Clinical pharmacology of analgesic medicines in older people: impact of frailty and cognitive impairment

McLachlan, Andrew J.; Bath, Sally; Naganathan, Vasi; Hilmer, Sarah N.; Couteur, David G. Le; Gibson, Stephen; Blyth, Fiona

doi:10.1111/j.1365-2125.2010.03847.x

Cited by 185 publications

(164 citation statements)

References 150 publications

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“…People with frailty tend to have less predictable drug responses, increased drug sensitivity, and the potential for harmful side effects 51 . A recent review of the clinical pharmacology of analgesic medicines in older people with frailty, suggest that frailty may be predictive of an individual's pharmaco-kinetic and pharmacodynamics response, however, there are limited data examining this 54 .…”

Section: Discussionmentioning

confidence: 99%

Pain in older people with frailty

Brown

Young

Clegg

et al. 2015

Rev. Clin. Gerontol.

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In this review we identified cohort and cross-sectional studies which assessed pain in community-dwelling older people (> 65 years) reliably characterised as frail. Secondly, we considered biologically plausible mechanisms which may alter pain perception, or contribute to, or exacerbate pain in an older person with frailty. Thirdly, we considered specific implications of pain management for this group of people. From the limited data from the seven included studies, it would appear that the presence of pain is higher in older people with frailty compared to people characterised as pre-frail or not frail. Thus, older people reporting pain are more likely to be frail. However, a lack of prospective data precludes inferences about the direction of the relationship: that is whether pain or frailty is the antecedent. Further research is needed to understand the direction of the relationship, and to identify appropriate pain management strategies for older people with frailty.

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Section: Discussionmentioning

confidence: 99%

Pain in older people with frailty

Brown

Young

Clegg

et al. 2015

Rev. Clin. Gerontol.

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“…The validity of a 'start low and go slow' approach has been called into question for this reason, i.e. that it leads to inadequate analgesia in patients who are already at higher risk of confusion and agitation [46]. However, pethidine is consistently associated with delirium, and should be avoided, as its metabolite norpethidine can cause excitement, agitation, twitching and tremors.…”

Section: Opioid Therapymentioning

confidence: 99%

“…However, pethidine is consistently associated with delirium, and should be avoided, as its metabolite norpethidine can cause excitement, agitation, twitching and tremors. Frail and cognitively impaired patients do not appear to have reduced pain perception and hence appear to require similar doses of analgesia to ablate pain, although more research is needed to confirm this [46] and analgesia should be prescribed with particular caution to these groups [63]. Buprenorphine may be a more appropriate choice of opioid for patients with renal disease, as its pharmacokinetics are unaltered by renal function [49].…”

Section: Opioid Therapymentioning

confidence: 99%

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The assessment and management of peri‐operative pain in older adults

Schofield

2013

Anaesthesia

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SummaryA number of recent reports have highlighted the inadequate provision of pain relief for older inpatients. Despite the availability of numerous validated pain measures, pain remains poorly assessed in some cases and, particularly, in the cognitively impaired. Without proper assessment, patients may receive inadequate or inappropriate analgesia, both of which can worsen outcome. Most drugs and techniques that are used for analgesia in younger patients are also suitable for older patients, although dosages may have to be adjusted to avoid the side‐effects that are consequent upon age‐related changes in drug pharmacokinetics and pharmacodynamics, co‐morbidity, frailty, cognitive impairment and polypharmacy. This paper reviews current guidelines and methods of assessing pain in the older adult, and describes the use of, and problems with, mild, moderate, strong, adjuvant and local anaesthetic drugs in the older population for analgesia, advocating multimodal intervention to reduce dose‐related side‐effects, particularly of opioids.

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“…Chronological age has also been cited as an important predictor of analgesic response [36]. However, the paucity of evidence relating pharmacodynamic responses to frailty is acknowledged as a limiting factor in establishing optimal dosing regimes in this patient group [37].…”

Section: Pharmacodynamic Changesmentioning

confidence: 99%

Prescribing appropriately in frail older people

2015

Healthy Aging Res

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Frailty is one of the most important aspects associated with the elderly. It is defined as a state of increased vulnerability to poor resolution of homeostasis after a stressor event, which increases the risk of adverse outcomes such as falls, institutionalization and death. Frail older adults are more likely to have several concurrent disorders, requiring multiple treatments and hence, considerable medication consumption. The functional reserve of multiple organs deteriorates with ageing and this often leads to changes in drug pharmacokinetics and metabolism. As a result, prescribing medications for frail older people is often complex and challenging. Furthermore, there is a paucity of evidence from clinical trials on the effects of multiple drug consumption in patients aged above 80 years since people from this age group tend to be excluded from such studies. Because of the changes in the pharmacokinetics and pharmacodynamics of drugs in older people, especially in those who are frail, there is an increased risk of adverse drug events for these patients, which can result in hospitalization, increased morbidity and mortality. In this review, appropriate prescribing for frail older people is explored. Consideration will be given to the impact of frailty on medication prescribing and how individualized prescribing could reduce the risk of adverse drug events in at-risk older patients. Tools used to enhance prescribing practice are examined, including those aimed at reducing polypharmacy, underprescribing and inappropriate prescribing. These tools use either explicit (criterion-based) or implicit (judgment-based) criteria. However, most of the current therapeutic guidelines are applicable mainly for the fit older population and cannot be directly applied where frail individuals are concerned. Approaches to improving appropriate prescribing among frail elderly patients, including those with limited life expectancy, are also reviewed.

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Clinical pharmacology of analgesic medicines in older people: impact of frailty and cognitive impairment

Cited by 185 publications

References 150 publications

Pain in older people with frailty

Pain in older people with frailty

The assessment and management of peri‐operative pain in older adults

Prescribing appropriately in frail older people

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