Top

Current Geriatrics Reports

Published in:

13-04-2024 | Opioids | REVIEW

Pain Management Considerations in the Geriatric ED Patient: Start Low, Go Slow, But Get Somewhere

Authors: Robert S. Anderson Jr, Hannah L. Mazur, Timothy Sweeney

Published in: Current Geriatrics Reports | Issue 2/2024

Abstract

Purpose of Review

Safely treating pain in older adults can be a daunting undertaking. The authors sought clarity in available analgesic choices and dosing recommendations.

Recent Findings

There is limited current research into this topic, there is a range of medications and dosing suggested in the literature. The 2023 American Geriatrics Society updated Beers Criteria represents the most up to date expert panel guidance on a wide variety of medications including analgesics. There is an opportunity in the literature to provide a more concrete framework for treating pain in older adults.

Summary

In this paper, medication choices, dosing ranges, and considerations available in the literature were reconciled into two tables. Moreover, an approach to thinking about and treating older adults as both a homogenous group but more importantly as a heterogenous group was undertaken. There are ample opportunities to further study how individual goals, functional status, frailty, old old age, comorbidities, and co-pharmacy impact analgesic choices for older adults.

Hoel RW, Giddings Connolly RM, Takahashi PY. Polypharmacy Management in Older Patients. Mayo Clin Proc. 2021;96(1):242–56. https://doi.org/10.1016/j.mayocp.2020.06.012.CrossRefPubMed

Gazelka HM, Leal JC, Lapid MI, Rummans TA. Opioids in Older Adults: Indications, Prescribing, Complications, and Alternative Therapies for Primary Care. Mayo Clin Proc. 2020;95(4):793–800. https://doi.org/10.1016/j.mayocp.2020.02.002.CrossRefPubMed

Domenichiello AF, Ramsden CE. The silent epidemic of chronic pain in older adults. Prog Neuropsychopharmacol Biol Psychiatry. 2019;93:284–90. https://doi.org/10.1016/j.pnpbp.2019.04.006.CrossRefPubMedPubMedCentral

• Elder NM, Heavey SF, Tyler KR. Emergency Department Pain Management in the Older Adult. Clin Geriatr Med. 2023;39(4):619–34. https://doi.org/10.1016/j.cger.2023.05.012. Inclusive, wide ranging articles with sections on physiology, pain syndromes, and multiple tables outlining medication choices.CrossRefPubMed

Tyler KR, Hullick C, Newton BA, Adams CB, Arendts G. Emergency department pain management in older patients. Emerg Med Australas. 2020;32:840–6. https://doi.org/10.1111/1742-6723.13562.CrossRefPubMed

Escourrou E, Laurent S, Leroux J, Oustric S, Gardette V. The shift from old age to very old age: an analysis of the perception of aging among older people. BMC Prim Care. 2022;23(1):3. https://doi.org/10.1186/s12875-021-01616-4. Published 1 Jan 2022.CrossRefPubMedPubMedCentral

Khan KT, Hemati K, Donovan AL. Geriatric Physiology and the Frailty Syndrome. Anesthesiol Clin. 2019;37(3):453–74. https://doi.org/10.1016/j.anclin.2019.04.006.CrossRefPubMed

Zucchelli A, Vetrano DL, Grande G, et al. Comparing the prognostic value of geriatric health indicators: a population-based study. BMC Med. 2019;17(1):185. https://doi.org/10.1186/s12916-019-1418-2. Published 2 Oct 2019.CrossRefPubMedPubMedCentral

Vrettos I, Voukelatou P, Panayiotou S, et al. Factors Associated With Mortality in Elderly Hospitalized Patients at Admission. Cureus. 2022;14(2):e22709. https://doi.org/10.7759/cureus.22709. Published 28 Feb 2022.CrossRefPubMedPubMedCentral

10.

Pietiläinen L, Bäcklund M, Hästbacka J, Reinikainen M. Premorbid functional status as an outcome predictor in intensive care patients aged over 85 years. BMC Geriatr. 2022;22(1):38. https://doi.org/10.1186/s12877-021-02746-1. Published 10 Jan 2022.CrossRefPubMedPubMedCentral

11.

Magidson PD, Thoburn AK, Hogan TM. Emergency orthogeriatrics: concepts and therapeutic considerations for the geriatric patient. Emerg Med Clin North Am. 2020;38(1):15–29. https://doi.org/10.1016/j.emc.2019.09.002.CrossRefPubMed

12.

•• American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. J Am Geriatr Soc. 2023;71(7):2052–81. https://doi.org/10.1111/jgs.18372. Periodically updated benchmark article. Provides clinicians with a framework for understanding how to safely prescribe medications to older adults. Organizes the approach based on the medications themselves, in context of other medications, and in context of disease states.CrossRef

13.

Joseph A, Vemula B, Smith TJ. Symptom Management in the Older Adult: 2023 Update. Clin Geriatr Med. 2023;39(3):449–63. https://doi.org/10.1016/j.cger.2023.04.006.CrossRefPubMed

14.

American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. Pain Med. 2009;10(6):1062–83. https://doi.org/10.1111/j.1526-4637.2009.00699.x

15.

• Rajput K, Ng J, Zwolinski N, Chow RM. Pain Management in the Elderly: A Narrative Review. Anesthesiol Clin. 2023;41(3):671–91. https://doi.org/10.1016/j.anclin.2023.03.003. Inclusive, wide ranging articles with sections on physiology, pain syndromes, and multiple tables outlining medication choices.CrossRefPubMed

16.

Mattison MLP. Delirium. Ann Intern Med. 2020;173(7):ITC49–64. https://doi.org/10.7326/AITC202010060.CrossRefPubMed

17.

Liu YP, Chien WC, Chung CH, Chang HA, Kao YC, Tzeng NS. Are Anticholinergic Medications Associated With Increased Risk of Dementia and Behavioral and Psychological Symptoms of Dementia? A Nationwide 15-Year Follow-Up Cohort Study in Taiwan. Front Pharmacol. 2020;11:30. https://doi.org/10.3389/fphar.2020.00030. Published 14 Feb 2020.CrossRefPubMedPubMedCentral

18.

Growdon ME, Gan S, Yaffe K, Steinman MA. Polypharmacy among older adults with dementia compared with those without dementia in the United States. J Am Geriatr Soc. 2021;69(9):2464–75. https://doi.org/10.1111/jgs.17291. Epub 2021 Jun 8. PMID: 34101822; PMCID: PMC8440349.CrossRefPubMedPubMedCentral

19.

Fong TG, Inouye SK. The inter-relationship between delirium and dementia: the importance of delirium prevention. Nat Rev Neurol. 2022;18(10):579–96. https://doi.org/10.1038/s41582-022-00698-7.CrossRefPubMedPubMedCentral

20.

Sillner AY, Holle CL, Rudolph JL. The Overlap Between Falls and Delirium in Hospitalized Older Adults: A Systematic Review. Clin Geriatr Med. 2019;35(2):221–36. https://doi.org/10.1016/j.cger.2019.01.004.CrossRefPubMed

21.

Daoust R, Paquet J, Moore L, et al. Recent opioid use and fall-related injury among older patients with trauma. CMAJ. 2018;190(16):E500–6. https://doi.org/10.1503/cmaj.171286.CrossRefPubMedPubMedCentral

22.

Bolding DJ, Corman E. Falls in the Geriatric Patient. Clin Geriatr Med. 2019;35(1):115–26. https://doi.org/10.1016/j.cger.2018.08.010.CrossRefPubMed

23.

Baker M, Perazella MA. NSAIDs in CKD: Are They Safe? Am J Kidney Dis. 2020;76(4):546–57. https://doi.org/10.1053/j.ajkd.2020.03.023.CrossRefPubMed

24.

Martinelli AN. Rapid Fire: Polypharmacy in the Geriatric Patient. Emerg Med Clin North Am. 2021;39(2):395–404. https://doi.org/10.1016/j.emc.2021.01.001.CrossRefPubMed

25.

Koyyada A. Long-term use of proton pump inhibitors as a risk factor for various adverse manifestations. Therapie. 2021;76(1):13–21. https://doi.org/10.1016/j.therap.2020.06.019.CrossRefPubMed

26.

Garlich JM, Pujari A, Debbi EM, et al. Time to block: early regional anesthesia improves pain control in geriatric hip fractures. J Bone Joint Surg Am. 2020;102(10):866–72. https://doi.org/10.2106/JBJS.19.01148.CrossRefPubMed

27.

Wolmarans M, Albrecht E. Regional anesthesia in the emergency department outside the operating theatre. Curr Opin Anaesthesiol. 2023;36(4):447–51. https://doi.org/10.1097/ACO.0000000000001281.CrossRefPubMedPubMedCentral

28.

Lexicomp Online, Pediatric and Neonatal Lexi-Drugs Online. Waltham, MA: UpToDate, Inc.; July 30, 2021. https://online.lexi.com. Accessed 7 Dec 2023.

29.

Varrassi G, Pergolizzi JV, Dowling P, Paladini A. Ibuprofen Safety at the Golden Anniversary: Are All Nsaids the Same? A Narrative Review. Adv The 2020;37(1):61–82.

30.

Motov S, Yasavolian M, Likourezos A, et al. Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial. Ann Emerg Med. 2017;70(2):177–84.CrossRefPubMed

31.

Platt E, Neidhardt JM, End B, et al. Safety and efficacy of low-dose versus high-dose parenteral ketorolac for acute pain relief in patients 65 years and older in the emergency department. Cureus. Published online 12 Jun 2023.

32.

Motov S, Mann S, Drapkin J, et al. Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. 2019;37(2):220–7.CrossRefPubMed

33.

Fields TR. The challenges of approaching and managing gout. Rheum Dis Clin North Am. 2019;45(1):145–57.CrossRefPubMed

Title: Pain Management Considerations in the Geriatric ED Patient: Start Low, Go Slow, But Get Somewhere
Authors: Robert S. Anderson Jr
Hannah L. Mazur
Timothy Sweeney
Publication date: 13-04-2024
Publisher: Springer US
Keywords: Opioids
Opioids
Paracetamol
Published in: Current Geriatrics Reports / Issue 2/2024
Electronic ISSN: 2196-7865
DOI: https://doi.org/10.1007/s13670-024-00412-z

Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin

Prof. Florian Limbourg

Prof. Anoop Chauhan

Developed by: Springer Medicine

Obesity Clinical Trial Summary

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

Please log in to get access to this content

Other articles of this Issue 2/2024

Postoperative Neurologic Complications in the Older Adult

Patient Centered Outcomes After Surgery in the Older Adult

Managing Delirium in the Emergency Department: An Updated Narrative Review

Social Isolation/loneliness and Mobility Disability Among Older Adults

Failure to Rescue in the Geriatric Surgical Population: A Literature Review

Geriatric Emergency Departments: Emerging Themes and Directions

Keynote webinar | Spotlight on medication adherence

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

At a glance: The STEP trials