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NSAIDs are widely prescribed, and frequently efficacious, in the acute care
setting. NSAIDs are particularly effective in ameliorating pain from a variety of
inflammatory conditions, including rheumatologic disorders often encountered
in the elderly. However, it is well known that NSAID use, even in healthy
younger adults, risks renal and gastrointestinal side effects. Older patients’
physiology and associated alterations in drug pharmacokinetics and pharmacodynamics
compound NSAID-associated risks.
Though the reasons for NSAID risk in geriatric patients are myriad, major
contributing risks include concomitant use of steroids or anticoagulants. The
combination of NSAIDs with either of these medication classes substantially
increases the chance of peptic ulcer disease complications, including bleeding.
13 Older age also increases the risk of NSAID-related renal disease. 26
NSAID-mediated sodium retention is a particular concern in elder patients,
as hypertension and congestive heart failure exacerbation can result. In fact,
use of NSAIDs (indomethacin and piroxicam in particular) appears to result
in a systolic blood pressure elevation of approximately 5 mmHg in geriatric
patients. 27 NSAID-related congestive heart failure risk from renal impairment
and sodium retention is further increased by water retention, increased
peripheral vascular resistance, and antagonism of beta-blocker effects. 28
Whereas NSAIDs are characterized by a ceiling analgesic effect, risks of
adverse effects continue to rise as doses are increased. 29 Therefore, especially
for severe pain, increasing the NSAID dose beyond recommended levels serves
only to increase adverse effect risk without improving analgesic benefit. For
those instances where NSAIDs are used in the elderly, the lowest possible dose
should be administered for the shortest reasonable duration, and vigilance for
complications must be assured both in the ED and upon follow-up.
n Opioids
Geriatric analgesia 47
Opioid selections for moderate (e.g. hydrocodone) or severe (e.g. morphine)
pain in the elderly are generally similar to those for younger adults. As a
guiding principle, “start low and go slow,” is a prudent approach to prescribing
opioids to the elderly. As long as appropriate pain reassessment is performed,
instituting opioid therapy with low doses optimizes both safety and efficacy.