Principles & Practice of Pain Medicine > Part V. Pain Syndromes > E. Pediatric and Geriatric Pain > Chapter 57. Pain in the Elderly Aida Won

Pain Management in the Elderly

"Many older patients experience pain daily, yet they receive inadequate analgesia. Although many older people have a higher incidence of side effects, this is not a good excuse for undertreatment. Analgesics can still be used, but should be used more wisely and cautiously. The following guiding principles and caveats have been extracted from the American Geriatrics Society Clinical Practice Guidelines, and may help maximize treatment efficacy and minimize adverse effects in the elderly.²² These principles are summarized in Table 57-3.Hepatic and renal function is often reduced as a normal part of aging. This results in a higher peak plasma level, as well as a longer half-life of many drugs. For example, peak plasma levels of oxycodone are 15% greater in elderly than in younger patients. Persons with a creatinine clearance <60 may have peak plasma levels that are 20% to 50% higher. Thus elderly patients may achieve pain relief from smaller doses of analgesics than those required by younger patients. Therefore, if the pain is mild to moderate, an opioid-naïve elderly person may have a good response with a half tablet to one tablet of oxycodone or hydrocodone. Although the patient may ultimately need higher doses for adequate pain relief, the old adage "start low and go slow" accurately reflects the need for gradual and careful titration. Extra caution should be taken when converting to long-acting forms of analgesics because of the problem of drug accumulation...."