May 142012

When I first started working in homecare my primary area was the drug district of the county. Crack was just coming onto the drug scene and the dealers would literally hold the bags of crack out hawking the price when I drove by. Once they learned that I was a nurse and in the area only to do a job they began watching out for me. But that is another story. I am telling you this so you will understand why Mrs. Boone and the director picked me to be their information source.

Mrs. Boone was a nurse who had come out of retirement when her husband retired. She was an older woman who always wore a skirt and did not work on Tuesdays because that was when her Bible study group met. She was the kind of person who never had to tell you she was a Christian and never judged anyone who was not. We all liked and respected her.

One morning as I arrived at work the director opened her office door and motioned me to enter. Sitting inside was Mrs. Boone. Before I could even say good morning, Mrs. Boone asked me, “Do you know where I can buy some pot?” My mouth literally hung open and I could not utter a single word. Mrs. Boone and the director both laughed at my reaction and I know it took me a full minute before I could say a word. That was the last question I expected!

Mrs. Boone usually volunteered to take on the most challenging of patients, one of whom was a young mother dieing of breast cancer. The mom was not handling the morphine well, could not eat and was always nauseated. Mrs. Boone had talked with the doctor and they had tried everything they knew. But the idea that Mrs. Boone would even consider recommending marijuana much less purchasing it herself was completely beyond my comprehension.

I told her to talk to the lady’s teenage daughter. She would know where to get it and if she got caught, the worst she would get would be a slap on the wrist. No way was I gonna buy it and I knew Mrs. Boone was not sneaky enough. I assumed she followed my advice because when I asked her later, the patient had acquired the pot and was doing well with it.

Our director was a former hospice nurse and she had seen how well marijuana worked for some people. It helps reduce pain, stimulates the appetite and lowers nausea. It also can produce a feeling of euphoria and help to combat depression. (I have to admit that I get somewhat amused at the literature that lists a feeling of euphoria as a side effect as if that is a bad thing.)

I once took care of a quadriplegic who saved the Valium his doctor gave him to control his severe muscle spasms for when he could not obtain pot. He claimed the pot worked better and he was concerned about becoming addicted to the Valium. And in all honesty, after I had seen the severity of his muscle spasms and how quickly the pot worked I only requested he not smoke it while I was there. AIDS patients, those with multiple sclerosis, sufferers of depression, people with Chron’s disease and whole list of other illnesses claim to be helped by smoking pot.

It is not legal to use marijuana for medicinal purposes in my state but that does not stop healthcare professionals from quietly recommending it to some patients. We look the other way when a patient tells us that they smoke pot because we understand that for some people, it really is a viable treatment option. We just do not admit that out loud.

Like any medication there is not guarantee that marijuana will help and is not without potential side effects such as paranoia, short-term memory impairment, difficulty learning, loss of coordination, increased heart rate or the exacerbation of an already existing lung condition. And of course the previously mentioned euphoria. Most of these, however, only last a short while.

Unfortunately, our current political climate is not conducive to scientific testing of pot and its usefulness, so most evidence is anecdotal. It may be just producing a placebo effect for those who claim it helps them. However, there is some research available and a website that offers a more balanced look at the use of medical marijuana.

Just remember, it is not legal for medical use in all states. If you live in a state where it is legal for medicinal purposes, you must have a prescription and most other states will not honor it. Also, it is still a federal offense no matter where you live.

May 132012

As stated previously, those who have dementia often cannot tell us they hurt verbally. That does not mean there are not other signs and symptoms. The Pain Assessment in Advanced Dementia (PAINAD) Scale was developed with these people in mind. Though it was designed for professionals, I think you will find it useful too.

The areas assessed are breathing, negative vocalization, facial expression, body language and consolablitiy. The scale is a simple 0-2 scale making it easy to use for anyone.

Breathing is rated as 0=normal. 1=Occasional labored breathing. Short period of hyperventilation. 2=Noisy labored breathing. Long period of hyperventilation. *Cheyne-Stokes respirations.

Negative Vocalization is rated as 0=none. 1=Occasional moan or groan. Low-level speech with a negative or disapproving quality. 2=Repeated troubled calling out. Loud moaning or groaning. Crying.

Facial Expression is rated as 0=Smiling or inexpressive. 1=Sad. Frightened. Frown. 2=Facial Grimacing

Body Language is rated as 0=Relaxed. 2=Tense. Distressed pacing. Fidgeting. 3=Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out.

Consolability is rated as 0=No need to console 1=Distracted or reassured by voice or touch. 2=Unable to console, distract or reassure.

Add the scores up for interpretation. Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score indicating more severe pain (0=”no pain” to 10=”severe pain”).

More information is available at the AMDA website.
If you would like to see this assessment in action there is a case study posted at the Nursing Center
There are videos of nursing students learning to use this assessment scale.

Make note of these assessment areas so that you can discuss this with your healthcare provider. Everyone deserves good pain control and you may find that negative behaviors decrease when pain is managed appropriately.

Other signs of severe pain include profuse sweating, hands and/or feet may be cold to touch. They may guard an area that is hurting by placing a hand over it in a protective manner. You may notice them reluctant to use a hand or move their arm beyond a certain point. They may limp or have an altered gain, especially if they have low back pain.

You may notice your parent has given up an activity they previously enjoyed, their grooming habits and/or housekeeping habits have declined. They may move slower or with more caution. They may spend more time lying around.

Poor pain management lowers the quality of life for the sufferer, shortens their lifespan and often leads to depression and even suicide. If your elderly parent is suffering with pain, please be an advocate for them if they can not do so themselves. This is one area of their lives you can really help them.

*Cheyne-Stokes respirations refers to an abnormal breathing pattern characterized by respirations becoming progressively deeper and faster, followed by a progressively shallower and slower breathing that stops temporarily. The pattern repeats in cycles lasting from 30 seconds to two minutes and is often seen near death.

May 122012

As I said in Part I, chronic pain serves no purpose. But what exactly is chronic pain? Chronic pain is defined as pain lasting 6 months after the body has healed. There are many causes of chronic pain including nerve damage, certain diseases, bone pain, muscle spasms, and circulatory problems; just to name a few.

Pain is measured as mild, moderate or severe by the World Health Organization. Healthcare professionals will often ask you to rate your pain on a scale from one to ten, with ten being excruciating and one almost no pain. They may have you point to a face on the pain scale that represents how you feel. With acute pain there are often physical signs such as elevated pulse and blood pressure. This is not always the case with chronic pain which sometimes leads sufferers to be labeled as malingering or drug seekers.

As a society we are very judgmental about chronic pain sufferers. We tend to judge them as lazy, attention seeking or drug-seeking. Many people will suffer rather than deal with the judgment they receive when they seek help. We are so busy judging we forget there are other things that will also help alleviate pain.

Though I started out this series on a rant about using narcotics, they are a last choice and should be used as little as possible while still maintaining a high quality of life. Narcotics are not without side effects including nausea, vomiting, constipation, confusion, hallucinations, and increase risk for falls to name a few. A lot of times the elderly will avoid taking narcotis because of the side effects.

With that in mind, there are other alternatives that should be explored as part of your elderly parents pain management regime such as: physical therapy, chiropractor treatments, nerve blocks, Lidoderm patches, heat, cold, massage, acupuncture, meditation, exercise etc. should all be considered in addition to medication. Anti-inflammatories and non-opioid analgesics such as tramadol are also good alternatives. But when none of those works, please, let us give our parents the drugs!

As I said in Part I of this dissertation on pain, if you or a loved one has chronic pain find a doctor who specializes in the management of pain. They have ideas and treatments that your medical doctor has not heard about. I am not going to tell you they can alleviate the pain completely, but how different would life be if the pain level dropped from a nine to a five? For my mom, it is a huge improvement in her quality of life.

The really sad part of all this is those who can not tell us they hurt. In those who have dementia or confusion it is often difficult to tell if they are in pain. In the third article in this series we will look at a pain scale designed especially for those patients and I will give you some references that I think you will find useful.

In the meantime, here are some organizations that deal with chronic pain and have information that you may find helpful:

American Chronic Pain Association Make sure you look at the 2011 Guide to Pain Management and Treatment and Using Opioids Safely

American Pain Foundation

American Pain Society

May 112012

Pain management in the United States is terrible! This is especially true of the elderly and it is a pet peeve of mine so please forgive me if I go off on a rant. I have fought this battle for more than one patient and my own mother and I find it frustrating that I am still fighting it in this day and time.

I do not know if healthcare professionals realize how severe chronic pain can be or if it is fear of reprisal from our current anti-drug environment but it is past time for people to come into the twenty-first century and take advantage of the resources available to them. With the knowledge and the medications available to us there is no reason for people to suffer in pain. To do so is not only unethical in my opinion but cruel.

Pain is often called the fifth vital sign and I really wish that professional caregivers would check it at least as often as they do the other vital signs. While acute pain serves to tell us something is wrong and prevent further injury, chronic pain serves no purpose and can have severe consequences. A person living with chronic pain is often depressed and even suicidal. Their quality of life is lower, they lose strength due to lack of activity and normal activities become harder.

When in pain, the surrounding musculature tightens, exacerbating the pain. To make matters worse, as the pain goes on the nerve fibers get even better at transmitting the painful impulses and the brain signals the pain intensity up trying to get your attention. The result is that even though the pain might not be any worse your pain level is! It quickly turns into a vicious cycle.

While the goal of acute pain is to alleviate it, this is seldom possible with chronic pain. The best you can hope for is to control it. This means it needs to be treated just like any other chronic condition such as diabetes or hypertension with diet, exercise and daily medication. Unfortunately this is not what happens.
Some doctors are reluctant to use powerful pain medications known as opioids (also known as narcotics) to treat pain even when non-opioid medications have not worked. As one doctor told me; the more you take, the more you need. My response was, “So?” Elderly people in particular are leery of using narcotics because of either the side-effects or fear of addiction. We fought for years to get past this same mentality for cancer patients but we have made very little progress for those suffering from chronic pain.

Even doctors are afraid of making an elderly person addicted. Really? The ignorance on this subject is amazing in part fostered by our government anti-drug campaign. (That is the subject I will address in the future). The truth of the matter is that if you are in real pain you will not become addicted to pain medication. That is as silly as my grandma not wanting to use her oxygen for fear of becoming addicted to oxygen.

Am I comparing pain medication with oxygen as necessary for life? If you are in chronic pain, then yes I am. When you live in pain your body is in constant stress, producing chemicals that literally damage your heart as well as the rest of your body, not to mention the mental and psychological toll. I said it before and I will say it again, there is no benefit to chronic pain. It can in fact lead to an early death.

In their defense doctors live in fear of investigation if they prescribe too many narcotics and I do understand that. Even if they do not get fined or lose their license, their reputation is affected as well as the time, aggravation and financial strain of defending themselves.

As a society we have decided it is more important to prevent a drug-seeker from getting their fix than to alleviate the pain and suffering of someone whose only relief comes from narcotics. Because of our backwards priorities, we are letting good people suffer.

If your elderly parent is suffering from chronic pain, be an advocate for them. Talk with their doctor and if you do not get the results you want, get a referral to a pain specialist. Medication is not the only answer but it is one that needs to be included.

Next up, some things to try before you try narcotics.