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

Abstract

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.

Challenges in anaesthesia for elderly

“…The variability in pharmacodynamics and kinetics is high; usually, smaller doses are needed for clinical effect compared to the adult population, and the duration of action is prolonged. Therefore dosing should be carefully titrated by the principle: "start low -go slow" [8]. Using local anaesthetics for elderly is usually safe.…”

Pharmacology for the Geriatric Surgical Patient

“…Physical cues that a patient is in pain may be present, but if a patient has a chronic pain syndrome, common clinical signs such as tachycardia and hypertension may be absent. 8 For patients who are impaired, family input can be helpful in some circumstances.…”

“…A combination of weaker and stronger analgesics along with adjuvant and nonpharmacologic treatments may decrease the risk of severe adverse reactions. 8 Delirium is frequently considered an adverse effect of opioid medications. In some studies, the risk of delirium was increased in patients receiving opioids in comparison with those who did not.…”

Peri‐operative care of the elderly 2014

“…The use of peri-operative analgesia protocols is recommended, and improves patient satisfaction [72], but must be individualised for each patient, to take into account, for example, his/her chronic pain status, frailty, pain assessment, concurrent medication, renal function and cognitive impairment [73,74]. Multimodal analgesia is not restricted to pharmacological agents, and may involve, for example, postural support, pressure care and patient warming.…”