1
Aging Q3 Pain Management ACOVE Pharmacological
treatment with analgesics for pain is the most
common in the elderly, however, the use of
alternative medications and non-pharmacological
interventions should also be considered.
Treatment decisions require continuous weighing
of risks and benefits. (Etzioni, et al. JAGS 2007
55S403-S408)

•  
• Nociceptive
• Neuropathic
• Peripheral sensitization
• (hyperalgesia, allodynia)
• Central sensitization (NMDA)
• Desensitization (tolerance)
• Disinhibition (GABA)
•  

Mechanisms of Chronic Pain
NON-OPIOID TREATMENT OPTIONS (ADJUVANTS) FOR PAIN IN THE ELDERLY NON-OPIOID TREATMENT OPTIONS (ADJUVANTS) FOR PAIN IN THE ELDERLY NON-OPIOID TREATMENT OPTIONS (ADJUVANTS) FOR PAIN IN THE ELDERLY
Drug Description Comments/Side Effects
Acetaminophen First-line agent for patients with OA and patients with mild to moderate pain. Limit dose in elderly. Avoid combining with opioids.
Anticonvulsants Primarily in neuropathic pain (carbamazepine divalproex, gabapentin, pregabalin, topiramate) Carbamazepine blood dyscrasias, Gabapentin/ Pregabalin Ataxia, dizziness, somnolence
Antidepressants TCAs, SNRIs Start low dose,increase slowly Anticholinergic side effects of TCAs BP effects of SNRIs
Local Anesthetics Lidocaine patches Capsaicin Lidocaine may apply up to 3 patches q 12 hours Capsaicin burning pain intolerable by some patients.
NSAIDS Avoid in elderly if possible (AGS) Cox-2 probably OK. Avoid combining with opioids
Tramadol Start low dose, increase slowly Drowsiness, nausea, constipation May not be best option for patients on antidepressants
Muscle Relaxants Cyclobenzaprine, Carisoprodol Avoid in elderly if possible (AGS) Anticholinergic side effects, arrhythmias

• Level 3 (Severe pain)
• strong opioids morphine, hydromorphone,
  fentanyl, oxycodone /- adjuvants
• Level 2 (moderate to severe pain)
• acetaminophen plus opioid (hydrocodone, codeine,
  oxycodone) tramadol /1 adjuvants
• Level 1 (mild to moderate pain)
• acetaminophen, aspirin, NSAIDS (cox-2) /-
  adjuvants
•  http//www.geriatricpain.org/Content/Management/I
  nterventions/Documents/WHO20ladder.pdf

•  
• Nausea and vomiting (central)
• Delayed gastric emptying
• Constipation
• Hypotension
• Myoclonus
• Respiratory depression
• CNS
• GU
• Pruritus
•  

WHO Ladder
Opioid Side Effects
Equianalgesic Doses of Opioid Analgesics Used for
the Control of Pain
http//www.musc.edu/pharmacyservices/medusepol/Opi
oidAnalgesicConversionChart.pdf