Dialogue Volume 13 Issue 4 2017 - Page 49

PRACTICE PARTNER Opioids and the Elderly: Care and Caution Needed Much room for improvement in managing pain for seniors By Stuart Foxman I t started with a fall. From the day a 71-year-old woman was admitted to long- term care, she was complaining about lingering pain. Staff contacted the physician she had seen in emergency, and her medication was adjusted. Instead of 4 mg of hydromorphone per day (usually in doses of 1 mg), the woman was put on 3 mg every two hours as needed. Then her order changed again, to hydromorphone contin 12 mg twice a day, along with hydromorphone for breakthrough pain. When she became unresponsive to verbal stimula- tion, her skin clammy and slightly pale, the woman was transported to hospital. In emergency, she was treated with two doses of naloxone with some sponta- neous improvement. But she remained unresponsive and died soon after. It was just eight days after she had gone into long-term care. Dr. Ramesh Zacharias, a Coroner who serves on the province’s Geriatric and Long-Term Care Death Review Committee, says that while the death is upset- ting, unfortunately, the circumstances are not shock- ing. “Any opioids can be a problem,” he says. “There’s a lack of training in pain management, and more so for pain management in the elderly. We don’t do a good job.” Dr. Zacharias is also Medical Director at the Michael G. DeGroote Pain Clinic, Hamilton Health Sciences. Opioid use, misuse and abuse have become a flashpoint in medicine. Over the last several months, we have looked at different facets of the issue in Dialogue. We continue the focus by looking at the impact of opioids on the elderly. Special Challenges in the Elderly Pain is the most frequently reported symptom by older persons. Research has also identified that up to 80% of elderly living in institutionalized settings experience persistent pain. The presence of pain in the elderly is associated with ongoing medical conditions including osteoarthritis, diabetes, low back pain, and peripheral vascular disease. At the same time, older adults have multiple conditions – both chronic and/or acute – that may result in suffering from multiple types of and sources of pain. The impacts of pain on an older person’s well-being are diverse and multiple, interfer- ing with daily functioning, mobility, mood, sleep, appetite, and social activities. Pain management can be tough at the best of times. The right assessments and follow-ups are always critical. Treating the elderly with opioids only adds complexities. For example:  pioids (like other drugs) are metabolized and cleared O differently with age. ISSUE 4, 2017 DIALOGUE 49