Page 287 Guide to Pain Management in Low-Resource Settings

Pain in Old Age and Dementia 275

Pearls of wisdom • Opioids are the analgesics of choice for strong
cancer pain unresponsive to NSAIDs. Keep in
• Th ere is no evidence that older patients have less mind that around four half-lives (for morphine
pain and need less pain medication than younger the total time would be about one day) will be
patients. Also, the belief that opioid receptor den- necessary before a steady-state situation will be
sity is reduced has not been confi rmed by recent reached in the patient and that women usually
research. Th erefore, withholding opioids because need less opioids than men. In most older pa-
the patient is old is not correct. tients, a longer dosing interval might be a good
• Pain is underdiagnosed in the elderly patient. Al- solution (morphine t.i.d.). If available, combine
ways ask about pain, and do not rely on analogue slow-acting morphine for basic analgesia with
scales (e.g., NRS or VAS); instead, use careful ob- fast-acting morphine for on-demand doses.
servation of the noncommunicating patient for • Coanalgesics should be used only in individually
diagnosing unrelieved pain. selected patients. If coanalgesics are unavoidable,
• Elderly patients tend to act in a “socially accept- calcium-channel-blocking anticonvulsants (gaba-
able” manner, meaning that they try to be a good pentin or pregabalin) should be preferred.
patient (“if I am no burden to anyone, everybody • Nonpharmacological treatment strategies should
will value me higher” and “the doctor knows what always be implemented if possible and feasible:
is best for me and will ask me if necessary”), and education, activity, cognitive techniques, and
they tend to suff er through things, especially counterirritation (e.g., acupuncture). Do not for-
pain, deprivation, and isolation (“nobody can help get integration of spiritual beliefs into the treat-
me,” “it is the destiny of the older person to suff er,” ment plan.
“there is no hope for me”). • End-of-life decisions should respect the wishes of
• NSAIDs or paracetamol (acetaminophen) or di- the elderly patient to die at home, in dignity, and
pyrone are drugs of fi rst choice for metastatic appreciated, with their pain under control.
(bone) pain, depending on the risk profi le of the • Rule of thumb: Start low, go slow.
patient (NSAIDs may be used nevertheless in the
short term for pain exacerbations). Use the lowest References
possible dose of NSAIDs, and avoid long-acting
NSAIDs that might accumulate (piroxicam and [1] AGS Panel on Persistent Pain in Older Persons. Th e management of
persistent pain in older persons. J Am Geriatr Soc 2002;50:S205–24.
others). Avoid NSAIDs with a history of steroid [2] Hadjistavropoulos T. International expert consensus statement. Clin J
Pain 2007;23:S1.
medication, gastrointestinal bleeding, and kidney [3] Manfredi PL, Breuer B, Meier DE, Libow L. Pain assessment in elderly
dysfunction. patients with severe dementia. J Pain Symptom Manage 2003;25:48–52.
• If no infl ammatory pain component is suspected,
and the anti-infl ammatory activities of NSAIDs Websites
are not relevant, than always choose an antipyret-
www.merck.com (the Merck manual on geriatrics)
ic analgesic such as paracetamol or dipyrone.
www.canceradvocacy.org (pain in the elderly)