Treating Elderly Patients
Like other adults, older patients require comprehensive assessment and
aggressive management of cancer pain. Older patients are at risk for
undertreatment of pain, however, because of underestimation of their
sensitivity to pain, the expectation that they tolerate pain well, and
misconceptions about their ability to benefit from the use of opioids. Issues
in assessing and treating cancer pain in older patients include:
- Multiple chronic diseases and sources of pain.
Age and complex medication regimens place them at increased risk for drug-drug
and drug-disease interactions.
- Visual, hearing, motor, and cognitive impairments.
The use of simple descriptive, numeric, and visual-analog pain-assessment
instruments may be impeded. Cognitively impaired patients may require simpler
scales and more frequent pain assessment.
- Nonsteroidal anti-inflammatory drug (NSAID) side effects.
Although effective alone or as adjuncts to opioids, NSAIDs are more likely to
cause gastric and renal toxicity and other drug reactions such as cognitive
impairment, constipation, and headaches in older patients. Alternative NSAIDs
(e.g., choline magnesium trisalicylate) or coadministration of misoprostol
with NSAIDs should be considered to reduce gastric toxicity.
- Opioid effectiveness.
Older persons tend to be more sensitive to the analgesic and central nervous system depressant
effects of opioids. Peak opioid effects are generally greater and the duration
of pain relief may be longer.
- Patient-controlled analgesia.
Slower drug clearance and increased sensitivity to undesirable drug effects
(e.g., cognitive impairment) indicate the need for cautious initial dosing and
subsequent titration and monitoring of continuous parenteral infusions.
- Alternative routes of administration.
Although useful for patients who have nausea or vomiting, the rectal route may
be inappropriate for elderly or infirm patients who are physically unable to
place the suppository in the rectum.
- Postoperative pain control.
Following surgery, surgeons and other health care team members should maintain
frequent direct contact with the elderly patient to reassess the quality of
pain management.
- Change of setting.
Reassessment of pain management and appropriate changes should be made whenever
the elderly patient moves (e.g., from hospital to home or nursing home).
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