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Postoperative Analgesia in Elderly Patients

  • Therapy in Practice
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Abstract

Elderly people represent the fastest-growing segment of our society and undergo surgery more frequently than other age groups. Effective postoperative analgesia is essential in these patients because inadequate pain control after surgery is associated with adverse outcomes in elderly patients. However, management of postoperative pain in older patients may be complicated by a number of factors, including a higher risk of age- and disease-related changes in physiology and disease–drug and drug–drug interactions. Physiological changes related to aging need to be carefully considered because aging is individualized and progressive. Assessment of pain management needs to include chronological age, biological age with regard to renal, liver and cardiac functions, and the individual profile of pathology and prescribed medications. In addition, ways in which pain should be assessed, particularly in patients with cognitive impairment, must be considered. Cognitively intact older patients can use most commonly used unidimensional pain scales such as the visual analogue scale (VAS), verbal rating scale (VRS), numeric rating scale (NRS) and facial pain scale (FPS). VRS and NRS are the most appropriate pain scales for the elderly. In older patients with mild to moderate cognitive impairment, the VRS is a better tool. For severe cognitively impaired older patients, behavioural scales validated in the postoperative context, such as Doloplus-2 or Algoplus, are appropriate. For postoperative pain treatment, most drugs (e.g. paracetamol, nonsteroidal anti-inflammatory drugs, nefopam, tramadol, codeine, morphine, local anaesthetics), techniques (e.g. intravenous morphine titration, subcutaneous morphine, intravenous or epidural patient-controlled analgesia, intrathecal morphine, peripheral nerve block) and strategies (e.g. anticipated intraoperative analgesia or multimodal analgesia) used for acute pain management can be used in older patients. However, in view of pharmacokinetic and pharmacodynamic changes in older persons, the higher incidence of co-morbidities and concurrent use of other drugs, each must be carefully adjusted to suit each patient. Evaluation of treatment efficacy and incidence and severity of adverse events should be monitored closely, and the concept of ‘start low and go slow’ should be adopted for most analgesic strategies.

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References

  1. Aubrun F, Marmion F. The elderly patient and postoperative pain treatment. Best Pract Res Clin Anaesthesiol. 2007;21(1):109–27.

    Article  PubMed  Google Scholar 

  2. Saleh KL. The elderly patient in the post anesthesia care unit. Nurs Clin N Am. 1993;28(3):507–18.

    CAS  Google Scholar 

  3. Macintyre PE, Upton RN, Ludbrook GL. Acute pain management in the elderly patient. In: Rowbotham DJ, Macintyre PE, editors. Acute pain: clinical management. London: Arnold; 2003. p. 117–36.

    Google Scholar 

  4. Jin F, Chung F. Minimizing perioperative adverse events in the elderly. Br J Anaesth. 2001;87(4):608–24.

    Article  PubMed  CAS  Google Scholar 

  5. Gagliese L. Assessment of pain in elderly people. In: Turk DC, Melzack R, editors. Handbook of pain assessment. New York: The Guilford Press; 2001. p. 119–33.

    Google Scholar 

  6. Herr KA, Garand L. Assessment and measurement of pain in older adults. Clin Geriatr Med. 2001;17(3):457–78. (vi).

    Article  PubMed  CAS  Google Scholar 

  7. Coldrey JC, Upton RN, Macintyre PE. Advances in analgesia in the older patient. Best Pract Res Clin Anaesthesiol. 2011;25(3):367–78.

    Article  PubMed  CAS  Google Scholar 

  8. Gagliese L. Pain and aging: the emergence of a new subfield of pain research. J Pain. 2009;10(4):343–53.

    Article  PubMed  Google Scholar 

  9. Gagliese L, Katz J. Age differences in postoperative pain are scale dependent: a comparison of measures of pain intensity and quality in younger and older surgical patients. Pain. 2003;103(1–2):11–20.

    Article  PubMed  Google Scholar 

  10. Gagliese L, Weizblit N, Ellis W, et al. The measurement of postoperative pain: a comparison of intensity scales in younger and older surgical patients. Pain. 2005;117(3):412–20.

    Article  PubMed  Google Scholar 

  11. Herr KA, Mobily PR, Kohout FJ, et al. Evaluation of the faces pain scale for use with the elderly. Clin J Pain. 1998;14(1):29–38.

    Article  PubMed  CAS  Google Scholar 

  12. Zwakhalen SM, Hamers JP, Abu-Saad HH, et al. Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatr. 2006;6:3.

    Article  PubMed  Google Scholar 

  13. Torvik K, Kaasa S, Kirkevold O, et al. Validation of Doloplus-2 among nonverbal nursing home patients: an evaluation of Doloplus-2 in a clinical setting. BMC Geriatr. 2010;10:9.

    Article  PubMed  Google Scholar 

  14. Rat P, Jouve E, Pickering G, et al. Validation of an acute pain-behavior scale for older persons with inability to communicate verbally: Algoplus. Eur J Pain. 2010;15(2):198 e1–e10.

    Google Scholar 

  15. Ravaud P, Keita H, Porcher R, et al. Randomized clinical trial to assess the effect of an educational programme designed to improve nurses’ assessment and recording of postoperative pain. Br J Surg. 2004;91(6):692–8.

    Article  PubMed  CAS  Google Scholar 

  16. Liukas A, Kuusniemi K, Aantaa R, et al. Pharmacokinetics of intravenous paracetamol in elderly patients. Clin Pharmacokinet. 2011;50(2):121–9.

    Article  PubMed  CAS  Google Scholar 

  17. Barkin RL, Beckerman M, Blum SL, et al. Should nonsteroidal anti-inflammatory drugs (NSAIDs) be prescribed to the older adult? Drugs Aging. 2010;27(10):775–89.

    Article  PubMed  CAS  Google Scholar 

  18. Macintyre PE, Schug SA, Scott DA, Visser EJ, Walker SM, APM: SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute pain management: scientific evidence. 3rd ed. Melbourne: ANZCA & FPM; 2010.

    Google Scholar 

  19. Kapfer B, Alfonsi P, Guignard B, et al. Nefopam and ketamine comparably enhance postoperative analgesia. Anesth Analg. 2005;100(1):169–74.

    Article  PubMed  Google Scholar 

  20. Mimoz O, Incagnoli P, Josse C, et al. Analgesic efficacy and safety of nefopam vs. propacetamol following hepatic resection. Anaesthesia. 2001;56(6):520–5.

    Article  PubMed  CAS  Google Scholar 

  21. Guirimand F, Dupont X, Bouhassira D, et al. Nefopam strongly depresses the nociceptive flexion (R(III)) reflex in humans. Pain. 1999;80(1–2):399–404.

    Article  PubMed  CAS  Google Scholar 

  22. Heel RC, Brogden RN, Pakes GE, et al. Nefopam: a review of its pharmacological properties and therapeutic efficacy. Drugs. 1980;19(4):249–67.

    Article  PubMed  CAS  Google Scholar 

  23. Bhatt AM, Pleuvry BJ, Maddison SE. Respiratory and metabolic effects of oral nefopam in human volunteers. Br J Clin Pharmacol. 1981;11(2):209–11.

    Article  PubMed  CAS  Google Scholar 

  24. Gloth FM 3rd. Pain management in older adults: prevention and treatment. J Am Geriatr Soc. 2001;49(2):188–99.

    Article  PubMed  Google Scholar 

  25. Brouquet A, Cudennec T, Benoist S, et al. Impaired mobility, ASA status and administration of tramadol are risk factors for postoperative delirium in patients aged 75 years or more after major abdominal surgery. Ann Surg. 2010;251(4):759–65.

    Article  PubMed  Google Scholar 

  26. Jick H, Derby LE, Vasilakis C, et al. The risk of seizures associated with tramadol. Pharmacotherapy. 1998;18(3):607–11.

    PubMed  CAS  Google Scholar 

  27. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352(11):1112–20.

    Article  PubMed  CAS  Google Scholar 

  28. Gillman PK. A review of serotonin toxicity data: implications for the mechanisms of antidepressant drug action. Biol Psychiatry. 2006;59(11):1046–51.

    Article  PubMed  CAS  Google Scholar 

  29. Chauvin C, Sandouk P, Scherrmann JM, et al. Morphine pharmacokinetics in renal failure. Anesthesiology. 1987;66:327–31.

    Article  PubMed  CAS  Google Scholar 

  30. Pergolizzi J, Boger RH, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract. 2008;8(4):287–313.

    Article  PubMed  Google Scholar 

  31. Aubrun F, Bunge D, Langeron O, et al. Postoperative morphine consumption in the elderly patient. Anesthesiology. 2003;99(1):160–5.

    Article  PubMed  CAS  Google Scholar 

  32. Burns JW, Hodsman NBA, McLintock TTC, et al. The influence of patient characteristics on the requirements for postoperative analgesia. Anaesthesia. 1989;44:2–6.

    Article  PubMed  CAS  Google Scholar 

  33. Macintyre PE, Jarvis DA. Age is the best predictor of postoperative morphine requirements. Pain. 1996;64(2):357–64.

    Article  PubMed  CAS  Google Scholar 

  34. Ready LB. Acute pain: lessons learned from 25,000 patients. Reg Anesth Pain Med. 1999;24(6):499–505.

    PubMed  CAS  Google Scholar 

  35. Kehlet H. Surgical stress: the role of pain and analgesia. Br J Anaesth. 1989;63(2):189–95.

    Article  PubMed  CAS  Google Scholar 

  36. Kehlet H, Werner M, Perkins F. Balanced analgesia: what is it and what are its advantages in postoperative pain? Drug. 1999;58:793–7.

    Article  CAS  Google Scholar 

  37. Elia N, Lysakowski C, Tramer MR. Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials. Anesthesiology. 2005;103(6):1296–304.

    Article  PubMed  CAS  Google Scholar 

  38. Evans MS, Lysakowski C, Tramer MR. Nefopam for the prevention of postoperative pain: quantitative systematic review. Br J Anaesth. 2008;101(5):610–7.

    Article  PubMed  CAS  Google Scholar 

  39. Scott JC, Stanski DR. Decreased fentanyl and alfentanil dose requirements with age. A simultaneous pharmacokinetic and pharmacodynamic evaluation. J Pharmacol Exp Ther. 1987;240(1):159–66.

    PubMed  CAS  Google Scholar 

  40. Minto CF, Schnider TW, Egan TD, et al. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil. I. Model development. Anesthesiology. 1997;86(1):10–23.

    Article  PubMed  CAS  Google Scholar 

  41. Minto CF, Schnider TW, Shafer SL. Pharmacokinetics and pharmacodynamics of remifentanil. Anesthesiology. 1997;86(1):24–33.

    Article  PubMed  CAS  Google Scholar 

  42. Rivera R, Antognini JF. Perioperative drug therapy in elderly patients. Anesthesiology. 2009;110(5):1176–81.

    Article  PubMed  Google Scholar 

  43. Binhas M, Decailliot F, Rezaiguia-Delclaux S, et al. Comparative effect of intraoperative propacetamol versus placebo on morphine consumption after elective reduction mammoplasty under remifentanil-based anesthesia: a randomized control trial [ISRCTN71723173]. BMC Anesthesiol. 2004;4(1):6.

    Article  PubMed  Google Scholar 

  44. Du Manoir B, Aubrun F, Langlois M, et al. Randomized prospective study of the analgesic effect of nefopam after orthopaedic surgery. Br J Anaesth. 2003;91(6):836–41.

    Article  PubMed  Google Scholar 

  45. Guignard B, Coste C, Costes H, et al. Supplementing desflurane-remifentanil anesthesia with small-dose ketamine reduces perioperative opioid analgesic requirements. Anesth Analg. 2002;95(1):103–8.

    Article  PubMed  CAS  Google Scholar 

  46. Mao J, Price DD, Mayer DJ. Mechanisms of hyperalgesia and morphine tolerance: a current view of their possible interactions. Pain. 1995;62(3):259–74.

    Article  PubMed  CAS  Google Scholar 

  47. Bell RF, Dahl JB, Moore RA, et al. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev 2006 (1): CD004603.

  48. Aubrun F, Monsel S, Langeron O, et al. Postoperative titration of intravenous morphine. Eur J Anaesthesiol. 2001;18:159–65.

    PubMed  CAS  Google Scholar 

  49. Aubrun F, Monsel S, Langeron O, et al. Postoperative titration of intravenous morphine in the elderly patient. Anesthesiology. 2002;96:17–23.

    Article  PubMed  CAS  Google Scholar 

  50. Dahmani S, Dupont H, Mantz J, et al. Predictive factors of early morphine requirements in the post-anaesthesia care unit (PACU). Br J Anaesth. 2001;87:385–9.

    Article  PubMed  CAS  Google Scholar 

  51. Keita H, Tubach F, Maalouli J, et al. Age-adapted morphine titration produces equivalent analgesia and adverse effects in younger and older patients. Eur J Anaesthesiol. 2008;25(5):352–6.

    Article  PubMed  CAS  Google Scholar 

  52. Capdevila X, Biboulet P, Barthelet Y. Postoperative analgesia. Specificity in the elderly. Ann Fr Anesth Reanim. 1998;17(6):642–8.

    Article  PubMed  CAS  Google Scholar 

  53. Gagliese L, Jakson M, Ritvo P, et al. Age is not impediment to effective use of patient controlled analgesia by surgical patients. Anesthesiology. 2000;93:601–10.

    Article  PubMed  CAS  Google Scholar 

  54. Macintyre PE, Jarvis DA. Age is the best predictor of postoperative morphine requirements. Pain. 1995;64:357–64.

    Article  Google Scholar 

  55. Keita H, Geachan N, Dahmani S, et al. Comparison between patient-controlled analgesia and subcutaneous morphine in elderly patients after total hip replacement. Br J Anaesth. 2003;90:53–7.

    Article  PubMed  CAS  Google Scholar 

  56. Mann C, Pouzeratte Y, Boccara G, et al. Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology. 2000;92(2):433–41.

    Article  PubMed  CAS  Google Scholar 

  57. Tramer MR, Walder B. Efficacy and adverse effects of prophylactic antiemetics during patient-controlled analgesia therapy: a quantitative systematic review. Anesth Analg. 1999;88(6):1354–61.

    PubMed  CAS  Google Scholar 

  58. Sharrock NE. Epidural anesthetic dose responses in patients 20 to 80 years old. Anesthesiology. 1978;49(6):425–8.

    Article  PubMed  CAS  Google Scholar 

  59. Svircevic V, van Dijk D, Nierich AP, et al. Meta-analysis of thoracic epidural anesthesia versus general anesthesia for cardiac surgery. Anesthesiology. 2011;114(2):271–82.

    Article  PubMed  CAS  Google Scholar 

  60. Mann C, Pouzeratte Y, Eledjam JJ. Postoperative patient-controlled analgesia in the elderly: risks and benefits of epidural versus intravenous administration. Drugs Aging. 2003;20(5):337–45.

    Article  PubMed  CAS  Google Scholar 

  61. Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology. 1995;82(6):1474–506.

    Article  PubMed  CAS  Google Scholar 

  62. Kampe S, Kiencke P, Delis A, et al. The continuous epidural infusion of ropivacaine 0.1% with 0.5 microg x mL(-1) sufentanil provides effective postoperative analgesia after total hip replacement: a pilot study. Can J Anaesth. 2003;50(6):580–5.

    Article  PubMed  Google Scholar 

  63. Liu SS, Allen HW, Olsson GL. Patient-controlled epidural analgesia with bupivacaine and fentanyl on hospital wards: prospective experience with 1,030 surgical patients. Anesthesiology. 1998;88(3):688–95.

    Article  PubMed  CAS  Google Scholar 

  64. Egbert AM. Postoperative pain management in the frail elderly. Clin Geriatr Med. 1996;12(3):583–99.

    PubMed  CAS  Google Scholar 

  65. Silvasti M, Pitkanen M. Patient-controlled epidural analgesia versus continuous epidural analgesia after total knee arthroplasty. Acta Anaesthesiol Scand. 2001;45(4):471–6.

    Article  PubMed  CAS  Google Scholar 

  66. Wigfull J, Welchew E. Survey of 1057 patients receiving postoperative patient-controlled epidural analgesia. Anaesthesia. 2001;56(1):70–5.

    Article  PubMed  CAS  Google Scholar 

  67. Gray JR, Fromme GA, Nauss LA, et al. Intrathecal morphine for post-thoracotomy pain. Anesth Analg. 1986;65(8):873–6.

    Article  PubMed  CAS  Google Scholar 

  68. Murphy PM, Stack D, Kinirons B, et al. Optimizing the dose of intrathecal morphine in older patients undergoing hip arthroplasty. Anesth Analg. 2003;97(6):1709–15.

    Article  PubMed  CAS  Google Scholar 

  69. Yamashita K, Fukusaki M, Ando Y, et al. Postoperative analgesia with minidose intrathecal morphine for bipolar hip prosthesis in extremely elderly patients. J Anesth. 2009;23(4):504–7.

    Article  PubMed  Google Scholar 

  70. Klein SM, Nielsen KC, Greengrass RA, et al. Ambulatory discharge after long-acting peripheral nerve blockade: 2382 blocks with ropivacaine. Anesth Analg. 2002;94(1):65–70.

    PubMed  Google Scholar 

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No sources of funding were used to assist in the preparation of this article. The authors have no conflicts of interest that are directly relevant to the content of this article.

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Authors and Affiliations

  1. Département d’Anesthésie-Réanimation, Hôpital d’instruction des Armées Percy, 101 avenue Henri Barbusse, BP 406, 92141, Clamart Cedex, France

    Elisabeth Falzone & Clément Hoffmann

  2. Service d’Anesthésie, Hôpital Louis Mourier, AP-HP, Université Paris 7, 178 rue des Renouillers, 92700, Colombes, France

    Hawa Keita

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  1. Elisabeth Falzone
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  2. Clément Hoffmann
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  3. Hawa Keita
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Correspondence to Hawa Keita.

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Falzone, E., Hoffmann, C. & Keita, H. Postoperative Analgesia in Elderly Patients. Drugs Aging 30, 81–90 (2013). https://doi.org/10.1007/s40266-012-0047-7

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