TREATMENT OF ACUTE POSTOPERATIVE PAIN
Both experimental and clinical studies provide support for the
notion of an age-related decrease in pain perception (see Chapter
72
).[169]
[170]
However, it is not clear whether the observed changes are caused by the aging process
or reflect other age-associated effects such as an increased
presence of comorbid disease.[171]
A greater problem
occurs in cognitively impaired patients. Evidence suggests that evaluation of pain,
especially in a severely cognitively impaired individual, is difficult even for a
geriatrician.[172]
Nonetheless, the basic principles
of evaluation of pain in the elderly are similar to those in other age groups.[50]
In addition, as discussed earlier in this chapter, aging alters functional organ
reserve and pharmacokinetics. Thus, the combination of pain assessment and drug
dose adjustment provides challenges in the management of postoperative pain in the
elderly. Many of the principles of postoperative pain management in the elderly
are discussed in Chapter 72
.
Several general principles should be kept in mind when managing frail, elderly patients.
For one, it is important to try to incorporate multiple modalities of analgesia,
for example, intravenous patient-controlled analgesia and regional nerve blocks,
which will enhance analgesia and reduce narcotic toxicity. This principle is especially
important in frail elders, who often tolerate systemic narcotics poorly. Second,
the use of site-specific analgesia is a helpful adjunct. Certain operative sites,
such as the upper extremity, are especially amenable to local nerve blocks. Others,
such as thoracotomy, are especially painful, and intercostal nerve block might be
considered. Third, whenever possible, nonsteroidal anti-inflammatory drug preparations
should be used to spare narcotics, enhance analgesia, and decrease inflammatory mediators.
Unless the patient has a contraindication or there is a strong concern about hemostasis
or peptic ulceration, nonsteroidal anti-inflammatory drugs should generally be administered.
[173]
Opioid-based postoperative pain management
may be used in the elderly. However, it is imperative to keep in mind the alterations
in dose requirements that occur with age.[27]
