PRACTICE PARTNER
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