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