Managing acute pain in older people
Management of acute pain in older people can be complicated by:
- age-related changes in physiology, pharmacodynamics and pharmacokinetics
- a higher prevalence of concurrent diseases and polypharmacy
- altered responses to pain (eg reduced pain perception)
- difficult pain assessment (see Additional considerations when assessing pain in older people and Additional considerations when assessing pain in people with impaired cognition).
Clinicians may undertreat pain in older people because of concerns about increased sensitivity to analgesics or drug interactions; however, most analgesics for acute pain management are suitable for older patients when dosed appropriately. Opioids and other sedating analgesics (eg gabapentinoids, ketamine, tricyclic antidepressants) should be initiated at lower doses and titrated to effect to prevent adverse effects. Older people are more sensitive to centrally-acting medications. Age-related physiological changes (eg kidney impairment) also play a role.
People with impaired cognition (eg dementia, delirium) have difficulty reporting pain, which influences the accuracy of analgesic dose titration (in particular, opioid titration). These patients often receive lower doses of analgesics than cognitively intact patients with similar acute pain conditions (eg fractured neck of femur). Do not withhold opioids for fear of aggravating cognitive impairment in older people. Although reported anecdotally, evidence is inconclusive that tramadol increases the risk of developing confusion in older patients compared to other opioids.