Older Adults

Overview:

Pain is not a normal part of aging. The underlying causes and treatment strategies are similar, though in older adults pain it is often unrecognized and undertreated. Providing adequate pain control can minimize the potentially serious negative physical, psychological, and social consequences associated with pain.

Challenges

The use of pain medication in older adults is associated with a higher risk of complications and adverse events. Common barriers to effective pain management include: clinician inexperience with pain assessment, lack of a clear action plan to treat pain, and overestimation of the risk for opioid tolerance and addiction.
In addition to pharmacologic pain management options, it is essential to maximize nonpharmacological strategies and to avoid undertreatment of acute or persistent pain due to concern for worsening cognitive impairment.
Effective non-pharmacologic approaches include physical therapy, acupuncture and most importantly, patient and caregiver education interventions. Consider placing a referral to a mental health clinician such as a psychiatrist, psychologist, counselor, or integrated primary care specialist who are able to provide cognitive behavioral therapy as a means of treating acute or chronic pain.

Treatment Recommendations

-Treatment of acute pain should start with Tylenol, preferably scheduled, at a maximum daily dose of 3g/day.

- NSAID therapy should be used with caution and only for short periods of time due to an increased risk for gastrointestinal, renal, and cardiovascular side effects in older adults.

- Topical NSAIDs such as diclofenac gel has been shown to be efficacious in the treatment of arthritis with minimal risks associated with systemic absorption.

- Consider other topical agents such as topical lidocaine patches and capsaicin cream for treatment of neuropathic or musculoskeletal pain.

- Opioid analgesics are the preferred pharmacotherapy for postoperative or severe pain.

Special Considerations

Considerations should be taken to create an optimal pain management plan that balances the risk of:

        Hypo/hyperactive delirium
        Polypharmacy
        Drug interaction
        Altered clearance (dose adjustments, different side-effect profile)

References:

Rajan J, Behrends M. Acute Pain in Older Adults: Recommendations for Assessment and Treatment. Anesthesiol Clin. 2019 Sep;37(3):507-520. doi: 10.1016/j.anclin.2019.04.009. Epub 2019 Jul 1. PMID: 31337481.

Bettinger J, et al. Pain Management in the Elderly: Focus on Safe Prescribing. Pract Pain Manag. 2017 May;17(3):
https://www.practicalpainmanagement.com/treatments/pain-management-elderly

Wei J, Lane N, et al. Association of Tramadol Use with Risk of Hip Fracture. J Bone Miner Res. 2020 Apr;35(4):631-640. Doi:10.1002/jbmr.3935. Epub 2020 Feb 5.

Perry G. Fine, MD, Treatment Guidelines for the Pharmacological Management of Pain in Older Persons, Pain Medicine, Volume 13, Issue suppl_2, April 2012, Pages S57–S66, https://doi.org/10.1111/j.1526-4637.2011.01307.x

Gomes T, Juurlink DN, Antoniou T, Mamdani MM, Paterson JM, van den Brink W. Gabapentin, opioids, and the risk of opioid-related death: A population-based nested case-control study. PLoS Med. 2017 Oct 3;14(10):e1002396. doi: 10.1371/journal.pmed.1002396. PMID: 28972983; PMCID: PMC5626029.

Wallach JD, Ross JS. Gabapentin Approvals, Off-Label Use, and Lessons for Postmarketing Evaluation Efforts. JAMA. 2018 Feb 27;319(8):776-778. doi: 10.1001/jama.2017.21897. PMID: 29486013.

Author:

Candace Kim

- Morphine and codeine are to be avoided in patients who have a GFR <50 due to the accumulation of its metabolites and increased risk of developing respiratory depression, nausea, vomiting and myoclonus. In these individuals, fentanyl, hydromorphone and oxycodone are better choices.

- Tramadol should be avoided in older adults due to its noradrenergic properties which can lead to insomnia and delirium, multiple drug-drug interactions, risk for seizures, high affinity for physical dependence and concern for increased risk of fractures.

- Anticonvulsants such as gabapentin and pregabalin are commonly used for treatment of neuropathic pain. Both medications are eliminated by the kidneys and should be avoided or dose reduced for anyone with renal insufficiency. Common adverse effects that have been reported include somnolence, dizziness and increased rates of falls. Because studies have shown an increased risk of opioid overdose, it should also be avoided or cautiously prescribed when used concomitantly with opioids.

- When considering cannabinoids for pain management in older adults, note common side effects, which include euphoria, anxiety, psychosis, sedation, dizziness, cognitive effects, tachycardia, palpitations, and postural hypotension. Elderly are at higher risk of dysphoric effects related to cannabinoids. Advise against driving due to the effects of cannabinoids on reaction time and motor control.

Key Take Aways

Always follow a multi-modal pain management approach in older adults, using both pharmacologic and non-pharmacologic strategies
NSAIDs should be used with caution and for limited time
Start any pain management with scheduled Tylenol 1000mg TID (3,000mg/day), decreasing dose to 2g/day in those with chronic liver disease.
Treatment with opioids is preferred in the acute setting for postoperative or severe pain
Avoid treatment with tramadol in older adults
Gabapentin and pregabalin dosing should be reduced in those with renal insufficiency and avoided if used concomitantly with opioids.
Medical use of cannabinoids has not been well-studied in older adults, who more commonly have adverse dysphoric side-effects.

Pain Management Education at UCSF

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Older Adults

Challenges

Treatment Recommendations

Special Considerations

Key Take Aways