1. Prevent predictable
pain, such as occurs postoperatively. Anticipatory
pain management is particularly important in the elderly, who frequently attempt to "tough it out" without much
analgesia. 2. Assume the patient is in
pain if the situation is potentially painful, even without verbal complaints. Confused elders may be unable or unwilling to verbalize
pain. For example, a confused 90-year-old woman with an acute hip fracture should be treated for
pain, even if she does not complain of it. Elders, especially if demented, may not have the usual external "
pain behaviors." 3. Do not routinely use
antiemetics, especially
phenothiazines. The incidence of
postoperative nausea and vomiting is probably less in the elderly, and
antiemetics are strongly
anticholinergic and poorly tolerated in the frail elderly. 5. Do not use IM
narcotics at all, except as "rescue
analgesia" or when
acute pain has subsided. Their high peak, low trough profile leads to a
respiratory depression, excess
pain cycle which is poorly tolerated in the elderly IV, or even oral,
morphine is better tolerated. 6. Use multiple modalities for
analgesia; for example, intercostal nerve block and epidural
opioids, or IV-PCA and IV
NSAIDs. This will enhance
analgesia and reduce
narcotic toxicity. This is especially important in frail elders, who often tolerate systemic
narcotics poorly. 7. Use site-specific
analgesia. Certain operative sites, such as the upper extremity, are especially amenable to local
nerve blocks. Others, such as
thoracotomy, are especially painful and need potent
analgesia. For upper-extremity surgery, consider interscalene
nerve block and
NSAIDs. For
thoracotomy, use extrapleural, intercostal nerve block and epidural
narcotics. Local
bupivacaine and
NSAIDs work well after inguinal
herniorrhaphy. For knee surgery, consider intra-articular
morphine and
NSAIDs. 8. Whenever possible, add a scheduled parenteral, rectal, or oral
NSAID, in order 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,
NSAIDs should generally be administered. The major concern in frail elders is
acute renal failure; therefore, ensure good hydration and avoid use of
NSAIDs if renal function is diminished.
NSAIDs should be used on a scheduled (not prn) basis.