Chronic Pain Medications in Geriatric
Patients :

Because geriatric patients frequently have multiple health
problems. Research has continued to highlight the complexity. American
Geriatrics Society (AGS) recommends starting treatment with acetaminophen;  NSAIDs are traditionally the next step.
However, there is heightened risk of GI toxicity, effects on renal function,
and cardiovascular problems ie, myocardial infarctions and strokes.  It therefore concludes that for many
geriatric patients, other drugs—including opioids—may be a safer choice.



There is  potential promise of topical
NSAIDs but even these medications are far from risk-free. About 17.5%  reported 
systemic adverse effects. Up to another 39% of patients had problems at
the application site of the topical drug, and there were 5 cases of  warfarin potentiation.

Yet to be answered is the very important question of whether the topical NSAIDs
are as effective as the oral ones for chronic pain.



With regard to opioids, geriatric patients are at risk for abuse and
dependence. Delirium is of special concern in the geriatric population..
Benzodiazepines and opioids combo, appear to be most likely to increase the
risk. The AGS guideline notes that benzodiazepines have little role in the
management of chronic pain. Oxycodone has least risk of contributing to
delirium and meperidine (Demerol), the most.

 The majority of the studies of oxycodone , immediate-release
formulation was used rather than the extended-release formulation, because the
extended-release form may accumulate and 
it might be more strongly associated with delirium.



One especially interesting finding was that in severe acute pain like in hip
fractures, lower doses of opioids were associated with an increased risk of
delirium.

 The AGS guideline mention that Neuropathic pain (eg, diabetic neuropathic pain
and postherpetic neuralgia) can occur at any age but is more likely to afflict
older persons. Although opioids can provide some benefit, the non-opioids
appear to be more effective for these conditions.

 These include:

• Anticonvulsants such as Pregabalin (Lyrica) and   (Neurontin)

• Antidepressants, including the tricyclics and other serotonin-norepinephrine
reuptake inhibitors, such as Duloxetine ,  
(Cymbalta) and venlafaxine (Effexor)

• Topical agents such as the (Lidoderm) and capsaicin (Zostrix)

 Adapted from “Analgesic Medications and Geriatric
Patients “ by Steven King MD, MS  June
7, 2012  in ConsultantLive.