Review Article

The assessment and management of peri-operative pain in older

adults
P. A. Schoeld
Professor of Nursing, School of Health & Social Care,
University of Greenwich, Eltham, London, UK
Summary
A number of recent reports have highlighted the inadequate provision of pain relief for older inpatients. Despite the
availability of numerous validated pain measures, pain remains poorly assessed in some cases and, particularly, in the
cognitively impaired. Without proper assessment, patients may receive inadequate or inappropriate analgesia, both of
which can worsen outcome. Most drugs and techniques that are used for analgesia in younger patients are also suitable
for older patients, although dosages may have to be adjusted to avoid the side-effects that are consequent upon age-
related changes in drug pharmacokinetics and pharmacodynamics, co-morbidity, frailty, cognitive impairment and
polypharmacy. This paper reviews current guidelines and methods of assessing pain in the older adult, and describes the
use of, and problems with, mild, moderate, strong, adjuvant and local anaesthetic drugs in the older population for anal-
gesia, advocating multimodal intervention to reduce dose-related side-effects, particularly of opioids.
.................................................................................................................................................................
Correspondence to: P. A. Schoeld
Email: p.a.schoeld@greenwich.ac.uk
Accepted: 28 October 2013
Pain in older people is under-recognised and under-
treated [16]. Even when treatment is prescribed, it is
often limited to basic medication, and seldom tailored
to the individual [710]. In addition, professionals
often fail to consider alternative pain relief options,
such as exercise, rest and thermal strategies [4]. There
is undoubtedly more that needs to be done with
regards to pain management for the older adult.
National guidance is overdue for both acute and
chronic pain management, bearing in mind that, as
long ago as 1997, Desbiens et al. [11] demonstrated
that 46% of older people admitted to hospital reported
pain, 19% of whom had moderate or extremely severe
pain, and 13% of whom were dissatised with their
pain management. Pain relief is as effective for older
as for younger patients, but professionals tend to
underestimate pain needs, underprescribe and un-
dermedicate [12].
Admissions to medical and surgical wards are
three times more common for over 65-year-olds than
for younger patients, yet staff lack the experience in
pain assessment and management that might be
expected in dealing with the specic problems associ-
ated with this population. Attitudinal barriers to pain
assessment and analgesia persist among health profes-
sionals, related to prescribing potentially harmful drugs
for patients with co-morbidities, consequent poly-
pharmacy, cognitive impairment, frailty, reduced
physiological reserve, and age-related changes in pharmaco-
kinetics and pharmacodynamics [13].
Both the peripheral and central nervous systems
are affected by ageing, with reduction in b-endorphin
54 2013 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2014, 69 (Suppl. 1), 5460 doi:10.1111/anae.12520
content and c-aminobutyric acid (GABA) synthesis in
the lateral thalamus, a decline in the concentration of
central GABA and serotonin receptors, a decrease in
the speed of nociceptive processing, and a decline in C
and Ad bre function [14].
The threshold for pain perception appears to be
increased in older people when nociceptive stimuli are
shorter, of lower spatial extent, are presented at
peripheral cutaneous or visceral sites, or are thermally
or electrically induced [15], but it remains uncertain
whether or not pain perception threshold generally
increases with age [16].
The assessment of pain in the older
population
Pain is a subjective, personal experience, known only
by the person who suffers it. The experience of pain is
multidimensional and may be described variously
according to sensory (intensity, location and charac-
ter), affective (emotional perception) and functional
(impairment of functional ability) components. The
process of assessment may be further complicated if
the patient has severe cognitive impairment, or there
are communication difculties or language and cultural
barriers.
Pain is the fth vital sign and any peri-operative
assessment of older surgical patients should include a
question about whether the patient has pain [17],
using an intensity rating scale, which also enables
assessment of the response to treatment, for example,
the Numeric Rating Scale (0 no pain, 13 mild pain,
46 moderate pain, 710 severe pain), Verbal Descrip-
tor Scale none, mild, moderate, severe) or Visual Ana-
logue Scale [18]. Intensity scales can be used for older
people with all but severe cognitive impairment, but
vary in how easy they are to complete according to
age and cognitive function [1922]. Follow-up ques-
tions about the nature of pain (does it ache?, is it
sore?) can be useful if a patient denies pain [23], as
older people may be stoic, or reticent about reporting
pain for fear of complaining [24]. Whichever scale is
selected, attention should be paid to the presentation
to ensure that it is in large, clear letters/numbers and
presented in good lighting.
Observing the patient can also provide some very
useful information regarding pain, particularly when
there are communication difculties. Behavioural indi-
cators of pain, such as facial expressions, physical reac-
tions (e.g. guarding, bracing, rubbing the painful area)
and negative reactions (e.g. agitation) [25], can vary
between individuals and within the same individual,
and can occur simultaneously. Facial expressions asso-
ciated with pain, including brow raising and lowering,
cheek raising, eyelid tightening, nose wrinkling, lip
corner pulling, chin raising and lip puckering, are cor-
related with the experience of pain, particularly in cog-
nitively impaired patients [26]. However, some
indicators, for example, social withdrawal, can be sub-
tle, and associated with causes other than pain [27].
Behavioural changes should prompt carers or health-
care professionals to exclude pain as a cause, through
more detailed clinical assessment. It is important to
include carers in any pain assessment process as they
are often more familiar with the subtle changes in the
patients behaviour that indicate pain, although they
may overestimate the presence and degree of pain
[28]. Physiological cues, such as pallor, tachycardia
and hypertension, can indicate pain, but may be absent
if the pain is chronic.
In the peri-operative setting, acute pain is most
likely to be related to the surgery performed, but may
be superimposed upon chronic pain. Fuller assessment
of the patients background pain should therefore be
undertaken as part of general pre-operative assess-
ment, including information about onset, time, course,
radiation, aggravating and relieving factors, quality,
associated symptoms and medication. Location can be
mapped graphically with reasonable testretest reli-
ability in the elderly [29]. Multidimensional assess-
ment is ideal, because it includes assessment of mood
and function, both of which can affect postoperative
rehabilitation [30, 31], and can be performed using
scales such as the McGill Pain Questionnaire [32],
brief pain inventory [33] or geriatric pain measure
[34], although further research is needed to support
the validity of using these in some older patient
groups [35].
The assessment of pain in older adults
with cognitive impairment
A number of behavioural scales have been developed
to assess pain in older adults with cognitive impair-
2013 The Association of Anaesthetists of Great Britain and Ireland 55
Schoeld | Peri-operative pain in older adults Anaesthesia 2014, 69 (Suppl. 1), 5460
ment [3642], and consistently include seven main
indicators: physiological observation; facial expressions;
body movements; verbalisations; and changes in inter-
personal interactions, activity/routines and/or mental
status. No single instrument can be recommended cur-
rently for general use [43].
The 2007 Royal College of Physicians/British Pain
Society/British Geriatrics Society guidelines The Assess-
ment of Pain in Older People [43] distinguish two dif-
ferent approaches to pain assessment according to an
older patients ability to communicate, providing an
algorithm for use in clinical practice (see Appendix 2,
reference [44]). Updated guidelines will be published
early in 2014.
Pharmacological interventions
Approximately 56% of men and 65% of women aged
over 75 years are normally in pain or discomfort, a
proportion that rises with institutionalisation and hos-
pitalisation, yet the elderly are consistently less likely
than younger patients to receive good pain manage-
ment [1, 45, 46].
Few studies have specically investigated the
effects of analgesic drugs in older people. Generally,
results have been extrapolated across the age spectrum
from primary studies involving younger participants
[47], which is problematic in many ways [48]. For
many analgesic medicines, for example, a lower initial
dose may be required compared with that adminis-
tered to younger adults, with subsequent doses titrated
according to response.
Both the American [47] and British [49] Geriatrics
Societies advocate a pain ladder approach to pharma-
cological pain management in the older population,
using the safest drugs administered by the least inva-
sive route, and only escalating treatment if analgesia
remains ineffective. The American guidelines of 2002
[50], which recommended cyclo-oxygenase-2 (COX-2)
inhibitors, were revised in 2009 [47], after the with-
drawal of rofecoxib and valdecoxib due to concerns
about cardiovascular safety in patients with heart dis-
ease or cerebrovascular accident [51]. Paracetamol is
recommended as rst-choice oral analgesia [47, 49],
due to its efcacy and safety. At the lowest effective
dose, non-steroidal anti-inammatory drugs (NSAIDs)
can be added or substituted in patients who do not
respond adequately to paracetamol. In patients with an
increased risk of gastrointestinal problems, either a
COX-2 inhibitor or an NSAID with a gastro-protective
agent should be used. Opioid analgesics, with or with-
out paracetamol, can be useful when NSAIDs or COX-
2 inhibitors are ineffective, contraindicated or poorly
tolerated [47, 49].
Multimodal therapy, using combinations of weaker
and stronger analgesics in combination with adjuvant
agents, local or regional analgesia and non-pharmaco-
logical therapies (e.g. cooling, elevation, splinting, sur-
gery) may provide analgesia whilst sparing the patient
side-effects associated with stronger opioid analgesia
[49]. Like any other age group, older patients will
respond better to treatment if they are given the
opportunity to make an informed choice about analge-
sia. Information should be provided in an age-friendly
format (e.g. large print, simple drug information and
dosage scheduling) and in accessible packaging after
hospital discharge.
Mild pain
Paracetamol
Paracetamol is readily available over the counter, and
in many over-the-counter cold and u preparations. It
is the preferred analgesic for older adults with muscu-
loskeletal problems and can be used for some mild
forms of neuropathic pain. No dosage reduction is
necessary for older adults, although care should be
taken not to exceed a 4-g limit in 24 h. Liver damage
is more likely when the patient is fasted, dehydrated,
poorly nourished or has high alcohol consumption.
Non-steroidal anti-inammatory drugs
Non-selective cyclo-oxygenase inhibition, together with
age-related pharmacokinetic changes and co-morbidi-
ties, renders the older patient at relatively higher risk
of adverse effects from NSAID consumption, including
gastrointestinal toxicity and bleeding, renal dysfunc-
tion, hyponatraemia and impaired hepatic function
[52]. Caution should be used when prescribing in
older adults with pre-existing peptic ulceration, cardiac
failure, hypertension or renal impairment. NSAIDs
with short half-lives, such as ibuprofen and diclofenac,
appear to have fewer side-effects. Patients should take
the lowest effective dose of NSAIDs or COX-2 selec-
56 2013 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2014, 69 (Suppl. 1), 5460 Schoeld | Peri-operative pain in older adults
tive inhibitors for the shortest time necessary to con-
trol symptoms [53]. Co-administration with food, or
with a proton pump inhibitor or misoprostil, reduces
the risk of gastrointestinal complications.
Despite concerns about the side-effects and
adverse reactions associated with NSAIDs, they are
highly effective in most cases for reducing mild to
moderate pain [54]. NSAIDs alone produce as good
analgesia as single or multiple doses of weak opioids
alone or in combination with non-opioid analgesics
[55].
Moderate pain
Codeine
Codeine is often used for short-lasting predictable inci-
dent pain and can be used alone or, more effectively,
in combination with paracetamol. There is a degree of
variability in effectiveness, with up to 30% of patients
being poor debrisoquine hydroxylators/O-demethyla-
tors of codeine to form morphine, such that analgesia
is limited or not achieved [56]. Conversely, 13% of
British patients are ultrafast metabolisers of codeine
and tramadol (UM CYP2D6 genotype), converting
these prodrugs to their active forms rapidly, leading to
their accumulation in renal failure, and resulting in
respiratory depression or apnoea [57]. Conversion to
active metabolites is inhibited by common medica-
tions, including cimetidine, haloperidol, amitriptylline
and many selective serotonin re-uptake inhibitors (e.g.
uoxetine). Use is further limited by side-effects,
including constipation, confusion and nausea.
Tramadol
In the older population, tramadol may cause fewer
respiratory and gastrointestinal side-effects than other
opioids, but is associated with delirium [58], and can-
not be tolerated by a third of patients, due to nausea,
vomiting, sweating, dizziness, tremors and headaches.
Severe pain
Opioid therapy
In spite of there being little evidence for their specic use
in the elderly [59, 60], opioids are well established for the
treatment of cancer pain, and increasingly used for the
treatment of chronic pain. Similarly to prescribing other
analgesics, the general rule for prescribing opioids in
older adults is to start low and go slow, anticipating
side-effects and treating them accordingly [61] rather
than stopping treatment, and introducing different medi-
cations sequentially. For example, co-administration of
stool softeners and anti-emetics helps to prevent the
common side-effects constipation and nausea. Drowsi-
ness is common in the rst few days of prescription and
patients should be warned about this. From the limited
number of studies available in the older population, opi-
oids do not appear to increase postoperative delirium,
although this effect is difcult to determine as compara-
tive patients prescribed insufcient non-opioid analgesia
are at greater risk of delirium [62]. The validity of a start
low and go slow approach has been called into question
for this reason, i.e. that it leads to inadequate analgesia in
patients who are already at higher risk of confusion and
agitation [46]. However, pethidine is consistently associ-
ated with delirium, and should be avoided, as its metabo-
lite norpethidine can cause excitement, agitation,
twitching and tremors. Frail and cognitively impaired
patients do not appear to have reduced pain perception
and hence appear to require similar doses of analgesia to
ablate pain, although more research is needed to conrm
this [46] and analgesia should be prescribed with particu-
lar caution to these groups [63]. Buprenorphine may be a
more appropriate choice of opioid for patients with renal
disease, as its pharmacokinetics are unaltered by renal
function [49].
Adjuvant analgesics
Older people experience neuropathic pain with a dis-
proportionately higher incidence than younger people,
related to increased co-morbidity. Patients may present
for surgery already taking antidepressant, anticon-
vulsant or anti-epileptic drugs, which cause numer-
ous side-effects and potential for drug interactions
[64].
Newer postoperative analgesia strategies involving,
amongst others, gabapentin, pregabalin, ketamine and
dexmetomidine are promising, but may be limited by
side-effects in older patients, in whom more specic
research needs to be carried out. Topical therapies
involving lidocaine, capsaicin and NSAIDs are not
without side-effects, but may be more appropriate for
localised pain distant to the site of operation in
patients who cannot tolerate systemic analgesia [49].
2013 The Association of Anaesthetists of Great Britain and Ireland 57
Schoeld | Peri-operative pain in older adults Anaesthesia 2014, 69 (Suppl. 1), 5460
Local/regional analgesia
Regional techniques, either as the sole method of
anaesthesia or as adjuvant analgesia, are well tolerated
by the older population, attenuating the surgical stress
responses, limiting opioid co-administration and accel-
erating patient rehabilitation and recovery [65]. Their
use may benet the elderly more than younger
patients, due to the relatively greater risk of side-effects
in the older adult if opioids were otherwise used [13,
6668], although, as ever, more research is required
comparing postoperative opioid with regional analgesia
in the elderly. Age-related alterations in both anatomy
and neural micro-anatomy may make correct siting of
any block technically more difcult, and drug effects
less predictable [69], blockade being achieved with
lower doses of local anaesthetic [70] and lasting longer
[71].
In conclusion, older adults represent the most rap-
idly expanding demographic in society and present
disproportionately more frequently for surgery than
younger patients. They are more likely to experience
chronic pain as a result of their increased prevalence
of co-morbidities, and, although currently more stoic
and less likely to report pain, consequently take greater
numbers of analgesic medications long-term, increas-
ing the likelihood of peri-operative drug interactions.
Postoperative analgesia is often inadequate, and poorly
assessed in patients with communication difculties or
cognitive decit [72], despite recent advances in both
provision and validation of evaluation tools. Multi-
modal pain intervention reduces the likelihood of opi-
oid use and side-effects, to which the older population
may be particularly prone.
However, the evidence base for specic analgesic
interventions in the older population is based on expe-
rience and derivation from studies involving younger
adults, placing older patients at higher risk of avoid-
ably poor outcome, resulting from both inadequate
analgesia and side-effects of medication. Further
advances are not simply a case of more research is
needed so much as identifying what specic questions
need asking, and how research might best address
these, with the goal of providing universally adequate
analgesia for the older population, with minimal side-
effects.
Competing interests
No external funding and no competing interests
declared.
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Anaesthesia 2014, 69 (Suppl. 1), 5460 Schoeld | Peri-operative pain in older adults