Pautex Sophie, Vogt-Ferrier Nicole, Zulian Gilbert B
Community Palliative Care Unit, Division of Primary Care, Department of Community Medicine and Primary Care, Geneva University Hospitals, Geneva, Switzerland.
Drugs Aging. 2014 Jun;31(6):405-11. doi: 10.1007/s40266-014-0181-5.
The prevalence of pain is high in the elderly and increases with the occurrence of cancer. Pain treatment is challenging because of age-related factors such as co-morbidities, and over half of the patients with cancer pain experience transient exacerbation of pain that is known as breakthrough pain (BTP). As with background pain, BTP should be properly assessed before being treated. The first step to be taken is optimizing around-the-clock analgesia with expert titration of the painkiller. Rescue medication should then be provided as per the requested need, while at the same time preventing identified potential precipitating factors. In the elderly, starting treatment with a lower dose of analgesics may be justified because of age-related physiological changes such as decreased hepatic and renal function. Whenever possible, oral medication should be provided prior to a painful maneuver. In the case of unpredictable BTP, immediate rescue medication is mandatory and the subcutaneous route is preferred unless patient-controlled analgesia via continuous drug infusion is available. Recently, transmucosal preparations have appeared in the medical armamentarium but it is not yet known whether they represent a truly efficient alternative, although their rapid onset of activity is already well recognized. Adjuvant analgesics, topical analgesics, anesthetic techniques and interventional techniques are all valid methods to help in the difficult management of pain and BTP in elderly patients with cancer. However, none has reached a satisfying scientific level of evidence as to nowadays make the development of undisputed best practice guidelines possible. Further research is therefore on the agenda.
疼痛在老年人中普遍存在，且随着癌症的发生而增加。由于并存疾病等与年龄相关的因素，疼痛治疗具有挑战性，超过一半的癌症疼痛患者会经历疼痛的短暂加剧，即爆发性疼痛（BTP）。与背景疼痛一样，BTP在治疗前应进行适当评估。首先要采取的步骤是通过专家滴定止痛药来优化全天候镇痛。然后应根据所需需求提供急救药物，同时预防已确定的潜在诱发因素。在老年人中，由于与年龄相关的生理变化，如肝肾功能下降，以较低剂量的镇痛药开始治疗可能是合理的。只要有可能，在进行疼痛操作之前应提供口服药物。对于不可预测的BTP，必须立即使用急救药物，除非有通过持续药物输注的患者自控镇痛，否则首选皮下途径。最近，透粘膜制剂已出现在医疗手段中，但尽管其起效迅速已得到充分认可，但尚不清楚它们是否是一种真正有效的替代方法。辅助镇痛药、局部镇痛药、麻醉技术和介入技术都是帮助管理老年癌症患者疼痛和BTP的有效方法。然而，目前尚无达到令人满意的科学证据水平，以至于无法制定无可争议的最佳实践指南。因此，进一步的研究已提上日程。
