Guide to Pain Management in Low-Resource Settings

What monitoring would be 
necessary for analgesia in the 
postoperative period?
Resuscitation measures should be available at the bed-
side for all patients who are receiving opioid infusions. 
Routine monitoring and recording of pain score, se-
dation score, and respiratory rate is important in all 
moderately to severely painful conditions, and for all 

Pain Management in Children
267
patients on infusion. All children on opioid medica-
tion should be monitored carefully for at least the fi rst 
24 hours, including children on PCA without back-
ground infusion. Sedation always precedes respiratory 
depression in opioid overdose. Th
 erefore, observation 
of the patient’s alertness is the key to safety monitoring. 
A monitoring frequency of check-ups every 4 hours is 
considered to be safe to detect increasing sedation. A 
decrease of respiratory rate below 30% of basal resting 
value may also be used as an alarm parameter. Oxygen 
saturation is a better monitor than apnea/respiratory 
rate monitors as it would detect airway obstruction ear-
lier, but for the average situation and patient outside the 
intensive care ward, there is no indication that regular 
sedation control would be inferior to pulse oximetry.
A diff erent story: do children      
also experience chronic pain?
Yes they do, but little is known about the epidemiology 
of chronic pain in children, even in the affl
  uent  coun-
tries. Chronic pain is commonly observed in adoles-
cents. Common conditions are headache, abdominal 
pain, musculoskeletal pain, pain of sickle cell disease, 
complex regional pain syndrome, and post-traumatic or 
postoperative neuropathic pain. Children with cancer or 
AIDS suff er from varying degrees of pain as the disease 
progresses. Recurrent pain becomes chronic because of 
failed attempts to adjust and cope with an uncontrol-
lable, frightening, and adverse experience. Over time it 
is the weight of this experience that leads the patient to 
develop concomitant symptoms of chronic physical dis-
ability, anxiety, sleep disturbance, school absence, and 
social withdrawal. Parents report severe parenting stress 
and dysfunctional family roles. Th
  ere is a greater psy-
chological element in chronic pain as compared to acute 
pain as in adults.
How is chronic pain                            
in children treated?
Assessment of chronic pain should establish not only 
the site, severity, and other characteristics of pain, but 
also the physical, emotional, and social impact of pain.
Treatment should include specifi c therapy directed 
to the cause of pain and associated symptoms such as 
muscle spasms, sleep disturbance, anxiety, or depression. 
Standard analgesics such as NSAIDs and opioids may be 
used, along with antidepressants and anticonvulsants in 
neuropathic pain. Pharmacological management must 
be combined with supportive measures and integrative, 
nonpharmacological treatment modalities such as mas-
sage, acupuncture, relaxation, and physiotherapy. Physical 
methods include a cuddle or hug from the family, mas-
sage, transcutaneous electrical nerve stimulation, com-
fortable positioning, physical or occupational therapy, as 
well as rehabilitation. Cognitive-behavioral techniques 
include guided imagery, hypnosis, abdominal breathing, 
distraction, and storytelling. Th
  e treatment plan should 
include passive, and if possible, active coping skills, to be 
implemented considering the child’s wishes and those of 
his or her family.
Pearls of wisdom
• For eff ective pain management in children, it is 
very important to know how to assess pain in dif-
ferent age groups.
•  For perioperative pain management it is neces-
sary to have basic knowledge of the specifi c phar-
macokinetics and pharmacodynamics in this spe-
cial age group.
• Th
  ere should be an analgesia plan or algorithm 
available on the ward for typical therapeutic situ-
ations. Nonpharmacological treatment options 
should be integrated into the analgesia plan.
•  Apart from perioperative pain management, a ba-
sic ability to diagnose and manage simple chronic 
pain syndromes should be available. Th
 e majority 
of patients, almost 80–90%, may be managed by 
simple means, which should be available even in 
remote or very low-resource environments. Only 
a small percentage of patients need invasive tech-
niques like epidural analgesia, which might be 
limited to referral centers.
•  With regard to monitoring of analgesia side ef-
fects, nothing can substitute for vigilance and fre-
quent clinical assessment.
•  No child should be withheld adequate and safe 
analgesia because of insuffi
  cient knowledge.
Table 4
Dose of caudal bupivacaine (0.125–0.25%)
0.5 mL/kg 
for penile and anal surgery
0.75 mL/kg  
up to lumbar spine
1.00 mL/kg 
up to T10
1.25 mL/kg  
upper abdominal up to T6

268
Dilip Pawar and Lars Garten
References
[1]  Bouwmeester NJ, Anderson BJ, Tibboel D, Holford NH. Developmental 
pharmacokinetics of morphine and its metabolites in neonates, infants 
and young children. B J Anaesth 2004;92:208–17.
[2]  Duhn LJ, Medves JM. A systematic integrative review of infant pain as-
sessment tools. Adv Neonatal Care 2004;4:126–40.
[3]  Elia N, Tramer MR. Ketamine and postoperative pain—a quantitative 
systematic review of randomised trials. Pain 2005;113:61–70.
[4]  Gaughan DM, Hughes MD, Seage GR 3rd, Selwyn PA, Carey VJ, Gort-
maker SL, Oleske JM. Th
  e prevalence of pain in pediatric human im-
munodefi ciency virus/acquired immunodefi ciency syndrome as report-
ed by participants in the Pediatric Late Outcomes Study (PACTG 219). 
Pediatrics 2002;109:1144–52.
[5]  Pawar D, Robinson S, Brown TCK. In: Brown TCK, Fisk GC, editors. 
Pain management in anaesthesia for children, 2nd edition. Melbourne: 
Blackwell Scientifi c; 1992. p. 127–37.
[6]  Pain control and sedation. Semin Fetal Neonatal Med 2006;11(4).
[7]  Stoddard FJ, Sheridan RL, Saxe GN, King BS, King BH, Chedekel DS, 
Schnitzer JJ, Martyn JA. Treatment of pain in acutely burned children. J 
Burn Care Rehabil 2002;23:135–56.
[8]  Wong DL, Baker CM. Pain in children: comparison of assessment 
scales. Pediatr Nurs 1988;14:9–17.
[9]  Zeltzer LK, Anderson CT, Schechter NL. Pediatric pain: current status 
and new directions. Curr Probl Pediatr 1990;20:409–86.
[10]  World Health Organization. Pocket book of hospital care for children: 
guidelines for the management of common illnesses with limited re-
sources. Geneva: World Health Organization; 2005. Available at: www.
who.int/publications.
[11]  World Health Organization. Integrated management of childhood ill-
ness: complementary course on HIV/AIDS. Geneva: World Health Or-
ganization; 2006.
[12]  World Health Organization. Palliative care: symptom management and 
end-of-life care. Geneva: World Health Organization; 2004.
[13] World Health Organization. Symptom management and end-of-life 
care. Geneva: World Health Organization; 2005.
Websites
www.whocancerpain.wisc.edu
Up-to-date information about pain and palliative care published by the 
WHO Pain & Palliative Care Communications Program
www.whocancerpain.wisc.edu/related.html 
Lists of numerous websites related to pain and palliative care
www.ippcweb.org
Online education program for health care professionals by the “Initiative for 
Pediatric Palliative Care”
Table 5
Duration of action of caudal bupivacaine with adjuvants
Drug 
    Duration 
of 
Action 
(hours)
Bupivacaine 
0.25%    4–6
Bupivacaine 0.25% with ketamine 0.5 mg/kg 
 
8–12
Bupivacaine 0.25% with clonidine 1–2 μg/kg 
 
8–12
Bupivacaine 0.25% with tramadol 1.5 mg/kg 
 
12
Bupivacaine 0.25% with morphine 30–50 μg/kg  
12–24
Bupivacaine 0.25% with ketamine 0.5 mg/kg 
and morphine 30 μg/kg 
 
 
 
24
Table 6
Dosage of epidural infusions
Bupivacaine 0.1% with fentanyl 
1–2 μg/mL
Infants under 6 months  
 
0.1 mL/kg/h
Children over 6 months  
 
0.1–0.3 mL/kg/h
Table 7
Frequently used drugs and their dosage regimes
Drug Dosages and Regimens
Dose According to Body Weight
Drug
Dosage
Form
3–6 kg
6–10 kg
10–15 kg
15– 20 kg
20– 29 kg
Paracetamol 
(acetaminophen)
10–15 mg/kg, up to 4 times a 
day
100-mg tablet
500-mg tablet
-
-
1
¼
1
¼
2
½
3
½
Ibuprofen
5–10 mg/kg orally 6–8 hourly 
to a maximum of 500 mg/day
200-mg tablet
400-mg tablet
-
-
¼
-
¼
-
½
¼
¾
½
Codeine
0.5–1 mg/kg orally 6–12 hourly
15-mg tablet
¼
¼
½
1
1½
Morphine
Calculate EXACT dose based on weight of child!
Oral: 0.2–0.4 mg/kg 4–6 hourly; increase if necessary for severe pain.
Intramuscular: 0.1–0.2 mg/kg 4–6-hourly.
Intravenous bolus: 0.05–0.1 mg/kg 4–6-hourly (give slowly!).
Intravenous infusion: 0.005–0.01 mg/kg/hour (in neonates only 0.002–0.003!).
Ketamine
0.04 mg/kg/hr–0.15 mg/kg/hr i.v./s.c.
(titrated to eff ect: usually maximum 0.3 mg/kg/h–0.6 mg/kg/h)
OR 0.2 mg/kg/dose–0.4 mg/kg/dose orally t.i.d., q.i.d., and p.r.n.
Tramadol
1 mg/kg–2 mg/kg 4–6 hourly (max. of 8 mg/kg/day)
Adapted from: World Health Organization. Pocket book of hospital care for children—guidelines for the management of 
common illness with limited resources. World Health Organization; 2005.

269
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th
  is material may be used for educational 
and training purposes with proper citation of the source. Not for sale or commercial use. No responsibility is assumed by IASP for any injury and/or damage to persons or property 
as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the 
medical sciences, the publisher recommends that there should be independent verifi cation of diagnoses and drug dosages. Th
  e mention of specifi c pharmaceutical products and any 
medical procedure does not imply endorsement or recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.
Guide to Pain Management in Low-Resource Settings
Chapter 35
Pain in Old Age and Dementia
Andreas Kopf
What is a geriatric patient?
A geriatric patient is a person of advanced biological age 
(the age in years being less important), with multiple 
morbidity, possibly multiple medications, psychosocial 
deprivation, and an indication for (general) rehabilita-
tion. Th
  e treatment of geriatric patients is complicated 
when dementia is present, because of the patient’s im-
paired communication abilities.
Pain management                                
in geriatric patients
Why is pain management for the geriatric 
patient a medical challenge for tomorrow?
An important demographic phenomenon of the last few 
decades in highly industrialized countries is the con-
tinuous increase of the higher age groups in relation to 
the younger generation. Within a few decades, the same 
demographic change will take place in countries outside 
the Organization for Economic Co-operation and De-
velopment (OECD) as well. For example, in Germany 
the number of inhabitants in the age group of above 80 
years increased from 1.2 million in 1960 to 2.9 million 
today, and will further increase to 5.3 million by 2020. 
Th
  erefore, the health care system and health care work-
ers will need to be prepared to be able to cope with this 
special patient group. With regard to pain problems, 
the geriatric patient will be a special challenge, since the 
percentage of patients with chronic pain (pain lasting 
more than 6 months) increases continuously from 11% 
to 47% between the ages of 40 to 75 years. Health care 
workers have to be aware that geriatric patients not only 
expect the general respect of society but—with increas-
ing life-expectancy—deserve adequate medical treat-
ment, including pain management. Societies have to 
discuss how they want to cope with this demand.
What do elderly patients expect                       
from their doctor?
In surveys, the older generation has defi ned a “wish list”: 
being active until death, individual treatment, no pain, 
autonomous decision making, being able to die “early 
enough” before needless suff ering starts, and addressing 
reduced social context and contacts.
Why do elderly patients not receive the care 
they need and deserve?
From the patient’s perspective:
• Th
  e incidence of dementia increases with age, 
resulting in impaired communication.
•  Elderly patients tend to behave like “good pa-
tients”.
• Th
 ey have a traditional “trusting” view of the 
doctor “who will take care of everything that is 
necessary.”

270
Andreas Kopf
• Th
  ey tend to not insist on certain medical inter-
ventions.
From the patient’s and doctor’s perspective:
•  Pain in old age is “part of life” and “fate.”
From society’s perspective:
•  Inadequate resources in the health care system 
restrict adequate treatment.
From the doctor’s perspective:
•  Elderly patients do not feel pain as intensely as 
younger patients.
• Th
  ey cope better with pain and therefore need 
less analgesia.
What are the opinions and statements                
of scientifi c medical organizations?
A wealth of literature shows that geriatric patients are 
not provided with adequate pain management. Medi-
cal societies have made the elderly patient a medical 
priority. Since pain is frequent, meaningful, underdi-
agnosed, and undertreated, and since research on this 
topic is scarce, pain in the elderly has to be declared a 
medical priority. Consequently, the IASP in September 
2006 proclaimed “pain in old age” the main target of the 
“Global Day of Pain.”
Is it true that pain is frequent                                 
in elderly patients?
A number of studies document that the incidence of 
pain is high. In old people’s homes, up to three-quarters 
of interviewed residents reported pain. Half of these had 
daily pain, but less than one-fi fth were taking an anal-
gesic medication. Studies show that unrelieved pain is 
one of the most important predictive factors for physi-
cal disability.
What are the typical pain locations                      
in elderly patients?
Th
  e number one cause of pain in elderly patients is 
degenerative spine disease, followed by osteoarthro-
sis and osteoarthritis. Other important pain etiolo-
gies include polyneuropathy and postherpetic neural-
gia. Cancer pain is also a very relevant pain etiology. 
In highly industrialized countries cancer pain in the 
elderly is often—at least partially—adequately con-
trolled. But in other countries, management of cancer 
pain often is not a top priority, although good cancer 
pain management could be accomplished fairly easy 
with simple treatment algorithms based mainly on an 
adequate opioid supply.
If adequate pain medication is provided for 
elderly patients, why might they still not receive 
suffi
  cient pain control?
Communication problems and misconceptions of pain 
are relevant causes of this situation. A number of par-
ticularities must be considered in the geriatric patient:
•  Compliance: Geriatric patients will have predict-
able practical problems with their pain medica-
tion. Impaired vision and motor skills, combined 
with xerostomia (dry mouth) and disturbances 
of memory, may make an adequate treatment a 
complete failure. It has to be noted that the aver-
age geriatric patient in industrialized countries 
has a prescription for seven diff erent drugs, and 
only a minority of patients have been prescribed 
fewer than fi ve daily drugs, making noncompli-
ance and drug interactions highly likely. Noncom-
pliance rates are estimated to be as high as 20%. 
Apart from that, intellectual, cognitive, and sim-
ple manual impairments may interfere with treat-
ment. More than a fi fth of geriatric patients fail 
at the task of opening drug packages and blister 
packs. Another patient-related compliance factor, 
compared to younger patients, is reduced “posi-
tive thinking”: only 20% of geriatric patients ex-
pect recovery and healing.
•  Availability of opioids and the risks of prescrip-
tion.
•  Comorbidity: Comorbidity may impair physical 
performance, thereby possibly reducing the ef-
fects of rehabilitation eff orts.
• Pharmacokinetic changes: One of the main 
physiological changes in geriatric patients is the 
reduction of cytochrome P450-dependent me-
tabolization. Also, due to reduced hepatic func-
tion, plasma protein levels are generally lower 
in elderly patients. Both altered mechanisms 
may cause potential dangerous drug interac-
tions and unpredictable plasma levels. Th
 is ef-
fect may be most pronounced for drugs that are 
eliminated through the kidneys, since glomeru-
lar fi ltration rate is generally reduced, too, and 
for drugs with high plasma protein binding, 
where unpredictable serum levels of free sub-
stance may result.
•  Vegetative state: Sympathetic reactions are re-
duced, causing misunderstanding and underesti-
mation of pain, since the elderly patient appears 
to be less strained by pain.

Pain in Old Age and Dementia
271
With regard to the opioid-receptor population and 
subjective sensitivity to painful stimuli, there is confl ict-
ing evidence. Th
  erefore the conclusion has to be that 
pain perception and analgesic interactions are unpre-
dictable.
Do patients with impaired communication, 
such as those with Alzheimer disease, receive 
insuffi
  cient analgesia?
Unfortunately, a number of studies show that patients 
with Alzheimer disease, and diffi
  cult  or  impossible 
communication, receive insuffi
  cient  analgesia.  Th
 is has 
been shown both for acute situations such as fractures 
of the neck of the femur and for chronic pain. Th
 is ob-
servation is alarming since there is evidence showing 
that the pain perception of Alzheimer patients is undis-
turbed.
What is likely to be the most important reason 
for inadequate pain management?
Much of the problem of inadequate pain management 
of the geriatric patient is the lack of appropriate assess-
ment. Especially in patients with dementia, failure to 
assess pain properly results in insuffi
  cient analgesia, be-
cause less than 3% of these patients will communicate 
that they need analgesics themselves.
How is pain in the geriatric patient          
assessed eff ectively?
Th
  e main rule for the geriatric patient is: “ask for pain.” 
Th
  e patient may not ask for analgesia spontaneously. All 
reported pain should be taken seriously; it is the patient 
who has the pain, and the pain is what the patient tells 
you it is. Conventional instruments may be used for 
pain assessment, such as analogue scales or verbal rat-
ing scales, if the patient is able to communicate prop-
erly. But rating and analogue scales will fail in the non-
communicating patient. Th
  erefore, it will be necessary 
to use more sophisticated techniques. All these tech-
niques are based on careful observation and interpre-
tation of the patient’s behavior. Several scoring systems 
have been developed for this task. Typical items for ob-
servation include facial impression, daily activity, emo-
tional reactions, body position, the chance of consola-
tion, and vegetative reactions. Some scores also include 
the subjective impression of the therapist. Recent clini-
cal research has tried to interpret various therapeutic 
interventions to fi nd out more about the patient’s pain, 
with trials called “sequential intervention trials.”
Case report: Mr. Ramiz Shehu 
(prostate cancer)
Mr. Shehu is a 72-year-old farmer from the north-
ern part of Albania, living in the village of Filipoje. He 
was diagnosed with prostate cancer 3 years ago when 
he presented himself to the local doctor, Dr. Frasheri, 
with diffi
  culties with urination. As disease of the pros-
tate was suspected, blood was drawn and send to the 
district hospital for the prostate-specifi c antigen (PSA) 
test. Unfortunately, the PSA was highly positive. After 
careful evaluation of the individual situation, espe-
cially regarding the comorbidity with hypertension and 
heart insuffi
  ciency as well as the patient’s advanced 
age, Dr. Frasheri concluded that there would not be 
an indication to send Mr. Shehu to the capital Tirana 
for surgery, chemotherapy, or radiotherapy. Now, after 
3 years, Mr. Shehu was still in relatively good general 
condition, being an important and active member of St. 
Bartholomew’s church in his home village. But in the 
recent weeks he had developed increasing pain in his 
left chest and left hip. He described his pain as “drill-
ing,” increasing with activity, especially when walking 
and taking a deep breath. Visitors from Italy had fi rst 
suspected coronary disease and hip arthritis, since the 
high PSA had been forgotten by that time. But the local 
doctor drew the correct conclusions.
1) Th
  e options in Filipoje
Local therapy: Use a walking stick, apply a home-made 
elastic bandage around the chest.
Systemic therapy: Th
  e only pain killers available were di-
clofenac and morphine.