Wilder-Smith Oliver H G
Pain Knowledge Centre, Department of Anaesthesiology, Radboud University Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
Eur J Pain. 2005 Apr;9(2):137-40. doi: 10.1016/j.ejpain.2004.07.011.
Pain treatment in the elderly is an important challenge to Western societies due to increasing numbers of old persons, their higher incidence of pain, and their greater susceptibility to adverse effects of pain medication. We provide an overview of the factors liable to influence opioid action in the elderly population. A major challenge for the physician prescribing opioids in the elderly is their greater risk of medication-associated problems. Thus, older patients suffer increased vulnerability to adverse drug effects and interactions, higher rates of polypharmacy, and more comorbidity. These problems are compounded by a relative lack of definitive published information. There is clearly a need for more research in this area. Aging affects opioid pharmacokinetics via altered body composition (distribution volumes) and organ function (liver=metabolism, kidney=excretion). Pharmacodynamics is affected via impaired neurotransmitter/peptide production and changed receptor affinities/populations. Older women may need less morphine analgesia postoperatively, while pain sensitivity tends to increase particularly in older men. However, the net effects of changes in opioid pharmacology with age on clinical opioid analgesia remain unclear, probably due to the significantly greater variability in body function with increasing age. Practical recommendations for opioid prescription in the elderly include meticulous review of indication for opioid use, not only initially but also at regular intervals thereafter. A policy of careful titration should be followed, with conservative choice of dosage on starting. Dosing intervals may need to be lengthened subsequently. Finally, it should be remembered that old persons do not necessarily need less opioid than younger ones.
由于老年人数量不断增加、疼痛发生率较高以及他们对止痛药不良反应的易感性更强，老年人的疼痛治疗对西方社会而言是一项重大挑战。我们概述了可能影响老年人群体中阿片类药物作用的因素。老年患者开具阿片类药物时，医生面临的一个主要挑战是他们发生药物相关问题的风险更高。因此，老年患者更容易受到药物不良反应和相互作用的影响，多重用药率更高，合并症更多。这些问题因缺乏明确的已发表信息而更加复杂。显然，这一领域需要更多研究。衰老通过改变身体成分（分布容积）和器官功能（肝脏代谢、肾脏排泄）影响阿片类药物的药代动力学。药效学受到神经递质/肽产生受损以及受体亲和力/数量变化的影响。老年女性术后可能需要较少的吗啡镇痛，而疼痛敏感性往往会增加，尤其是老年男性。然而，随着年龄增长阿片类药物药理学变化对临床阿片类镇痛的总体影响仍不清楚，这可能是由于随着年龄增长身体功能的变异性显著增加。老年患者阿片类药物处方的实用建议包括不仅在最初而且在此后定期仔细审查阿片类药物使用的适应证。应遵循谨慎滴定的原则，开始时保守选择剂量。随后可能需要延长给药间隔。最后，应该记住，老年人不一定比年轻人需要更少的阿片类药物。
