CME Articles

Accreditation Statement:
Dannemiller is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Physicians
Dannemiller designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s).™ Each physician should claim only those credits that he/she actually spent in the activity.

Nurse Practitioners
This program is approved for 1 contact hours of continuing education (which includes 0.5 hours of pharmacology) by the American Academy of Nurse Practitioners. Program ID 0903112. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

Registered Nurses
Dannemiller is a provider approved by the California Board of Registered Nursing, Provider Number 4229 for 1.2 contact hours.

RNs outside California must verify with their licensing agency for approval of this course.

Pharmacists

Purdue University School of Pharmacy and Pharmaceutical Sciences is accredited by the Accreditation Council on Pharmacy Education as a provider of continuing pharmaceutical education. This program is a knowledge continuing education activity of Purdue University, an equal access/equal opportunity institution. Universal Program Number (UPN): 018-999-09-025-H01-P, 1.0 Contact hours (.100 CEU) Release Date: 04/10/2009 Expiration Date: 03/31/2011

Intended Audience
This educational activity is intended for physicians, pharmacists and nurses involved in pain management.

Needs Assessment
According to the U.S. Census Bureau’s 2005-2007 American Community Survey, the number of United States citizens over 65 years of age is 37,265,110 —and growing daily. In April 2008, The Institute of Medicine of the National Academies reported that the nation faces an impending health care crisis as the number of older patients with more complex needs outpaces the number of geriatric specialists. Between 2005 and 2030, the number of older adults in the country will nearly double.

Studies indicate that over 62% of nursing home residents and 25-50% of community-dwelling residents suffer significant pain. As the rank of individuals 65 years and older continues to rise, frailty and chronic diseases associated with pain will likely increase. Thus, a significant challenge will face primary care physicians in the area of pain management in older adults. Unfortunately, according to a recent statement in AARP, The Magazine, only three percent of all medical schools in the United States offer separate courses in pain management.

Since virtually all health care providers treat older patients to some extent during their careers and will likely do so more frequently as the geriatric population continues to grow, a minimal level of competence in geriatric care is vital.

The research literature also indicates that pain continues to be grossly under reported by geriatric patients, which leads to misdiagnosis and improper management by healthcare providers. It’s important that healthcare providers be able to assess and treat pain as it has major implications for older adults’ health, including their general functioning and quality of life. If unrelieved, pain is associated with depression, sleep disturbances, withdrawal and decreased socialization, functional loss, increased dependency, exacerbation of cognitive impairment, and increased health care utilization and costs. Physicians often cite that they provide inadequate pain control because they believe they lack proper training, use inappropriate pain assessment tools, and are reluctant to prescribe opioids.

In turn, geriatric patients withhold reporting pain because they fear loss of independence and believe that pain is a natural part of the aging process. Thus, proper pain assessment is critical in the treatment plan for any geriatric patient. The patient’s own description is the most accurate and reliable evidence for the existence and intensity of pain, but this description is often times downplayed or dismissed by the patient as part of the aging process. It is then incumbent on the health care provider to identify any pain that the patient has. Pain assessment must be regular, systematic, and documented. When possible, use of an interdisciplinary team approach to assessing and managing pain in the elderly is encouraged.

Pharmacologic intervention for pain management is the principle treatment, even though adverse drug reactions in the elderly are a significant risk. Lesser dosages may be effective due to the increased sensitivity in older patients. Selecting an agent likely to cause the fewest side effects is paramount and should be determined by targeting the underlying pathophysiology. Primary care physicians should regularly and carefully monitor for drug side effects and adverse events.

A greater understanding of clinical manifestations of pain, improved methods of assessment, and use of both pharmacologic and nonpharmacologic interventions can result in more favorable outcomes in the treatment of older adults for pain.

References:
(1.) U.S. Census Bureau 2205-2007 American Community Survey. view Accessed 12/15/2008.
(2.) American Society of Consultant Pharmacists. Pain recognition and assessment in older adults. Available at: href="http://www.ascp.com/public/pr/policy/painrecognition/. Accessed 12/15/2008.
(3.) American Geriatrics Society Panel on Persistent Pain in Older Persons. (2002). The management of persistent pain in older persons. Journal of the American Geriatrics Society, 50, S205–S224. Evidence Level VI: Expert Opinion. http://www.consultgerirn.org/topics/pain/want_to_know_more accessed Dec 16, 2008
(4.) Cavalieri TA. Pain management in the elderly. J Am Osteopath Assoc. 2002; 102:481-485
(5.) Gibson SJ, Helme RD. Age-related differences in pain perception and report. Clin Geriatr Med. 2001; 17: 457-458.
(6.) Retooling for an Aging America, Building the Health Care Workforce, Committee on the Future Health Care Workforce for Older Americans, Board on Health Care Services, Institute of Medicine of the National Acadeemies. www.nap.edu. Accessed December 17, 2008.
(7.) Khazzoom, L. (2009). “Drug-Free Remedies for Chronic Pain” AARP, pps. 26-30.

Learning Objectives
Upon completion of this activity, the participant should be able to:

• Describe how the approach to pain management is different for older adults compared to younger adults.
• Evaluate pain more accurately in elderly persons, including those with cognitive impairment.
• Identify age-related physiological and pharmacological changes that effect drug prescribing for older adults.
• Appropriately prescribe analgesic drugs for older adults.

Method of participation:
The activity should take approximately 1 hour to complete. The participant should, in order, read the objectives and other introductory CME information, proceed to the educational offering, complete the registration form, post-test, and evaluation form. To access the registration form and post-test, click on the prompt on the final slide in the presentation. To receive credit for this activity, follow the instructions provided on the post-test. This credit is valid through 3/31/2011. No credit will be given after this date. There is no fee associated with this CME activity.

In the event you are unable to print the certificate, please e-mail editor@dannemiller.com and a certificate will be mailed within 2 weeks.

Faculty Disclosure
In accordance with the Accreditation Council for Continuing Medical Education (ACCME), Dannemiller requires that any person who is in a position to control the content of a CME activity must disclose all relevant financial relationships they have with a commercial interest. Accordingly, Dr. Ferrell reported that he has no financial relationship with any commercial interests that are relevant to this activity.

Dannemiller staff and all others involved in the development of this activity have no relationships with commercial interests. To resolve identified conflicts of interest, the educational content was fully reviewed by a physician member of the Dannemiller Clinical Content Review Committee who has nothing to disclose. The resulting certified activity was found to provide educational content that is current, evidence based and commercially balanced.

Off-label statement
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by FDA. The opinions expressed in the educational activity are those of the faculty. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. Further, participants should appraise the information presented critically and are encouraged to consult appropriate resources for any product or device mentioned in this program.

Disclaimer
The contents and views presented in this educational activity are those of the authors and do not necessarily reflect those of Dannemiller or Purdue Pharma, L.P. This material is prepared based upon a review of multiple sources of information, but it is not exhaustive of the subject matter. Therefore, healthcare professionals and other individuals should review and consider other publications and materials on the subject matter before relying solely upon the information contained within this educational activity.

For questions regarding the content of this activity and technical assistance, contact Dannemiller, accredited provider for this CME activity, at editor@dannemiller.com.