Blog – Coleen P. Kenny

So let’s start talking about types of pain and their management.

Foremost, I see a lot of arthritis pain. Even this needs to be broken down. Osteoarthritis (OA) is from “wear and tear” on the joints and affects us all. Rheumatoid Arthritis (RA) is caused by inflammation in the body and impacts the whole body, not just the joints. I’ll cover RA later.

OA—“oh my aching back/knees/hips/shoulders/etc” is the most common reason for pain. Due to repetitive use, misuse, poor alignment/posture or body mechanics, overweight, or even underuse, joints lose their protective glide. And pain happens.

In OA, the pain is chronic, stiff, and achy; redness, heat, and swelling are not common. The achy/stiff is usually worst in the morning, improves as you move, and returns later as joints fatigue.

The worst thing you can do is to stop moving! Sitting still increases the stiffness.

The best things you can do:

1. Lose weight; every little bit counts. Our hips and knees are designed to carry a weight specific to our body structure. Extra stresses the machine.
2. Put your pocketbook on a diet. Slinging a heavy purse, tote or book bag over one shoulder is a recipe for poor posture and shoulder strain and pain.
3. Move! Yoga is excellent for keeping the joints gliding and working on posture and mechanics. Walking is great for keeping us limber and fit. Whatever you can do helps.
4. Try heat or ice or IcyHot or Ben Gay; you may need to try a few.
5. Tylenol. Great medication, BUT just because you can buy it with your soda and toothpaste doesn’t make it totally safe. Don’t use it if you drink alcohol (both are processed by the liver), and don’t use more than 3000mg/day; that’s 6 Extra Strength. And be careful of the “acetaminophen” in cold or sleep medications; count those toward your 3000/day total.
6. Avoid NSAIDs (Ibuprofen, Aleve, Motrin, Advil). OA is not inflammatory and that’s what these are made for. They can cause blood pressure to rise or a bleeding ulcer.
7. If your insurance will cover, a Physical or Occupational Therapy consult helps a great deal with body mechanics and strengthening.

1-7 apply to all of us, not just the older folks I care for. Their joints are beyond Tylenol, and often we prescribe a low dose narcotic, such as Vicodin. Families get concerned about addiction, but we’re very careful about how much we use and monitor the effect. And I refer families to the complications of not treating the pain (See post #10).

Joint injections by a qualified physician are an option, as is joint replacement, but I will not cover those here. Let me know if you have any questions, comments, or concerns!

As I’ve said, pain management is one of the most challenging yet most rewarding tasks I tackle as a Nurse Practitioner. Last week I provided a tool for the assessment of pain. Today I want to talk about why pain management is important and why treatment isn’t always adequate.

First, why is pain management essential in the elderly? Well, you may say, no one wants to hurt. True. Quality of life is essential. And most people with pain report depression, insomnia, and anxiety. In turn, depression and insomnia exacerbate pain. The cycle can be vicious.

But it’s not just about feeling good. A person with cognitive changes may not be able to say “I hurt.” They may just act out with wandering, combativeness, resisting care, or rocking back and forth. As I tell my students, “If I hurt and can’t tell you, and you try to get me dressed or out of bed, I will slug you.”

Unfortunately, if a cause for the behavior is not found, the person may end up being sedated. They’re quiet and compliant, but still hurt.

If the pain is great enough, the person may stay very still which leads to skin breakdown (pressure ulcers). As the person holds a position, often rigidly, the muscles tighten leading to contractures and weaken leading to falls and possible fractures. Pain interferes with therapy after an injury. Appetite decreases and so does weight.

So why don’t we do a better job treating pain in the elderly?

Sometimes people don’t tell us they hurt; “Oh, it’s just part of aging”…I do my best to set that record straight. Sometimes no one asks. If the person can’t communicate, like I said above, the cues are missed and mistreated. Or maybe the last time pain was treated, it didn’t work and the person doesn’t want to try again.

Time is a huge issue; some providers see a patient every 7 minutes—how well can pain be assessed? Medication costs, side effects, and drug interactions factor in. Provider knowledge isn’t always up to date on the many treatments are available.

Families don’t always believe that mom or dad is in pain even when the person says so. I’ve had people tell me to discontinue pain medications because they were afraid the parent or spouse would get addicted.

But as my coworkers would tell you, I treat pain as aggressively as a Cardiologist treats a heart attack. So I assess and I treat, and I reassess, and I educate. (And I speak!)

Next time, I will cover some specific treatments for different types of pain. Feel free to contact me with any questions you have!
–Coleen Kenny
Nurse Practitioner/Speaker/Geriatric Expert

(Golden Lassos refers to heartstrings of gold stronger than any lasso Wonder Woman ever owned which bind me to my elderly patients.)

My soapbox led me to post on Facebook, “If you could ask a geriatric expert a healthcare question about your aging parent or grandparent, what would it be?”

This is the first question and answer in what I hope becomes a blog series useful to all those struggling…

Q: How do you get patients motivated to get up and move around without getting them upset?

My mom is having this problem with my grandma. When my mom tries to get her out of bed, my grandma gets upset with my mom and then it’s hurt feelings all around.

My grandma is 87 and used to doing everything herself so i am certain she has got to be struggling with having to depend on someone to take care of her. Her broken arm is healing well, but I’m sure she is stiff and achey just from being 87!

The staff at the rehab hospital don’t have any ideas, and they are going to discharge her in the next week or two, so this information is going to help my mom when she brings grandma home… and me when my parents need care!

Some ideas to make it less stressful for everyone would be great!

A: My answer is threefold for this complex and not unusual situation.

1. Is her pain managed?

You hit the nail on the head when you mentioned “stiff and achey just from being 87.” Her arm may be healing well, but generalized pain is often overlooked. The frail elder may be comfortable lying still in the bed, but try to move those stiff old muscles and bones, and it hurts. In the hospital, nursing home, or at home, we need to assess pain during movement and not just at rest!! Then one key is timing the pain medication 45-60 minutes before therapy or getting up for the day.
Pain management in the frail elderly is a complex topic, and I will discuss it in a future blog.

2.Depression must be treated!

Anyone in a hospital or rehab loses both function and control; add pain into the mix, and your grandma has every right to, and every likelihood of, a clinical depression.

This depression is not something you or your mom or the staff can pep talk her out of or hug away or tell her to get over, or as one of my patient’s sons did today tell her, “There are people a lot worse off than you.” (I almost kicked him in the shin!)

There are new excellent anti-depressants with fewer side effects than ever before available; I have three medications of choice with my LOLs (little old ladies) depending on other factors such as appetite and pain. Again, in the interest of blogging brevity, depression in the frail elderly is another day’s topic, but please note I do not use fluoxetine (Prozac), paroxetine (Paxil), or sertraline (Zoloft) in my frail elder patients.

3 Medical issues must be considered.

Is she uncomfortable due to constipation? Does she have a bladder infection? Is she dizzy when she gets up? Dizziness can be due to several issues but blood pressure should be checked lying, sitting, and standing (if standing is tolerated) and reported to the doc or Nurse Practitioner.

And finally, and yes, fourth-fold, sometimes the family member has to stop pushing. A dignity/control issue may develop with a “Who is the parent?” scenario. I acknowledge this becomes more difficult if your mom will be taking her home.

My thoughts and prayers are with my friend who sent this question, and with each of you reading this blog. Please pass it along if you find it useful, and be sure to comment and send me your questions!

—Coleen