neurologic disorders
Treatment of Pain
Geriatrics Essentials
In older patients, the most common causes of pain are musculoskeletal disorders. However, pain is often chronic and multifactorial, and the causes may not be clear. Risk of ulcers and gastrointestinal (GI) bleeding due to NSAIDs for people>65 is 3 to 4 times higher than that for middle-aged people. Risk depends on drug dose and duration of therapy. Older patients at high risk of GI adverse effects may benefit from concomitant use of cytoprotective drugs (usually, a proton pump inhibitor; occasionally, the prostaglandinmisoprostol) or substitution of a selective COX-2 inhibitor (coxib; eg,celecoxib). Risk of GI adverse effects is significantly reduced in patients who are taking a selective COX-2 inhibitor (coxib) compared with those taking a nonselective NSAID (eg,ibuprofen). The risk of cardiovascular toxicity, which occurs with nonselective NSAIDs and with coxibs, is particularly relevant to older patients, who are more likely to have cardiovascular risk factors (eg, a history of myocardial infarction (MI) or cerebrovascular or peripheral vascular disease). Both nonselective NSAIDs and coxibs can impair renal function and cause sodium and water retention; they should be used cautiously in older patients, particularly in those who have a renal or hepatic disorder, heart failure, or hypovolemia. Rarely, NSAIDs cause cognitive impairment and personality changes in older patients.Indomethacincauses more confusion in older patients than other NSAIDs and should be avoided. Given the overall greater risk of serious toxicity in older patients, long-term NSAID therapy should be used with caution, if at all, and only for pain likely to be responsive. NSAIDS are most likely to relieve pain resulting from inflammation. Low doses of NSAIDs should be used if possible, and using short-term therapy or interrupted therapy to confirm effectiveness should be considered.Naproxenmay be preferred because it appears to have a lower risk of cardiovascular adverse effects than other commonly prescribed NSAIDs. In older patients, opioids have a longer half-life and possibly a greater analgesic effect than in younger patients. In older patients with chronic pain, short-term use of opioids appears to reduce pain and improve physical functioning but to impair cognitive function. As recognition of overdosage risks with opioids is increasing, practitioners should consider whether cognitive impairment in older patients might interfere with a patient's use of opioids and whether a caregiver can responsibly co-manage the patient's drug therapy. Opioid-related constipation and urinary retention tend to be more problematic in older patients. Risk of falls and fracture during the first 2 weeks of treatment is higher with opioids than with NSAIDs in older patients, presumably because of the opioid's sedative, cognitive, and balance adverse effects. Long-term opioid therapy can also lead to osteoporosis, partly because opioids inhibit the hypothalamic-pituitary-gonadal axis, causing androgen (testosterone) andestrogendeficiency. The long-term fracture risk due to osteoporosis is a concern in older patients taking long-term opioid therapy. Compared with other opioids,buprenorphine, an opioid agonist/antagonist, has a more favorable risk:benefit profile in older patients with renal insufficiency. 