Although adults older than 65 years have surgical procedures more frequently than any other group,30 they also have the worst postoperative pain management.6,46,48 Approximately 50–75% of patients report inadequate postoperative pain relief,11,37 and the evidence is not limited to results from one study or to one geographic region.6,12,13,15 Although a few studies have examined pain management in the postoperative geriatric patient, there is little in the way of evidence-based guidelines or even a literature informed approach to pain management. The studies document, rather, that the older adult is under-medicated for pain. One study done at a large community teaching hospital in the United States showed that after surgery older patients were prescribed less opioid analgesic medications than younger patients. In addition, only 25% of doses of as-needed medications ordered actually were administered to the older patient, and this percentage continued to decline with advancing age.24 Results of another study of pain management after hip fracture in geriatric patients showed that fewer than 25% of the patients who were cognitively intact received an order for standing analgesia throughout their hospital stay.46 We suggest guidelines for physicians to follow in treating a geriatric orthopaedic patient experiencing postoperative pain and include a stepwise approach for managing side-effects from the pharmacologic therapy.
Reasons for Undertreatment of Pain
Common reasons cited in the literature for poor pain management of older adults in the acute postoperative period include: failure to assess for pain, inadequate knowledge about pain assessment and management, a misperception that pain is a natural and expected consequence of aging,34 a belief that pain should be expected after surgery, and concerns about the use of analgesics in patients with cognitive dysfunction or other comorbid illnesses. As a result, physicians remain ineffective at assessing and treating pain after surgery among older adults.25,28,46
Consequences of Untreated Pain
Untreated acute pain has physiologic, economic, and quality of life consequences. Poorer clinical outcomes,1,42,43 delirium,20,42 impaired cognitive function,19,38 depression,44,56 sleep disturbances,27,44 decreased functional abilities,10,27,28,44 increases in length of hospital stay, and healthcare use and costs29,52 all have been documented. In addition, pain after surgery can compromise pulmonary function and has been shown to contribute to the development of postoperative ileus.41
These disturbing data have led organizations such as the American Pain Society,4 the Agency for Health Care Policy and Research (AHCPR),1,2 and the American Geriatrics Society,3 to create evidence-based clinical practice and quality assurance pain management guidelines for clinicians and other members of the healthcare team. In addition, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently instituted survey criteria and pain management standards as part of its formal assessment protocol.39
We review standards for pain assessment in cognitively intact and impaired older adults, provide detailed guidelines for the pharmacologic treatment of postoperative pain in the geriatric patient with an orthopaedic disorder, and review the stepwise approach to effective side-effect management in this population.
Acute postoperative pain usually is defined by its distinct onset, obvious pathology, and relatively short duration.26 No matter how successful a surgery, the result is significant tissue damage and subsequent release of potent inflammatory and pain mediators.33 The site and type of surgery have a profound effect on the amount of postoperative pain, and orthopaedic procedures, particularly those that involve the large joints of the body, are among the most painful. Therefore, in older adults having orthopaedic surgery, most commonly surgical repair of hip fractures or hip replacements, significant postoperative pain can and should be anticipated. Therefore, the best postoperative pain management plan begins preoperatively. It is advisable to inform the patient before surgery about what to expect regarding the type of pain, how to report pain using a pain scale, and what to expect regarding pain relief postoperatively.31
The clinical assessment of postoperative pain in the geriatric patient who has had orthopaedic surgery begins with a comprehensive pain evaluation (Table 1). Because patient self-reporting is the most accurate and reliable evidence of the existence of pain and its intensity,1–4 a detailed history is necessary for accurate assessment. This is critical to the development of appropriate interventions and the subsequent evaluation of treatment efficacy.34 In addition, a thorough physical examination is recommended with particular attention given to the surgical site, and the musculoskeletal and neurologic systems.
Pain Assessment Instruments
Various self-reporting pain measurement tools are available to assess pain intensity, some of which are more appropriate than others for use in the older adult who is in the hospital.34 These include the faces pain scale (FPS),36 verbal descriptor scale (VDS),35 visual analog scale (VAS),35,59 and numeric rating scale (NRS)35 (Fig 1). However, an older adult’s literacy and educational level, cognitive and sensory functioning (hearing and vision), and motor abilities must be assessed before choosing an instrument. The key is to find an assessment tool that the patient is comfortable with and consistently use the same instrument for each assessment because this has been shown to result in improved pain management for the older adult.34
Pain Evaluation in the Older Adult Who is Cognitively Impaired
In older adults who are cognitively impaired, it may be difficult to use some of the aforementioned instruments. These adults, often the most vulnerable postoperatively, may not be able to articulate the severe pain they feel postoperatively and are at increased risk for being overlooked during assessment and have undertreatment thereafter. In this situation, nonverbal cues, vocalizations, facial indices, and changes in behavior may be used to assess pain levels. However, these indicators may be attenuated in older adults and because of this difficulty, an alternative approach has been proposed in the literature based on a study comparing pain management after hip fracture surgery in older adults who are cognitively intact and those with advanced dementia.46 On average, 44% of patients who were cognitively intact in this study reported severe to very severe pain preoperatively and 42% reported a similar degree of pain postoperatively. Moreover, because the patients who were cognitively impaired received only ⅓ the amount of analgesia compared with their cognitively intact counterparts, it is likely that the majority of these patients experienced severe to very severe pain preoperatively and postoperatively.46 Using the experiences of the cognitively intact subgroup as surrogate measures for the experiences of patients with advanced dementia, the authors of this study suggested that it is in the patient’s best interest to assume that procedures and diseases that are distressing to people who are cognitively intact are likely to be at least as distressing to those with cognitive impairment.45,46 Therefore, decisions regarding pain management should be made bearing this in mind.
Finally, the most important aspect of pain evaluation is frequent reevaluation and reassessment. Although institutional commitments and system-wide protocols39 are becoming increasingly prevalent, patient outcomes will not improve unless physicians individually commit themselves to improve pain management.
Pharmacologic Management of Acute Postoperative Pain in the Geriatric Patient
Treatment should not be delayed while diagnostic procedures, if any, are being pursued after a thorough pain evaluation.37 To guide the pharmacologic management of pain, the World Health Organization (WHO) has developed a three-step conceptual model (Fig 2). Although initially developed to guide the management of cancer pain, this ladder since has been adapted widely as a conceptual guide for the management of nonmalignant pain. Its simple, well-tested approach allows for the rational selection, administration, and titration of a myriad of analgesics and emphasizes the intensity of pain rather than its specific etiology.21,58
Once the pain severity has been determined, management begins at the corresponding step. It is not necessary to traverse each step sequentially; a person with severe pain may need to have Step 3 opiate analgesics immediately.21 Because patients having orthopaedic surgical procedures are most likely to have moderate to severe pain postoperatively, we will present a detailed discussion of Step 3 analgesics with only a brief mention of some other commonly used agents.
Opioids remain the mainstay of, and are among the safest and most effective options for, postoperative pain management in older adults.31 However, it is essential to address the concerns and misperceptions that patients may have about opioids before prescribing them for the control of postoperative pain. Most prevalent among these is the fear of addiction. Studies of medical patients51 and burn patients in hospitals,40,49 and an analysis of the patterns of drug intake in patients with cancer receiving chronic opioids, suggest that the medical use of opioids rarely, if ever, leads to drug abuse or iatrogenic opioid addiction.32 This being said, prescribers must understand that physical dependence (not addiction) is a predictable pharmacologic effect that will be seen in response to repeated dosing of an opioid and is similar to that seen with beta-blockers or corticosteroids.
Dependence versus Addiction
Physical dependence describes the phenomenon of symptoms of withdrawal if an opioid is discontinued abruptly. Tapering the opiate during a several-day period before discontinuation can prevent withdrawal symptoms. The signs and severity of withdrawal symptoms are dependent on the dose and duration of previous opioid administration, and usually occur within 6–12 hours after discontinuation of the opioid. Commonly seen symptoms are nervousness and irritability, salivation, lacrimation, nausea and vomiting, abdominal cramps, and sweating. This phenomenon is distinctly different from addiction, a complex psychiatric phenomenon defined by the psychologic dependence on drug use and a behavioral syndrome characterized by compulsive drug use and continued use, despite harm to self and others.21
Because synthetic opioids such as fentanyl have different kinetics, metabolism, and bioavailability than nonsynthetic opiates such as morphine, it is imperative to review the individual agent’s pharmacokinetics before use and titration. We have chosen to present the information relevant to morphine.
Morphine has no ceiling (the maximum dose past which toxicity rises and no additional efficacy can be expected) to its analgesic effects and has been shown to relieve all types of pain. The time to peak plasma concentration depends on the route of administration. Oral or rectal morphine takes between 60 and 90 minutes, subcutaneous or intramuscular injections take 30 minutes, and intravenous injections take 6 minutes to peak. Because opiates and their metabolites have effective half-lives of approximately 3–4 hours, steady state usually is reached within 1 day.
Elimination of morphine occurs by conjugation in the liver followed by renal excretion of the metabolites. Advanced age is associated with altered pharmacokinetics caused by renal dysfunction and a more prolonged half-life, so reduced doses or lengthened time intervals should be used in older adults.26,32 In older adults with dehydration, acute renal failure, or minimal to no urine output postoperatively, routine dosing should be discontinued and the opiate only should be administered as needed.
Dose Selection and Adjustment
Opioids may be administered orally, rectally, subcutaneously, intramuscularly, intravenously, transmucosally, or transdermally. Site-specific bioavailability is different among opioids and as such, morphine has lower bioavailability through the transmucosal or transdermal route. Although oral dosing is preferred and is most convenient, other routes may be useful in selected patients after surgery. Depending on the route of administration, the dose of opioid can be calculated using the equianalgesic table (Table 2). Because first-pass drug metabolism occurs with opioids, higher doses are required for the same analgesic effect if the agent is administered orally or rectally as opposed to being administered subcutaneously or intravenously.
In acute postoperative pain syndromes, it is recommended to start with an immediate release, short half-life opiate such as morphine. As shown in Figure 3, for a patient in moderate to severe pain who is opioid naive, begin with 10–30 mg of immediate-release morphine in tablet or liquid concentrate form every 4 hours. Additionally, provide the patient with access to as-needed doses of the same medication for breakthrough pain. These rescue or as-needed doses should be 5–15% of the total 24-hour dose, and the frequency of administration is based on time to onset of effect and will depend on the route of administration (Table 3). At the end of the first 24 hours if the pain remains uncontrolled, increase the standing dose by 25–50% for mild to moderate pain or by 50–100% for severe or uncontrolled pain or alternatively, by an amount at least equal to the total dose of rescue medication used in the previous 24 hours.21
Extended-release or controlled-release opiates are available and are designed to release medication in a controlled fashion for 8–24 hours, depending on the product. They must be ingested whole, not crushed, or chewed. Because steady state for these formulations takes between 2 and 4 days, dose adjustments should not be made more frequently than that. Once a patient’s continuous pain has been controlled, switch to an extended-release form to simplify dosing and improve adherence. To convert, calculate the total morphine usage in a 24-hour period. Depending on the extended-release product, divide this amount by two for a product given every 12 hours or by three for a product given every 8 hours. Extended-release opioid tablets cannot be used for rescue dosing and therefore it is important to provide doses of immediate-release opioid for breakthrough pain. Once again, that dose is calculated as 5–15% of the 24-hour dose, and its frequency should be based on the time to onset of effect depending on the route of administration.
Pharmacologic tolerance is expected to develop in patients prescribed opioids for pain relief. Tolerance refers to the diminished effectiveness of a given dose of a drug that occurs with time as the person is exposed to the drug. For opioids, clinical evidence suggests that this tolerance is relatively specific to the opioid in current use and may not be as marked for other opioids. This phenomenon has been referred to as incomplete cross-tolerance and likely is attributable to the subtle differences in the molecular structure of each opioid.21 Knowledge of this fact is important when switching opioids for a given patient. In the case of a patient experiencing adequate pain control with one opioid who needs to be switched to another opioid because of conversion from parenteral to an oral form, begin the new opioid at 50–75% of the equianalgesic dose. If the same patient has moderate to severe pain before the switch, do not reduce the dose by as much. However, if the patient has had intolerable adverse side-effects on the first agent, start the new agent at an even lower dose32 (Table 4) or consider reducing the dose of the first agent by 20% instead of switching opioids.
As pain diminishes with time in the postoperative period, the opioid dose can be reduced by 25–50%32 every 2–3 days and then stopped. However, if the dose is lowered too rapidly and physical withdrawal symptoms occur, it may be necessary to transiently increase the dose to settle the symptoms.21
Adverse Effects of Opioid Analgesics and Their Management
There are numerous side effects that can and do occur with opioid use in the acute postoperative period. An understanding of these is critical because a crucial part of pain management is side effect, management. Tolerance does develop to several side effects, and treatment options are available. Constipation, sedation, nausea, and vomiting are the most common adverse effects seen, but dizziness, hallucinations, confusion, and respiratory depression also may occur.
Constipation is the most common adverse effect of opioid treatment and can be expected to occur as a result of the opioid’s effect on the central nervous system and on the myenteric plexus of the gut. The symptom persists with continued use and there is very little, if any, tolerance that develops. Ongoing therapy with an opioid, therefore, must be accompanied by a prophylactic bowel regimen. Standing doses of stimulant laxatives (bisacodyl, senna), adequate hydration, stool softeners (docusate), and adequate mobility all are integral parts of the regimen.21,26,31 Bulk forming agents (psyllium) are not recommended postoperatively for older patients who have had orthopaedic surgery because these require substantial fluid intake.21 In patients with persistent constipation despite basic therapies, it is critical to check for and then treat fecal impaction. Finally, osmotic agents (lactulose, milk of magnesia) may be beneficial in patients without impaction but in whom the symptom persists.
Nausea, with or without vomiting, is another anticipated side effect of opioid treatment, but tolerance develops within several days. The symptom may be attributable to direct stimulation of chemoreceptors in the midbrain, gastric and colonic paresis, or vestibular activation. If the cause is suspected to be direct chemoreceptor stimulation, traditional neuroleptic antiemetics such as prochlorperazine (10 mg before the opioid and every 6 hours) result in relief. Alternatively, low-dose haloperidol (1 mg before the opioid and every 6 hours) may be effective. For paresis-induced nausea, a promotility agent such as metoclopramide (10 mg before the opioid and every 6 hours) may be helpful. Finally, if vertiginous symptoms accompany the nausea an antihistamine antiemetic such as meclizine (25 mg before the opioid and every 6 hours) may prove beneficial.26
Opioid-induced sedation can and does occur in patients who are opiate naïve immediately after beginning the medication and is a predictable effect of dose escalation. Symptoms of daytime drowsiness, mental clouding, or dizziness usually resolve in a few days as tolerance develops.26,32 It is important at this point to distinguish sedation from delirium. Characterized by an acute and fluctuating course, inattentiveness, disorganized thinking, and an altered level of consciousness,23 delirium occurs frequently in the postoperative period in older adults. Although these symptoms and confusion, agitation, and restlessness may be suggestive of opioid excess, two studies have shown that delirium is more commonly the result of untreated pain,20,42 rather than an opioid overdose. If the delirium is caused by opioid excess, the respiratory status should be evaluated. If there is no evidence of respiratory depression (< 6 breaths/minute), all opioids should be discontinued and the patient should be hydrated and closely monitored. Only if there is respiratory compromise should naloxone be administered as will be described.
The most life threatening side-effect of strong opioids is the depression of all phases of the respiratory cycle. Most commonly seen after acute administration of an excess amount of opiate in a patient who is opioid naïve, respiratory depression always is preceded by other signs of central nervous system depression such as sedation, somnolence, and mental cloudiness.32 If the opioid dose has been titrated carefully against pain, clinically important respiratory depression is rare.21,32 Naloxone, an opioid antagonist, only should be used if the patient is becoming progressively obtunded with severe respiratory depression (< 6 breaths/minute). In this situation, 1 mL injections of a dilute solution containing 0.4 mg of naloxone in 10 mL of normal saline can be given intravenously every 5 minutes and titrated to the respiratory rate.8 However, because naloxone may result in an acute opioid withdrawal reaction it must be used judiciously and only in the appropriate situation. Finally, because the half-life of naloxone is measured in minutes and that of the opiate in hours, continued administration of the dilute naloxone will be necessary until the opiate overdose has cleared the body.
Nonsteroidal Antiinflammatory Drugs (NSAIDs) and Cyclooxygenase-2 (COX-2) Inhibitors
Nonsteroidal antiinflammatory drugs are among the most widely prescribed class of drugs in the world.5 Approximately 50% of the more than 60 million NSAID prescriptions written in the United States are for patients older than 60 years.22,50 Coupled with the broad availability of over-the-counter NSAIDs in the United States, NSAID exposure in elderly patients may be even higher than these estimates.5
Nonsteroidal antiinflammatory drugs provide rapid and sustained analgesia for mild to moderate pain, and at the same time, can reduce the swelling and tenderness associated with postoperative inflammation. However, despite their efficacy, NSAIDs are associated with significant adverse side effects, most notably gastrointestinal (GI) and renal toxicity.7,17 Among the elderly, these risks are even greater because of the significant pharmacokinetic changes in metabolism and excretion of the drugs.17,57 Specifically in older adults, hepatic Phase 1 (oxidation and reduction) reactions are reduced leading to increased drug accumulation, and renal function also is diminished resulting in decreased drug elimination.
Nonsteroidal antiinflammatory drug-related dyspepsia occurs in approximately 30% of patients, gastric erosions occur in more than 50%, and serious GI events (perforation, ulceration, and bleeding) occur in 2–4% of patients treated for 1 year.55,57 Misoprostal, an oral cytoprotective prostaglandin E1 analog, acts by replacing GI mucosal prostaglandins that have been reduced by NSAIDs. Cotherapy of NSAIDs with misoprostal has been shown to decrease the rate in the incidence of complicated GI events such as perforations, obstructions, and bleeding episodes by 40%.53 However, the inconvenience of NSAID dosing (four times a day) and the frequent adverse events (abdominal pain, heartburn, and diarrhea) often limit therapy, particularly in older adults.5
Fluid retention is the most common renal manifestation of NSAID therapy resulting in peripheral edema, weight gain, and hypertension.9 In addition, papillary necrosis and interstitial nephritis have been shown to occur as a result of NSAID use.14,21 Elderly patients, with typical age-related decreases in kidney function and chronic diseases that put them at increased risk for renal impairment and heart failure, should be monitored carefully for renal dysfunction, worsening blood pressure, and heart failure during NSAID therapy.5
Cyclooxygenase-2 inhibitors, which at therapeutic doses do not inhibit the COX-1 isoform of cyclooxygenase and therefore have an improved GI safety profile compared with traditional NSAIDs, have gained prominence.54 They are most effective for the treatment of mild to moderate pain, and as such there is little difference in analgesic efficacy when compared with conventional NSAIDs.18 Despite the significant reduction in GI complications afforded by the coxibs, there is no decrease in the risk of renal complications. Moreover, compared with other NSAIDs, COX-2 inhibitors seem to increase the risk for cardiovascular thrombotic events in patients not taking aspirin.47 Therefore, as with all NSAIDS, elderly patients should be monitored carefully while taking a COX-2 inhibitor.5
Used for the treatment of mild to moderate pain but without significant antiinflammatory effects, acetaminophen is an effective Step 1 analgesic and often is used as an adjuvant to other analgesic agents. However, hepatotoxicity can occur at doses \G 4.0 g/24 hours in adults with normal liver function tests and at doses of \G 2 g/24 hours in older adults.21 Furthermore, acetaminophen’s ceiling effect, or maximum dose past which no additional efficacy can be expected, also limits its use. Finally, long-term high-dose (> 2 g/24 hours) use of acetaminophen can result in renal and hepatic injury in older adults.
Meperidine, an opioid analgesic, has very poor oral absorption and a short half-life of approximately 3 hours; therefore routine dosing of the agent is necessary to achieve analgesia. Normeperidine is a toxic metabolite of meperidine and with a half-life of 6 hours and no analgesic benefits of its own, unavoidably accumulates with successive dosing. As the level of the metabolite increases, adverse effects such as tremors, drowsiness, sedation, seizures, and myoclonus are seen. Because of these significant risks, meperidine is not recommended for use in postoperative pain management of older adults.
These products combine opioid analgesics and nonopioid analgesics into one formulation. Frequently prescribed combination analgesic agents include propoxyphene or hydrocodone with acetaminophen, and codeine or oxycodone with either acetaminophen or aspirin. However because acetaminophen and aspirin have ceiling effects and are toxic to the kidney and liver, there is a significant risk of toxicity if these agents are taken in excess or for a prolonged period. Physicians inadvertently may increase the dose of such a combination product or prescribe an additional nonopioid, such as acetaminophen, along with the combination product. Older adults in pain may take, and forget to report, over-the-counter acetaminophen or aspirin along with the combination product and put themselves at additional risk. In a study of 2065 adults in nursing homes receiving pharmacologic therapies for pain, more than 65% received acetaminophen in addition to a combination analgesic containing acetaminophen.16 In light of these increased risks, combination analgesics are not recommended for pain management in older adults.
Improved pain management is mandated not only by recently adopted guidelines but also by a commitment to quality patient care. Neglect of pain management in older adults is too common, and physicians should be aware of their biases and knowledge deficits. The literature indicates that it is physician assumptions that most limit the physician’s ability to properly ascertain postoperative pain management in the elderly. Physicians believe they are treating pain adequately but study results suggest otherwise. Physicians assume that the cognitively intact patient needs more effective pain management than the cognitively impaired patient and again, studies indicate that this is not so. Physicians presume that opioid analgesic side effects are not manageable but instead they are effective and their side effects are managed easily. As a result, they usually are safer than other commonly used classes of analgesics (NSAIDs, acetaminophen) in elderly patients. Effective pain management not only reduces preventable human suffering but is associated with improved clinical outcomes including the ability to participate in rehabilitation, earlier mobilization, and a reduced risk of delirium after orthopaedic surgery. We reviewed an effective postoperative pain management plan that includes detailed assessment and frequent reevaluation, evidence-based treatment, and fastidious side-effect management. If followed, patient care and health outcomes certainly will improve.
We thank Drs. Daniel Fischberg and Emily Chai for manuscript review, Helen Schaub and Kathel Dunn for critical comments, and Jacqueline Medina for technical assistance.
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