492. SECTION 5 / NEUROLOGIC DISORDERS body movements (tailing of limbs and pulling legs in), wth drawal, and change in eating and sleeping habits.* Preschool children experiencing pain may become cling, lose motor and verbal sls and start to deny pain because tretment may be linked to dicomifort or punishment. School-age children may exhibit aggressiveness nightmares, aniety and withdrawal wien in pain, while adolescents may respond to pain with opposi- tional behavior and depression. Hey Most ofthe previously discussed pain scales can be wsed in older persons that are cognitively intact or withmild dementia “The pa thermoricter and FACES of pain have been staid in ‘older persons. In persons with moderate to severe dementia or those wo are nonverbal, servation of pain behaviors sach as guarding or grimacing, provides an alternative for pain asess- ‘ment. The Pun sessment in Advanced Dementa (PAINAD) tool may e used to quanti signs of pain and imolves obseving the older adult fr 15 minutes for breathing, negative vocaliza- tions, facial expresion, body language, and consolabiity* Regards of which pain assessment too is wed, the practioner should fist determine ifthe patent understands the concept of the scale to ensure reliability ofthe insrument. TREATMENT General Approsch to Treatment © Bective treatment imolves an evaluation of the cause duration, and intensity of the pain and election ofan appropiate treatment modaliy for the pain situation. Depending on the type of pain, trestment may involve pharmacologic or non- pharmacologic therapy or both. General principles for the ‘pharmacologic management of pain are listed in the section 60n patient care and monitoring. Two common approaches to the selection of treatment are based on severity of pain and the mechanism responsible fr the pain (Fig. 30-2). Cimical practice guidelines for pain management are available from the APS, the Agency for Healthcare Research and Quality (AHRQ), the American Geriatrics Society (AGS), ané the ‘American Society of Anesthesiologiss (ASA), Selection of Agent Based on Severity of Pain © Whenever posible, the lout potent oral enalgesi sould esata ‘Guidelines forthe selection of therapeutic agents based on pain imensity are derived fom the World Healt Organization (WHO) analgesic ladder for the management of cancer pain (Tabie30-1),* a to moderate pan generaly Ueated with non-opioid anakesics. Combinations of medium-potency opioids and acetaminophen oF non-steroidal anti-inlarama- tory rags (NSAIDs) are olen used for modercte pain, Potent opioids are recommended for severe pai. Throughout this pYogresion adjurant medications sxe added as needed to ‘mahage side effects and to augment analgesia. While these Part 1 HPL 1h ia S-yearold male rece dhagnosed with ang cance Following surgery he was placed on morphine patient. ‘onvolled analgesia PCA. He has been using 120 mg. ‘morphine/24 hours with adequate pain contra. PMH Hypertension x 18 years rH Non-centibutory SH Lives with wie: hae four grown cildhon emoked packs of cigates per day > 40 years (quit with diagmsis of larg cancer) Meds HipbonhNonthiatih 25 eg enya Pain assessment: Patint rates pain a5 8 on a scale of 1 to 10. “The physician would like to convert him toa combinaticn preperation of oxycodone and acetaminophen, What dos- ing regimen wauld you + Six months lata, BAS pain is contcled withthe escalat ing doses ofthe combinaion product; however, he has reached the macimum dese of acetaminophen, What ‘would you suggest at this time? ‘guidelines canbe useful fr initial therapy, the clinical situation (type of pain; cos and pharmacokinetic profile of availible drugs; and patient speci factors (age, concomitant illnesses, previous response, nd other medicatons) mus also be con- sidered. Pain medications may also be used in the absence of| ‘pain in anticipation of a painful event such as surgery to min- ‘mize peripheral and central sensitization, ‘Mechanistic Approach to Therapy (Carrent analgesic therapy i aimed at controling or blunting pain symptoms. However, dierse mechanisms contributing to ‘the varius types cf pain continue to be further elucidated. An ‘understanding of these new mechanisms of pain transmision ‘may lead to improvement in pain management, as pharmaco- logis management of pain becomes mors mechanism speci. Use of NSAIDs for inflammatory types of pain isan example of ‘a mechanistic approach, Since several mechanisms of pain often ‘o-2xist2 polypharmacy approach seems rational to target each mechani, ‘Two current foi in pain management ate to identity the ‘mechanisms that ae responsible fr puin hypersensitivity and to prevent this intial hypersensitivity Therefore, the god of pain therapy i to reduce peripheral sensitization and subse- ‘quent central stimulation and amplification associated with ‘wind-up spread, and central sensitization.”CHAPTER 30 / PAIN MANAGEMENT. 493 FIGURE 30-2, Pain algorithm. AED, antiepileptic drug: APAP, acetaminophen; NSAID, nor-stroidal atin flammatory drug: SNRI,serotonin-norepinephrine reuptake inhibitor, SSRI, selective serotonin reuptake inhibitor TCA, tricyclic antidepresrant. Nonpharmacologic Therapy Nonpharmacologic therapies (psychological interventions and physical therapy) may be used in both acute and chronic pain, Psychological interventions can reduce pains well as tne anxiety, depression, far, and anger associated with pan. Psychological interventions helpful in management of acute pain are imagery (picturing oneself in a safe, peacetl place) and distraction (istening to music or focusing on breathing). CChronic pain patients may benefit ftom relaxation, biofeed. ‘back, cognitive behavioral therapy, psychotherapy, support TABLE 30-1. Selection of Analgesics Based on Intensity of Pain” ‘groups, and spiritual counseling. Biofeedback teaches patients ‘to control physiologic responses to pain and has been effective in headache and chronic low back pain. Cognitive therapy ‘encourages patients to monitor their perceptions of pain, reducing stress and negativism. Psychotherapy is very useful for patients with chronic pain, and it can also assist in treat- ‘ment of psychiatric comorbidities and help patients to deal with terminal inesss.%* The patient should be educated about what to expect regarding pain and its treatment ‘whether pain is acute (Le., preoperative explanations of Corresponding WHO Therapeutic ‘samples of ial a baal Wut at ox i Comments. Mild 1370 Non-opioid analgesic regular Acetaminophen 1000 mg ‘Consider adding an ‘chedled doting fever & hou; upon ‘june or using {500 ng every 6 hours an alternate regen if pain snot duced in days Moderte 4.610 ‘Add an opi othe ‘Acctaminophen 325 mq + ‘Consider step-up therapy ‘onpoidfor moderte ‘codeine 6m evey i pain ent releved pain regular scheduled ‘Thours: Acetaminophen by greater anor dosing 325 mg + oxycodone al 2 or more Simgevery # hours ruse severe za010 switch 3 hi Morphine 10 mg every enolase soe Thess puoi Sosing 4 mgevery hour ‘WHO, Word Heath Onanizaton,