Table 2.

Analgesic Trial for Suspected Pain in Non-communicative, Cognitively Impaired Older Adults

Initiate an empiric analgesic trial if: Pathologic conditions likely to cause pain exist. Procedures likely to cause pain are scheduled. Behaviors suggest pain (assessed by a pain behavior tool). Pain behaviors continue after attention to potential causes of pain, delirium, and/or agitation. Pain behaviors continue after attention to basic needs and comfort measures. Pain behaviors do not respond to complementary therapies (i.e., non-drug interventions). Proxy (i.e., personal care assistants, family, or caregivers) reports previous chronic pain, behaviors indicative of pain, or changes in function.

Provide a step-wise analgesic trial and titration appropriate to the estimated intensity of pain based on instances above, severity of behaviors, analgesic history, and prior assessment. Step 1a: Administer Acetaminophen 500 to 1000 mg every 6 hours for 24 hours, not to exceed 3000 mg in a 24 hour period in frail elder. If the oral or rectal route is not an option, IV acetaminophen (Ofirmev 15 mg/kg every 6 hours or 12.5 mg/kg every 4 hours). Step 1b: If behaviors or function improve, assume pain was cause, continue analgesic as a routine medication, add appropriate complementary interventions, and document assessment. Step 2a: If behaviors continue, consider topical lidocaine for suspected neuropathic pain or topical NSAID if pain is localized, then observe the effect. Step 2b: If behaviors continue, consider a single low dose, short-acting opioid (e.g. hydrocodone, oxycodone, or morphine), then observe behaviors. Step 2c: If no change in behavior, titrate opioid dose upward by 25% to 50% until a therapeutic effect is seen, bothersome side effects or adverse effects occur, or no benefit is determined. Step 3: If there is no benefit from opioid titration and behaviors persist, consider buprenorphine transdermal patch 5 mcg/hour, with a maximum dose of 10 mcg/hour. Step 4: If no change in behavior and neuropathic pain suspected, consider pregabalin 25 mg per day, with a maximum dose of 300 mg per day. Step 5: Explore other potential causes if behaviors continue after reasonable analgesic trial and/or consult a pain management specialist.

© 2014 Herr K, Booker S, Bartoszczyk D. “Analgesic Trial for Suspected Pain in Non-communicative, Cognitively Impaired Older Adults.” Adapted and used with permission from Herr K, Coyne P, McCaffery M, et al. Pain assessment in the patient unable to self-report: Position statement with clinical practice recommendations. Pain Manag Nurs. 2010;12(4): 230-50.