Abstract
Postoperative patient-controlled analgesia provided by the intravenous route using morphine (PCA) or by the epidural route using an opioid in combination with a local anaesthetic (patient-controlled epidural analgesia; PCEA) is not yet routinely used in the elderly. However, this modality theoretically provides adequate control of postoperative pain in such patients.
Firstly, an assessment of the level of pain is particularly difficult in the elderly, and patient-controlled techniques that enable the self-administration of analgesic could resolve this problem. Secondly, these techniques provide a fine and controlled titration of analgesic doses. Since analgesic-induced adverse effects increase with age, the risk of overdose is therefore reduced. Thirdly, effective postoperative patient-controlled analgesia may attenuate detrimental physiologic responses, and contribute to improvement in patient outcomes.
In the elderly, PCEA provides better pain relief, particularly for dynamic pain, and improves postoperative recovery with a low incidence of adverse effects compared with PCA. PCA and PCEA techniques have a good safety profile in the elderly only when there is careful preoperative patient selection and strict postoperative monitoring. Standard observation of vital signs, sedation and pain scores and assessment of mental status are required. Patient selection is necessary to identify those patients who may be incapable of using the device (e.g. patients with evidence of cognitive dysfunction or physical disabilities). In addition, caution is required among patients with respiratory, renal or hepatic insufficiency.
PCA and PCEA are particularly useful for elderly patients undergoing major thoraco-abdominal surgery. However, there is a need for further research in elderly patients. In the future, improvements in the management of postoperative pain in the elderly will lead to a greater expansion of self-controlled techniques.
Similar content being viewed by others
References
Hecker BR, Albert L. Patient-controlled analgesia: a randomized prospective comparison between two commercially available PCA pumps and conventional analgesic therapy for postoperative pain. Pain 1988; 35: 115–20
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: 688–95
Etches RC. Patient-controlled analgesia. Surg Clin North Am 1999; 79: 297–312
Macintyre PE. Safety and efficacy of patient-controlled analgesia. Br J Anaesth 2001; 87: 36–46
Bollish SJ, Collins CL, Kirking DM, et al. Efficacy of patient-controlled versus conventional analgesia for postoperative pain. Clin Pharm 1985; 4: 48–52
Ballantyne JC, Carr DB, Chalmers TC, et al. Postoperative patient-controlled analgesia: meta-analyses of initial randomized control trials. J Clin Anesth 1993; 5: 182–93
Brockopp D, Warden S, Colclough G, et al. Elderly people’s knowledge of and attitudes to pain management. Br J Nurs 1996; 5: 556–62
Ready LB. PCA is effective for older patients: but are there limits? Anesthesiology 2000; 93: 597–8
Sherman ED, Robillard E. Sensitivity to pain in the aged. CMAJ 1960; 83: 944–7
Lynch EP, Lazor MA, Gellis JE, et al. Patient experience of pain after elective noncardiac surgery. Anesth Anaig 1997; 85: 117–23
Gagliese L, Jackson M, Ritvo P, et al. Age is not an impediment to effective use of patient-controlled analgesia by surgical patients. Anesthesiologie 2000; 93: 601–10
Egbert AM, Parks LH, Short LM, et al. Randomized trial of postoperative patient-controlled analgesia versus intramuscular narcotics in frail elderly men. Arch Intern Med 1990; 150: 1897–903
Moller JT, Cluitmans P, Rasussen LS, et al. for the ISPOCD investigators. Long term postoperative cognitive dysfunction in the elderly. Lancet 1998; 351: 857–61
Krulewitch H, London MR, Skakel VJ, et al. Assessment of pain in cognitively impaired older adults: a comparison of pain assessment tools and their use by nonprofessional caregivers. J Am Geriatr Soc 2000; 48: 1607–11
Lynch EP, Lazor MA, Gellis JE, et al. The impact of postoperative pain on the development of postoperative delirium. Anesth Analg 1998; 86: 781–5
Swift CG. Pharmacodynamics: changes in homeostatic mechanisms, receptor and target organ sensitivity in the elderly. Br Med Bull 1990; 46: 36–52
Epstein M. Aging and the kidney. J Am Soc Nephrol 1996; 7: 1106–22
Zoli M, Magalotti D, Bianchi G, et al. Total and functional hepatic blood flow decrease in parallel with ageing. Age Ageing 1999; 28: 29–33
Owen JA, Sitar DS, Berger L, et al. Age-related morphine kinetics. Clin Pharmacol Ther 1983; 34: 364–8
Scott JC, Stanski DR. Decreased fentanyl and alfentanil dose requirements with age: a simultaneous pharmacokinetic and pharmacodynamic evaluation. J Pharmacol Exp Ther 1987; 240: 159–66
Matteo RS, Schwartz AE, Ornstein E, et al. Pharmacokinetics of sufentanil in the elderly surgical patient. Can J Anaesth 1990; 37: 852–6
Minto CF, Schnider TW, Shafer SL. Pharmacokinetics and pharmacodynamics of remifentanil: model application. Anesthesiology 1997; 86: 24–33
Burns JW, Hodsman NB, McLintock TT, et al. The influence of patient characteristics on the requirements for postoperative analgesia: a reassessment using patient-controlled analgesia. Anaesthesia 1989; 44: 2–6
Macintyre PE, Jarvis DA. Age is the best predictor of postoperative morphine requirements. Pain 1996; 64: 357–64
Woodhouse A, Mather LE. The influence of age upon opioid analgesic use in the patient-controlled analgesia (PCA) environment. Anaesthesia 1997; 52: 949–55
Aubrun F, Monsel S, Langeron O, et al. Postoperative titration of intravenous morphine in the elderly patient. Anesthesiology 2002; 96: 17–23
Austin KL, Stapleton JV, Mather LE. Multiple intramuscular injections: a major source of variability in analgesic response to meperidine. Pain 1980; 8: 47–62
Semple TJ, Upton RN, Macintyre PE, et al. Morphine blood concentrations in elderly postoperative patients following administration via an indwelling subcutaneous cannula. Anaesthesia 1997; 52: 318–23
Gustafsson LL, Grell AM, Garle M, et al. Kinetics of morphine in cerebrospinal fluid after epidural administration. Acta Anaesthesiol Scand 1984; 28: 535–9
Veering BT, Burma AGL, Van Kleef JW, et al. Epidural anesthesia with bupivacaine: effects of age on neural blockade and pharmacokinetics. Anesth Analg 1987; 66: 589–93
Burm A, Vermeulen N, van Kleef J, et al. Pharmacokinetics of lidocaine and bupivacaine in surgical patients following epidural administration: simultaneous investigation of absorption and disposition kinetics using stable isotopes. Clin Pharmacokinet 1987; 13: 191–203
Bowdle AT, Freund PR. Effects of age on local anesthetic agents. In: McLeskey CH, editor. Geriatric anesthesiology. Baltimore: Williams & Wilkings, 1997: 367–80
Woodhouse A, Hobbes AF, Mather LE, et al. A comparison of morphine, pethidine and fentanyl in the postsurgical patient-controlled analgesia environment. Pain 1996; 64: 115–21
Herrick IA, Ganapathy S, Komar, et al. Postoperative cognitive impairment in the elderly: choice of patient-controlled analgesia opioid. Anaesthesia 1996; 51: 356–60
Lavand’Homme P, De Kock M. Practical guidelines on the postoperative use of patient-controlled analgesia in the elderly. Drugs Aging 1998; 13(1): 9–16
Mather LE, Woodhouse A. Pharmacokinetics of opioids in the context of patient controlled analgesia. Pain Rev 1997; 4: 20–32
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: 433–41
Etches RC. Respiratory depression associated with patient-controlled analgesia: a review of eight cases. Can J Anaesth 1999; 41: 125–32
Rudolph H, Cade JF, Morley PT, et al. Smart technology improves patient-controlled analgesia: a preliminary report. Anesth Analg 1999; 89: 1226–32
Arunasalam K, Davenport HT, Painter S, et al. Ventilatory response to morphine in young and old subjects. Anaesthesia 1983; 38: 529–33
Daykin AP, Bowen DJ, Saunders DA, et al. Respiratory depression after morphine in the elderly: a comparison with younger subjects. Anaesthesia 1986; 41: 910–4
Fleming BM, Coombs DW. A survey of complications documented in a quality-control analysis of patient-controlled analgesia in the postoperative patient. J Pain Symptom Manage 1992; 7: 463–9
Looi-Lyons LC, Chung FF, Chan VW, et al. Respiratory depression: an adverse outcome during patient controlled analgesia therapy. J Clin Anesth 1996; 8: 151–6
Catley DM, Thornton C, Jordan C, et al. Pronounced episodic oxygen desaturation in the postoperative period: its association with ventilatory pattern and analgesic regimen. Anesthesiology 1985; 63: 20–8
Geller RJ. Meperidine in patient-controlled analgesia: a near-fatal mishap. Anesth Analg 1993; 76: 655–7
Parker RK, Holtmann B, Smith I, et al. Use of ketorolac after lower abdominal surgery: effects on analgesic requirement and surgical outcome. Anesthesiology 1994; 80: 6–12
Sharma SK, Davies M. Patient-controlled analgesia with a mixture of morphine and droperidol. Br J Anaesth 1993; 71: 435–6
Wigfull J, Welchew E. Survey of 1057 patients receiving postoperative patient-controlled epidural analgesia. Anaesthesia 2001; 56: 70–5
Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia: their role in postoperative outcome. Anesthesiology 1995; 82: 1474–506
Liu S, Carpenter RL, Mackey DC, et al. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 1995; 83: 757–65
De Leon-Casasola OA, Lema MJ, Karabella D, et al. Post-operative myocardial ischemia: epidural versus intravenous patient-controlled analgesia. Reg Anesth 1995; 20: 105–12
Crawford EM, Moiniche S, Orbaek J, et al. Orthostatic hypotension during postoperative continuous thoracic epidural bupivacaine-morphine in patients undergoing abdominal surgery. Anesth Analg 1996; 83: 1028–32
Silvasti M, Pitkanen M. Patient-controlled epidural analgesia versus continuous epidural analgesia after total knee arthroplasty. Acta Anaesthesiol Scand 2001; 45: 471–6
Brodner G, Mertes N, Van Aken H, et al. A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg 1998; 86: 228–34
Wiebalck A, Brodner G, Van Aken H. The effects of adding sufentanil to bupivacaine for postoperative patient-controlled epidural analgesia. Anesth Analg 1997; 85: 124–9
Brodner G, Mertes N, Buerkle H, et al. Acute pain management: analysis, implications and consequences after prospective experience with 6349 surgical patients. Eur J Anaesthesiol 2000; 17: 566–75
Pouzeratte Y, Delay JM, Brunat G, et al. Patient-controlled epidural analgesia after abdominal surgery: ropivacaine versus bupivacaine. Anesth Analg 2001; 93: 1587–92
Hansdottir V, Woestenborghs R, Nordberg G. The cerebrospinal fluid and plasma pharmacokinetics of sufentanil after thoracic or lumbar epidural administration. Anesth Analg 1995; 80: 724–9
Ritchie K, Polge C, de Roquefeuil G, et al. Impact of anesthesia on the cognitive functioning of the elderly. Int Psychogeriatr 1997; 9: 309–26
Frantzides CT, Cowles V, Salaymeh B, et al. Morphine effects on human colonic myoelectric activity in the postoperative period. Am J Surg 1992; 163: 144–9
Wallin G, Cassuto J, Hogstrom S, et al. Failure of epidural anesthesia to prevent postoperative paralytic ileus. Anesthesiology 1986; 65: 292–7
Hjortso NC, Neumann P, Frosig F, et al. A controlled study on the effect of epidural analgesia with local anaesthetics and morphine on morbidity after abdominal surgery. Acta Anaesthesiol Scand 1985; 29: 790–6
Komatsu H, Matsumoto S, Mitsuhata H, et al. Comparison of patient-controlled epidural analgesia with and without background infusion after gastrectomy. Anesth Analg 1998; 87: 907–10
Egan KJ, Ready LB. Patient satisfaction with intravenous PCA or epidural morphine. Can J Anaesth 1994; 41: 6–11
Miaskowski C, Crews J, Ready LB, et al. Anesthesia-based pain services improve the quality of postoperative pain management. Pain 1999; 80(1–2): 23–9
Chumbley GM, Hall GM, Salmon P. Patient-controlled analgesia: an assessment by 200 patients. Anaesthesia 1998; 53: 216–21
Ni Chonchubhair A, Valacio R, Kelly J, et al. Use of the abbreviated mental test to detect postoperative delirium in elderly people. Br J Anaesth 1995; 75: 481–2
Stone JG, Cozine KA, Wald A. Nocturnal oxygenation during patient-controlled analgesia. Anesth Analg 1999; 89: 104–10
Singelyn FJ, Deyaert M, Joris D, et al. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg 1998; 87: 88–92
Singelyn FJ, Gouverneur JM. Postoperative analgesia after total hip arthroplasty: i.v. PCA with morphine, patient-controlled epidural analgesia, or continuous ‘3-in-1’ block?: a prospective evaluation by our acute pain service in more than 1300 patients. J Clin Anesth 1999; 11: 550–4
Acknowledgements
The authors have provided no information on sources of funding or on conflicts of interest directly relevant to the content of this review.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Mann, C., Pouzeratte, Y. & Eledjam, JJ. Postoperative Patient-Controlled Analgesia in the Elderly. Drugs Aging 20, 337–346 (2003). https://doi.org/10.2165/00002512-200320050-00003
Published:
Issue Date:
DOI: https://doi.org/10.2165/00002512-200320050-00003