Drugs & Aging

, Volume 13, Issue 1, pp 9–16 | Cite as

Practical Guidelines on the Postoperative Use of Patient-Controlled Analgesia in the Elderly

Review Article Drug Therapy

Abstract

Inadequate pain control after surgery is associated with adverse outcomes in elderly patients; for this reason, effective analgesia is an essential component of postoperative care in this patient group. However, postoperative pain management is challenging in the elderly because of concomitant disease states and physiological factors that can affect the pharmacodynamic and pharmacokinetic properties of analgesic drugs.

Patient-controlled analgesia (PCA) offers advantages over traditional intramuscular analgesia in this setting, because it provides the opportunity to tailor therapy to the individual, as opposed to the average, patient. Morphine is the most widely used, and presently the most suitable, drug for use in PCA in the elderly. Studies have indicated that, after acute pain has been brought under control, PCA should be initiated at a dose of 1 or 1.5mg per dose, with a lockout period of 5 to 7 min. Continuous background infusions of opioids are contraindicated.

Education of patients and healthcare professionals alike is necessary to optimise the utility of PCA in older patients. In addition, every effort should be made to avoid the development of postoperative confusion, as this is associated with an increased risk of inefficient pain relief and its deleterious consequences. In summary, close monitoring and evaluation of the patient throughout the perioperative period is required to ensure the appropriate and successful use of PCA in elderly patients.

Keywords

Morphine Adis International Limited Postoperative Pain Ketorolac Postoperative Delirium 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Ferrell BA. Pain in the elderly. In: Ferrell BR, editor. Overview of aging and pain. Seattle (WA): IASP Press, 1996: 1–10Google Scholar
  2. 2.
    O’Neill D. The aging process. Baillieres Clin Anaesthesiol 1993; 7: 17–37CrossRefGoogle Scholar
  3. 3.
    Breivik H. Pain management. Baillieres Clin Anaesthesiol 1994; 8: 775–95CrossRefGoogle Scholar
  4. 4.
    Rosenberg J, Rosenberg-Adansen S, Kehlet H. Postoperative sleep disturbance: causes, factors and effects on outcome. Eur J Anaesthesiol 1995; 12Suppl. 10: 28–30Google Scholar
  5. 5.
    Driggleby W, Lander J. Cognitive status and postoperative pain: older adults. J Pain Symptom Manage 1994; 9: 19–27CrossRefGoogle Scholar
  6. 6.
    Gilson S, Helme R. Age differences in pain perception and report: a review of physiological, psychological, laboratory and clinical studies. Pain Rev 1995; 2: 111–37Google Scholar
  7. 7.
    Oberle K, Paul P, Wry J, et al. Pain, anxiety and analgesics: a comparative study of elderly and younger surgical patients. Can J Aging 1990; 91: 13–22CrossRefGoogle Scholar
  8. 8.
    Perry F, Parker RK, White PF, et al. Role of psychological factors in postoperative pain control and recovery in patient controlled analgesia. Clin J Pain 1994; 10: 52–63CrossRefGoogle Scholar
  9. 9.
    Ferrell BA, Ferrell BR, Rivers L. Pain in cognitively impaired nursing home patients. J Pain Symptom Manage 1995; 10(8): 591–8PubMedCrossRefGoogle Scholar
  10. 10.
    Pasero C, McCoffery M. Postoperative pain management in the elderly. In: Ferrell BR, Ferrell BA, editors. Pain in the elderly. Seattle (WA): IASP Press, 1996: 45–68Google Scholar
  11. 11.
    Knape KG. Postoperative analgesia in geriatric patients. In: Smith RB, Gurkowski MA, Bracken CA, editors. Anesthesia and pain control in the geriatric patient. New York: McGraw-Hill Inc., 1990: 457–77Google Scholar
  12. 12.
    Mangat PS, Jones JG. Postoperative pain control in the elderly. Baillieres Clin Anaesthesiol 1993 Mar; 7(1): 169–93CrossRefGoogle Scholar
  13. 13.
    Dodds C. Anaesthetic drugs in the elderly. Pharmacol Ther 1995; 66: 369–86PubMedCrossRefGoogle Scholar
  14. 14.
    Owen JA, Sitar DS, Berger L, et al. Age-related morphine kinetics. Clin Pharmacol Ther 1983; 34: 364–8PubMedCrossRefGoogle Scholar
  15. 15.
    Phillips AC, Polisson RP, Simon LS. NSAIDs and the elderly: toxicity and economic implications. Drugs Aging 1997; 10(2): 119–30PubMedCrossRefGoogle Scholar
  16. 16.
    Petrov VD, Petrov VV, Stancheda SL. Age related changes in brain neurotransmission. Gerontology 1988; 43: 14–21Google Scholar
  17. 17.
    Veno E, Lui DD, Ho IK, et al. Opiate receptor characteristics in brain from young, mature and aged mice. Neurobiol Aging 1988; 9: 279–83CrossRefGoogle Scholar
  18. 18.
    Egbert AM, Park LH, Short LH, et al. Randomized trial of postoperative patient-controlled analgesia vs intramuscular narcotics in frail elderly men. Arch Intern Med 1990; 150: 1897–903PubMedCrossRefGoogle Scholar
  19. 19.
    Egbert AM, Lampos LL, Parks LL. Effects of patient-controlled analgesia on postoperative anxiety in elderly men. Am J Crit Care 1993; 2(2): 118–24PubMedGoogle Scholar
  20. 20.
    Ballantyne JC, Carr DB, Chalmers TC, et al. Postoperative patient controlled analgesia: meta-analyses of initial randomized controlled trials. J Clin Anesth 1993; 5: 182–93PubMedCrossRefGoogle Scholar
  21. 21.
    Monk TG, Parker RK, Withe PF. Use of PCA in geriatric patients — effects of aging on the postoperative analgesic requirements [abstract]. Anesth Analg 1990; 70: S272CrossRefGoogle Scholar
  22. 22.
    MacIntyre PE, Jarvis DA. Age is the best predictor of postoperative morphine requirements. Pain 1995; 64: 357–64CrossRefGoogle Scholar
  23. 23.
    Owen H, Plummer JL, Armstrong I, et al. Variables of patient controlled analgesia: 1. Bolus size. Anaesthesia 1989; 44: 7–11PubMedCrossRefGoogle Scholar
  24. 24.
    Frank SM, Fleisher L, Olson K, et al. Multivariate determinants of early postoperative oxygen consumption in elderly patients. Anesthesiology 1995; 83: 241–9PubMedCrossRefGoogle Scholar
  25. 25.
    Schug SA, Torrie JJ. Safety assessment of postoperative pain management by an acute pain service. Pain 1993; 55: 387–91PubMedCrossRefGoogle Scholar
  26. 26.
    Herrick IA, Ganapathy S, Komar W, et al. Postoperative cognitive impairment in the elderly: choice of patient-controlled analgesia opioid. Anaesthesia 1996; 51(4): 356–60PubMedCrossRefGoogle Scholar
  27. 27.
    Plummer JL, Owen H, Ilsley AH, et al. Morphine patient-controlled analgesia is superior to meperidine patient-controlled analgesia for postoperative pain. Anesth Analg 1997; 84: 794–9PubMedGoogle Scholar
  28. 28.
    Stone PA, Macintyre PE, Jarvis DA. Norpethidine toxicity and patient controlled analgesia. Br J Anaesth 1993; 71: 738–40PubMedCrossRefGoogle Scholar
  29. 29.
    Tsui SL, Tong WN, Irwin M, et al. The efficacy, applicability and side-effects of postoperative intravenous patient controlled morphine analgesia: an audit of 1233 Chinese patients. Anaesth Intensive Care 1996; 24: 658–64PubMedGoogle Scholar
  30. 30.
    Petros JG, Mallen JK, Howe K, et al. Patient controlled analgesia and postoperative urinary retention after open appendicectomy. Surg Gynecol Obstet 1993; 177: 172–5PubMedGoogle Scholar
  31. 31.
    De Leon Casasola OA, Karabella D, Lema MJ. Bowel function recovery after radical hysterectomies: thoracic epidural bupivacaine-morphine versus intravenous patient controlled analgesia with morphine: a pilot study. J Clin Anesth 1996; 8: 87–92PubMedCrossRefGoogle Scholar
  32. 32.
    Edwards ND, Fletcher A, Cole JR, et al. Combined infusions of morphine and ketamine for postoperative pain in elderly patients. Anaesthesia 1993; 48: 124–7PubMedCrossRefGoogle Scholar
  33. 33.
    Marcantonio ER, Juarez G, Goldman L, et al. The relationship of postoperative delirium with psychoactive medications. JAMA 1994; 272: 1518–22PubMedCrossRefGoogle Scholar
  34. 34.
    Berggren D, Gustafson Y, Eriksson B, et al. Postoperative confusion after anesthesia in elderly patients with femoral neck fractures. Anesth Analg 1987; 66: 497–504PubMedCrossRefGoogle Scholar
  35. 35.
    Haan J, Van Kleef JW, Bloem BR, et al. Cognitive function after spinal or general anesthesia for transurethral prostatectomy in elderly men. J Am Geriatr Soc 1991; 39: 596–600PubMedGoogle Scholar
  36. 36.
    Williams-Russo P, Urquhart BL, Sharrok NE, et al. Postoperative delirium: predictor and prognosis in elderly orthopedic patients. J Am Geriatr Soc 1992; 40: 759–67PubMedGoogle Scholar
  37. 37.
    Aakerlund LP, Rosenberg J. Postoperative delirium: treatment with supplementary oxygen. Br J Anaesth 1994; 72: 286–90PubMedCrossRefGoogle Scholar
  38. 38.
    Wheatley RG, Somerville ID, Sasford D, et al. Postoperative hypoxaemia: comparison of extradural, IM and patient-controlled opioid analgesia. Br J Anaesth 1990; 64: 267–75PubMedCrossRefGoogle Scholar
  39. 39.
    De Kock MF, Pichon G, Scholtes JL. Intraoperative clonidine enhances postoperative patient controlled analgesia. Can J Anaesth 1992; 39: 537–44PubMedCrossRefGoogle Scholar
  40. 40.
    Beattie WS, Warriner CB, Etches R, et al. The addition of continuous intravenous infusion of ketorolac to a patient controlled analgesic morphine regime reduced postoperative myocardial ischemia in patients undergoing elective total hip or knee arthroplasty. Anaesth Analg 1997; 84: 715–22Google Scholar
  41. 41.
    Fredman B, Olsfanger D, Flor P, et al. Ketorolac does not decrease postoperative pain in elderly men after transvesical prostatectomy. Can J Anaesth 1996; 43(5): 438–41PubMedCrossRefGoogle Scholar
  42. 42.
    Etches RC. Respiratory depression associated with patient controlled analgesia: a review of eight cases. Can J Anaesth 1994; 41: 125–32PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 1998

Authors and Affiliations

  1. 1.Department of AnaesthesiologyUniversity of Louvain, St Luc HospitalBrusselsBelgium

Personalised recommendations