Skip to main content
SpringerLink
Log in

Pharmacological Management of Cancer Pain in the Elderly

  • Review Article
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Existing studies indicate a high prevalence rate and poor management of cancer pain in the elderly. Pain is often considered an expected concomitant of aging, and older patients are considered more sensitive to opioids. Despite the well known pharmacokinetic changes in the elderly, the complex network of factors involved in the opioid response make the evaluation of a single element, such as age, more difficult.

Notwithstanding such difficulties, appropriate analgesic treatment is able to control cancer pain in the elderly in most cases. Skills necessary to optimise pain control in older cancer patients include the ability to objectively assess functional age (not necessarily related to chronological age since the rate of decline is variable), understand the impact of coexisting conditions, carefully manage the numbers and types of drugs taken at the same time and adequately communicate with patients and relatives.

The most common treatment of cancer pain consists of the use of regularly given oral analgesics. The elderly are at increased risk of developing toxicity from NSAIDs, and the overall safety of these drugs in frail elderly patients should be considered. When older patients have clear contraindications to NSAIDs, manifest signs of toxicity from these agents, or find that pain is no longer controlled with this class of drugs, opioids should be started. A variety of opioids are available, and they differ widely with respect to analgesic potency and adverse effects among the elderly.

Although the aged population requires lower doses of opioids, only careful titration based on individual response can ensure the appropriate response to clinical demand. Elderly patients are potentially more likely to be affected by opioid toxicity because of the physiological changes associated with aging. Nevertheless, appropriate dosage and administration may limit these risks. Cancer patients with pain who do not respond to increasing doses of opioids because they develop adverse effects before achieving acceptable analgesia may be switched to alternative opioids. Despite the favourable effects reported with opioid switching, monitoring is crucial, particularly in the elderly or patients who are switched from high doses of opioids. Adjuvant analgesics, including antidepressants, antiepileptics, corticosteroids and bisphosphonates may help in the treatment of certain types of chronic pain.

With an appropriate and careful approach, it should be possible to reduce or eliminate unrelieved cancer pain in most elderly patients and, consequently, to enhance their quality of life. Older patients with cancer should be continuously assessed for cancer pain, both before and after analgesic treatment.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Table I
Table II

Similar content being viewed by others

References

  1. Balducci L. Management of cancer pain in geriatric patients. J Support Oncol 2003; 1: 175–91

    PubMed  Google Scholar 

  2. Stein W, Miech R. Cancer pain in the elderly hospice patient. J Pain Symptom Manage 1993; 8: 474–82

    Article  PubMed  CAS  Google Scholar 

  3. Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994; 330: 592–6

    Article  PubMed  CAS  Google Scholar 

  4. Cohen-Mansfield J. The adequacy of minimum data set assessment of pain in cognitively impaired nursing home residents. J Pain Symptom Manage 2004; 27: 343–51

    Article  PubMed  Google Scholar 

  5. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. JAMA 1998; 279: 1877–82

    Article  PubMed  CAS  Google Scholar 

  6. Landi F, Onder G, Cesari M, et al. Pain occurs daily, remains untreated among elderly patients in community settings. Arch Intern Med 2001; 161: 2721–4

    Article  PubMed  CAS  Google Scholar 

  7. Fine P. Pharmacological management of persistent pain in older patients. Clin J Pain 2004; 20: 220–6

    Article  PubMed  Google Scholar 

  8. Edgards R, Fillingim R, Ness T. Age-related differences in endogenous pain modulation: a comparison of diffuse noxious inhibitory controls in healthy older and younger adults. Pain 2003; 101: 155–65

    Article  Google Scholar 

  9. Gibson S, Farrell M. A review of age differences in the neurophysiology of nociception and perceptual experience of pain. Clin J Pain 2004; 20: 227–39

    Article  PubMed  Google Scholar 

  10. Mercadante S, Portenoy RK. Opioid poorly-responsive cancer pain: part 1. Clinical considerations. J Pain Symptom Manage 2001; 21: 144–50

    Article  PubMed  CAS  Google Scholar 

  11. Wang Y, Mitchell JK, Moriyama K, et al. Age-dependent morphine tolerance development in the rat. Anesth Analg 2005; 100: 1733–9

    Article  PubMed  CAS  Google Scholar 

  12. 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 

  13. Kirkova J, Davis MP, Tiernan E, et al. Cancer symptom assessment instruments: a systematic review. J Clin Oncol 2006; 24: 1459–73

    Article  PubMed  Google Scholar 

  14. Cancer pain release. Volume 17, nos. 1 & 2 — 2004 [online]. Available from URL: http://www.whocancerpain.wisc.edu/eng/17_1-2/17_1-2.html [Accessed 2007 Aug 1]

  15. World Health Organization. Cancer pain relief. Geneva: World Health Organization, 1986

    Google Scholar 

  16. Kolesnikov YA, Wilson RS, Pasternak GW. The synergistic analgesic interactions between hydrocodone and ibuprofen. Anesth Analg 2003; 97: 1721–3

    Article  PubMed  CAS  Google Scholar 

  17. Davis MP, Srivastava M. Demographics, assessment and management of pain in the elderly. Drugs Aging 2003; 20: 23–57

    Article  PubMed  CAS  Google Scholar 

  18. Mercadante S, Arcuri E. Opioids and renal function. J Pain 2004; 5: 2–19

    Article  PubMed  CAS  Google Scholar 

  19. Wong NA, Jones HW. An analysis of discharge drug prescribing amongst elderly patients with renal impairment. Postgrad Med J 1998; 74: 420–2

    Article  PubMed  CAS  Google Scholar 

  20. Mercadante S, Porzio G, Ferrera P, et al. Low morphine doses in opioid-naive cancer patients with pain. J Pain Symptom Manage 2006; 31: 242–7

    Article  PubMed  CAS  Google Scholar 

  21. Glare PA, Walsh TD. Dose-ranging study of oxycodone for chronic pain in advanced cancer. J Clin Oncol. 1993; 11: 973–8

    PubMed  CAS  Google Scholar 

  22. Chen ZR, Somogyi AA, Reynolds G, et al. Disposition and metabolism of codeine after single and chronic doses in one poor and seven extensive metabolisers. Br J Clin Pharmac 1991; 31: 381–90

    Article  CAS  Google Scholar 

  23. Likar R, Wittels M, Molnar M, et al. Pharmacokinetic and pharmacodynamic properties of tramadol IR and SR in elderly patients: a prospective, age-group-controlled study. Clin Ther 2006; 28: 2022–39

    Article  PubMed  CAS  Google Scholar 

  24. Caracci G. The use of opioid analgesics in the elderly. Clin Geriatr 2003; 11: 18–21

    Google Scholar 

  25. Walsh D. Advances in opioid therapy and formulations. Support Care Cancer 2005; 13: 138–44

    Article  PubMed  Google Scholar 

  26. Skaer TL. Practice guidelines for transdermal opioids in malignant pain. Drugs 2004; 64(23): 2629–38

    Article  PubMed  CAS  Google Scholar 

  27. Payne R, Mathias SD, Pasta DJ, et al. Quality of life and cancer pain: satisfaction and side effects with transdermal fentanyl versus oral morphine. J Clin Oncol 1998; 16: 1588–93

    PubMed  CAS  Google Scholar 

  28. Mercadante S. Transdermal buprenorphine in cancer pain: a renewed therapeutic opportunity. Support Palliat Cancer Care 2006; 3: 117–22

    Google Scholar 

  29. Vigano A, Bruera E, Suarez-Almazor M. Age, pain intensity and opioid dose in patients with advanced cancer. Cancer 1998; 83: 1244–50

    Article  PubMed  CAS  Google Scholar 

  30. Mercadante S, Radbruch L, Caraceni A, et al. Episodic (breakthrough) pain: consensus conference of an expert working group of the European Association for Palliative Care. Cancer 2002; 94: 832–9

    Article  PubMed  Google Scholar 

  31. Popp B, Portenoy RK. Management of chronic pain in the elderly: pharmacology of opioids and other analgesics. In: Ferrell BR, Ferrell BA, editors. Pain in the elderly. Seattle (WA): IASP Press, 1996: 21–34

    Google Scholar 

  32. Ashby M, Fleming B, Wood M, et al. Plasma morphine and glucuronide (M3G and M6G) concentrations in hospice patients. J Pain Symptom Manage 1997; 14: 157–67

    Article  PubMed  CAS  Google Scholar 

  33. Sorkin BA, Rudy TE, Hardon RB, et al. Chronic pain in old and young patients: differences appear less important than similarities. J Gerontol 1990; 45: 64–8

    Article  Google Scholar 

  34. Ventafridda V, Oliveri E, Caraceni A, et al. A retrospective study on the use of oral morphine in cancer pain. J Pain Symptom Manage 1987; 2: 77–81

    Article  Google Scholar 

  35. Mercadante S, Casuccio A, Pumo S, et al. Factors influencing the opioid response in advanced cancer patients with pain followed at home: the effects of age and gender. Support Care Cancer 2000; 8: 123–30

    Article  PubMed  CAS  Google Scholar 

  36. Hall S, Gallagher R, Gracely E, et al. The terminal cancer patient: effect of age, gender, and primary tumor site on opioid dose. Pain Med 2003; 4: 125–34

    Article  PubMed  Google Scholar 

  37. Rees WD. Opioid needs of terminal care patients: variations with age and primary site. Clin Oncol (R Coll Radiol) 1990; 2: 79–83

    Article  CAS  Google Scholar 

  38. Bercovitch M, Waller A, Adunsky A. High dose morphine use in the hospice setting: a database survey of patient characteristics and effect on life expectancy. Cancer 1999; 86: 871–7

    Article  PubMed  CAS  Google Scholar 

  39. Mercadante S, Villari P, Ferrera P, et al. Opioid-induced or pain relief-reduced symptoms in advanced cancer patients? Eur J Pain 2006; 10: 153–9

    Article  PubMed  CAS  Google Scholar 

  40. Mercadante S, Villari P, Ferrera P, et al. Opioid escalation in patients with cancer pain: the effect of age. J Pain Symptom Manage 2006; 32: 413–9

    Article  PubMed  CAS  Google Scholar 

  41. Pereira J, Hanson J, Bruera B. The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer 1997; 79: 835–42

    Article  PubMed  CAS  Google Scholar 

  42. Manfredi P, Breuer B, Wallenstein S, et al. Opioid treatment for agitation in patients with advanced dementia. Int J Geriatr Psychiatry 2003; 18: 700–5

    Article  PubMed  Google Scholar 

  43. Chang V, Hwang S, Kasimis B. Longitudinal documentation of cancer pain management outcomes: a pilot study at a VA medical center. J Pain Symptom Manage 2002; 24: 494–505

    Article  PubMed  Google Scholar 

  44. Ripamonti C, Bruera E. Chronic nausea and vomiting. In: Ripamonti C, Bruera E, editors. Gastrointestinal symptoms in advanced cancer patients. Oxford: Oxford University Press, 2002: 169–92

    Google Scholar 

  45. Gloth M. Geriatric pain: factors that limit pain relief and increase complications. Geriatrics 2000; 55: 46–54

    PubMed  Google Scholar 

  46. Reissig JE, Rybarczyk AM. Pharmacologic treatment of opioidinduced sedation in chronic pain. Ann Pharmacother 2005; 39: 727–31

    Article  PubMed  CAS  Google Scholar 

  47. Mercadante S, Bruera E. Opioid switching: a systemic and critical review. Cancer Treat Review 2006; 32: 304–15

    Article  CAS  Google Scholar 

  48. Donner B, Zenz M, Tryba M, et al. Direct conversion from oral morphine to transdermal fentanyl: a multicenter study in patients with cancer pain. Pain 1996; 64: 527–34

    Article  PubMed  CAS  Google Scholar 

  49. Mercadante S. Ketamine in cancer pain: an update. Palliat Med 1996; 10: 225–30

    PubMed  CAS  Google Scholar 

  50. Pavlakis N, Schmidt R, Stockier M. Bisphosphonates for breast cancer. Cochrane Database Syst Rev 2005; (3): CD003474

    Google Scholar 

  51. Roque M, Martinez MJ, Alonso P, et al. Radioisotopes for metastatic bone pain. Cochrane Database Syst Rev 2003; (4): CD003347

    Google Scholar 

Download references

Acknowledgements

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

Author information

Authors and Affiliations

  1. Anesthesia & Intensive Care Pain Unit and Pain Relief & Palliative Care Unit, La Maddalena Cancer Center, and Palliative Medicine, University of Palermo, Palermo, Italy

    Sebastiano Mercadante

  2. Pain Relief and Intensive Care Unit, National Cancer Institute Regina Elena, Rome, Italy

    Edoardo Arcuri

Authors
  1. Sebastiano Mercadante
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Edoardo Arcuri
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sebastiano Mercadante.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Mercadante, S., Arcuri, E. Pharmacological Management of Cancer Pain in the Elderly. Drugs Aging 24, 761–776 (2007). https://doi.org/10.2165/00002512-200724090-00004

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00002512-200724090-00004

Keywords

Search

Navigation