Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK.
Library and Knowledge Service, North Bristol NHS Trust, Bristol, UK.
Drugs Aging. 2023 Oct;40(10):869-880. doi: 10.1007/s40266-023-01052-2. Epub 2023 Aug 11.
In the context of an ageing population, the demographic sands of trauma are shifting. Increasingly, trauma units are serving older adults who have sustained injuries in low-energy falls from a standing height. Older age is commonly associated with changes in physiology, as well as an increased prevalence of frailty and multimorbidity, including cardiac, renal and liver disease. These factors can complicate the safe and effective administration of analgesia in the older trauma patient. Trauma services therefore need to adapt to meet this demographic shift and ensure that trauma clinicians are sufficiently skilled in treating pain in complex older people. This article is dedicated to the management of acute trauma pain in older adults. It aims to highlight the notable clinical challenges of managing older trauma patients compared with their younger counterparts. It offers an overview of the evidence and practical opinion on the merits and drawbacks of commonly used analgesics, as well as more novel and emerging analgesic adjuncts. A search of Medline (Ovid, from inception to 7 November 2022) was conducted by a medical librarian to identify relevant articles using keyword and subject heading terms for trauma, pain, older adults and analgesics. Results were limited to articles published in the last 10 years and English language. Relevant articles' references were hand-screened to identify other relevant articles. There is paucity of dedicated high-quality evidence to guide management of trauma-related pain in older adults. Ageing-related changes in physiology, the accumulation of multimorbidity, frailty and the risk of inducing delirium secondary to analgesic medication present a suite of challenges in the older trauma patient. An important nuance of treating pain in older trauma patients is the challenge of balancing iatrogenic adverse effects of analgesia against the harms of undertreated pain, the complications and consequences of which include immobility, pneumonia, sarcopenia, pressure ulcers, long-term functional decline, increased long-term care needs and mortality. In this article, the role of non-opioid agents including short-course non-steroidal anti-inflammatory drugs (NSAIDs) is discussed. Opioid selection and dosing are reviewed for older adults suffering from acute trauma pain in the context of kidney and liver disease. The evidence base and limitations of other adjuncts such as topical and intravenous lidocaine, ketamine and regional anaesthesia in acute geriatric trauma are discussed.
在人口老龄化的背景下，创伤领域的人口统计学状况正在发生变化。越来越多的创伤单位开始收治因从站立高度跌倒而受伤的老年患者。年龄增长通常与生理变化相关，同时还会增加衰弱和多种合并症的患病率，包括心脏病、肾病和肝病。这些因素可能会使老年创伤患者的镇痛治疗变得复杂。因此，创伤服务需要进行调整以适应这种人口结构变化，并确保创伤临床医生具备足够的技能来治疗复杂的老年患者的疼痛。本文专门介绍老年患者急性创伤疼痛的管理。它旨在强调与年轻患者相比，管理老年创伤患者的显著临床挑战。本文概述了常用镇痛药的优缺点和更多新型、新兴镇痛辅助药物的相关证据和实用观点。一名医学图书馆员通过在 Medline（Ovid，从创建到 2022 年 11 月 7 日）中进行搜索，使用创伤、疼痛、老年人和镇痛药的关键字和主题词来识别相关文章。结果仅限于过去 10 年发表的英文文章。手动筛选相关文章的参考文献以确定其他相关文章。目前，针对老年人创伤相关疼痛管理的高质量证据非常有限。与年龄相关的生理变化、多种合并症的积累、衰弱以及因镇痛药物而继发谵妄的风险，给老年创伤患者带来了一系列挑战。治疗老年创伤患者疼痛的一个重要细微差别是平衡镇痛的医源性不良反应与未治疗疼痛的危害之间的关系，未治疗疼痛的并发症和后果包括活动受限、肺炎、肌肉减少症、压疮、长期功能下降、长期护理需求增加和死亡率增加。在本文中，讨论了包括短期非甾体抗炎药（NSAIDs）在内的非阿片类药物的作用。讨论了伴有肾脏和肝脏疾病的老年急性创伤疼痛患者的阿片类药物选择和剂量。讨论了在急性老年创伤中其他辅助药物（如局部和静脉用利多卡因、氯胺酮和区域麻醉）的证据基础和局限性。
