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Older people tend to suffer more side effects( especially constipation, sedation and falls), and often at lower doses than in younger adults.
Too often for the elderly, Dr. Zacharias suggests, doctors go directly to the opioid route without exhausting other options.
When elderly people have dementia, pain assessments need to take into account the cognitive impairment. Watch for changes in behaviour that may indicate pain. And good pain assessment tools do exist for persons with dementia( i. e., PAINAD), Dr. Zacharias says.
Older patients may be less likely than younger ones to complain about pain or accept opioids. They may associate opioids with severe or terminal illness. Another issue: older patients fear that discussing their pain may lead to unnecessary investigations or hospitalization.
Some patients may also worry about addiction. This is a legitimate concern, and needs to be managed in the context of the goals of the patient and their prognosis, says Toronto geriatrician Dr. Heather Gilley.
Because of the risks, it’ s especially important to take a patient-focused approach to pain management in the elderly, says Dr. Gilley, who works at St. Michael’ s Hospital, and also serves on the Geriatric and Long- Term Care Death Review Committee.“ How is pain impacting their day-to-day function? You may not eliminate the pain, but may get to the point where they can reach their functional goals,” she says.“ If their priority is to walk to the mailbox and back, you don’ t want to push the medication beyond them reaching that goal.” If prescribing opioids, she’ ll talk to her patients about the heightened danger of side effects, and about addiction, too. Are elderly patients prescribed opioids too often or not often enough? It can be both, she says. To date she has seen more overprescribing, noting that for longterm chronic non-cancer pain there’ s little evidence for the ongoing use of opioids.“ But now we see the pendulum swinging far in the other direction, with underprescribing for acute pain.” For the elderly with pain, start with the right treatment protocol.“ The challenge is doing a proper assessment, before you even look at opioids,” says Dr. Zacharias, who is also Medical Director of the Village of Erin Meadows nursing home. That can mean functional and pain assessment scales, followed by non-drug options like physiotherapy, massage therapy or hydrotherapy. For localized pain, Dr. Zacharias says there are anti-inflammatory creams or gels. Non-opioid analgesics, such as acetaminophen on a scheduled basis, are the cornerstone of pain management initially. NSAIDs are problematic in the elderly because of their adverse effects on blood pressure, adverse cardiac events, gastrointestinal and kidney function, but can be used with caution in appropriate patients. Next come non-opioids, such as anti-convulsants or low dose anti-depressants. Among medications, he says, opioids are the third or fourth line choice.
Opioid-related Hospitalizations for Seniors Spike The Canadian Institute for Health Information( CIHI) has reported that the rate of hospitalizations for opioid poisoning( mostly accidental) has increased more than 30 % since 2007. Seniors( aged 65-plus) account for nearly 25 % of these hospitalizations, the highest rate of any group. An article in the Canadian Medical Association Journal last year suggested possible reasons: the elderly population is rising, seniors are more sensitive to drugs overall and they take a higher number than younger adults, all increasing the chance of bad reactions and medication mix-ups. The recently released 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain does not contain specific guidance on managing opioids in the elderly. If you must use opioids, the 2010 Canadian Guideline, and the American Geriatrics Society Guidelines contain the following suggested approaches to opioids in the elderly:
Use the least invasive route for medication;
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DIALOGUE ISSUE 4, 2017