Acute Postoperative Pain Management in the Older Patient

Thor Hallingbye; Jacob Martin; Christopher Viscomi


Aging Health. 2011;7(6):813-828. 

In This Article

Pain Experience in the Older Adult

The pain experience in older persons is likely different from that in younger counterparts. Many factors contribute to this phenomenon. Pain-transmitting C and Aδ peripheral nerve fiber function declines progressively with age.[6] Conditions that normally cause pain in earlier adulthood may be perceived differently by older adults. Two life-threatening examples include myocardial infarction and duodenal ulcers, which may cause little-to-no pain.[29] There is a common belief among providers that older persons experience less pain or have higher pain tolerance than the young. This is thought to be due to the misconceptions that pain is a normal part of aging, pain perception decreases with age, older people who do not complain of pain are not in pain, and pain reports may be a way of seeking attention.[22,25] Older adults themselves may in fact believe that pain is something to be tolerated because it is an inevitable part of aging and may show increased stoicism when reporting pain.[2,22,25,30] Postoperative pain has been reported to be less in older persons and diminish with time.[31] Experimental pain threshold, the point at which pain is first felt, is likely slightly higher. However, pain tolerance, the maximum pain level endured, is probably reduced. In older patients with dementia, pain threshold and pain tolerance may be higher.[32,33] The sum of these results may or may not be clinically significant.[6]

Sex-related differences likely exist in gonadal hormone-producing adults, with women experiencing lower pain threshold and lower pain tolerance compared with men.[34] However, men and women appear to respond to opioid and nonopioid analgesics in a similar manner.[35] Any sex-related differences in pain experience tend to disappear as people age, particularly after the menopause.[36]

In cognitively impaired individuals, pain management can be more challenging. Assessment of pain is likely better with a behavioral pain scale, but this can be time consuming. Degree of cognitive impairment influences the amount of analgesics given to older patients postoperatively.[20] This predisposes these patients to undertreatment, which can lead to worsened cognitive function.[37] It can also limit mobilization, which can lead to hypercoagulation, ileus and respiratory complications.[30] Treatment of pain with opioids, unfortunately, can result in delirium. With the exception of meperidine, no significant increased risk has been demonstrated between opioids for development risk of POD and POCD.[18] The use of meperidine is generally advised against.


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