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11.2.5 Patient-controlled analgesia

Many pharmacological and non‐pharmacological treatments may be used in the management
of acute pain in older people, either alone or in combination. However, differences between
older and younger patients are more likely to be seen in treatments using analgesic drugs.
PCA is an effective method of pain relief in older people (Gagliese et al, 2000; Mann et al, 2000;
Mann et al, 2003). Compared with younger patients (mean age 39 years), older patients (mean
age 67 years) self‐administered less opioid than the younger group, but there were no
differences in pain relief, satisfaction with pain relief and level of control, or concerns about
pain relief, adverse drug effects, risks of addiction or use of the equipment (Gagliese et al, 2000
Level III‐2).
Compared with IM morphine analgesia in older men, PCA resulted in better pain relief, less
confusion and fewer severe pulmonary complications (Egbert et al, 1990 Level II). In older
patients PCA also resulted in significantly lower pain scores compared with intermittent
SC morphine injections (Keita et al, 2003 Level II).
11.2.6 Epidural analgesia

In the general patient population epidural analgesia can provide the most effective pain relief
of all analgesic therapies used in the postoperative setting (see Section 7.2). Older patients
given PCEA (using a mixture of bupivacaine and sufentanil) had lower pain scores at rest and
movement, higher satisfaction scores, improved mental status and more rapid recovery of
bowel function compared with those using IV PCA (Mann et al, 2000 Level II). After hip fracture
surgery, epidural analgesia with bupivacaine and morphine also provided better pain relief
both at rest and with movement, but this did not lead to improved rehabilitation (Foss et al,
2005 Level II).
Older patients are more likely to have ischaemic heart disease and in such patients coronary
blood flow may be reduced rather than increased in response to sympathetic stimulation.
High thoracic epidural analgesia (TEA) also improved left ventricular function (Schmidt et al,
2005 Level III‐3; Jakobsen et al, 2009 Level III‐3) and myocardial oxygen availability (Lagunilla et al,
2006 Level II) in patients with ischaemic heart disease prior to coronary artery bypass surgery
(CABG) surgery, and partly normalised myocardial blood flow in response to sympathetic
stimulation (Nygard et al, 2005 Level III‐3). However, epidural analgesia in patients undergoing
CABG surgery has not been shown to improve ischaemic outcome (Barrington et al, 2005
Level II).
After a small study during and after surgery for hip fracture, older patients who had received
epidural bupivacaine/fentanyl analgesia had significantly better pain relief than those who
were given IM oxycodone; there was no difference in the number of patients who developed
postoperative ischaemia or hypoxia, however the number of episodes and total duration of CHAPTER 11
ischaemia in each patient was markedly greater in the oxycodone group (Scheinin et al, 2000
Level II).
Epidural morphine requirements decrease as patient age increases (Ready et al, 1987).
However, a comparison of fentanyl PCEA in patients aged over 65 years with those aged 20 to
64 years showed no difference in fentanyl requirements although pain relief on coughing (at
24 hours) was better in the older patient group; there was no difference in the incidence of
pruritus (Ishiyama et al, 2007 Level III‐3).
Age is also a determinant of the spread of local anaesthetic in the epidural space and the
degree of motor blockade (Simon et al, 2002; Simon et al, 2004), thus smaller volumes will be
needed to cover the same number of dermatomes than in a younger patient. When the same

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