Demented Patients

Started by PainDr
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PainDr

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I recently saw a pt in clinic with obvious cognitive issues. She couldn't recall any of the many pain procedures she'd had in the past and couldn't really provide me with any of her history. I contacted the PCP and told him I was very concerned about her situation. He had her on Methadone 10mg TID (down from 20 TID). I said I wasn't comfortable providing medication until her cognitive issues and home situation were evaluated. I'm not sure why he didn't pick up on her condition since it was obvious to everyone in our clinic. It also wasn't anything new as we later discovered that she hadn't opened her mail in over 5 months. Adult protective services has now stepped in and her PCP has admitted her for neuro eval. Anyway, how would you manage this pt? Basically, longstanding DDD with axial and radicular pain. Nothing surgical. Would you continue her methadone?
 
PainDr said:
I recently saw a pt in clinic with obvious cognitive issues. She couldn't recall any of the many pain procedures she'd had in the past and couldn't really provide me with any of her history. I contacted the PCP and told him I was very concerned about her situation. He had her on Methadone 10mg TID (down from 20 TID). I said I wasn't comfortable providing medication until her cognitive issues and home situation were evaluated. I'm not sure why he didn't pick up on her condition since it was obvious to everyone in our clinic. It also wasn't anything new as we later discovered that she hadn't opened her mail in over 5 months. Adult protective services has now stepped in and her PCP has admitted her for neuro eval. Anyway, how would you manage this pt? Basically, longstanding DDD with axial and radicular pain. Nothing surgical. Would you continue her methadone?
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consider lidoderm.....sometimes effective in this situation.....very little risk especially cognitively......i would consider decreasing the methadone slowly down to about 2.5 mg qid and then reevaluate cognitive function
 
Methadone is a wildcard and not so cardiac friendly- see the recent FDA warning (2 weeks ago or so).

DC Methadone immediately and start 5mg Oxycodone prn if she has the family support to know when she hurts enough to give the medication.
A 12.5mcg Duragesic, though costly, would be a set it and forget it as long as administered by caregiver q72hr.

I had a moderately demented ALzheimers patient 2 months ago. He was a retired DMD brought in by his son. THe patient was 92 yrs old. ISIS paradigm for facets and post-RF he did not need meds any longer. He was unable to tell me if he hurt and when, but his son provided excellent clinical info as far as grimacing and pt's activity.

Caring for demented patients requires intensive family support. I do not rely on the patients history as it is unreliable. I also had the son sign the consent with the patient.
 
I agree with Steve. Methadone, even in very low doses, can have severe cognitive effects in the elderly, in those taking other drugs such as klonopin or soma, or in those with an already compromised memory or orientation.
 
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