How To Manage Surgical Pain In Elderly Patients
A Review Of Medications For Mild To Moderate Pain
Most clinicians are familiar with the conceptional guide that was originally developed by the World Health Organization (WHO) for malignant pain. This guide is now widely referred to when physicians are treating nonmalignant pain.3 It provides a time-tested, three-step approach to the rational selection of analgesics in an ascending fashion. Classically, aspirin, acetaminophen and NSAIDs comprise the first step for treating mild pain and there is a progression to opioids for moderate to severe pain. Acetaminophen is considered to be the agent of choice for managing mild to moderate pain in older adults.4 It is safe and effective in this age group when one uses it within normal dosing parameters. While the risk for hepatotoxicity is well known, these effects are primarily dose-dependent as opposed to being caused by altered pharmacokinetics. Acetaminophen is metabolized by phase II conjugation, which remains essentially unchanged with advancing age. Although the maximum adult recommended dose is 4 g/day, some gerontologists recommend limiting the intake to 3,200 mg/day.5 Podiatrists should be aware that older adults may place themselves at risk in exceeding their total daily intake if they forget to report or inadvertently consume over-the-counter acetaminophen in combination products such as those for headache or cold relief. When it comes to prescribing NSAIDs during the preoperative period, they do offer the benefits of an opioid-sparing effect and the potential to reduce postoperative inflammation. However, these medications are not without risks. The multitude of potential complications affecting the gastrointestinal, renal, hepatic, cardiovascular, central nervous system and hematologic systems has been well documented. The risk of these side effects is higher in the elderly population due to their widespread use of NSAID medications. Approximately half of all NSAID prescriptions are written for patients beyond 60 years of age.6 These risks become more significant when they are combined with the decrease in activity of hepatic phase I oxidation and reduction reactions leading to drug accumulation, as well as diminished kidney function that results in decreased renal elimination.7 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.