Prescribing analgesics for elderly patients can be difficult. Older patients are much more likely than younger ones to experience GI and other side effects of drug use. In addi- tion, they are generally taking more medications that may interact with the prescribed analgesic. Other factors, such as reduced renal and hepatic function, can also affect the efficacy and accumulation of the analgesic, thus increasing the risk of drug toxicity.
Practitioners must therefore take a careful medical and drug history to determine potential contraindications to analgesics. Prior analgesic use should be reviewed to determine, if possible, what analgesics were effective and what side effects, if any, occurred. This review is a very practical process in selecting the proper analgesic for all patients, especially the elderly. Acute renal failure induced by the NSAIDs is more common in older patients, espe- cially in those who are taking diuretics or who have congestive heart failure, liver disease, or kidney disease. Safer analgesics for these patients include sulindac (Clinoril) or a nonacetylated salicylate. Ibuprofen and diclofenac are potential alternatives because they do not tend to accumulate in patients with renal impairment. Acetaminophen is another option, because it rarely causes acute renal failure when used on a short-term basis.
One of the major problems with use of NSAIDs in elderly patients, especially women, is the increased inci- dence of gastric mucosal damage (NSAID gastropathy). This condition can lead to significant GI bleeding and
even death. Options for preventing or treating this prob- lem include the following: (1) use of drugs that may produce less gastric irritation, such as ibuprofen, fenopro- fen, diclofenac, COX-2 inhibitors, choline–magnesium sali- cylate, enteric-coated aspirin, or acetaminophen; (2) use of an H2blocker, such as ranitidine or famotidine prophy-
lactically; (3) use of misoprostol (Cytotec), a synthetic prostaglandin E1 analogue, which inhibits gastric acid
secretion while possessing mucosal protective proper- ties; and (4) use of omeprazole (Prilosec), a proton pump inhibitor, which significantly reduces gastric acid secre- tion and may have fewer side effects than misoprostol.
Most patients having cataract extraction are elderly, and some may have bleeding disorders. Because aceta- minophen and the nonacetylated salicylates affect platelet aggregation only minimally, these analgesics are preferred for preoperative or postoperative use.
Treatment of Mild to Moderate Pain
The most useful nonopioid analgesics for treatment of pain in the elderly are listed in Box 7-3. For treatment of mild to moderate acute pain, a practical approach is to initiate therapy with acetaminophen, 650 to 1,000 mg to a maximum of 4,000 mg/day. If pain continues, an NSAID should be substituted. If pain still persists, an alternative NSAID, preferably from a different therapeutic class, should be selected. If the alternative NSAID is ineffective, full-dose acetaminophen combined with an NSAID should be considered. Combinations of several NSAIDs, however, should not be used. This approach is often effective without resorting to the use of opioid analgesics.
Treatment of Moderate to Severe Pain
Elderly patients in moderate to severe pain may require narcotic analgesics, but the use of opioids can be associ- ated with significant toxicity because of the unique meta- bolic and physiologic alterations in aging patients.
Box 7-3 Preferred Analgesics for Use in Elderly Patients Nonopioids Acetaminophen Ibuprofen Diclofenac Diflunisal Fenoprofen Naproxen sodium COX-2 inhibitors Opioids
Codeine with acetaminophen Oxycodone with acetaminophen
Opioids are detoxified in the liver.The metabolic capacity of the liver declines with age, thus reducing drug clear- ance and enhancing the cumulative effects of narcotics. This is of special concern in elderly patients with heart failure or liver disease. In addition, the degree of analgesia and CNS depression produced by opioids is enhanced by normal aging, especially in patients with preexisting CNS dysfunction such as stroke or dementia. Furthermore, opioid-induced respiratory depression is enhanced in the elderly and in persons with depressed CO2drives associ-
ated with obesity or chronic obstructive pulmonary disease. Urinary retention can also be a problem in elderly men with benign prostatic hypertrophy.
The opioid analgesics of choice for use in the elderly are listed in Box 7-3. For treatment of moderate to severe pain, an effective opioid regimen consists of a combina- tion of acetaminophen with 15 to 60 mg codeine or acet- aminophen with 5 to 30 mg oxycodone.Acetaminophen combinations with hydrocodone are also frequently used. If pain persists, an alternative opioid analgesic should be selected. Adjuvants such as caffeine may enhance the analgesic activity of the opioid.
Management of Side Effects
Opioid-induced constipation is more troublesome in older patients, and it should be anticipated by instituting laxative therapy along with the narcotic.A typical laxative regimen consists of psyllium and a stool softener. A mild stimulant laxative such as bisacodyl (Dulcolax) can be added if constipation becomes problematic.
Nausea and vomiting are other opioid-induced effects that are more significant in elderly patients. Nausea can result from vestibular stimulation, so limiting physical activity may be useful to reduce symptoms. If drug therapy is needed, hydroxyzine is preferable to a phenothiazine. Because the antihistamines have significant anticholinergic effects that can be troublesome in elderly individuals, these drugs should not be routinely given with the opioid unless absolutely needed.
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