitive and comorbid illness worries
Physician fears, biases, lack of education, legal concerns with opioids, lack of guidelines/protocols
Difficulties in management for older persons
Polypharmacy
Multiple comorbidity
Lack of research upon this age group
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:
Dental problems
Fractures
GORD
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:
Exercise - Choice of exercise needs to be considered in the setting of comorbidities
Psychological - Impaired memory, executive function, visuospatial skills, impact upon ability to perform mindfulness and CBT training
Music therapy may be of assistance particularly in behavioural difficulties
Reiki and reflexology
Heat therapies
Rocking chair therapy
Pharmacological treatments include:
Paracetamol - Very commonly used but evidence is limited. Harms are likely low so less risk.
NSAIDs - These should be avoided in the elderly due to high risks of complications including increased risks of bleeding, cardiac events etc.
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
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:
Thorough timely assessment should be completed
Clinical objective measures may be useful
Sign language experts specifically clinical if possible should be used
Family members should be used as much as possible if suitable
Minimise sedatives and hypnotic medications as this will further impair communication
Avoid postoperative delirium and psychosis
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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