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has been shown to provide good analgesia with no changes in the patients’ heart rate or blood
pressure (Akin et al, 2005 Level II).
Unlike epidural analgesia, age did not influence the spread of bupivacaine in the thoracic
paravertebral space (Cheema et al, 2003 Level III‐2).
Key messages
1. Experimental pain thresholds to a variety of noxious stimuli are altered in older people;
there is also a reduction in tolerance to pain (Q) (Level I).
2. PCA and epidural analgesia are more effective in older people than conventional opioid
regimens (U) (Level II).
3. Reported frequency and intensity of acute pain in clinical situations may be reduced in the
older person (U) (Level III‐2).
4. Common unidimensional self‐report measures of pain can be used in the older patient in
the acute pain setting; in the clinical setting, the verbal descriptor and numerical rating
scales may be preferred (S) (Level III‐2).
5. Undertreatment of acute pain is more likely to occur in cognitively impaired patients (N)
(Level III‐2).
6. There is an age‐related decrease in opioid requirements; significant interpatient variability
persists (U) (Level IV).
7. The use of nsNSAIDs and coxibs in older people requires extreme caution; paracetamol is
the preferred non‐opioid analgesic (U) (Level IV).
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
The assessment of pain and evaluation of pain relief therapies in the older patient may
present problems arising from differences in reporting, cognitive impairment and
difficulties in measurement (U).
Measures of present pain may be more reliable than past pain, especially in patients with
some cognitive impairment (U).
The physiological changes associated with ageing are progressive. While the rate of change
can vary markedly between individuals, these changes may decrease the dose
(maintenance and/or bolus) of drug required for pain relief and may lead to increased
accumulation of active metabolites (U).
The age‐related decrease in opioid requirements is related more to the changes in
pharmacodynamics that accompany aging than to the changes in pharmacokinetics (N). CHAPTER 11
Acute pain management: scientific evidence 407
