The elderly also present special problems in the provision of analgesia. There may be great difficulty in communication and assessment and the choice of analgesic techniques should reflect this. As a general rule the elderly report pain less frequently and require smaller doses of analgesic drugs to achieve adequate pain relief. Many patients are anxious, however, and this may correlate with increased pain postoperatively.

Assessment of pain may be carried out by normal methods and conventional numerical or graphical methods work well. However, impairment of higher intellectual functions may mean that observational techniques similar to those described earlier be needed. When analgesic drugs are given they may not be absorbed as well or metabolised as efficiently. In practical terms, doses of drugs such as NSAIDs and opioids should be reduced because of a decrease in liver metabolism. In addition, since the metabolites of drugs such as morphine and pethidine are excreted by the kidneys, any decrease in renal function may lead to accumulation with repeated doses. The elderly are more likely to be receiving more than one drug for underlying medical conditions and the possibility of drug interaction is greater (see Table 7).

NSAIDs are often undervalued. However, gastrointestinal disorders are more common and care should be taken in patients with compromised hepatic or renal function.

Opioids. Self-medication with opioids is not always wise in elderly patients and thus the role of PCA may be limited. It is probably better to use conventional intravenous and intramuscular methods of delivery which will give an immediate effect which can be assessed by those caring for the patient. The elderly may be particularly sensitive to opioids and side effects such as confusion, sedation and respiratory depression assume greater importance. Because of changes in hepatic and renal function lower doses of opioids are needed and the expected length of action may be longer.

Only one drug should be used at a time. In general about half the normal adult dose should be given at first, especially if the drug is being given intravenously. Small doses should be given regularly to anticipate pain where appropriate.

Pain from other Acute Causes Many of the principles of pain relief contained in this survey apply to the management of other pain conditions; burns and trauma are obvious examples. A difference is that pain as a symptom may last longer than when seen in association with surgery. The initial pain of the injury will require treatment in the normal fashion, but there are subsequent phases of healing and rehabilitation which may be long and painful.

The healing phase may take many weeks depending upon the nature of the injury and the length of the rehabilitation phase. It is important to provide adequate analgesia for the performance of procedures such as dressings, physiotherapy and skin grafts. Emotional consequences and tissue damage from the burn or injury, such as nerve damage, may require additional treatment. In these circumstance use of short-acting drugs is inappropriate. In addition, it is better to establish regimens of regular pain relief. Combined techniques to address all aspects of the pain problem are best carried out by a multidisciplinary team.

This article contained links to the following additional information:

Table 1 - Local anaesthetics for the treatment of acute pain
Table 2 - NSAIDs
Table 3 - Strong Analgesics
Table 4 - Guidelines for patient controlled intravenous opioid administration
Table 5 - Intrathecal and epidural opioids for treatment of acute pain
Table 6 - Pain assessment for children under four years
Table 7 - Analgesic-drug interactions

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