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Geriatric patients may not experience increased risk of oligoanalgesia in the emergency department

ResearchBlogging.org

The current Annals of Emergency Medicine has an editorial and two studies of pain management in older adults.

One study is a 10-year prospective, observational study of a convenience sample of patients who had pain on presentation to the ED. Over 10 years any Hawthorne effect can be expected to wear off. Over a decade a lot can change, especially with the ways that pain management has progressed.

Exclusion criteria included patients younger than 18 years, patients with a critical illness, or patients meeting criteria for trauma designation.[1]

It would be nice to know how many patients were affected by the trauma exclusion.

Advanced age significantly affects trauma triage decisions. If trauma patients had been included, would this be likely to show a significant difference in either direction?


Click on images to make them larger.

There is a big difference in chest pain, but that does not appear to alter the results.

Patient information was collected 7 days a week, between 8AM and midnight, during the 10-year period.[1]

Hence, a convenience sample.

Opiate analgesia was defined as any oral, intramuscular, or intravenous opioid medication, including morphine, hydromorphone, acetaminophen with oxycodone, and acetaminophen with codeine, administered in the ED. Morphine dose was calculated only for intravenous administration of morphine.[1]

Acetaminophen with codeine for moderate to severe pain? I have not seen that used much, but I have never seen it improve the patient’s pain rating. It would be nicer if they had fewer drug variables.

After multivariable adjustment for sex, race, chief complaint, and the degree of pain at presentation, the geriatric patients on average received lower doses of morphine (3.3 versus 4.2 mg) and had longer waiting times for their initial dose of analgesic medication (65 versus 75 minutes).[1]

The lower dosing of morphine is to be expected in older patients. We are advised to decrease dosing in older patients.

I start at about half of what I would for a young, otherwise healthy patient, but that is an important difference – otherwise healthy. The increased age is not always the most important factor limiting doses. Many of these patients will have illnesses that affect the metabolism of opioids, illnesses that may produce exaggerated side effects when opioids are given (such as COPD), illnesses that are treated with medications that interact with opioids, and other co-morbid complications.

This does not mean that we should not use opioids, but that we should start with lower doses and/or consider using other medications.
 

The range of morphine doses is much narrower in older patients. Is this due to a difference in comfort level with repeat dosing?

The doses of morphine are smaller in older patients, too.

Are these differences due to more appropriate caution, more inappropriate caution, more successful pain management, or something else?

We excluded patients with comprehension barriers, including dementia or delirium. So our results are limited to a nondemented, nondelirious patient group, which means that oligoanalgesia in demented, delirious patients is still a possibility.[1]

This is a group of patients that my protocols prohibit me from treating on standing orders.


Protocol limitation source.[2]

Are disoriented patients going to receive more aggressive care in the ED?

Is there any good reason to not treat the pain of disoriented patients?

Maybe, but that depends on what is going on.

Is the patient not fully oriented because the patient is truly having 10 out of 10 pain?[3]

Footnotes:

[1] Geriatric patients may not experience increased risk of oligoanalgesia in the emergency department.
Cinar O, Ernst R, Fosnocht D, Carey J, Rogers L, Carey A, Horne B, Madsen T.
Ann Emerg Med. 2012 Aug;60(2):207-11.
PMID: 22818367 [PubMed – in process]

[2] Musculoskeletal Trauma 6003 and Burns 6071
Pennsylvania Statewide Advanced Life Support Protocols
7007 – ALS – Adult/Peds
Page 73/128 and Page 80/128
Free Full Text PDF of All ALS Protocols

[3] Is It Possible To Be Alert And Oriented With 10/10 Pain – Part I
Rogue Medic
Thu, 01 Mar 2012
Article

Cinar O, Ernst R, Fosnocht D, Carey J, Rogers L, Carey A, Horne B, & Madsen T (2012). Geriatric patients may not experience increased risk of oligoanalgesia in the emergency department. Annals of emergency medicine, 60 (2), 207-11 PMID: 22818367

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Comments

  1. One thing that interests me is that, as some older patients are already taking regular opioids for chronic pain, for them the dosage should be increased in order to get the same effect. I’m guessing that there are studies on that.

    When I was working for London ambulance the upper dose of IV morphine we could give was 20mg. And I think it was only limited to that because we were to only draw out two 10mg ampules. I may be wrong – it was a fair time ago.

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