Pain Management in the Elderly Stinks!

Pain management in the elderly is something I deal with on a daily basis.  It can be extremely challenging as there are potential negatives of using medications around every corner.  Here’s a case that highlights a few challenges:

88 year old male with a history of atrial fibrillation, GERD, Hypertension, Seizures, CKD, and Constipation.  Current medications include:

  • Omeprazole
  • Coumadin
  • Lisinopril
  • Senna-S
  • Hydrochlorothiazide
  • Keppra

This gentleman begins to complain about pain in multiple joints.  He states he has always had it, but it seems to be getting worse.  He is diagnosed with mild to moderate osteoarthritis and prescribed routine Tylenol 500 mg twice daily.

A week later he is reevaluated and still having issues.  He states that the Tylenol has helped a little bit, but the pain is still bothering him all over.  He is now prescribed Oxycontin 10 mg twice daily.

So let’s back up and look at a few options we have here other than the Oxycontin.  Let’s consider NSAIDs first.  NSAIDs are not the safest in the elderly by any stretch of the imagination and especially not a good choice in this patient.  High GI risk with Coumadin and they already have had GI issues with being on omeprazole.  CKD is also another concern with the NSAID.  COX-2 might be slightly better for GI risk, but the patient still has the CKD risk.

Topical medications – probably not an option due to the “all over” nature of the pain, but definitely a consideration in cases with localized involvement only.

Alternative opioids – Some providers like to use low dose Ultram, but with this patients seizure history, probably not a good choice.  Regardless of whether using Oxycontin or some other opioid, we’d need to watch the constipation issue closely and likely bump up preventative measures.

As you can see, selecting analgesics in the elderly stinks.  In this case, looking at the severity of the pain, and if the patient would be acceptable to increasing the Tylenol, that is probably the route I would have recommended first before adding the Oxycontin.

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3 Comments

  1. Annek

    Being on a thiazide diuretic, and if he was dehydrated,( as elderly often do not drink enough fluids) could he potentially be having issues with high uric acid levels, or gout related pain?
    May want to rule this out as well before going the opioid route.

    Reply
  2. richi

    Its really a difficult one when treating elders but under the guidance of doctors can go with many opioids.

    Reply
  3. Matt

    I really question this patient having pain. I would request a pain consult possibly. Does a test exist that could be given to patient to determine nature of pain and etiology. The osteoarthritis is a possibility. How long has the patient had pain and nature of pain severity and been on Tylenol. I would give patient a physical exam of his joints and potentially consider diagnostic exam/x-ray of joints to determine if further etiology exists. Considering this pts med history and clinical condition; other med options are more risky than beneficial at this point. I agree careful increase of Tylenol dose to maximum may be appropriate providing it provides further pain relief. I would not go to opioids at this point, it goes against all med pain guidelines, is high risk. Dive further into pts pain scenario and monitor closely for triggers.

    Reply

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Written By Eric Christianson

April 26, 2015

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