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P S
D
MERI HIX
L O
1. Discuss the risk factors and etiology of cataract, glaucoma, macular degeneration, and dry eye.
2. Evaluate the evidence supporting treatment guidelines for vision disorders and pain in elderly patients.
3. Recommend a therapeutic regimen for vision impairment based on appropriateness, efficacy, and adverse
effects.
4.
Discuss how physical impairments, cost, and complex regimens may impact medication adherence in elderly
patients with glaucoma.
5.
Describe strategies for improving communication with patients with vision and hearing impairment.
6.
Describe the etiologies and presentation of persistent pain in elderly patients.
7.
Explain the challenges in assessing and treating pain in elderly patients with or without cognitive impairment.
8. List the classes of medications commonly used to treat nociceptive and neuropathic pain.
9. Discuss common adverse effects of medications that impact treatment decisions in elderly patients with pain.
14
K T D
BREAKTHROUGH PAIN: Acute pain that occurs despite consistent treatment with long-acting analgesia.
DERMATOME: Localized region of skin that is innervated by a single nerve root.
DRUSEN: Yellow or white deposits on the retina that are more common in older patients; correlated with the
risk of developing macular degeneration.
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MACULAR DEGENERATION: Eye disease of the macular retina affecting central vision; classified as either
exudative/neovascular or nonexudative.
NEUROPATHIC PAIN: Pain initiated or caused by a primary lesion or dysfunction in the nervous system.
NOCICEPTORS: Receptors preferentially sensitive to a noxious stimulus or to a stimulus that would become
noxious if prolonged.
PRESBYCUSIS: Bilateral, high-frequency hearing loss that is the most common hearing disorder in older
patients.
PRESBYOPIA: Inability to focus near vision due to decreased lens accommodation.
I
S
ensory deficits in the elderly are a chief
contributor to decreased quality of life. As
vision, taste, smell, and hearing diminish, simple
daily pleasures are reduced. Loss of vision or
hearing is especially difficult and contributes to
increased dependence on others for activities of
daily living. In addition, the sense of touch may
become altered with neuropathy from a variety of
etiologic sources. Pain management is especially
problematic in older adults because of the effects
of analgesic medications on the senses and the
major organ systems. This chapter focuses on
vision and hearing loss, pain management, and
the pharmacotherapy associated with these
disorders.
V H
I
Etiology, Epidemiology, and
Clinical Presentation Specic to
Geriatrics
Visual impairment in geriatric patients is largely
due to age-related changes in the eye that
may be either structural or functional in nature
(Table 14-1).
1
Presbyopia, a functional change,
and increased intraocular pressure, a structural
change, are common with aging. Increased
intraocular pressure is a risk factor for glaucoma.
Another functional change, reduced tear produc-
tion, results in dry eyes, but there may also be
an inflammatory component.
2
Other etiologies
of visual impairment include cataract, macular
degeneration, and diabetic retinopathy.
Visual impairment affects an estimated 3.3
million people in the United States over the age
of 40 and is projected to increase to 5.5 million
(3.6% of the population) in the year 2020.
3
Race,
ethnic group, and age account for differences
in prevalence of low vision and blindness. Cata-
ract is the most common cause of low vision
across ethnic groups, and in African Americans,
cataract is also the leading cause of blind-
ness.
3,4
Macular degeneration and glaucoma
are the leading causes of blindness in white and
Hispanic persons, respectively. Depending on
ethnic group, blindness and low vision is esti-
mated to increase two- to eightfold after age 80.
The etiology of hearing loss falls into two
categories, conductive and sensorineural.
Cerumen impaction, excessive noise, cerebro-
vascular accident, trauma, tumors, ototoxic medi-
cations, and presbycusis are common causes.
1
The prevalence of hearing loss increases with
age. Close to 17% of adults in the United States
report hearing loss.
5
This number increases to
47% in people ages 75 and above. Hearing loss
is common and may go undetected because of
its gradual onset or apprehension on the part of
the patient when admitting impairment.
6
Elderly patients may experience visual
and hearing impairments because of natural
age-related declines, but drug-induced causes
may be present, either due to chronic toxicities
or increased sensitivity to adverse effects. For
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instance, antipsychotic medications have been
associated with cataracts, as has corticosteroid
use in the context of both cataracts and open-
angle glaucoma, whereas anticholinergics and
adrenergics have both been associated with
acute closed-angle glaucoma.
7
Aminoglycoside
antibiotics and nonsteroidal anti-inflammatory
drugs (NSAIDs) are common contributors to
ototoxicity.
Comorbidities also increase risk for visual
issues in older patients. Sjögren’s syndrome,
an autoimmune disease that affects exocrine
glands, increases the risk for dry eye. Diabetes
is the most common cause of retinopathy and a
possible risk factor for cataract and glaucoma.
1,8,9
Functional losses and emotional prob-
lems are consequences of visual and hearing
impairment. Both activities of daily living and
self-administration of medication can become
limited.
10
Depression, social isolation, and cogni-
tive impairment are reported consequences of
declining hearing and vision.
4,10,11
KEY POINT:
Vision and hearing loss
may aect cognitive and psychosocial
function of older adults as well as confound
performance on mental status tests,
leading to inappropriate diagnoses.
Summary of Standard Treatment in
General Adult Population
Management of glaucoma is targeted at
decreasing intraocular pressure and preventing
angle closure. First-line pharmacotherapy for
primary open-angle glaucoma includes topical
beta blockers or prostaglandin analog eye
drops.
9
Prostaglandin analogs appear to be the
most effective initial option but may be more
expensive.
9
Other pharmacotherapeutic options
include topical alpha-2 adrenergic agonists,
topical or oral carbonic anhydrase inhibitors,
and topical parasympathomimetic agents.
Decreasing intraocular pressure in primary
open-angle glaucoma is accomplished by either
decreasing aqueous production or increasing its
outflow. Beta-adrenergic blockers and carbonic
anhydrase inhibitors decrease aqueous humor
production (Table 14-2). Prostaglandin analogs
and cholinergic agents increase outflow of
aqueous humor.
12
Alpha-adrenergic agonists
perform both of these actions. A 20% reduction
of intraocular pressure is often the initial goal of
pharmacotherapy.
9
It is recommended that if one
agent is effective but a target intraocular pressure
has not been reached, then combination therapy
should be used. However, if one agent is ineffec-
tive, an alternative drug class should be used.
9
Table 14-1. Age-Related Eye Changes
Functional Presbyopia
Decreased refractive power
Decreased dark adaptation
Decreased contrast sensitivity
Visual field constriction
Decreased tear production, resulting in dry eyes
Increased difficulty with upward gaze, convergence
Structural Lens enlargement, resulting in narrowing of the anterior chamber angle
Decreased lens translucency, resulting in decreased retinal illumination
Increased lens stiffness and decreased curvature
Rod cell loss
Liquefaction of vitreous gel
Loss of eyelid tone, resulting in entropion or ectropion
Rising intraocular pressure
Source:
Adapted with permission from Lewis T, Warshaw G.
Current Geriatric Diagnosis and Treatment.
©2004.
McGraw-Hill Education, LLC.
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| Fundamentals of Geriatric Pharmacotherapy
Nonpharmacologic approaches to mild
dry eye, such as minimization of medications
and modification of environmental factors that
may worsen dry eye, are recommended.
13
The
common management of dry eyes includes
lubricant and anti-inflammatory eye drops. Lubri-
cant eye drops, gels, or ointments are effective in
both mild and severe disease.
13,14
Preservative-
free tear substitutes are recommended when
they are used frequently.
13
The efficacy of lubri-
cants is limited by short contact time with the
eye. Hypotonic solutions, tear stabilizing mole-
cules, and lipid formulations have enhanced
contact time with the eye and the viscosity and
stability of the tear film.
2
Cyclosporine and corticosteroid eye drops
inhibit inflammation and increase the health of the
ocular surface.
2
With both of these agents, little
systemic absorption occurs, although prolonged
use of topical corticosteroids is not recom-
mended because of minimal efficacy in clinical
trials and increased risk of cataract develop-
ment and elevated intraocular pressure.
2,13
Other
methods to treat dry eyes have been examined
in smaller trials and demonstrate modest benefit.
Table 14-2. Common Treatments that Decrease Intraocular Pressure
in Open-Angle Glaucoma
Class
Medication
Examples
General Adult
Treatment Principles Geriatric Considerations
Beta blockers Timolol
Betaxolol
First-line therapy.
Possible systemic
absorption. Available
in combination with
other agents.
May be difficult to administer. Once
or twice daily dosing improves
adherence. Cautious use with
concomitant disease states such
as depression, bradycardia,
heart block, asthma, and chronic
obstructive pulmonary disease.
Prostaglandin analogs Latanoprost
Travoprost
Bimatoprost
First-line therapy.
Most effective at
lower IOP. Available
in combination with
other agents.
May be difficult to administer. Once-
daily dosing improves adherence.
Fewer adverse effects than beta
blockers. Use may lead to macular
edema or activation of herpes
virus.
Alpha-adrenergic
agonists
Brimonidine
Apraclonidine
Alternative or add-on
therapy. Possible
systemic absorption.
May be difficult to administer.
Frequent dosing will decrease
adherence. Additive effects on
the cardiovascular system may
be more pronounced. Drug-drug
interaction with monoamine
oxidase inhibitors.
Carbonic-anhydrase
inhibitors
Dorzolamide
Acetazolamide
Alternative or add-on
therapy. Available
in combination with
other agents.
May be difficult to administer.
Frequent dosing will decrease
adherence. Acetazolamide given
orally is an easier-to-administer
alternative. Age-related declines
in renal and hepatic function may
lead to increased adverse effects.
Parasympathomimetic
agents
Pilocarpine
Carbachol
Alternative or add-on
therapy. Possible
systemic absorption.
May be difficult to administer.
Frequent dosing will decrease
adherence. Long-term use may
lead to cataract. Cautious use in
patients with Parkinson disease.
IOP, intraocular pressure.
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Oral omega-3 fatty acid supplementation has
resulted in minimal improvement in dry eye in
clinical trials and may be used.
13
Topical or oral
secretagogues and hormone replacement have
been studied or used off-label for dry eye.
2,14
New agents that blunt inflammatory responses
in the eye (e.g., interleukin-1 and T-helper cells)
are currently being studied in clinical trials and
represent new pharmacologic targets in the
treatment of dry eye disease.
15
The treatment for cataract is primarily
surgical. Although many studies have exam-
ined nutritional supplementation, such as beta-
carotene, to reduce the incidence of cataract,
they have been largely unsuccessful.
8
Recom-
mended methods to prevent cataract are
aimed at nonpharmacologic methods, such as
smoking cessation, avoidance of certain medi-
cations that may cause cataract, and reduction
of sun exposure.
For age-related macular degeneration (AMD),
no pharmacologic prevention is recommended,
and treatment depends on the type of AMD, either
wet or dry. Initial treatment of dry, or atrophic, AMD
is reserved until there is intermediate macular
degeneration, evidenced by the presence of
drusen in both eyes, or advanced disease in one
eye, evidenced by drusen and blurred vision.
16
Oral antioxidant vitamin and mineral supplements
that include vitamin C, vitamin E, beta-carotene,
copper, and zinc are the treatments of choice in
mild disease or advanced dry AMD, as deter-
mined by a group of studies undertaken by the
Age-Related Eye Disease Research Group.
16,17
As
beta-carotene has been associated with increased
risk for lung cancer, a smoker’s formulation is avail-
able without this vitamin.
KEY POINT: Use of
eye formulations
consisting of antioxidants and minerals
for prevention of cataract or AMD
is not currently recommended.
When evidence of neovascularization is
present in a patient with AMD, referred to as
wet AMD, treatment with periodic intravitreal
injections of anti-vascular endothelial growth
factor (anti-VEGF) agents ranibizumab, beva-
cizumab, and pegaptanib is currently recom-
mended.
16
Ranibizumab and bevacizumab are
the most recently studied anti-VEGF agents that
reduce angiogenesis in macular degeneration,
although bevacizumab is an older agent that is
used off-label for AMD. They are typically dosed
monthly, but guidelines allow for clinical judg-
ment regarding follow-up treatment, which may
result in less frequent administration. In more
advanced neovascular disease, photodynamic
therapy with verteporfin, an agent that destroys
abnormal blood vessels, may be used.
16
Further
study on newer anti-VEGF therapies such as
aflibercept, combination therapy with different
anti-VEGF agents, or anti-VEGF agents with
photodynamic therapy may reveal new treatment
directions.
Treatment of hearing loss depends on the
etiology. Hearing may be restored if the causes
are treatable, such as cerumen impaction,
seasonal allergies, or a brain tumor. However, in
cases where the cause is irreversible, manage-
ment of the hearing loss with hearing aids, assis-
tive listening devices, or cochlear implants may
be necessary.
1
The decision as to what kind of
aid is most beneficial is the specialty practice of
audiologists.
Review of Evidence Supporting
Treatment Recommendations for
Elderly Patients
The presence of visual impairment increases
with age, emphasizing the importance of follow-
up eye examinations, even in the oldest patients.
Most studies do not specifically evaluate the
results of elderly patients who are enrolled, but
the majority of subjects are typically over the age
of 65, except in glaucoma studies, where the
average age tends to be younger.
Monotherapy with prostaglandin analogs
or beta-adrenergic blockers is recommended
in glaucoma guidelines.
9
Bimatoprost, a pros-
taglandin analog, was compared to twice-daily
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| Fundamentals of Geriatric Pharmacotherapy
timolol in patients with an average age of 60,
ranging up to 90.
18
Once-daily bimatoprost signif-
icantly reduced intraocular pressure compared
with timolol. Twice-daily dosing of bimatoprost
was not more beneficial than once-daily dosing.
Once-daily latanoprost lowered intraocular pres-
sure more than twice-daily timolol in chronic,
closed-angle glaucoma.
19
The average age of
participants was 63. Aside from ocular hypo-
tensive effects, latanoprost showed a significant
improvement in contrast sensitivity compared
with timolol in a study of patients with an average
age of 61, ranging up to 69.
20
A preservative-
free formulation of a prostaglandin analog, taflu-
prost, was compared with twice-daily timolol in a
12-week study.
21
The mean age of subjects was
63. The intraocular pressure lowering of taflu-
prost was noninferior to timolol, but its primary
role is to serve as an alternative treatment for
patients with allergies to preservative-containing
formulations.
Combination therapy is commonly studied
because of the additive effects of two classes
of medications versus monotherapy. A combina-
tion of brimonidine, an alpha-adrenergic agonist,
and timolol demonstrated significantly greater
reductions in intraocular pressure compared
with either agent alone.
22
A study of over 200
patients randomized to either a timolol plus
latanoprost group or timolol plus dorzolamide, a
carbonic anhydrase inhibitor, demonstrated that
the combination with latanoprost significantly
lowered intraocular pressure more than the
dorzolamide combination.
23
A fixed-dose combi-
nation product with brimonidine and brinzol-
amide, a carbonic anhydrase inhibitor, demon-
strated significantly more intraocular pressure
lowering when compared with each agent as
monotherapy.
24
The mean age of patients was
64, but about 50% of patients were over 65.
Using multiple single-agent formulations or fixed-
dose combination products may be an option in
elderly patients who do not achieve adequate
results with monotherapy.
Trials in the management of dry eye disease
are not specific for older patients. One study of
topical cyclosporine demonstrated significant
symptomatic improvement of mild-to-moderate
dry eye and objective improvement in severe
dry eye.
25
These patients ranged in age from 23
to 88, with an average age of 63. Blurred vision,
grittiness, itchiness, and dryness were signifi-
cantly decreased from baseline in cyclosporine
treatment groups compared to a placebo vehicle
in another study, where the mean age of partici-
pants was 60.
26
Objective measures were also
significantly improved. Consumption of omega-3
fatty acids may improve dry eye. In studies
ranging from 30 days to 3 months, the use of
omega-3 fatty acids significantly improved
both subjective and objective measures of dry
eye.
27,28
These studies primarily enrolled younger
patients (mean age of 40), and authors acknowl-
edged that further evaluation of treatment is
necessary. Application to elderly patients may
not be evidence-based, but adverse effects
appear to be minor.
Larger trials of at least 1,000 patients evalu-
ating dietary supplements in cataracts have
included a fair number of patients over 65.
Researchers in the Age-Related Eye Disease
Study (AREDS),
29
the Clinical Trial of Nutritional
Supplements (CTNS),
30
and the Carotenoids
in the Age-Related Eye Disease Study
31
have
investigated antioxidants and multivitamins in
relation to incidence or progression of lens opac-
ities. Investigators in the largest study, AREDS,
29
reported no effect with high doses of vitamin C,
vitamin E, and beta carotene on the develop-
ment of any type of lens opacity. Results of a later
study, CTNS,
30
demonstrated an 18% reduc-
tion of the development or progression of lens
opacities with intake of a multivitamin supple-
ment. There is some evidence to suggest higher
dietary lutein and zeaxanthin may reduce the risk
of developing nuclear cataract.
31
With conflicting
results, pharmacotherapy is not recommended.
Other large studies have demonstrated a
reduced occurrence of age-related macular
degeneration with concurrent intake of vitamins
C and E, beta carotene, copper, and zinc. The
AREDS,
17,32
Blue Mountains Eye Disease Study,
33
and other similar studies of age-related macular
degeneration included 2,400 to 4,170 patients
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with either double-blind,
17
case-control,
32
or
prospective cohort designs.
33,34
The average
age of participants in these trials was at least 65.
Results of 10-year follow-up of the AREDS study
demonstrated a continued significant reduction
in the incidence of advanced AMD, neovascular
AMD, and moderate vision loss.
35
Higher dietary or supplemental intake of
lutein, zeaxanthin, and zinc with or without other
vitamins or antioxidants (vitamins C and E and
beta carotene) reduced incidence of advanced
AMD.
17,34
Although some initial evidence
suggested lutein and zeaxanthin decreased risk
of developing AMD, newer studies contradict
this. Over 1,600 patients with an average age
of 74 were enrolled in a follow-up to the AREDS
study, the AREDS2 study.
36
They took the orig-
inal or reformulated AREDS supplement and
were randomly assigned to receive a combina-
tion of lutein plus zeaxanthin, omega-3 fatty
acids (docosahexaenoic acid plus eicosapen-
taenoic acid), both, or placebo.
37
Although all
patients were at risk for worsening AMD, there
was no significant reduction in the incidence of
advanced AMD with these additional agents.
Treatment with vascular endothelial growth
factor inhibitors has been studied for more
advanced macular degeneration. In patients with
an average age of 77, ranibizumab decreased
neovascularization and improved or maintained
visual acuity in over 90% of patients compared
to 62% or less in the control group.
38
In a pair of
rigorous studies comparing bevacizumab with
ranibizumab, where the average age of partici-
pants was at least 78, changes in visual acuity
were assessed to be noninferior, although some
results were inconclusive.
39,40
Preservation of
visual acuity has also been reported in patients
with mean ages of 75 to 77 treated with pegap-
tanib.
41
These studies demonstrate lasting effect
with continued treatment over a 2-year period.
The ideal administration schedule of these injec-
tions is unclear. Whether injections should be
given on a monthly basis or given as needed
based on objective worsening of AMD has been
studied, but data have not produced clear and
convincing results.
Common Problems Encountered
When Treating Elderly Patients
with ese Conditions
Eye drop containers may be difficult to handle for
an elderly person trying to administer the solu-
tion. Older patients, especially those with lower
visual acuity, have greater difficulty opening and
administering eye drops than younger patients.
42
In one study, 42% of patients were observed
to have difficulty with instilling eye drops.
43
The
pharmacist should instruct patients on proper
administration technique, which includes pulling
down the lower eye lid with one hand and
steadying the other hand that is holding the bottle
against the forehead. To prevent some systemic
absorption, the patient should apply pressure on
the tear duct in the corner of the eye after admin-
istration of eye drops. Mobility impairments,
such as tremor, arthritis, or paralysis, also make
it difficult for patients to administer these medi-
cations. There are aids to help with squeezing
and holding bottles so that placement of eye
drops is accurate. The pharmacist has a unique
opportunity in the community setting to assess a
patient’s ability to self-administer eye drops. In
settings where eye drops are administered by
a healthcare professional, such as a long-term
care facility, the pharmacist should periodically
observe administration technique by the patient
and/or nursing staff.
KEY POINT:
Instillation of eye drops
is a dicult task for older patients who
require aids and innovative techniques
for sucient administration.
Eye drops for the treatment of glaucoma
range in the frequency of dosing, and adher-
ence to therapy may be directly related to the
complexity of dosing.
9
Some require only once-
daily dosing, such as prostaglandin analogs,
while others require three-times-daily dosing,
such as brimonidine monotherapy. If dual
therapy is required, the patient is required to
wait between the administrations of two separate
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| Fundamentals of Geriatric Pharmacotherapy
agents. The option of using fixed-dose combi-
nation products is convenient for patients who
could benefit from more than one class of medi-
cation.
Cost may also be an issue with some treat-
ments for visual impairment. For primary open-
angle glaucoma, prostaglandin analogs are
more effective at lowering intraocular pressure
than other agents and are typically chosen as
initial therapy.
9
If a patient can tolerate this drug
class, then additional therapies may not be
needed, thereby reducing drug costs. In AMD,
medical costs are increased because treat-
ments require an ophthalmologist for administra-
tion. Although bevacizumab for the treatment of
neovascular AMD is an older anti-VEGF agent
and less expensive, it is used off-label and may
not be paid for by insurance.
16
Elderly patients with visual impairment may
rely on caregivers to perform or communicate
tasks required for daily living and medical care.
However, many patients want to maintain inde-
pendence. Strategies for effective communica-
tion with patients with vision loss include the use
of corrective lenses, magnifying aids, large-print
written material, and adequate lighting.
44
Communication can be challenging with
someone who has hearing loss. An individual
with presbycusis needs extra time to process
what has been said. Speech should be clear and
louder than normal but not necessarily slower.
45
A quiet place, free from extraneous background
noise, in close proximity, directly face-to-face
with the patient will improve communication.
1
Asking the patient to repeat information will help
identify whether key concepts have been under-
stood. Rephrasing to less complicated and
shorter sentences, pausing between sentences,
and using written communication are all strate-
gies to better communicate if the first attempt is
unsuccessful.
1,45
A potentially under-recognized compli-
cation of hearing and vision loss is the misla-
beling of a patient as cognitively impaired or
depressed. Assessment tests for cognition
often rely on both adequate hearing and vision,
and those with impairments may not perform
well.
46
In social situations, patients with hearing
or vision loss may attempt to compensate for
misunderstanding information with an inappro-
priate response, or no response. A noted corre-
lation with decreased hearing or vision is social
isolation, depression, and cognition decline.
4,10,46
In patients with hearing loss, the use of a hearing
aid may improve cognition and mood.
47,48
KEY POINT:
Many patients with hearing
impairment rely on lip reading and facial
gestures, and exaggerated enunciation or
slowed speech impairs this process.
P
Etiology, Epidemiology, and
Clinical Presentation Specic to
Geriatrics
Pain is a subjective sensation that often serves
as a signal of potential or actual damage to nerve
fibers. Pain is classified by its onset, duration, or
etiology. Acute injury or sudden onset of pain
defines acute pain. Chronic, or persistent, pain
may be initiated by an acute injury but has lasted
beyond the normal healing time. Persistent pain
may also arise from chronic diseases, cancer, or
unknown causes and include both nociceptive
and neuropathic features.
Nociceptive pain is initiated by thermal,
electrical, or mechanical impulses that stimulate
nerve fibers, called nociceptors. This type of pain
may be less severe in older patients because of
age-related changes in nerve fibers, but modu-
lation of persistent pain may be impaired due to
age-related declines in neurotransmitter produc-
tion.
49
Neuropathic pain is often associated with
conditions such as diabetic peripheral neurop-
athy, postherpetic neuralgia, phantom limb pain
after amputation, and central post-stroke pain. It
also arises from persistent, nociceptive pain.
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Regardless of etiology, neuropathic pain
is often characterized by a burning, buzzing,
stinging, shock-like, or deep aching pain or
discomfort. The location of symptoms may vary.
Peripheral diabetic neuropathic pain is bilateral
and symmetrical, usually affecting the lower
limbs.
50
Postherpetic neuralgia occurs asym-
metrically along a dermatome, typically weeks
to months after onset of rash.
51
Despite adequate treatment, incidents of
acute pain, or breakthrough pain, may occur.
Causes of breakthrough pain include end-of-
dose failure, when analgesia wanes before the
next dose is scheduled; incident pain, when
movement provokes pain; and spontaneous
pain.
52
In residents of long-term care facilities,
prevalence of pain ranges from about 50 to
80 percent.
53
The most common type of pain
reported in older patients is musculoskeletal.
Neuropathic pain represents 10% of all pain,
but prevalence increases with age.
54
Peripheral
diabetic neuropathic pain affects close to 25%
of all patients with diabetes.
55
Post-stroke pain
affects 21% of patients after the first stroke.
56
Inadequately treated pain in the elderly popula-
tion leads to depression, anxiety, sleep distur-
bance, decreased quality of life, and reduced
independence in daily living.
52,57
Assessment of the presence and severity of
pain can be difficult in elderly patients. Reluc-
tance to admit pain may be for cultural or social
reasons. The most common methods of assess-
ment are visual analog scales; numerical rating
scales; verbal descriptor scales; or faces scales
comprised of simple drawings of faces depicting
varying levels of discomfort as described in
Chapter 4. These scales may be used reliably
in patients who are cognitively intact. The faces
scale has demonstrated utility in patients with
cognitive impairment. However, patients with
advanced dementia may not express pain and
will instead display behaviors such as aggres-
sion, irritability, groaning, rigidity, altered facial
expressions, changes in eating patterns, or
social withdrawal.
49,52
Summary of Standard Treatment in
the General Adult Population
The experience of pain is subjective, and a
systematic approach to assessment is needed
to create a successful treatment plan. Before
pharmacologic treatment begins, patients may
need to be evaluated for risk of substance abuse,
especially if opioids are to be used.
58
Pain level,
quality of life, mood, and sleep quality are evalu-
ated to assess treatment efficacy in patients
with persistent pain. Safety is also evaluated by
noting adverse effects, drug interactions, and
pharmacokinetic and pharmacodynamic param-
eters. Nociceptive pain can be successfully
treated with typical analgesics, such as acet-
aminophen, NSAIDs, and opioids. Neuropathic
pain is less predictably responsive to these anal-
gesics. Alternative classes, or adjuvant drugs,
such as antidepressants, antiepileptic drugs,
and topical agents, have demonstrated efficacy
in neuropathic pain.
The World Health Organization describes
a step-wise approach to the management of
cancer pain, which is often extended to other
types of pain.
59
The American Pain Society and
American Academy of Pain Medicine suggest
that opioids for chronic, noncancer pain be
initiated on a trial basis to determine benefit.
58
The pharmacologic approaches described
in these guidelines are largely based on
consensus expert opinion, knowledge of drug
action, and presentation of the disease. A
cautious approach is generally recommended,
such as using nonopioid analgesics in mild
pain and low doses of opioids in opioid-naive
patients. Opioid analgesics are recommended
as pain persists. Scheduling doses or using
long-acting agents will provide more consis-
tent pain relief. Short-acting opioids with a fast
onset should be added for breakthrough pain,
as needed. Titration to higher doses of long-
acting agents should be based on the usage
of as-needed doses. At any pain level, skeletal
muscle relaxants, benzodiazepines, or other
adjuvant drugs used for neuropathic pain are
recommended.
59
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| Fundamentals of Geriatric Pharmacotherapy
Specific expert consensus guidelines are
also available for knee osteoarthritis pain. For
all patients, intra-articular corticosteroids are
recommended to complement nonpharmaco-
logic therapies, such as weight training.
60
Other
pharmacologic agents frequently recommended
include acetaminophen, oral and topical
NSAIDs, capsaicin, and duloxetine.
KEY POINT:
Dierent opioids
have similar ecacy and adverse eects
when used in equipotent doses.
U.S. consensus guidelines and literature
reviews for the treatment of diabetic peripheral
neuropathic pain and postherpetic neuralgia
describe the general approach for management
of neuropathic pain.
61,62
Pharmacologic treat-
ment includes the use of tricyclic antidepres-
sants, serotonin-norepinephrine reuptake inhibi-
tors, antiepileptic drugs, opioids, and topical
lidocaine or capsaicin (Table 14-3). General
approaches to therapy include initiating at low
doses, slow titration to an effective dose to
avoid excessive adverse effects, switching to a
different class if monotherapy fails, and addition
of a different class if monotherapy demonstrates
suboptimal efficacy. Efficacy of these treat-
ments may take several weeks, and a change
in therapy should not be considered until an
adequate amount of time has passed.
KEY POINT:
Combination therapy with
analgesics and adjuvant drugs may be necessary
to eectively manage persistent pain.
Review of Evidence Supporting
Treatment Recommendations for
Elderly Patients
The American Geriatrics Society provides
guidelines for the assessment and treatment
of persistent pain in the geriatric population.
39
Two follow-up guidelines specifically address
pharmacologic management, outlining use of
nonopioid and opioid analgesics.
63,64
In general,
studies of the treatment of persistent pain are
varied with regard to underlying etiologies,
pharmacotherapy, and length, and very few are
conducted in elderly patients.
Initial treatment of musculoskeletal pain
with acetaminophen is recommended.
51
NSAIDs
should be reserved because of the high risk of
causing gastrointestinal bleeding, renal dysfunc-
tion, hypertension, and heart failure. Two studies
providing evidence for the treatment of chronic
osteoarthritis pain with acetaminophen in older
adults used 3.9–4 g for periods as long as 12
months.
65,66
The mean age of subjects was about
60 years but ranged as high as 90. Patients in
both studies reported significant improvement in
pain scores, but in one study, 1.9% of patients
had clinically significant elevations in hepatic
transaminases in the treatment arm.
62,65
Opioids
are recommended for moderate-severe pain,
and doses should be scheduled around the
clock for frequent or persistent pain.
52,63,64
These
recommendations are based on expert opinion,
pharmacokinetic and pharmacodynamic data,
and extrapolation of results from adult patients.
64
A weakness of many studies is that efficacy and
safety data specific to elderly participants are
lacking. One placebo-controlled study evaluated
controlled-release oxycodone in 133 subjects
with osteoarthritis (average age 62 years with
43% of patients ≥65).
67
Although this was only a
2-week trial, a clinically meaningful pain reduction
(20%) from baseline was achieved within 1 day
for the 10-mg arm and 2 days for the 20-mg arm.
Statistically significant improvements in mood,
enjoyment of life, and sleep when compared
with placebo were evident in the 20-mg arm.
However, over one-half of the patients withdrew
participation, primarily due to adverse effects
and dose-related ineffectiveness.
The use of adjuvant drugs in the treatment of
neuropathic pain is recommended in guidelines
for elderly patients.
63
A caution against the use of
the tricyclic antidepressants amitriptyline, imip-
ramine, and doxepin is detailed in the guidelines,
owing to adverse effects. In the 2012 update of
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