ACUTE PAIN MANAGEMENT IN OLDER ADULTS
Effective analgesia can not only improve patient comfort but may also reduce the risk of deleterious consequences as mentioned above. Pain assessment tools should be used and documented consistently across all clinical care settings that are appropriate to patient’s cognitive abilities. This will be necessary to overcome barriers that hinder communication regarding unrelieved pain. There are concerns for postoperative cognitive decline associated with the use of general anesthetics, benzodiazepines, and opioid analgesic medications in older adults. Physiological frailty makes the use of regional as well as neuraxial modalities challenging. Providers should recognize that older adult patients might respond differently than their younger counterparts to pain and analgesic medications, due to comorbidities and are more likely to be on multiple medications. Hence, providers need to be extra vigilant about dose titration, to avoid side effects of the drugs such as excessive somnolence, balance problems, and constipation. They should look into optimal utilization of nonpharmacological modalities such as heating pads, ice packs, and/or topical medications whenever possible. In this vulnerable population, a multimodal analgesic strategy should be used to optimize analgesia and minimize side effects. An example of “balanced analgesia” could include combining opioids with nonsteroidal anti-inflammatory drugs (NSAIDs) and neuromodulators such as gabapentin and pregabalin. At the same time, it could mean using regional techniques, such as peripheral nerve blocks and neuraxial analgesia concurrently with systemic pharmacologic options.19 Unfortunately, a paucity of well-designed studies to delineate an optimal combination of effective therapies has not been conducted. In lieu of focused studies, clinicians must use the available data, extrapolate available information, and individualize therapy based on patient-specific factors. A pain service consult should be requested for patients with inadequately controlled moderate to severe pain related to trauma, surgery, cancer, or acute on chronic pain flare-ups related to various disease states. Intravenous or neuraxial route may be required to control pain initially. Once the patient starts to tolerate oral medications, the analgesic regimen can be changed from intravenous to oral opioid, including oxycodone, hydrocodone, hydromorphone, morphine, tramadol, tapentodol, or combination medications like hydrocodone-acetaminophen or oxycodone-acetaminophen. Uses of oral acetaminophen and/or NSAIDs are recommended for additive effect.