Session 15L1 Pain management in the elderly: how, when and why?

Sunday 19 December, 09:45 – 10:30 – Channel 4

This Sunday morning session on pain in the elderly was presented by Dr Peter Lee, Consultant Anaesthesiologist Bon Secours Hospital Cork, Ireland.

“The undertreatment of postoperative pain in older people has been recognised as a problem in hospitals worldwide for at least 20 years,” he explained, “As well as the obvious suffering associated with moderate or severe pain, older people will also experience adverse cardiovascular and respiratory effects, delays in mobilisation and discharge, and are put at high risk of developing perioperative neurocognitive disorders such as delirium or delayed neurocognitive recovery.”

He asked why, despite numerous guidelines and increasing awareness of the issue, does this deficit continue to arise? “There can be real difficulties in assessing pain in older people, particularly where cognitive impairment is present,” he explained. “Pain assessment tools must be appropriate to a patient’s cognitive abilities and their ability to communicate their pain. Every anaesthetist should have access to, and be comfortable in the use of, appropriate tools for pain assessment, both self-report and observational. Even then there may be sociocultural reasons why older people are sometimes slow to report their pain or seek analgesia.”

The appropriate treatment and amelioration of pain in older people have its challenges. Age-related physiological change is both complex and subject to wide inter-individual variation. An anaesthesiologist working in the field must be aware of likely physiological changes, and the appropriate adjustments that should be made to the choice of analgesia used, and to the dose and time intervals for administration. The likely presence in many older people of multiple co-morbidities and consequent polypharmacy can narrow the therapeutic options available and increase the incidence of adverse effects. As many as 1 in 10 of the over 65s may be frail, a condition that heightens all of the general challenges of pain management in the elderly.

Dr Lee said: “A key part of the solution is the formulation of a perioperative analgesia plan for every older patient that takes into consideration all of the challenges outlined. Thereafter balanced multimodal analgesia is key, with the choice of analgesia and route of administration carefully tailored to the patient. Regional anaesthesia is likely to be an important component, with a strong evidence base present for certain types of surgery.”

He concluded that regardless of the mode of analgesia, frequent careful reassessment and titration of medication should improve pain control in older patients and reduce the incidence of a host of adverse effects.

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