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Published in:

01-05-2020 | Current Opinion

Chronic Post-Surgical Pain in the Frail Older Adult

Authors: Gary Esses, Stacie Deiner, Fred Ko, Yury Khelemsky

Published in: Drugs & Aging | Issue 5/2020

Abstract

Older adults are the fastest growing segment of the population and surgical procedures in this group increase each year. Chronic post-surgical pain is an important consideration in the older adult as it affects recovery, physical functioning, and overall quality of life. It is increasingly recognized as a public health issue but there is a need to improve our understanding of the disease process as well as the appropriate treatment and prevention. Frailty, delirium, and cognition influence post-operative outcomes in older adults and have been implicated in the development of chronic post-surgical pain. Further research must be conducted to fully understand the role they play in the occurrence of chronic post-surgical pain in the older adult. Additionally, careful attention must be given to the physiologic, cognitive, and comorbidity differences between the older adult and the general population. This is critical for elucidating the proper chronic post-surgical pain treatment and prevention strategies to ensure that the older adult undergoing surgical intervention will have an appropriate and desirable post-operative outcome.

Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010. Natl Health Stat Rep. 2017;102:1–15.

National Hospital Discharge Survey. Number of all-listed procedures for discharges from short-stay hospitals, by procedure category and Age: United States, 2010. 2010. https://www.cdc.gov/nchs/data/nhds/4procedures/2010pro4_numberprocedureage.pdf. Accessed 10 Apr 2020.

Macrae WA. Chronic post-surgical pain: 10 years on. Br J Anaesth. 2008;101:77–86.PubMed

Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367:1618–25.PubMed

Wang L, Guyatt GH, Kennedy SA, Romerosa B, Kwon HY, Kaushal A, et al. Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies. CMAJ. 2016;188:E352–E361361.PubMedPubMedCentral

Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017;10:2287–98.PubMedPubMedCentral

Baker DW. History of the Joint Commission’s pain standards: lessons for today’s prescription opioid epidemic. JAMA. 2017;317:1117–8.PubMed

Esses GJ, Liu X, Lin HM, Khelemsky Y, Deiner S. Preoperative frailty and its association with postsurgical pain in an older patient cohort. Reg Anesth Pain Med. 2019;44:695–9.

Campbell AJ, Buchner DM. Unstable disability and the fluctuations of frailty. Age Ageing. 1997;26:315–8.PubMed

10.

Lee DH, Buth KJ, Martin B-J, Yip AM, Hirsch GM. Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery. Circulation. 2010;121:973–8.PubMed

11.

Adams P, Ghanem T, Stachler R, Hall F, Velanovich V, Rubinfeld I. Frailty as a predictor of morbidity and mortality in inpatient head and neck surgery. JAMA Otolaryngol Head Neck Surg. 2013;139:783–9.PubMed

12.

Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210:901–8.PubMed

13.

Patel KV, Guralnik JM, Dansie EJ, Turk DC. Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study. Pain. 2013;154:2649–57.PubMed

14.

Helme RD, Gibson SJ. The epidemiology of pain in elderly people. Clin Geriatr Med. 2001;17:417–31.PubMed

15.

Thielke S, Sale J, Reid MC. Aging: are these 4 pain myths complicating care? J Fam Pract. 2012;61:666–70.PubMedPubMedCentral

16.

Institute of Medicine. Relieving pain in America. Washington: National Academies Press; 2011.

17.

Glare P, Aubrey KR, Myles PS. Transition from acute to chronic pain after surgery. Lancet. 2019;393:1537–46.PubMed

18.

Werner MU, Kongsgaard UE. Defining persistent post-surgical pain: is an update required? Br J Anaesth. 2014;113:1–4.PubMed

19.

Macrae WA. Chronic pain after surgery. Br J Anaesth. 2001;87:88–98.PubMed

20.

Poobalan AS, Bruce J, Smith WCS, King PM, Krukowski ZH, Chambers WA. A review of chronic pain after inguinal herniorrhaphy. Clin J Pain. 2003;19:48–544.PubMed

21.

Weinrib AZ, Azam MA, Birnie KA, Burns LC, Clarke H, Katz J. The psychology of chronic post-surgical pain: new frontiers in risk factor identification, prevention and management. Br J Pain. 2017;11:169–77.PubMedPubMedCentral

22.

Chapman CR, Vierck CJ. The transition of acute postoperative pain to chronic pain: an integrative overview of research on mechanisms. J Pain. 2017;18(359):e1–38.

23.

Cregg R, Anwar S, Farquhar-Smith P. Persistent postsurgical pain. Curr Opin Support Palliat Care. 2013;7:144–52.PubMed

24.

Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. A classification of chronic pain for ICD-11. Pain. 2015;156:1003–7.PubMedPubMedCentral

25.

Lavand’homme P. Transition from acute to chronic pain after surgery. Pain. 2017;158(Suppl 1):S50–S5454.PubMed

26.

Wylde V, Hewlett S, Learmonth ID, Dieppe P. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain. 2011;152:566–72.PubMed

27.

Hinrichs-Rocker A, Schulz K, Järvinen I, Lefering R, Simanski C, Neugebauer EAM. Psychosocial predictors and correlates for chronic post-surgical pain (CPSP): a systematic review. Eur J Pain. 2009;13:719–30.PubMed

28.

Althaus A, Hinrichs-Rocker A, Chapman R, Becker OA, Lefering R, Simanski C, et al. Development of a risk index for the prediction of chronic post-surgical pain. Eur J Pain. 2012;16:901–10.PubMed

29.

Callesen T, Bech K, Kehlet H. Prospective study of chronic pain after groin hernia repair. Br J Surg. 1999;86:1528–31.PubMed

30.

Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12:50–5.PubMed

31.

Tasmuth T, Kataja M, Blomqvist C, von Smitten K, Kalso E. Treatment-related factors predisposing to chronic pain in patients with breast cancer: a multivariate approach. Acta Oncol. 1997;36:625–30.PubMed

32.

Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science. 2000;288:1765–9.PubMed

33.

Katz J, Seltzer Z. Transition from acute to chronic postsurgical pain: risk factors and protective factors. Expert Rev Neurother. 2009;9:723–44.PubMed

34.

Bortz WM. A conceptual framework of frailty: a review. J Gerontol A Biol Sci Med Sci. 2002;57:M283–M288288.PubMed

35.

Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–M156156.PubMed

36.

Walston JD, Bandeen-Roche K. Frailty: a tale of two concepts. BMC Med. 2015;13:185.PubMedPubMedCentral

37.

Blyth FM, Rochat S, Cumming RG, Creasey H, Handelsman DJ, Le CDG, et al. Pain, frailty and comorbidity on older men: the CHAMP study. Pain. 2008;140:224–30.PubMed

38.

Shega JW, Dale W, Andrew M, Paice J, Rockwood K, Weiner DK. Persistent pain and frailty: a case for homeostenosis. J Am Geriatr Soc. 2012;60:113–7.PubMed

39.

Tian X, Wang C, Qiao X, Liu N, Dong L, Butler M, et al. Association between pain and frailty among Chinese community-dwelling older adults: depression as a mediator and its interaction with pain. Pain. 2018;159:306–13.PubMed

40.

Wade KF, Lee DM, McBeth J, Ravindrarajah R, Gielen E, Pye SR, et al. Chronic widespread pain is associated with worsening frailty in European men. Age Ageing. 2016;45:268–74.PubMed

41.

Lohman MC, Whiteman KL, Greenberg RL, Bruce ML, Edotor D, Kritchevsky S. Incorporating persistent pain in phenotypic frailty measurement and prediction of adverse Health outcomes. J Gerontol A Biol Sci Med Sci. 2017;72:216–22.PubMed

42.

Saraiva MD, Suzuki GS, Lin SM, de Andrade DC, Jacob-Filho W, Suemoto CK. Persistent pain is a risk factor for frailty: a systematic review and meta-analysis from prospective longitudinal studies. Age Ageing. 2018;47:785–93.PubMed

43.

Resnick NM, Marcantonio ER. How should clinical care of the aged differ? Lancet. 1997;350:1157–8.PubMed

44.

Puts MTE, Hardt J, Monette J, Girre V, Springall E, Alibhai SMH. Use of geriatric assessment for older adults in the oncology setting: a systematic review. J Natl Cancer Inst. 2012;104:1133–63.PubMed

45.

Lally F, Crome P. Understanding frailty. Postgrad Med J. 2007;83:16–20.PubMedPubMedCentral

46.

Rockwood K, Stadnyk K, MacKnight C, McDowell I, Hebert R, Hogan DB. A brief clinical instrument to classify frailty in elderly people. Lancet. 1999;353:205–6.PubMed

47.

Tejedor P, Pastor C, Gonzalez-Ayora S, Ortega-Lopez M, Guadalajara H, Garcia-Olmo D. Short-term outcomes and benefits of ERAS program in elderly patients undergoing colorectal surgery: a case-matched study compared to conventional care. Int J Colorectal Dis. 2018;33:1251–8.PubMed

48.

Lang P-O, Michel J-P, Zekry D. Frailty syndrome: a transitional state in a dynamic process. Gerontology. 2009;55:539–49.PubMed

49.

Katz J, Weinrib A, Fashler SR, Katznelzon R, Shah BR, Ladak SS, et al. The Toronto General Hospital transitional pain service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. J Pain Res. 2015;8:695–702.PubMedPubMedCentral

50.

Watkins LR, Maier SF, Goehler LE. Immune activation: the role of pro-inflammatory cytokines in inflammation, illness responses and pathological pain states. Pain. 1995;63:289–302.PubMed

51.

Haddad JJ. On the enigma of pain and hyperalgesia: a molecular perspective. Biochem Biophys Res Commun. 2007;353:217–24.PubMed

52.

De Jongh RF, Vissers KC, Meert TF, Booij LHDJ, De Deyne CS, Heylen RJ. The role of interleukin-6 in nociception and pain. Anesth Analg. 2003;96:1096–103.PubMed

53.

Zhou Y-Q, Liu Z, Liu Z-H, Chen S-P, Li M, Shahveranov A, et al. Interleukin-6: an emerging regulator of pathological pain. J Neuroinflammation. 2016;13:141.PubMedPubMedCentral

54.

DeVon HA, Piano MR, Rosenfeld AG, Hoppensteadt DA. The association of pain with protein inflammatory biomarkers: a review of the literature. Nurs Res. 2014;63:51–62.PubMed

55.

Kudoh A, Katagai H, Takazawa T. Antidepressant treatment for chronic depressed patients should not be discontinued prior to anesthesia. Can J Anesth. 2002;49:132–6.PubMed

56.

Reikeras O, Borgen P, Reseland JE, Lyngstadaas SP. Changes in serum cytokines in response to musculoskeletal surgical trauma. BMC Res Notes. 2014;7:128.PubMedPubMedCentral

57.

Desborough JP. The stress response to trauma and surgery. Br J Anaesth. 2000;85:109–17.PubMed

58.

Geiss A, Varadi E, Steinbach K, Bauer HW, Anton F. Psychoneuroimmunological correlates of persisting sciatic pain in patients who underwent discectomy. Neurosci Lett. 1997;237:65–8.PubMed

59.

Oliver JB, Kashef K, Bader AM, Correll DJ. A survey of patients’ understanding and expectations of persistent postsurgical pain in a preoperative testing center. J Clin Anesth. 2016;34:494–501.PubMed

60.

Tasmuth T, Smitten K, Hietanen P, Kataja M, Kalso E. Pain and other symptoms after different treatment modalities of breast cancer. Ann Oncol. 1995;6:453–9.PubMed

61.

Poobalan AS, Bruce J, King PM, Chambers WA, Krukowski ZH, Smith WCS. Chronic pain and quality of life following open inguinal hernia repair. Br J Surg. 2001;88:1122–6.PubMed

62.

Cornally N, McCarthy G. Chronic pain: the help-seeking behavior, attitudes, and beliefs of older adults living in the community. Pain Manag Nurs. 2011;12:206–17.PubMed

63.

Falzone E, Hoffmann C, Keita H. Postoperative analgesia in elderly patients. Drugs Aging. 2013;30:81–90.PubMed

64.

Turnheim K. When drug therapy gets old: pharmacokinetics and pharmacodynamics in the elderly. Exp Gerontol. 2003;38:843–53.PubMed

65.

Denic A, Glassock RJ, Rule AD. Structural and functional changes with the aging kidney. Adv Chronic Kidney Dis. 2016;23:19–28.PubMedPubMedCentral

66.

Gibson SJ. Pain and aging: the pain experience over the adult lifespan. In: Dostrovsky JO, Carr DB, Koltzenburg M, editors. Proceedings of the 10th World Congress on Pain. Seattle: IASP; 2003. p. 767–790.

67.

Garpestad E, Devlin JW. Polypharmacy and delirium in critically ill older adults: recognition and prevention. Clin Geriatr Med. 2017;33:189–203.PubMed

68.

Hein C, Forgues A, Piau A, Sommet A, Nourhashémi F, Vellas B. Impact of polypharmacy on occurrence of delirium in elderly emergency patients. J Am Med Dir Assoc. 2014;15(850):e11–e15.

69.

Field TS, Gurwitz JH, Avorn J, McCormick D, Jain S, Eckler M, et al. Risk factors for adverse drug events among nursing home residents. Arch Intern Med. 2001;161:1629–34.PubMed

70.

Kaye AD, Baluch A, Scott JT. Pain management in the elderly population: a review. Ochsner J. 2010;10:179–87.PubMedPubMedCentral

71.

Weiner DK, Karp J, Berstein C, et al. Pain medicine in older adults: how should it differ? In: Deer T, Seong M, editors. Compr treat chronic pain by medical, Interv Behav approaches Am Acad Pain Med Textb patient Manag. New York: Springer; 2015. p. 233–258.

72.

Berger M, Schenning KJ, Brown CH, Deiner SG, Whittington RA, Eckenhoff RG. Best practices for postoperative brain health: recommendations from the fifth international perioperative neurotoxicity working group. Anesth Analg. 2018;127:1406–13.PubMedPubMedCentral

73.

Jones J, Sim TF, Hughes J. Pain assessment of elderly patients with cognitive impairment in the emergency department: implications for pain management: a narrative review of current practices. Pharmacy (Basel). 2017;5:30.

74.

Robinson S, Vollmer C. Undermedication for pain and precipitation of delirium. Medsurg Nurs. 2010;19:79–83.PubMed

75.

Lynch EP, Lazor MA, Gellis JE, Orav J, Goldman L, Marcantonio ER. The impact of postoperative pain on the development of postoperative delirium. Anesth Analg. 1998;86:781–5.PubMed

76.

Vaurio LE, Sands LP, Wang Y, Mullen EA, Leung JM. Postoperative delirium: the importance of pain and pain management. Anesth Analg. 2006;102:1267–73.PubMed

77.

Swart LM, van der Zanden V, Spies PE, de Rooij SE, van Munster BC. The comparative risk of delirium with different opioids: a systematic review. Drugs Aging. 2017;34:437–43.PubMedPubMedCentral

78.

Latta KS, Ginsberg B, Barkin RL. Meperidine: a critical review. Am J Ther. 2002;9:53–68.PubMed

79.

Subramaniam B, Shankar P, Shaefi S, Mueller A, O’Gara B, Banner-Goodspeed V, et al. Effect of intravenous acetaminophen vs placebo combined with propofol or dexmedetomidine on postoperative delirium among older patients following cardiac surgery: the DEXACET randomized clinical trial. JAMA. 2019;321:686–96.PubMedPubMedCentral

80.

Connolly KP, Kleinman RS, Stevenson KL, Neuman MD, Mehta SN. Delirium reduced with intravenous acetaminophen in geriatric hip fracture patients. J Am Acad Orthop Surg. 2020;28:325–31.PubMed

81.

Politi JR, Davis RL, Matrka AK. Randomized prospective trial comparing the use of intravenous versus oral acetaminophen in total joint arthroplasty. J Arthroplasty. 2017;32:1125–7.PubMed

82.

Whitlock EL, Diaz-Ramirez LG, Glymour MM, Boscardin WJ, Covinsky KE, Smith AK. Association between persistent pain and memory decline and dementia in a longitudinal cohort of elders. JAMA Intern Med. 2017;177:1146–53.PubMedPubMedCentral

83.

Marcantonio ER. Delirium in hospitalized older adults. N Engl J Med. 2018;378:96–7.PubMed

84.

Fletcher D, Fermanian C, Mardaye A, Aegerter P. Pain and Regional Anesthesia Committee of the French Anesthesia and Intensive Care Society (SFAR). A patient-based national survey on postoperative pain management in France reveals significant achievements and persistent challenges. Pain. 2008;137:441–51.PubMed

85.

Jin F, Chung F. Minimizing perioperative adverse events in the elderly. Br J Anaesth. 2001;87:608–24.PubMed

86.

Fassoulaki A, Melemeni A, Stamatakis E, Petropoulos G, Sarantopoulos C. A combination of gabapentin and local anaesthetics attenuates acute and late pain after abdominal hysterectomy. Eur J Anaesthesiol. 2007;24:521–8.PubMed

87.

Wilson JA, Nimmo AF, Fleetwood-Walker SM, Colvin LA. A randomised double blind trial of the effect of pre-emptive epidural ketamine on persistent pain after lower limb amputation. Pain. 2008;135:108–18.PubMed

88.

Smith RV, Havens JR, Walsh SL. Gabapentin misuse, abuse and diversion: a systematic review. Addiction. 2016;111:1160–74.PubMedPubMedCentral

89.

Zhu W, Ding Z, Zhang Y, Shi J, Hashimoto K, Lu L. Risks associated with misuse of ketamine as a rapid-acting antidepressant. Neurosci Bull. 2016;32:557–64.PubMedPubMedCentral

90.

Şentürk M, Özcan PE, Talu GK, Kiyan E, Çamci E, Özyalçin S, et al. The effects of three different analgesia techniques on long-term postthoracotomy pain. Anesth Analg. 2002;94:11–5.PubMed

91.

Tiippana E, Nilsson E, Kalso E. Post-thoracotomy pain after thoracic epidural analgesia: a prospective follow-up study. Acta Anaesthesiol Scand. 2003;47:433–8.PubMed

92.

Brandsborg B, Nikolajsen L, Hansen CT, Kehlet H, Jensen TS. Risk factors for chronic pain after hysterectomy: a nationwide questionnaire and database study. Anesthesiology. 2007;106:1003–122.PubMed

93.

Kalliomäki M-L, Meyerson J, Gunnarsson U, Gordh T, Sandblom G. Long-term pain after inguinal hernia repair in a population-based cohort; risk factors and interference with daily activities. Eur J Pain. 2008;12:214–25.PubMed

94.

Katz J, Cohen L. Preventive analgesia is associated with reduced pain disability 3 weeks but not 6 months after major gynecologic surgery by laparotomy. Anesthesiology. 2004;101:169–74.PubMed

95.

Wylde V, Dennis J, Beswick AD, Bruce J, Eccleston C, Howells N, et al. Systematic review of management of chronic pain after surgery. Br J Surg. 2017;104:1293–306.PubMedPubMedCentral

96.

Scott JC, Stanski DR. Decreased fentanyl and alfentanil dose requirements with age: a simultaneous pharmacokinetic and pharmacodynamic evaluation. J Pharmacol Exp Ther. 1987;240:159–66.PubMed

97.

Dobscha SK, Corson K, Perrin NA, Hanson GC, Leibowitz RQ, Doak MN, et al. Collaborative care for chronic pain in primary care: a cluster randomized trial. JAMA. 2009;301:1242–52.PubMed

98.

Notcutt W, Gibbs G. Inadequate pain management: myth, stigma and professional fear. Postgrad Med J. 2010;86:453–8.PubMed

99.

Wang L, Chang Y, Kennedy SA, Hong PJ, Chow N, Couban RJ, et al. Perioperative psychotherapy for persistent post-surgical pain and physical impairment: a meta-analysis of randomised trials. Br J Anaesth. 2018;120:1304–14.PubMed

100.

Jain SK, Dar MY, Kumar S, Yadav A, Kearns SR. Role of anti-oxidant (vitamin-C) in post-operative pain relief in foot and ankle trauma surgery: a prospective randomized trial. Foot Ankle Surg. 2019;25:542–5.PubMed

101.

Reddi D. Preventing chronic postoperative pain. Anaesthesia. 2016;71:64–71.PubMed

102.

De Oliveira GS, Almeida MD, Benzon HT, McCarthy RJ. Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology. 2011;115:575–88.PubMed

103.

Rai A, Meng H, Weinrib A, Englesakis M, Kumbhare D, Grosman-Rimon L, et al. A review of adjunctive CNS medications used for the treatment of post-surgical pain. CNS Drugs. 2017;31:605–15.PubMed

104.

McKeown JL. Pain management issues for the geriatric surgical patient. Anesthesiol Clin. 2015;33:563–76.PubMed

105.

Nicholls JL, Azam MA, Burns LC, Englesakis M, Sutherland AM, Weinrib AZ, et al. Psychological treatments for the management of postsurgical pain: a systematic review of randomized controlled trials. Patient Relat Outcome Meas. 2018;9:49–644.PubMedPubMedCentral

106.

Jessen Lundorf L, Korvenius Nedergaard H, Møller AM. Perioperative dexmedetomidine for acute pain after abdominal surgery in adults. Cochrane Database Syst Rev. 2016;2:CD010358.PubMed

107.

Daykin H. The efficacy and safety of intravenous lidocaine for analgesia in the older adult: a literature review. Br J Pain. 2017;11:23–31.PubMed

108.

Sharrock NE. Epidural anesthetic dose responses in patients 20–80 years old. Anesthesiology. 1978;49:425–8.PubMed

Title: Chronic Post-Surgical Pain in the Frail Older Adult
Authors: Gary Esses
Stacie Deiner
Fred Ko
Yury Khelemsky
Publication date: 01-05-2020
Publisher: Springer International Publishing
Published in: Drugs & Aging / Issue 5/2020
Print ISSN: 1170-229X
Electronic ISSN: 1179-1969
DOI: https://doi.org/10.1007/s40266-020-00761-2

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