{'fraction_non_alphanumeric': 0.020938446014127143, 'fraction_numerical': 0.0030272452068617556, 'mean_word_length': 5.510673234811166, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
AGS GUIDELINES ON PERSISTENT PAIN IN OLDER PERSONS: LACK OF SPECIFIC PHARMACOTHERAPEUTIC RECOMMENDATIONS

To the Editor: The members of the American Geriatrics Society (AGS) panel on Persistent Pain in Older Persons 1 surely have to be congratulated for their extensive work in reviewing the literature on pain in older persons. There is no doubt that these guidelines will be helpful in providing better pain management for the elderly, especially the frail ones, in whom pain is too often neglected. Nevertheless, I was somewhat disappointed by the absence of more-precise recommendations regarding the pharmacological treatment of pain in the elderly. Although the table listing the drugs and doses is surely useful, it would have benefited from more comments on specific medications. Although it is well known from geriatricians and practitioners experienced in geriatrics that some medications are to be avoided in the elderly, pain physicians and general practitioners still use them frequently. The best example is amitriptyline. Because of its prominent anticholinergic properties, amitriptyline can cause sedation, cognitive impairment, orthostatic hypotension, arrhythmias, falls, urinary retention, and dry mouth. 2 It should therefore be avoided in the elderly, especially in those with cognitive impairment. If an antidepressant is indicated, the secondary amines, nortriptyline and desipramine, are better options. 3 This is such a crucial point that it deserved more than a footnote in the table. Carbamazepine has been associated with several side effects, including potentially life-threatening ones, and has numerous drug interactions. 4 In clinical practice, elderly patients rarely tolerate it. Because of its proven analgesic effect in several neuropathic pains, its good tolerability, and a paucity of drug-drug interactions, gabapentin appears to be a better choice for older persons and has been recommended as a first-line agent when an adjuvant analgesic is indicated. 5 Without specifically recommending using gabapentin rather than carbamazepine, the text accompanying the guidelines could have commented on their respective side-effect profiles. The use of clonazepam and other benzodiazepines as adjuvant analgesics is highly controversial, and critical reviews on these drugs do not support their analgesic effects. 6 However, they are well known, especially the longacting ones, including clonazepam, to cause numerous adverse events in elderly patients. 7 The inclusion of clonazepam in the pharmacotherapeutic options, with the same weight as gabapentin, can therefore be detrimental to older patients. Although it has not been included in the opioids list, meperidine has not been identified as an opioid of particular concern. Despite its well-known adverse events, especially in the elderly, due to the accumulation of a toxic metabolite, meperidine is still widely used in hospital units. A warning against its use would have been justified. Finally, although most healthcare practitioners know that nonsteroidal antiinflammatory drugs (NSAIDs) have to be used with caution in elderly patients, the recent availability of the selective cyclooxygenase-2 (COX-2) inhibitors has created a false sense of safety due to their better gastrointestinal profile. It has now been shown that NSAID-associated renal failure and fluid retention, which are at least as frequent as gastrointestinal toxicity in elderly patients, are encountered with the selective COX-2 inhibitors as often as with the traditional NSAIDs. 8,9 The guidelines should thus have emphasized that caution and frequent monitoring of renal function are still warranted when these drugs are prescribed. To help improve the pharmacological management of persistent pain in older persons, future versions of the AGS guidelines should provide more-specific pharmacotherapeutic recommendations reflecting the specificities of the pharmacotherapy of pain in older persons.