Pain Assessment and Management
Assessment
Patient self-report is the gold standard. Ask about location, quality, timing, radiation, aggravating and relieving factors, incident pain, and functional impact. Neuropathic pain is often burning, shooting, or electric. In advanced dementia, use a validated observational tool such as PAINAD and look for facial grimacing, guarding, and changes in behavior. Total pain includes physical, emotional, social, and spiritual contributors. A common trap is assuming that a patient with dementia, or one who is asleep, has no pain, or that normal vital signs exclude pain.
Pharmacologic management
Treat by severity. Mild pain may respond to acetaminophen or cautiously used NSAIDs. Moderate to severe pain usually requires opioids. Start short-acting opioids, titrate to effect, and provide a breakthrough dose. Before rotating opioids, calculate the total daily dose, convert using an equianalgesic table, reduce by 25 to 50 percent for incomplete cross-tolerance, and reassess frequently. Avoid morphine in advanced renal failure because metabolites accumulate and cause neurotoxicity; hydromorphone and fentanyl require caution too. Avoid meperidine. Transdermal fentanyl should be used only in opioid-tolerant patients. Add adjuvants for neuropathic pain, such as gabapentinoids or selected antidepressants. Prescribe a bowel regimen with opioids.
Traps
Underdosing because of exaggerated addiction fears is common; pseudoaddiction can mimic drug-seeking behavior when pain is undertreated. Do not forget to premedicate before painful procedures or incident pain. Do not use NSAIDs in renal failure or peptic ulcer disease. Do not forget naloxone counseling for high-dose or high-risk opioid patients.
Rule of thumb
For severe pain, titrate rapidly and reassess; for frail older adults, start low and go slow. Always calculate the total daily opioid dose before converting, and never simply swap drugs milligram for milligram.