Pain Control in the Elderly
An elderly gentleman presented to the ER with severe upper back pain. He had fallen at home two weeks before this visit, but he reported his pain was only mild until awakening him from sleep that night. Initial X-rays after the injury were reportedly negative.
He was alert and ambulatory but in moderate distress from his pain, which was midscapular and worse with movement. He denied chest pain, shortness of breath, fever, vomiting, or neurological deficits. He was markedly kyphotic and mildly tender over the upper spine, with muscle spasm and tenderness to the paraspinal muscles as well. Vital signs, distal pulses and neurologic exam were normal.
After obtaining an ECG and IV access, a chest X-ray was performed which revealed a severe mid thoracic vertebral compression fracture.
I began by giving 2 mg of morphine intravenously every 5 minutes, to a total dose of 10 mg. Subsequently two additional 5 mg doses were required, as well as 15 mg of Toradol. He never became sedated, confused, or hypotensive, and his pain was completely controlled. He refused inpatient admission, and was not very receptive to the concept of percutaneous vertebroplasty, although I strongly recommended that he at least consider it.
I discharge such patients with oral morphine immediate release tablets so that the daily morphine dose required for pain control can be determined. After a couple of days, an extended-release narcotic can be added to provide more continuous pain control without the need for frequent dosing. If the patient's renal function can tolerate NSAIDS and there are no other contraindications, then an anti-inflammatory such as ibuprofen or naproxen is added as well. Discussion of potential side effects, including dizziness, constipation, and delirium is mandatory. I recommend early initiation of stool softeners and close followup.
He was alert and ambulatory but in moderate distress from his pain, which was midscapular and worse with movement. He denied chest pain, shortness of breath, fever, vomiting, or neurological deficits. He was markedly kyphotic and mildly tender over the upper spine, with muscle spasm and tenderness to the paraspinal muscles as well. Vital signs, distal pulses and neurologic exam were normal.
After obtaining an ECG and IV access, a chest X-ray was performed which revealed a severe mid thoracic vertebral compression fracture.
I began by giving 2 mg of morphine intravenously every 5 minutes, to a total dose of 10 mg. Subsequently two additional 5 mg doses were required, as well as 15 mg of Toradol. He never became sedated, confused, or hypotensive, and his pain was completely controlled. He refused inpatient admission, and was not very receptive to the concept of percutaneous vertebroplasty, although I strongly recommended that he at least consider it.
I discharge such patients with oral morphine immediate release tablets so that the daily morphine dose required for pain control can be determined. After a couple of days, an extended-release narcotic can be added to provide more continuous pain control without the need for frequent dosing. If the patient's renal function can tolerate NSAIDS and there are no other contraindications, then an anti-inflammatory such as ibuprofen or naproxen is added as well. Discussion of potential side effects, including dizziness, constipation, and delirium is mandatory. I recommend early initiation of stool softeners and close followup.
posted by scalpel at 1:14 PM
4 Comments:
You know, I have a really large number of elderly patients in the home health setting who won't take pain meds despite enduring horrible, chronic pain (and sometimes acute pain from falls and injuries). They seem to think that they should be "brave" and not take any sort of pain meds, not even NSAIDS. They also report fear of "becoming addicted" to narcotic pain meds. It saddens me to see so much pain. (And as I'm starting to develop a little chronic arthritis pain myself, I'm beginning to be even MORE sympathetic-- and am considering buying stock in Motrin and Tylenol....)
Poor guy. I'd take pain med for anything I just don't see the point of being in pain if you don't have to.
My best friend K is the total oppsite, she had a bike accident and broke her arm and jaw. She got up walked home, with the bike and didn't think she needed the hospital! People she passed ask if she needed help (she was bleeding from her chin and arm) and she told them she be fine. It wasn't till she was dragged to the emergency room and the x-rays came back that she said "so that's why it hurts so much". The Doctors just stared at her in disbelife
My grandmother, with multiple thoracic compression fractures, resisted morphine for a very, very long time out of fear of addiction. We finally convinced her that she could just take it for the rest of her life and not have to worry about the withdrawal when she went off the med, because she wasn't going to go off of it. (She was 90 at that time.) She took it and was pretty comfortable for her last couple years. But she worried the whole time about "when she stopped taking it."
Your grandfather, when he was dying of cancer, wouldn't take morphine (or any other narcotic)because he was "allergic" to it. Toward the end, he was so restless that he couldn't stay still, and still denied that he was in pain. I was in pain, just watching him, and asked his doctors to give him a small test dose of morphine.
The doctor asked him about his allergy, and he said that it gave him hallucinations: he thought everything in the room was made of white cake with vanilla icing. The doctor laughed and said "That's what it's supposed to do!" He gave him some morphine, and that was the end of the problem. He was comfortable for the rest of his life (only about two weeks), and had no side effects.
The relief of pain is one of the best gifts we can give.
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