What is the most reasonable dose of hydromorphone (Hydromorphone) to add in the afternoon for a patient with dementia in a long-term care (LTC) setting, currently taking 4.5mg of hydromorphone continuous sustained release orally (PO) every night at bedtime (QHS)?

From the Guidelines

For a patient with dementia in long-term care who is currently taking hydromorphone contin sustained release 4.5mg PO at bedtime and requires an additional afternoon dose, I would recommend adding hydromorphone immediate release 2mg PO in the afternoon, as this dose is within the recommended starting dosing range of 2-4 mg PO Q4-6h PRN for short-acting oral opioid formulations, as per the study by 1. This dose provides meaningful pain relief while minimizing the risk of side effects in this vulnerable population. When initiating this additional dose, start at the recommended dose and assess the patient's response before considering any increase. For elderly patients with dementia, a conservative approach is essential as they are more sensitive to opioid effects and may experience increased confusion, sedation, or respiratory depression. Monitor the patient closely after implementing this change, particularly for signs of oversedation, confusion, constipation, or respiratory depression. If the afternoon dose proves effective and well-tolerated, consider adjusting the overall regimen to twice-daily sustained release dosing for more consistent pain control. Regular reassessment of pain control, functional status, and side effects should guide ongoing management, taking into consideration the patient's individual response and the potential for hydromorphone to cause little or no histamine release, as noted in the study by 1. Some key points to consider when prescribing opioids for adult patients, as outlined in the study by 1, include:

• Selecting between short-acting schedule II or III agents
• Using equianalgesic doses of opioids, which are equally efficacious in relieving pain
• Avoiding the use of long-acting or extended-released schedule II products for acute pain
• Considering the potential for abuse and the classification of opioids by the Drug Enforcement Administration. However, the most recent and highest quality study, 1, provides the most relevant guidance for this specific scenario, and its recommendations should be prioritized.

From the FDA Drug Label

For chronic pain, doses should be administered around-the-clock. A supplemental dose of 5 to 15% of the total daily usage may be administered every two hours on an as-needed basis.

The most reasonable dose of hydromorphone to add in the afternoon for a patient taking 4.5mg PO QHS would be 5-15% of the total daily usage.

• Total daily usage is 4.5mg (since it's given QHS, which is every night)
• 5-15% of 4.5mg is 0.225mg to 0.675mg So, a supplemental dose of 0.225mg to 0.675mg may be administered in the afternoon on an as-needed basis 2

From the Research

Dose of Hydromorphone for Patients with Dementia

• The provided studies do not directly address the question of the most reasonable dose of hydromorphone to add for patients with dementia who are already taking a sustained release formulation 3, 4, 5, 6, 7.
• However, it is known that people with dementia may have difficulty expressing pain and may require careful assessment and management of pain 5.
• A study on opioid use in nursing home residents with dementia found that opioid use declined from 2011 to 2017, and the use was lower in residents with dementia, possibly reflecting suboptimal pain management in this population 6.
• Another study found that pain was still prevalent in nursing home residents with advanced dementia despite the use of opioids, emphasizing the challenge of proper pain treatment and the need for regular evaluation of pain and pain management 7.
• In terms of dosing, one study found that 66.7% of opioid prescriptions were less than or equal to the lowest dosage of fentanyl patches (12 mcg/h) or buprenorphine (5 or 10 mcg/h) 7, but this does not provide direct guidance on the dose of hydromorphone to add.
• Given the lack of direct evidence, it is not possible to provide a specific recommendation for the dose of hydromorphone to add for patients with dementia who are already taking a sustained release formulation.

Considerations for Pain Management in Dementia

• Pain assessment and management in people with dementia is challenging due to communication barriers and a lack of skill training 5.
• Non-pharmacological strategies are often used as the first-line therapy to manage pain, but opioids may be necessary in some cases 5, 7.
• Regular evaluation of pain and pain management is necessary to ensure proper treatment and minimize the risk of adverse effects 7.