Special Concerns in
Caring for the
Elderly Adult
Pain Management
Violence and Elder Mistreatment
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Scenario….
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S. T. is a 68 year old female who comes alone to your E.R..
She complains of shortness of breath.
Vitals: Ht. 65” Wt. 101 lbs BP 155/84 Pulse 88
When electrodes are placed for an EKG, you notice bruising
across her chest.
• Her son comes in and states, “You fell down the stairs, again,
didn’t you, Mom?”
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What is pain?
• Pain is an unpleasant feeling often caused by noxious or
injurious stimuli
• Pain usually prompts the person to withdraw from the cause
of the pain and avoid it in the future
• Most pain resolves promptly once the cause is removed
• Other types of pain continue (chronic)
• At times pain occurs without any recognizable cause
• In the United States, pain complaints prompt the majority of
all doctor visits
• Pain is costly
• Pain can negatively affect a person's quality of life
• Psychological and social factors can affect the nature of pain
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Persistent pain in the elderly is
associated with…
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Functional impairment
Falls
Slow rehabilitation
Depression
Anxiety
Decreased socialization
Sleep disturbance
Increased healthcare utilization and costs
The Joint Commission on Accreditation of Healthcare
Organizations has mandated pain screening noting pain “the
fifth vital sign.”
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Importance in the care of the
elderly
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Painful conditions are common in this population
Undertreatment is common
Patients with dementia may not express pain effectively
Fear of “addiction” is common
Some believe unrelieved pain is to be expected
Lack of routine pain assessment
Ineffective methods of
assessment
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Duration of pain
• Acute pain—resolves quickly
• Chronic pain definition is arbitrary…
• More than 30 days
• 3 months
• 6 months
• Some say the transition from acute to chronic pain occurs at
12 months
• Chronic pain is sometimes classified as:
• Cancer pain, or,
• Benign pain
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Types of pain
Nocioceptive
(tissue
trauma)
Neuropathic
(damage to
CNS)
Visceral
(internal
organs)
Diabetic
neuropathy
Somatic
(muscles &
joints)
Post-herpetic
neuralgia
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Nocioceptive pain
• Nocioceptors are nerve cell endings that initiate the sensation
of pain
• They respond to stimuli that threaten to cause harm to the
individual
• Examples are
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Heat
Cold
Crushing or tearing
Chemical injury
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Neuropathic
• Pain caused by injury to the nervous system itself
• Described as
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Burning
Tingling
Electrical
Stabbing
Pins and needles
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Phantom pain
• Pain experience a part of the body that is no longer
• Type of neuropathic pain
• Common in amputee patients
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Psychogenic pain
• Pain affected by
• Mental,
• Emotional,
• Behavioral factors
• Sometimes include specific
situations with no other
identifiable cause…
• Headache
• Back pain
• Stomach pain
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Breakthrough pain
• Pain that “breaks through” a patient’s normal pain
management dosing
• Comes on suddenly
• Common in patients managed for cancer pain
• Alternating pain medicine dosing sometimes helpful
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Incident pain
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Episodic increase in pain intensity
Can come from a specific activity
Or, not related to any activity
Arthritic joint
Bumping an injured site
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Acute pain in older adults
• Similar to acute pain in other populations
• Also due to exacerbations of chronic conditions
• Situations to which they are more at risk:
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UTI
Decubitus ulcers
Pneumonia
Constipation
Injury due to diminished protective mechanisms
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Chronic pain in older adults
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1 in 5 patients age 65 or older
Generally lasting >3-6 months
All are candidates for pharmacological therapy
Exacerbated by depression
Can create a vicious cycle
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Pain causes among older adults
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Osteoarthritis and rheumatoid arthritis
Spinal stenosis
Peripheral neuropathy
Post-herpetic neuralgia
Fibromyalgia
GERD
Peripheral vascular disease
Headache
Post-surgical pain
Pressure ulcers
Angina, cardiac disease
Cancer pain, pain of treatment
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Process of hyperalgesia
(increased sensitivity to pain)
Pain is left untreated
Nociceptors more responsive
Increased sensitivity to pain
Exaggerated pain response
Further complaints may be ignored
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Assessing pain in the older adult
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Pain intensity (0-10)
Pain frequency
Pain location (use the “one finger” rule)
Duration
What makes it better?
What makes it worse?
What are the effects on his or her functional level?
Continue to assess until acceptable level of relief has been
achieved
• Assessment must be documented to be complete
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Special cases…the patient with
dementia
• Need to rely on cues other than verbal communication,
including…
• Facial expression
• Vocalizations
• Body movements
• Change in person-person interaction
• Change in activity patterns
• Mental status changes
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Pain management plans
• Include both acute and chronic pain
• Include both pharmacological and nonpharmacological
interventions
• Must be individualized
• Must be titrated, i.e., provided based on the level of pain
reported or the level of pain assessed if the patient is
nonverbal
• Start with smaller doses to avoid toxicity
• Consider oral route first
• Often involves “rational polypharmacy”
• 2 or more drugs in combination with
• Complementary therapy
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Pharmacological management
Analgesics
Nonopioids
Opioids
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Opioid use in the older adult
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Great efficacy in moderate to severe pain
No maximum dose
Can be used for long periods of time
Minimal organ damage
• Some are inappropriate for the
elderly adult:
Meperidine—confusion, seizures
Propoxyphene—delirium, ataxia,
dizziness
(withdrawn)
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Adverse side effects of opioids
• Constipation
• Sedation
• Respiratory depression
• Nausea and vomiting
• Myoclonus
• Pruritis
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Considerations in opioid use
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Titrate slowly
Bowel regimen to prevent constipation
Watch for signs of sedation and protect patient
Monitor for respiratory depression, provide O2 if necessary
Antiemetics for nausea/vomiting
Use antihistamines cautiously for pruritis
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Definition of elder abuse
• The physical or psychologic mistreatment, neglect, or financial
exploitation of the elderly.”
• Several types of abuse are common
• Each type may be intentional or unintentional
• Perpetrators are usually spouses or adult children
• May be other family members
• Paid or informal caregivers
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Physical abuse
• “The use of force that results in physical or psychological
injury.”
• Includes striking, shoving, shaking, beating, restraining and
improper feeding
• May include sexual assault, i.e., any
form of sexual intimacy without
consent or by force or threat of force
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Psychologic abuse
• The use of words, acts, other means that cause emotional
stress or anguish
• Includes threats (e.g. of institutionalization), insults and harsh
commands
• Remaining silent
• Ignoring the person
• Infantilization: encouraging
the victim to become
dependent on the abuser
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Neglect
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Failing to provide essentials
Food
Medicine
Personal care
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Financial abuse
• The exploitation of or inattention to a person’s possessions or
funds
• Includes swindling
• Pressuring a person to distribute assets
• Managing a person’s money irresponsibly
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Healthcare fraud and abuse
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Duplicate billings for the same medical service or device
Evidence of overmedication or undermedication
Evidence of inadequate care when bills are paid in full
Problems with a care facility
• Poorly trained, poorly paid or insufficient staff
• Crowding
• Inadequate responses to questions about
care
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Epidemiology of elder abuse
• True incidence is unclear
• Appears to be a growing public problem in the USA
• One large study showed 3.2% of individuals ≥ 65 years were
victims of physical abuse, psychologic abuse or neglect
• Study did not include financial abuse
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Risk factors for elder abuse (1)
• Chronic disease and or functional impairment of the victim
• The elder person’s ability to escape, seek help and defend himself
is reduced
• Social isolation of the victim
• Abuse of isolated persons is
less likely to be detected
and stopped
• Cognitive impairment
• Persons with dementia may
act aggressively and
disruptively, precipitating
abuse
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Risk factors for elder abuse (2)
• Substance abuse
• Alcohol or drug abuse
• Psychiatric disorder
• Schizophrenia, other psychoses
• Patients discharged from an inpatient
facility may return to their elder parents’
home for care
• These younger patients may become
violent at once at home
• History of violence
• History of violence in a relationship and outside the family may
predict abuse
• Violence is a learned response to life challenges
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Risk factors for elder abuse (3)
• Dependence of abuser on victim
• Financial support, housing, emotional support
• Family member’s attempts to obtain resources from elderly
person can result in abuse
• Dependence can produce resentment
• Stress affecting abuser
• Chronic financial problems
• Death in the family
• Responsibilities of caregiving
• Shared living arrangements
• Opportunities for tension and conflict are greater
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Difficulty of diagnosis
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Many signs are subtle
Victim often unwilling or unable to discuss the abuse
Shame
Fear of retaliation
Desire to protect the abuser
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Failure of healthcare
• “Ageist” response from nurses, doctors, others
• Dismiss complaints of abuse as:
• Confusion
• Paranoia
• Dementia
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Social isolation and identification
of abuse
• Abuse tends to increase the isolation
• Abuse limits the victim’s access to the outside world
• Denies visitors
• Refuses telephone calls
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Obtaining the history
• If abuse suspected, client should be interviewed alone for at
least part of the time
• Others may be interviewed separately
• Include general questions about feelings of safety
• If offered, note nature, frequency and severity of abusive
events
• “Do you have family or friends
who are willing to nurture,
listen, and assist you?”
• (More practicable) “Do you feel
safe at home?”
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Interview with family members
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Avoid confrontation
Explore if caregiving responsibilities are burdensome
Acknowledge the caregiver’s difficult role
Are there any recent stressful events?
Interview patient, family member separately
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Situations suggesting elder abuse
(1)
• When there is a delay between the injury or illness and the
seeking of medical attention
• When the accounts of the patient and the caregiver do not
agree
• When the severity of the injury does not fit the explanation
given by the caregiver
• When the explanation of the
patient or caregiver is implausible
or vague
• When visits to the emergency
department for chronic disease
are frequent despite appropriate
care and adequate resources
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Situations suggesting elder abuse
(2)
• When a functionally impaired patient presents for care
without a designated caregiver in attendance
• When laboratory findings are inconsistent with the history
• When the caregiver is reluctant to accept home health care or
to leave the elderly person alone with a health care
practitioner
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Signs of elder abuse (1)
• Behavior—withdrawal by the patient infantilization of the
patient by caregiver; caregiver insists on giving history
• General appearance—poor hygiene, inappropriate dress
• Skin/mucous membranes—signs of dehydration, multiple skin
lesions, bruises, pressure ulcers, deficient care for skin
problems
• Head and neck—traumatic alopecia
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Signs of elder abuse (2)
• Trunk—bruises, welts (shapes may suggest implement)
• Genitourinary area—rectal bleeding, vaginal bleeding,
pressure sores, infestations
• Extremities—wrist or ankle lesions suggesting restraints or
immersion to burn
• Musculoskeletal—occult fracture, pain, gait disturbances
• Mental and emotional health—depression, anxiety
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Roles of nursing and social work
• Members of interdisciplinary team
• May be appointed as coordinator to ensure pertinent data are
recorded correctly
• Relevant parties are contacted and informed
• Necessary care is available 24 hours per day
• Inservice education on elder abuse
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Reporting elder abuse
• Reporting of suspected or confirmed abuse is mandatory in all
states if abuse occurs in an institution
• Mandatory in most states if it occurs at home
• Adult protective services
• Burden of proof does not rest on the reporter
• Reporting suspected abuse without claim of abuse
• May be anonymous
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Formal evaluation
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What is your nursing diagnosis for S. T.?
What is your desired outcome?
What steps will you take?
What are your appropriate interventions?
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