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46 Geriatric analgesia
Analgesic approaches associated with risk in geriatric patients 24
Drug Concerns with use in older patients
Opioids
Meperidine Confusion; disadvantages compared with
other opioids
Pentazocine Compared with other opioids, higher
incidence of CNS side effects
Propoxyphene Incurs opioid risks, with minimal (if any)
analgesic benefit over acetaminophen
monotherapy
NSAIDs
General concerns GI ulcers; asymptomatic/unknown renal
disease (prevalent in elderly)
Indomethacin More CNS adverse effects than other NSAIDs
Benzodiazepines
Longer-acting agents (e.g. diazepam) Extended half-life (days); prolonged
sedation and fall/fracture risk
Shorter-acting agents (e.g. lorazepam) High sensitivity to these agents; syncope/
fall risk; impaired psychomotor function;
efficacy and safety optimized by use of
smaller doses
Non-benzodiazepine muscle relaxants
(e.g. cyclobenzaprine)
Anticholinergic effects, sedation, and
weakness
n First-line analgesia: acetaminophen
and NSAIDs
In geriatric patients as in other populations, first-line analgesia for mild-tomoderate
pain should usually entail non-opioids. For the elderly, acetaminophen
isthedrugoffirstchoice.Acetaminophen’s potential amplification
of warfarin’s anticoagulant effects has been mentioned, but even this is
subject to debate, and there are no other major drug interactions of concern
with acetaminophen. 25 Although acetaminophen should be used with caution
in patients with hepatic disease, the overall safety profile of the drug is
preferable to that of the main alternative, NSAIDs.