The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Pain & Palliative Care

Related Issues:

Discomfort, burning, numbness, cold, stabbing, sharp, dull, electric shock, pins and needles

Why Pain is Important:

• Inadequate treatment of pain may have serious consequences
• Persistent pain or poorly controlled pain is associated with falls, delayed rehabilitation, mood changes, sleep and appetite changes, and caregiver strain
• Cancer is associated with significant pain for one-third of patients with active disease and for two-thirds of those with advanced disease (Breivik et al, 2009)
• Cancer pain can be related to disease, treatment, co-morbid conditions, or a combination of all of the above

Normal Age-Related Changes:

• Physiologic decline in drug metabolism and elimination
• Altered pharmacokinetics secondary to decreased lean body mass, decreased total body water, renal function and increased percentage of body fat

Older adults are at increased risk if they have ay of the following:

Conditions

• Muscular skeletal conditions (arthritis, gout, degenerative disc disease, spinal stenosis and osteoporosis)
• Peripheral vascular disease                         
• Diabetes                                                       
• Infection                                                       
• Wounds                                                                                
• Shingles                                                        
• Are living in a setting in which the caregivers are not trained in the assessment and management of pain

Behavioral Risk Factors/Barriers to Effective Pain Management

• Difficulty adhering to prescribed administration schedule secondary to:
• Diminished ability to perform IADL’s
• Perceptual deficits (delirium, dementia, hearing & visual, language)
• Polypharmacy
• Concerns about side effects
• Fear of addiction
• Lack of resources (social, financial, insurance, transportation)
• History of substance abuse

Chemotherapy-Related Risk Factors

• Neuropathies secondary to specific cytotoxic agents:
• Vinca Alkaloids (Vinblastine, Vincristine, Vindesine, Vinorelbine)
• Carboplatin, Cisplatin, Oxaliplatin
• Taxanes (Docetaxel, Paclitaxel)
• Protease inhibitors (Bortezomib)
• Thalidomide
• Intrathecal Methotrexate
• Tumor pain:
• Velban
• Vein Irritation during administration:
• DTIC
• Gemcitabine

Medication-Related Risk Factors

• Bone pain secondary to:
• Colony stimulating factors (filgrastim, pegfilgrastim)
• Tumor flare pain:
• Bisphosphonates
• Radio-nucleotides
• Certain monoclonal antibodies
• Myalgias and joint pain secondary to hormone therapy:
• Aromatase inhibitors (Anastrozole, Letrozole, Exemestane)

Surgery-Related Risk Factors

• Procedural pain
• Post op pain

Radiation Risk Factors

Head and neck RT

• Trismus
• Stomatitis
• Painful swallowing, esophagitis

Abdominal RT

• Colitis, proctitis, cystitis, vaginitis
• Strictures and atrophy
• Skin changes (wounds, rashes and breakdown)

Cancer Diagnosis

• Multiple Myeloma
• Advanced cancers
• Metastatic disease (bone lesions)
• Pathologic fractures
• Spinal cord compression

Assessment:

1. Screening Questions

• Do you have any pain?
• What type of pain? (stabbing, burning, sharp, dull, numbness, tingling or radiating)
• Onset and duration? (when did the pain begin, how long does it last, intermittent, constant?)
• Precipitating Factors?  Was the pain associated with a particular activity or known medical event (shingles)?
• Associated Symptoms?  Did other symptoms accompany the onset of pain? (nausea, vomiting, etc.)
• Alleviating factors? (positioning, heat, cold, rest, analgesic relief on present medications)
• How is this impacting your life?

2. Observations

• Facial expressions (grimacing, frowning, distorted expression, tears)
• Verbalizations (sighing, moaning, groaning, grunting, crying)
• Body movements (rigid, tense posture, guarding, restricted movement)
• Declining ability to perform activities of daily living (ADLs)

3. Screening Tests and Measurements

• Numeric (0= no pain, 10=worst pain imaginable)
• FACES (Wong & Baker, 1988)
• Categorical (none, mild, moderate, severe)
• Pain Assessment in Advanced Dementia Scale (PAINAD) for patients with severe to moderate cognitive changes

4. Physical Assessment: Standard physical examination with special focus on

• Each site of pain (older adults may have multiple sites and sources of pain) for:
• Radicular or radiating pain
• Pain with movement, respiration, range of motion, weight bearing
• Pain with light touch
• Any wound, rash, erythema, edema
• Firmness, rebound tenderness, masses

Nursing Intervention:

• At every visit, conduct a comprehensive assessment of pain with all routine nursing assessments
• Review all medications
• Assess for other barriers to in providing effective analgesia (e.g. cultural beliefs, misinformation – explanation of terms: tolerance, dependency, and addiction)
• Educate patient/caregivers about:
• Medication dosing and schedule (around-the-clock dosing, long acting preparations, short acting preparations, rescue and PRN meds, adjuvant analgesia)
• Route (patch placement, rotating injection sites, rectal, vaginal)
• Side effect management (constipation, sedation, confusion)
• Safety with activities (driving)
• Evaluate effectiveness and presence of side effects of medications
• Adjust pain management regimen with LIP, if indicated
• If patient not satisfied with current pain management regimen consider referral to:
• Pain and palliative care team
• Other pain relief services (radiation therapy, anesthesia interventions)
• Integrative medicine
• Provide for non-pharmacologic interventions of pain:
• Cognitive therapies – relaxation, guided imagery
• Massage
• Acupuncture
• Reflexology
• TENS unit
• Music therapy
• Exercise and physical therapy

Related Issues:

Quality of life, comfort, advance directives, autonomy, hospice

Why Palliative Care is Important:

Understanding the difference between palliative care and hospice care is essential; unlike Hospice, which is focused on end of life care, palliative care can be provided to aggressively manage symptoms while the patient is undergoing cancer therapy

• Palliative care is an approach that:
• improves the quality of life of patient and their families facing a life threatening illness
• addresses the management of the combined multiple interacting and distressing symptoms of advanced cancer and comorbid conditions
• There is a prevalence of poorly-managed symptoms as the patient progress towards the end of life (Ferrell, Coyle & Paice, 2015)
• A 2009 AARP study indicated that fewer than 4 in 10 surveyed knew of Palliative Care and that it was a Medicare benefit (Connor, 2009; Guengerich, 2009)

Normal Age-Related Changes:

• Frailty commonly associated with aging makes older adults with cancer vulnerable

Older adults with any of the following could benefit from Palliative Care:

Conditions

• Inadequate symptom control (pain, shortness of breath, fatigue)
• Undiagnosed depression and anxiety
• Multiple comorbidities
• Unaddressed family distress (Irwin & von Gunten, 2010)
• Increasing frailty                             
• Functional and cognitive impairments
• Insufficient caregiver support

Behavioral Risk Factors/Barriers to Implementing Palliative Care:

• Underreporting symptoms
• Discomfort with open conversations about death and dying
• Inability to accept poor prognosis / denial of disease severity
• Conflicting or ambiguous information from care givers, unrealistic optimism
• Eroding confidence and increased uncertainty with information provided
• Perceptual deficits (delirium, dementia, hearing & visual, language)
• Lack of/unaware of resources (social, financial, insurance, transportation)

Assessment:

1. Screening Questions

• How would you describe the quality of your life?  Of your family’s lives?
• What is important to you now?
• How is illness/treatment impacting your life?
• What symptoms are most bothersome to you?

Nursing Intervention:

• Ongoing symptom assessment and management
• Conducting family meetings to identify needs, inform, clarify, establish care goals and discuss advance care planning
• Anticipate/discuss/educate about the palliative nature of:
• Interventional procedures to alleviate symptoms
• Radiation, chemotherapy, surgery
• Facilitate transitions
• Foster healing relationships
• Assure  patient/caregiver participation in decision making
• Acknowledge/assure that cultural, religious and spiritual beliefs are respected
• Discuss prognosis, risks & benefits, legal right to comprehensive symptom management
• Discuss end of life options
• Hospice referral as appropriate

Bennett, M.I., Rayment, C., Hjermstad, M., Aass, N., Caraceni, A. & Kaasa, S. (2012). Prevalence and aetiology of neuropathic pain in cancer patients: a systematic review. Pain, 153(2), 359-365.
Breivik, H., Cherny, N. Collett, B., de Conno, F., Filbet, M., Foubert, A.J., Cohen, R., Dow, L. (2009). Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Ann Oncol, 20(8), 1420-1433.
Connor, S.R. (2009). Hospice and palliative care: the essential guide, second edition. Alexandria, Va.: Routledge.
Coyle, N.M., & Derby, S. (2006). Symptom management of pain. In D. Cope & A. Reb (Eds.), An evidence-based approach to the treatment and care of the older adult with cancer (pp. 397-438). Pittsburgh: Oncology Nursing Society.
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Ferrell, B., Coyle, N. & Paice, J.A. (2015). Oxford textbook of palliative nursing. Oxford: Oxford University Press.
Guengerich, T. (2009). Caregiving and end of life issues:  A survey of AARP members in Florida. Retrieved from http://www.aarp.org/relationships/grief-loss/info-02-2009/fl_eol_08.html.
Institute of Medicine (U.S). Committee on advancing pain research care and education. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.​ Washington, D.C.: National Academies Press.
Irwin, S.A. & von Gunten, C.F. (2010).  The role of palliative care in cancer care transitions.  In J.C. Holland, P.B. Jacobsen, & R. McCorkle (Eds.), Psycho-oncology (2^nd ed., pp. 277-283).  New York: Oxford University Press.
Maguire, P. & Weiner, J.S. (1989).  Communication with terminally ill patients and their families.  In H.M. Chochinov & W. Breitbart (Eds).  Handbook of psychiatry in palliative medicine (2^nd ed., pp. 157-171).  New York: Oxford University Press.
Wong, D.L. & Baker, C.M. (1988). Pain in children: comparison of assessment scales. Pediatric Nursing, 14(1), 9-17.