Postoperative pain management in the frail elderly

1. Prevent predictable pain, such as occurs postoperatively. Anticipatory pain management is particularly important in the elderly, who frequently attempt to "tough it out" without much analgesia. 2. Assume the patient is in pain if the situation is potentially painful, even without verbal complaints. Confused elders may be unable or unwilling to verbalize pain. For example, a confused 90-year-old woman with an acute hip fracture should be treated for pain, even if she does not complain of it. Elders, especially if demented, may not have the usual external "pain behaviors." 3. Do not routinely use antiemetics, especially phenothiazines. The incidence of postoperative nausea and vomiting is probably less in the elderly, and antiemetics are strongly anticholinergic and poorly tolerated in the frail elderly. 5. Do not use IM narcotics at all, except as "rescue analgesia" or when acute pain has subsided. Their high peak, low trough profile leads to a respiratory depression, excess pain cycle which is poorly tolerated in the elderly IV, or even oral, morphine is better tolerated. 6. Use multiple modalities for analgesia; for example, intercostal nerve block and epidural opioids, or IV-PCA and IV NSAIDs. This will enhance analgesia and reduce narcotic toxicity. This is especially important in frail elders, who often tolerate systemic narcotics poorly. 7. Use site-specific analgesia. Certain operative sites, such as the upper extremity, are especially amenable to local nerve blocks. Others, such as thoracotomy, are especially painful and need potent analgesia. For upper-extremity surgery, consider interscalene nerve block and NSAIDs. For thoracotomy, use extrapleural, intercostal nerve block and epidural narcotics. Local bupivacaine and NSAIDs work well after inguinal herniorrhaphy. For knee surgery, consider intra-articular morphine and NSAIDs. 8. Whenever possible, add a scheduled parenteral, rectal, or oral NSAID, in order to spare narcotics, enhance analgesia, and decrease inflammatory mediators. Unless the patient has a contraindication or there is a strong concern about hemostasis or peptic ulceration, NSAIDs should generally be administered. The major concern in frail elders is acute renal failure; therefore, ensure good hydration and avoid use of NSAIDs if renal function is diminished. NSAIDs should be used on a scheduled (not prn) basis.