Managing Cancer Pain in Elderly Patients

By: Uray Ria Aprini S.Ked

Supervisor: dr. Achmadi Eko Sugiri Sp.PD
 Background
Pain in older cancer patients is a common event, and many times it is undertreated.
Barriers to cancer pain management in the elderly include concerns about the use of
medications, the atypical manifestations of pain in the elderly, and side effects related
to opioid and other analgesic drugs.
The care of older cancer patients experiencing pain involves a comprehensive
assessment, which includes evaluation for conditions that may exacerbate or be
exacerbated by pain, affecting its expression, such as emotional and spiritual distress,
disability, and comorbid conditions.
It is important to use appropriate tools to evaluate pain and other symptoms that can
be related to it. Pain in older cancer patients should be managed in an
interdisciplinary environment using pharmacologic and nonpharmacologic
interventions whose main goals are decreasing suffering and improving quality of life.
PAIN Definition
An unpleassant emotional
situation which is originating
from certain area, which is
Classification dependent or non dependent
on tissue damage and which
1. Mild is related to the past
experience of the person
2. Moderate
3. Severe
Pathophysiology of Pain
TANSDUCTION TRANSMISSION MODULATION PERCEPTION

Simultant -> Impuls -> Impuls from Perception is

nociceptor is aferen nerve spinal cord-> subjective
activated -> Spinal cortex process. The
Cord cerebral to g result of
et modulated modulation is
transmitted
to the effecto
r
 Some laboratory studies -> that greater age brings a higher
threshold for painful electrical, thermal, & mechanical stimuli
to the skin.

Older patients report pain less often than younger patients

because of alterations in the sensorineural apparatus.

The numbers of nociceptive receptors in the skin and of

afferent fibers decrease with age, altering the perception of pain.
Farrell & Gibson suggested that aging diminishes the capacity of
the nociceptive system to downregulate after sensitization.

Vigan et al studied 197 patients with advanced cancer,

measuring the mean daily pain intensity and daily opioid
consumption as a morphine equivalent daily dose.
They concluded that older patients (> 65 years) had similar
levels of pain intensity but required lower levels of opioid
analgesia than younger adults
CANCER
Definition
Abnormal prolferation & differentiation
of cell, that can invade to the
Diagnostic neighbor tissue and could metastate.
1. Physical Examination
2. Work Up Studies: Lab,
Thora, USG, MRI, CT- Treatment:
Scan, Mammografi,
1. Surgery
Ecdoscopic, Tumor
2. Radiation
marker & Histopatologi
3. Chemotherapy
PAIN ASSESMENT
SYNDROMES
 • Appropriate for elderly cancer patients with mild-to-
moderate pain
NSAIDS
Non-Opiods Acetaminophen
• Often indicated as first-line therapy
• Can be effective as an adjunct to opioids, especially
for bone pain & other inflammatory conditions.
WHO

Opiods

Weak Tramadol, Codein

Strong morphine
oxycodone
hydromorphone
fentanyl
methadone
 • Appropriate for elderly cancer patients with mild-to-
moderate pain
NSAIDS
Non-Opiods Acetaminophen
• Often indicated as first-line therapy
• Can be effective as an adjunct to opioids, especially
for bone pain & other inflammatory conditions.

Group of medications used for their anti-inflammatory

properties & to decrease fever and pain. Can be used in Acetaminophen does not have anti-inflammatory
combination with opioids. NSAID should in general be properties, but it has antipyretic and analgesic
avoided in older adults with cancer, given the adverse properties and can be combined with opioids. It's
risk profile in older patients, such as well tolerated and its elimination is not affected by
. aging. Total dose should not exceed 4 g/d, because
If NSAIDS are needed, use in short courses (not more in larger doses it .
than a week) and at the lowest effective dose.
 Weak Tramadol, Codein
Opiods
Strong morphine
oxycodone
hydromorphone
more likely to be affected by fentanyl
the acute&chronic methadone
toxicities of opioids

Elderly
cancer patients

1. initially administered
at a lower dose
2. titrated cautiously.
 Physical measures (hot and cold
massage, acupuncture and
acupressure);

Cognitive interventions aimed at

giving the patient a sense of control
over pain or the underlying disease;

Breathing exercises, relaxation,

mindfulness, imagery/hypnosis and
other behavioral therapies.
Pain is common in older cancer patients, and of
ten it is undertreated. Barriers to the
appropriate treatment of pain include adequate
assessment and knowledge about the benefits
and risks of pain treatment modalities.
A multidisciplinary approach should be taken
to identify the causes of pain andappropriate
treatments; the goals are to decrease the
suffering of the patient and family and improve
their quality of life.
 Thank you
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