How To Manage Surgical Pain In Elderly Patients

By Erwin Juda, DPM, R.Ph.

   Ibuprofen is a short-acting agent that has been deemed appropriate for mild to moderate pain in seniors. As a nonselective NSAID, there are still concerns for GI effects as well as the potential for prolonged bleeding postoperatively due to its anti-platelet activity. The COX-2 specific inhibitor celecoxib provides an improved GI safety profile without platelet inhibitory effects but offers little difference in analgesic efficacy over conventional NSAIDs. In light of the current cardiovascular concerns with COX-2 selective agents, using a COX-2 preferential inhibitor such as nabumetone, which is a nonacid derivative, is also considered a suitable alternative in the elderly.

Pertinent Points On Other Agents

   Ketorolac is available in a parenteral formulation and is effective for the short-term management of moderately severe pain that requires analgesia at the opioid level for up to five days. One should reduce the dosage to 15 mg IV or 30 mg IM in those over the age of 65.

   While nonacetylated salicylates, such as salsalate, diflunisal and choline magnesium salicylate, are weak COX-1 inhibitors that have been mentioned as alternatives, numerous clinicians have found them to be less efficacious than COX-2 inhibitors. Naproxen is among the most highly plasma protein bound of the NSAID group. Therefore, it poses a risk for drug displacement interactions with the multiple drug regimens in this age group. Due to the high propensity of CNS effects with indomethacin and the extremely long plasma half-life of piroxicam, using these medications as analgesics in the elderly is inappropriate.6,8,9

What You Should Know About Opioids

   More often than not, the realm of podiatric surgery, either by the nature of the operation or the performance of multiple procedures, lends itself to the anticipation of moderate to severe pain. The podiatric surgeon should assume pain is present in an older adult who has undergone a potentially painful procedure. Accordingly, clinicians will need to choose a preemptive drug regimen equal to the task of alleviating this pain.

   Opioids are the mainstay for treating moderately severe to severe postoperative pain in the geriatric age group.2 The commonly used pure agonists, such as morphine, hydromorphone, codeine, hydrocodone and oxycodone provide analgesia by stimulating the MU opioid receptor.10 When it comes to using pure agonists, they do offer distinct advantages in that they are short-acting agents (with a duration of three to four hours) and have no ceiling effect, which allows for dose titration.

   One can simply initiate dosing in the elderly with standing orders of a short-acting, immediate release preparation, such as 10 to 30 mg of morphine on a regular schedule every four hours to achieve steady state plasma levels quickly as opposed to starting the agent prn and then converting to an extended release product to improve compliance. If one employs controlled release preparations to achieve steady state plasma levels, then clinicians would also need to institute rescue doses of a short acting opioid, comprising about 5 to 15 percent of the total 24-hour dose, as needed for breakthrough pain.11

   Levorphanol and methadone are potentially useful for less frequent dosing. However, their longer duration of action creates the potential for drug accumulation and their risk for significant sedation makes them less than ideal for use in older adults. One should not consider fentanyl transdermal patches as a first line opioid due to erratic absorption from differences in body temperature as well as subcutaneous fat and water content in the elderly in comparison to younger individuals. The patch may be useful if the patient cannot take oral medication or there are impediments to other routes of administration. Nevertheless, one should ensure that the initial dose does not exceed 25 mcg/h and restrict the use of this patch to cognitively intact patients.2

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