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Universal Journal of Medical Science 1(2): 36-49, 2013

DOI: 10.13189/ujmsj.2013.010204


Perioperative Pain Management in the Elderly Surgical

Thomas M. Halaszynski
Department of Anesthesiology, Yale University School of Medicine and Yale-New Haven Hospital, 333 Cedar Street, P.O. Box 208051,
New Haven, Connecticut 06520-8051
*Corresponding Author: thomas.halaszynski@yale.edu

Copyright 2013 Horizon Research Publishing All rights reserved.


Background: There has been an increase in the

number of elderly patients undergoing surgery. This
particular patient population have unique age related
comorbidities that lead to an increase in postoperative
complications involving the neurological, pulmonary,
cardiac and endocrine systems. Despite advances in
anesthesia and analgesia, mono-therapy with opioids
continues to be the mainstay for treatment of post-op pain,
which often times leads to inadequate pain control, or
gastrointestinal and respiratory compromise. Regional
anesthesia and multimodal analgesic regimens are promising
alternatives to reduce high doses and dependence of opioids
and the adverse effects that accompany.Methods: The
authors searched the following databases for relevant
published trials: the Cochrane Central Register of Controlled
Trials and PubMed.Textbooks and meeting supplements
were also utilized. The authors assessed trial quality and
extracted data.Conclusions: Incorporating perioperative
regional techniques and multimodal drug therapy can be a
very effective approach to perioperative pain management in
the elderly and cognitively impaired. Regional anesthesia
can often reduce postoperative neurological, pulmonary,
cardiac and endocrine complications.It has not been
completely proven to improve long-term morbidity, but does
improve immediate post-operative pain control.Multimodal
drug therapy utilizes a variety of analgesic medications
(non-opioids) in order to minimize dosages and adverse
effects from opioids while maximizing analgesic effect and


Regional Anesthesia, Pain Management,

Elderly Surgical Population, Cognitive Dysfunction,
Co-morbid Diseases of the Elderly, Anesthesia and

1. Introduction
Aging is a complex and multifactorial process that

encompasses all organ systems.Due to diminished

physiologic reserve and cumulative effect of comorbid
conditions, any stressor can interfere with physiologic
homeostasis and lead to potential deleterious adverse
effects.With an increase in number of elderly patients
undergoing surgical intervention(s), it is important to
determine the optimal perioperative therapies to maximize
recovery while minimizing adverse effects for older surgical
patients.One important contribution to development of
perioperative complications is improper/inadequate
postoperative pain therapy.Inadequate post-surgical pain
management can be associated with poor interventional
outcomes, decreased perioperative pain anesthesia/analgesia
experience, patient and family member, dissatisfaction
associated with their surgical encounter, and potential higher
rates of medical complications.1,2
Debate continues over the optimal approach to anesthesia
and analgesia in the elderly.Planning an anesthetic technique
and perioperative pain regimen requires consideration of
several interventional details. It is always important to
consider patient age, anticipated surgical procedure, patient
pre-existing co-morbidities, and postoperative analgesic
requirements when deciding upon an appropriate
perioperative pain management strategy for the
elderly.Methods of perioperative pain management
thoroughly studied and explored in this article are regional
anesthesia, including neuraxial and peripheral nerve
blockade along with multimodal drug therapy.The focus of
this review is directed toward the beneficial effects of these
Geriatric surgical patients have unique age-related
physiological and pharmacological differences.In addition,
many elderly patients suffer from co-morbid diseases,
varying degrees of physical de-conditioning (especially prior
to lower extremity orthopedic procedures), poor
perioperative health status and compromised organ reserve
capacity.The nervous system, cardiovascular, pulmonary,
endocrine, and immune systems can all be affected by
aging.These systemic changes that accompany aging will be
carefully reviewed in order to determine suggested optimal

Universal Journal of Medical Science 1(2): 36-49, 2013

techniques for perioperative pain management.

Patient age alone should not be considered a major risk
factor for anesthesia and surgery.The number and extent of
any coexisting disease(s) and medical condition(s) are more
directly related to perioperative risk than to chronological
age for elderly patients.More important factors and better
predictors for the elderly are overall physical status, medical
history and disease state along with patient condition (ex.
physical deconditioning) and type of surgery.Complication
rates for both anesthetic and perioperative pain management
choices increase very little with advancing age in absence of
coexisting disease.However, there is a higher incidence of
disease and existing comorbidity(s) in the older patient
population. Many older patients (4/5th) have at least one
complicating medical condition and 1/3 have 3 or more
coexisting diseases.In addition, there are several medical
conditions that are predictive of high surgical risk and
include diabetes mellitus, hypertension and ischemic heart
disease.3 Additional predictors of perioperative outcome and
risk in the elderly patient include type, urgency and duration
of the planned surgery.Abdominal surgical procedures
followed by thoracic and open-heart surgery are associated
with the highest morbidity and mortality for elderly surgical
Therefore, this article will address several of the age
related changes of the human body with a review of the
major organ systems. Throughout the article are aspects of
how to focus and to best incorporate these physiologic
changes into development of an optimal perioperative pain
management plan. Also identified in the article are
summaries of many of the pathologic changes that may/can
occur with aging (ex. cognitive dysfunction) and how to
consider these various influences in pain therapy protocols.
Finally, the article will address options, some
evidence-based data, and concepts to consider when treating
the elderly surgical patient: multimodal analgesia and
implications of regional anesthesia.

2. Alterations in the Geriatric Nervous

In elderly patients, there is a continual loss of neuronal
substance and diminished supply of neurotransmitters
leading to reductions in brain reserve.Such reductions
increase the likelihood of increased sensitivity to anesthetic
and analgesic medications, symptoms and signs of
perioperative neurologic dysfunction, increased risk of
postoperative cognitive dysfunction (POCD), and decreases
in functional activities of daily living.The major signs and
symptoms include altered reflexes, deteriorations of gait and
mobility, altered sleep patterns, impairment of memory and
intellect, and decrement of the senses.
Changes that can occur in the aging somatic nervous
system include: a) peripheral nerve deterioration; b)
dysfunction of genes responsible for myelin sheath protein
components; and c) decreased myelinated nerve fiber


conduction velocity to identify a few of the changes involved.

The autonomic nervous system that dictates involuntary
physiological functions of the body, via sympathetic and
parasympathetic divisions, can also experience alterations
secondary to aging.Aging of the autonomic nervous system
is characterized by: a) limited adaptability to stress; b) net
increase in the activation of the sympathetic nervous system;
c) decreased basal activity of parasympathetic nervous
system; d) decreased baroreflex sensitivity; and e) slowing
and weakening of homeostatic functions; all of which may
play a role in achieving good perioperative pain
The aging autonomic nervous system has reduced
autonomic abilities to respond to physiologic changes,
stresses, surgery, pain, and anesthesia.Increases in
sympathetic nervous system activity are organ specific with
the gastrointestinal (GI) system and skeletal muscle as
targets.Neuronal noradrenergic reuptake is reduced in the
elderly resulting in an increased sympathetic tone of the
heart and an increase in basal adrenal secretions.There is a
loss of beat-to-beat heart rate variability during respiration in
the elderly due to reduced respiratory vagal modulation of
the resting heart.Decreased baroreflex sensitivity is due to
increased arterial stiffness and age associated alterations of
the autonomic nervous system.The autonomic nervous
system and its effectors play an important role in responses
to hemodynamic challenges.Therefore, any imbalance of
homeostatic mechanisms in patients of advanced age can
result in orthostatic hypotension, exercise intolerance,
increased upper body sweating, and temperature intolerance.
Table 1.
Changes in the Aging Central Nervous System
Decreased synaptic transmission
Diffuse slowing on EEG
Decreased oxygen & glucose consumption
Loss of neuronal substance
Decreased production of neurotransmitters
Decrease in cytoplasmic protein synthesis
Decreased myelin glycoproteins

Normal aging results in biochemical and anatomical

changes of the brain and spinal cord along with qualitative
and quantitative effects on the nervous system (Table 1). Age
related changes in the peripheral nervous system (PNS) and
central nervous system (CNS) may affect functional
outcomes during the perioperative period and should be
considered in a patients preoperative evaluation. Effect of
aging on functional reserves of CNS and PNS along with
potential surgical and anesthetic ramifications must also be
considered. Anatomical and biochemical changes of the
brain and spinal cord include: a) volume of brain mass,
number of synapses, and neurotransmitter concentrations; b)


Perioperative Pain Management in the Elderly Surgical Patient

cerebral electrical and metabolic activity; c) changes in brain

nerve fibers; d) changes within the spinal cord (cervical
spinal cord maintains it shape, but decreases in size); and e)
modification of the bony spinal canal.
Memory deterioration can occur in more than 40% of
people older than 60 years of age, and progressive loss of
intellectual activity along with mental deterioration (senile
dementia) happens in 14% of the population aged greater
than 75 years.34 Daily living activities can be dramatically
affected by age-related memory decline, but is not
inevitable.Deficiencies of specific neurotransmitters (related
to Parkinsons, Alzheimers dementia, and other brain
disorders) often occur in geriatric patients.Changes in
neurotransmitter activity and amounts have also been
implicated as a factor influencing anesthetic agent
sensitivity.Cerebral metabolic activity is decreased in older
subjects and may be a result of decreased neurotransmitter
concentrations and synaptic activity.Degenerative changes
of myelin sheaths in the CNS may lead to cognitive
dysfunction through changes in nerve conduction velocity
leading to disruption of normal timing of neuronal
circuits.Further contributions to cognitive decline are due to
loss of cerebral white matter nerve fibers resulting in
decreased connections between neurons.Although these
changes have been identified in the aging brain, the
mechanism causing effects on functional activity reserve
remain unclear. Therefore, all of the alterations and changes
of the nervous system described above can affect
perioperative pain management and should be considered.
Pharmacokinetic changes that accompany aging and the
geriatric nervous system can explain some components of
analgesic drug responses seen in the elderly.Brain sensitivity
to anesthetic and analgesic agents increases with age and are
unique to each drug.The mechanisms that define altered
brain pharmacodynamics to anesthetics and analgesics in the
elderly are unclear at the present, although altered brain
kinetics may provide some direction.Age related altered
brain sensitivity might result from changes in receptors,
signal transduction, and homeostatic mechanisms of the
CNS.In addition, alterations of brain phospholipid chemistry
associated with changes in second messengers, such as
diacylglycerol are evident.35
2.1. Cognitive Dysfunction in the Elderly
Postoperative delirium and cognitive dysfunction have a
higher incidence in the elderly surgical population.The exact
pathophysiology has not been completely defined and all
potential pathways determined.However, it has been
theorized that by avoiding (when possible) or reducing
centrally acting general anesthesia agents and centrally
acting opioids that regional analgesia along with multimodal
management.Such an anesthetic/analgesic patient-directed
and procedure-targeted plan in the elderly has also been
theorized to reduce emergence delirium and POCD.
General anesthesia (GA) is a potential pathogenic factor in

brain toxicity, inflammation and POCD.7,8Such findings

implying that modern anesthetics are completely reversible
may not be entirely correct and that efficacious differences
along with advantages in perioperative outcome may be
evident following local anesthetic techniques versus GA
could be postulated.However, no correlation between
anesthetic technique and long-term pain management
improvement or reduced incidence of POCD has been
found.Nevertheless, studies do demonstrate that short-term
gains (diagnosed seven days after surgery) have been
achieved with local anesthetic procedures compared to more
conventional GA.9
Reliance on opioids as the central or major role for pain
management in the elderly may also carry a host of
well-known adverse effects (AEs).10Opioids have been
linked to disturbed sleep architecture (reduced rapid eye
movement and slow wave sleep) which can lead to
hyperalgesia.Such increases in pain due to hyperalgesia can
further worsen sleep, thus continuing to perpetuate the
cycle.11 It has been well established that inadequate sleep can
lead to cognitive dysfunction as both adenosine and
acetycholine levels decrease in the basal forebrain after
opioid administration.Adenosine and acetycholine levels
help regulate centrally perceived pain, but they also play a
role to control memory, attention and wakefulness, all of
which are disturbed by opioids.The elderly are particularly
sensitive to reductions in these chemical mediators
(adenosine and acetycholine) as their baseline reserves are
typically reduced with aging.
Cognitive disorders can occur in all patients in which
mental function diminishes in the early postoperative period
and returns to preoperative levels within one week following
surgery.In addition, CNS dysfunction can be a common
finding in elderly postoperative patients.Stroke is one
possible cause for any negative influence on cognition in
patients, but occurs relatively infrequently.12More common
causes are postoperative delirium (POD) and POCD.POD is
the most common psychiatric condition of hospitalized
patients.The incidence of POD and POCD may exceed 50%
in certain surgical settings such as cardiac and orthopedic
surgeries.13,14 The incidence of POD and POCD is higher
than other postoperative co-morbidities such as respiratory
failure and myocardial infarction.15In these cases, it is
difficult to treat pain that cannot be properly assessed.
Geriatric patients undergoing certain high-risk surgeries,
older individuals with certain coexisting medical illnesses,
patients with preoperative cognitive dysfunction, and
surgical candidates of advanced age are at higher risk for
development of postoperative cognitive disorders and
long-term cognitive dysfunction.Cognitive disorders in
high-risk elderly patients occur more frequently than
anticipated as is evident by one study in which patients
(N=1200) older than 60 years had a 25.8% incidence of
cognitive impairment postoperatively at one week.In some
patients (9.9%) the impairment persisted for 3 months
following surgery.16
Complications of POD and POCD are significant because

Universal Journal of Medical Science 1(2): 36-49, 2013

such adverse outcomes can result in an increased length of

hospital stay and medical complications including unmet
postoperative analgesic needs, prolonged hospitalization,
unplanned discharge to a skilled care facility, and even
premature death.17 Patients with POCD are at an increased
risk of death in the first year after surgery 18,19and the
economic impact of delirium is also considerable, adding
costs to hospitalization, including billions in additional
Medicare charges.In addition, both POD and POCD occur
far more frequently in elderly than in younger patients.
2.2. Effects of Cognitive Dysfunction on Perioperative
Pain Management
Perioperative evaluation for major surgery in older
patients should be performed as a multidisciplinary team
approach to achieve optimal postoperative pain management,
recovery, and long-term follow-up when indicated.Elderly
patients often present with age-related changes of their organ
systems, and whether these changes are normal or pathologic,
they are to be considered in anesthetic and analgesic
management.Alterations of functional reserve in the elderly
may be reflected as increased susceptibility to POCD,
delirium, altered pharmacodynamics, stroke, hyperalgesia,
sleep disturbances, etc.Conditions involving cognitive
dysfunction in the elderly are identified in Table 2.
Table 2.
Definitions of Altered Mental Status
dysfunction (POCD)



Altered pharmacodynamics



Persistent deterioration of
cognitive performance after
surgery, most often resolves
within 3 months, but can last
Decline in mental status,
reduced awareness, cognitive
and psychomotor dysfunction,
disorientation, and memory
Increased effect of drug on the
body; example exaggerated
respiratory and cardiovascular
depression from narcotics
Decreased blood supply to the
brain due to ischemia or
hemorrhage. There is an
increased risk in elderly,
baroreceptor sensitivity, and
loss of vascular elasticity.
Paradoxical increase in pain
intensity, new pain complaints
and altered pain characteristics
while receiving treatment with

Functional status of elderly surgical patients may be more

relevant than their medical morbidity outcomes. Cognitive


status relates directly to the patients functional ability which

is a determining factor in rehabilitation, pain management,
and whether or not a patient is discharged to home or will
require a skilled care facility for recovery. In addition,
functional status serves as a strong predictor of mortality as a
result of hospitalization. 20 Decreased neurocognitive
function yields a decrease in health related quality of life
along with adverse financial and social impact for patients
and their care providers. 21

3. Alterations in the Geriatric

Cardiovascular System
Morphological and functional changes of the
cardiovascular system occur with the aging process (Table 3).
Aging of the heart and vascular systems have clinical
implications for treatment of older surgical patients,
including their postoperative pain management. There is not
significant evidence to suggest differences in cardiovascular
outcome, morbidity or mortality when using regional
modalities or multimodal drug therapy in the elderly 36, but
some studies do show a significant benefit and influence on
short-term survival with regional anesthesia. 37,38,39,40 As
an example, an epidural combined with general for elective
abdominal aortic aneurysm repair resulted in a shorter
duration of postoperative intubation, reduced incidence of
morbidity and mortality, reduced resource utilization,
decreased time in the intensive care unit, more optimal
postoperative pain relief, and improved overall outcome. 37
Preoperative placement of a continuous epidural in elderly
patients for hip fracture surgery (versus a regimen of
systemic opioids) has also demonstrated better perioperative
pain management and a reduced incidence of adverse cardiac
events. 38 In addition, thoracic epidural analgesia could
minimize adverse cardiovascular pathophysiology because
an effective epidural (analgesia achieved) decreases cardiac
sympathetic outflow yielding a favorable balance between
myocardial supply and demand. The statistically proven
benefit from regional procedures on the incidence of
myocardial ischemia, infarction or malignant myocardial
arrhythmias still remains uncertain. However, there is one
study demonstrating that thoracic epidural analgesia does
decrease the incidence of postoperative myocardial
infarction along with reduced ventricular malignant
arrhythmias. 39
Table 3. Cardiovascular System Changes in Elderly
Reduced exercise tolerance
Loss of vascular elasticity (example: LVH and hypertension)
Chronic blood pressure elevation & decreased baroreceptor
Increase in coronary arterioscleroris
Valvular heart disease

A host of perioperative stressors including disrupted

activities of daily living, anesthesia, surgery, and


Perioperative Pain Management in the Elderly Surgical Patient

postoperative pain can activate the sympathetic nervous

system (SNS) of elderly surgical patients to a varying
degree.Activation of the SNS can result in potentially
negative imbalances between myocardial oxygen supply and
demand.This in turn may predispose older patients with
reduced cardiac reserve to myocardial ischemia and
infarction.Perioperative deleterious cardiovascular events
such as congestive heart failure, myocardial infarction,
cardiac arrhythmias and sudden cardiac death can occur with
an increased frequency within the first several days of a
major surgical intervention.40,41
Patients undergoing various orthopedic procedures under
neuraxial blockade for perioperative anesthesia and/or
analgesia had a one-third reduction in overall mortality from
a recent meta-analysis of randomly controlled trials. 29,42
Another meta-analysis (N=68,723) on Medicare patients
found an association of significantly lower odds ratio of
death at both periods of 7 and 30 days when postoperative
epidural analgesia was used. 43 In yet another meta-analysis
(N=2427), it was found that patients who received an
epidural (with or without general anesthesia) had a reduced
incidence of perioperative myocardial infarction and in those
instances when a thoracic epidural was maintained for
analgesia longer than 24 hours, results showed significantly
fewer postoperative myocardial infarctions. 39,44

4. Alterations in the Geriatric

Respiratory System
Perioperative risk of respiratory complications among
elderly surgical patients can be explained by functional and
structural changes within the pulmonary system commonly
associated with aging (Table 4).Armed with an
understanding of the multiple respiratory system changes,
clinicians should always titrate analgesic medications
carefully and assess patients frequently for any evidence of
potential adverse effects.For example: 1) A greater decrease
in arterial oxygen tension and/or an increase in carbon
dioxide is necessary to increase minute ventilation in the
elderly; 2) Elderly patients may not adequately increase their
minute ventilation to meet respiratory demands induced by
hypoxia and hypercarbia under the stress of illness or injury;
and 3) Furthermore, this effect is exacerbated by the use of
opioids, benzodiazepines and inhalational anesthesia that can
promote respiratory depression. 45, 46
Analysis of several studies reveals that choice of
anesthetic shows no significant long-term effect on
perioperative respiratory morbidity and mortality within any
age group. However, it is intuitively reasonable and
clinically prudent to consider that older patients could
benefit from regional techniques due to minimal sedation
requirements, better postoperative pain control, and
preservation of pulmonary function. By preserving or
quickly restoring respiratory function, epidural anesthesia
appears to decrease morbidity, reduce length of hospital stay,
and lower health care costs. Also, any adverse respiratory

effects from inhalational anesthetics and airway

manipulation can be avoided. The decision to perform
regional must be assessed on a case-by-case basis
considering patients pulmonary function, type and duration
of planned surgery, anesthesiologist expertise, along with
consideration and reflection of the elderly patients health
Table 4. Pulmonary System Changes in Elderly 81
Decreased chest wall compliance due to changes in muscle & chest
wall joints
Increased lung compliance due to loss in parenchymal elasticity
Decreased lung parenchymal surface area leading to decreased
efficiency of alveolar gas exchange due to increase in dead space and
Decrease FEV1, decreased TV, increased RR
Hypotonia of pharyngeal muscles leading to upper airway
Decreased responsiveness to hypercapnea and hypoxia
Increased work of breathing

Following upper surgical abdominal incisions, a host of

potential pulmonary consequences are possible in older
surgical patients: a) vital capacity (VC) can be reduced
(25-50%); b) postoperative pain along with use of systemic
opioid analgesics can contribute to a reduction in tidal
volume; c) an impaired ability to clear secretions and
diminished cough reflexes can lead to atelectasis and
increased risk of pneumonia.General anesthesia may reduce
functional residual capacity (FRC) by 15-20% with duration
of effect that can last 7-10 days following surgery.47 Elderly
patients undergoing general anesthesia are predisposed to
atelectasis from a combination of age-associated increases in
closing volume and reduced FRC.Reduced FRC is
associated with ventilation-perfusion (V/Q) mismatching,
increased alveolar-to-arterial oxygen gradient, and decreased
efficiency of gas exchange.However, during neuraxial
anesthesia, FRC is often unchanged from baseline.
Studies have shown that older adults undergoing lower
extremity orthopedic procedures have fewer respiratory
complications when combining epidural plus general
anesthesia compared to general with postoperative
management.Hypoxic events are diminished and pulmonary
arterial oxygen (PaO2) levels (on post-op day 1) are higher
with epidural anesthesia as compared to systemic opioids for
perioperative pain management.48,49
Blunting of hypoxic pulmonary vasoconstriction (HPV) in
the elderly during general anesthesia also causes a greater
incidence of intraoperative V/Q mismatch and increased
alveolar-to-arterial oxygen gradient.Negative effects on
pulmonary function from opioids and inhalation anesthetics
predispose older patients to atelectasis, increased risk of
hypoxemia and pneumonia, V/Q mismatch, and other
postoperative pulmonary challenges.50 Compared to
systemic or epidural opioids, regional anesthesia using local

Universal Journal of Medical Science 1(2): 36-49, 2013

anesthetics for postoperative pain control may provide a

greater safety margin for older patients and may be more
appropriate for postoperative pain relief. 51 Opioids can
result in a higher incidence of hypoxic events compared to
regional techniques with local anesthetics alone.52 Epidural
local anesthetics compared to systemic opioids for
postoperative analgesia results in reduced incidence of
pulmonary infection, increased PaO2 levels, reduced
atelectasis and an overall decrease in pulmonary
complications.28Epidural local anesthetics or local
anesthetic-opioid mixtures also result in reduced
postoperative pulmonary morbidity following major
abdominal and thoracic surgery versus systemic opioids
In a review by Parker et al, a meta-analysis has shown that
neuraxial blockade versus patients receiving systemic
complications in hip fracture surgery leading to shortened
intensive care unit (ICU) stays and reduced intubation
times.23 Another meta-analysis of 141 clinical trials
examining thoracic epidural anesthesia and analgesia versus
general and postoperative patient controlled opioid analgesia
showed a 39% reduction in pneumonia and 60% reduction in
pulmonary depression.19 Although some studies appear to
demonstrate a clear advantage of regional anesthesia over
general anesthesia with systemic opioids, controversy arises
due to lack of differentiation and uniformity of epidural
analgesic mixtures, site of surgery in conjunction with level
of neuraxial blockade and the amount along with type of
systemic opioids used.

5. Alterations in the Geriatric Endocrine

& Immune Systems
Communicating capability of circulating immune cells
and cytokines of the immune system serves as one of the
bodys major defense mechanisms.There is a corresponding
reduction and deterioration of the cellular and humoral
aspects of the immune system as human beings age.The
thymus gland and hormones responsible for mature T-cell
modulation are also reduced, leading to a diminished supply
of functioning T lymphocytes.In an unstressed state, there is
minimal alteration of immune functioning in older
patients.However, when they encounter surgical stressors,
more clinically significant changes in immune function can
become evident.Studies reveal that regional techniques can
preserve humoral and cellular immune functions in surgical
patients 55, whereas administration of general anesthesia may
worsen the immunosuppression response that can occur
subsequent to surgery.By maintaining homeostasis and
reducing surgical stress, regional anesthesia better preserves
the immune system thereby possibly decreasing
post-operative infectious complications in older patients.
Metabolic effects of surgical stress and pain can often
produce hyperglycemia and overall catabolism that may
predispose patients, especially critically ill patients, to
increased mortality and morbidity including: polyneuropathy,


increased incidence of opportunistic infections, and

multi-organ dysfunction.However, regional anesthesia can
provide for more stable physiological parameters during
surgery and theoretically prevent or reduce such surgical
stress responses. 56 For example, regional techniques may
minimize surgical stress by blocking sympathetic and
somatic nervous systems from being activated.Epidural
blockade reduces postoperative hyperglycemia and improves
glucose tolerance despite plasma insulin concentrations
being unchanged. 45 Plasma glucose normalization and
improved glucose tolerance with regional techniques can
reduce catabolic response to surgery and improve upon
gastrointestinal rehabilitation, economy of proteins, and
nutritional status of surgical patients. 57

6. Multimodal Approach to Pain

Medicine in the Elderly
Secondary to a host of reasons and despite advances in
analgesia and newer analgesic techniques, mono-therapy
with opioids remains the mainstay of treatment for
postoperative pain.Opioids are a class of central-acting
analgesics that provide powerful dose-dependent relief of
pain.They are the most commonly used medication for
postoperative pain with good analgesic effect.However, they
can alter CNS activity and lead to physical and psychological
dependence with longer-term use.They are also burdened
with several potential adverse effects such as nausea,
sedation, constipation, ileus, dysphoria, respiratory
depression, and risk of abuse.5In the elderly, these adverse
effects can be exacerbated due to altered pharmacokinetics
and pharmacodynamics from age-related physiologic
changes.Examples of pharmacokinetic changes include
reduced hepatic and renal flow and reduction in total body
water that can alter clinical responses to these drugs in the
older patient population.In addition, examples of
pharmacodynamic changes include increased sensitivity to
CNS depressant agents resulting in cognitive dysfunction
and/or reduction in minimum alveolar concentration.
Dependence on opioid mono-therapy may result in
inadequate postoperative pain management and can often be
of limited value due to associated AEs.Opioid
mono-therapy can typically lead to requirements of higher
doses to achieve pain control, and with higher dosages, more
side effects become possible as well as intensity of adverse
events that are dose dependent.Over the previous decade, use
of multimodal drug therapy has gained value and utility as
being a more effective strategy in perioperative pain control.
Multimodal-analgesia can serve to optimize efficacy by
using different analgesic drug classes, each of which uses
different receptors and pathways for clinical effect(s).
The aspect of less dependence on only one medication
treatment modality often provides the practitioner with an
ability to use lower medication doses of individual
analgesics and with less reliance on each respective agent so
to limit adverse effects from any single agent as well as


Perioperative Pain Management in the Elderly Surgical Patient

possibly reducing tolerance and dependence.Clinicians often

find this approach to pain management beneficial, as it can
permit less reliance on any single ineffective agent or
adverse side effect profiles that can often be encountered
with opioids.Multimodal analgesia along with regional
anesthesia (RA) may enhance recovery while ensuring
rehabilitation, quicker transfer to an outpatient setting and
back to activities of daily living more expeditiously after
major surgery.This concept may in turn reduce use of
healthcare resources, help to minimize cost and provide
value to end users of any such procedure-specific pain
management treatment modality.Multimodal analgesic
models can be tailored to include fast onset of action,
designed toward improved safety profiles in certain patient
populations and effective reduction in pain levels by
medication/analgesic delivery directed from multiple routes
and by different receptor interfaces aimed toward reduced
AEs.This concept has been shown to be efficacious in
multiple studies and may also improve outcomes by reducing
opioid amounts required for optimal pain control for a wide
variety of surgical interventions.In addition, since surgical
patients rarely present with pure nociceptive or neuropathic
pain issues, but rather with a mixed component of
postoperative pain management needs, a rational and often
times multimodal approach is necessary to target key
portions of peripheral and central pain pathways.
Table 5. Regional Anesthesia
Types of Upper Extremity Blockade
Intravenous Regional
Types of Lower Extremity Blockade
Lumbar Plexus
Lateral Femoral Cutaneous
Popliteal and Saphenous
Types of Head and Neck Blockade
Cervical Plexus
Types of Truncal Blockade
TranversusAbdominis Plane

6.1. Regional Anesthesia

Regional anesthesia/analgesia involves loss of sensory

and/or motor function of a specific portion/dermatome of the
body by temporary interruption of normal nerve
conduction.It includes both neuraxial and peripheral nerve
blockade.There are a vast number of regional modalities
available (Table 5) and investigations in regional
investigations are variable and include different regional
techniques combined with various drug regimens including:
1) Peripheral nerve blocks alone; 2) Peripheral nerve block
combined with GA; 3)Neuraxial blockade; 4)Neuraxial
blockade with GA; and 5)Neuraxial blockade combined with
peripheral nerve block.Lack of consistency within RA
studies and protocols has limited the ability to portray firm
indications, guidelines, and recommendations about any
advantageous or optimal anesthetic technique in the geriatric
population.For the above reason, several retrospective and
prospective studies fail to show any difference or meaningful
objective outcome between general versus regional
anesthesia.In addition, no significant long-term variation in
morbidity and mortality has been established except
evidence of a reduced incidence of deep vein thrombosis and
reduced blood lose when RA is utilized.4
Clinically, the concept of RA appears to be an effective
and safe technique in elderly and cognitively impaired
surgical patients. Both established and theoretical benefits of
RA are listed in Table 6, however, even though RA has many
advantages, there are also issues specific to the elderly that
should be considered when choosing the most optimal
procedure-specific anesthetic/analgesic modality. For
example, spinal anesthesia in older patients can have a
reduced latency time likely due to diminished cerebral spinal
fluid (CSF) along with increased density. Diminished nerve
myelination in the elderly also results in a greater diffusion
of local anesthetic and wider nerve block extension. For
these reasons, a reduced dosage of local anesthetic is
recommended. 4 Therefore, in order to provide high-quality
care, there should be careful consideration of the patients
medical history, age-related physiologic changes, and
anticipated altered effects of anesthetic techniques in elderly
Table 6. Advantages of Regional Anesthesia/Analgesia
Benefits of Regional Anesthesia
-Improve acute perioperative pain management
-Reduced opioid use along with reduced incidence of adverse events
-Can obtain skeletal muscle relaxation, thus limiting need & risks of
IV muscle relaxants
-Option to maintain patient consciousness
-Continued presence of protective upper airway reflexes
-An isolated regional modality will have minimal effect on
pulmonary or cardiac disease

6.1.1. Regional Anesthesia & Analgesia and Anticoagulation

Despite the many known as well as potential benefits of

Universal Journal of Medical Science 1(2): 36-49, 2013

neuraxial blockade, the incidence of central neuraxial

neurologic compromise resulting from hemorrhagic
complications is not completely known.Although the
incidence cited in the literature is estimated to be less than 1
in 150,000 for epidurals and less than 1 in 220,000 for spinal
anesthetics, recent epidemiologic surveys suggest that the
frequency is increasing and may be as high as 1 in 3000 in
some patient populations (ex. patients with varying degrees
of coagulopathy, both clinical and sub-clinical).The risk of
clinically significant bleeding increases with advanced age,
associated abnormalities of the spinal cord and vertebral
column, the presence of an underlying coagulopathy,
difficulty during neuraxial needle placement, and presence
of an indwelling neuraxial catheter during sustained
Table 7.
ASRA Guidelines for RA in the Patient Receiving
Anticoagulation Therapy






No contraindications


No recommendations unknown risk




Delay administration >1 hour after

needle placement or catheter removal
Remove catheter 2-4 hours after last
Needle placement or catheter removal
10-12 hours after last dose
Delay dosing 2 hours after removal of
Needle placement or catheter removal
24 hours after last dose
Delay dosing 2 hours after removal of
Stop 4-5 days prior to neuraxial
technique, INR<1.5 prior to needle
placement or catheter removal
No contraindications


Delay 14 days


Delay 7 days

Herbal therapy

No contraindications

case reports, and hematology literature, but evidence-based

outcomes are currently unavailable. An abbreviated version
of the ASRA guidelines for regional anesthesia in patients
receiving anticoagulation is provided in Table 7.An
understanding of the complexity of this issue is essential in
deciding choice of the most appropriate perioperative
anesthetic management.
6.2. Non-opioid Adjuncts and the Elderly
In addition to regional analgesic modalities using local
anesthetics, additional options include non-pharmacological
strategies, such as psychological support and physical
therapy.Adjuvant drugs
such as antidepressants,
anticonvulsants, skeletal muscle relaxants and alpha 2
agonists are agents developed with additional clinical
indications for treatment other than pain, but later discovered
to provide analgesia.They should be and can be used to
contribute and improve perioperative pain management,
eliminate dependence on opioids, and limit potential AEs
from opioids in the elderly.Many of the adjunct analgesics
are recommended when toxic limits of any particular
analgesic is approached or reached or when the therapeutic
benefit of a primary analgesic appears to have plateaued.In
addition, these medications can be used in the presence of
other non-painful disabling complaints of the elderly such as
depression, anxiety, insomnia, and fatigue.59
Table 8. Nonsteroidal Anti-inflammatory Drugs


Acetic acid derivatives

GPIIB/IIIA Antagonists

Propionic acid derivatives



In response to the above patient safety issues, the

American Society of Regional Anesthesia and Pain Medicine
(ASRA) convened its Third Consensus Conference on
Regional Anesthesia and Anticoagulation and developed
practice guidelines/recommendations that summarize
evidence-based reviews and provides for expert opinion. 58
In addition, the rarity of neuraxial hematoma certainly defies
performing any prospective randomized trials.Since there are
no current laboratory models to base clinical
decision-making, the ASRA consensus statements represent
the collective experience of recognized experts in the field of
neuraxial anesthesia and anticoagulation. There is a fund of
knowledge that is based on clinical series, pharmacology,


Enolic acid derivatives (oxicams)

COX-2 selective (coxibs)

Mefenamic acid

Non-steroidal anti-inflammatory drugs (NSAIDs) are the

most widely prescribed and used medication in the U.S.
(Table 8). NSAIDs provide pharmacological action by
inhibition of prostaglandin synthesis that results in analgesic,
antipyretic, and anti-inflammatory activity. Even more
specific, selective cyclooxygenase-2 inhibitors (COX-2)
have additional benefit of reducing the incidence of
gastrointestinal side effects and positively influencing


Perioperative Pain Management in the Elderly Surgical Patient

thromboembolic events. 59 McDaid et al. demonstrated that

NSAIDs reduce morphine requirements in patient-controlled
analgesia following major surgery along with a concomitant
reduction in morphine-related nausea, vomiting, and
sedation. 60 An investigation by White et al. reported that
ibuprofen and celecoxib reduced pain and opioid needs after
ambulatory surgery thereby enhancing patient satisfaction
and the quality of their recovery. 61 NSAID administration is
a common non-opioid drug alternative and has been included
in practice guidelines for acute pain management in the
perioperative setting. 62 In addition, elderly patients taking
nonselective NSAIDs should use a proton pump inhibitor for
gastrointestinal protection. Patients should never take more
than one NSAID for pain control and absolute
contraindications include current active peptic ulcer disease,
chronic kidney disease, and heart failure. 63
Acetaminophen, a non-NSAID analgesic, should be
considered as an initial management therapy for pain (Table
9). It is ideal for post-surgical therapy because of its platelet
sparing properties and recent availability of an intravenous
formulation.It has already been incorporated into multimodal
analgesic regimens in several surgical institutions.The only
absolute contraindication of acetaminophen is liver failure.
Table 9. Other non-opioid, non-NASID analgesic
Para-aminophenol derivative

compliance or inadequate drug absorption. Therefore,

monitoring medication concentration may be very useful in
situations of treatment failure. Certain antidepressants are
widely used for the treatment of neuropathic pain (pain
characterized by damage or dysfunction of CNS and/or PNS).
They have also become popular as a non-opioid medication
in the treatment of postoperative pain as a multimodal
component (Table 10). Antidepressants have several
mechanisms of action: they block calcium channels, block
sodium channels, inhibit reuptake of chemical mediators,
activate opioid receptors and/or block NMDA receptors.
There are several classes of anti-depressants including
reversible inhibitors of monoamine oxidase inhibitors type A,
traditional tricyclic antidepressants (TCAs), selective
norepinephrine reuptake inhibitors (SNRIs), and selective
serotonin reuptake inhibitors (SSRIs).
Anxiolytics can also be included in a multimodal
perioperative pain management regimen.Although they have
no intrinsic analgesic activity, anxiety often accompanies
somatic complaints.Pain can cause anxiety and in turn,
anxiety often exacerbates the perception of pain.Therefore,
anxiolytics may provide for a mechanism to break this cycle
and indirectly help to relieve pain.
Table 11.


Table 10. Antidepressants









Multimodal incorporation of an antidepressant medication

into perioperative pain management also has advantages. In
addition to its value as an analgesic, it improves a patients
sense of well-being, reduces fatigue, and does not disrupt
the normal sleep cycle. A patients failure to respond to
treatment with antidepressants could be attributable to low
drug plasma concentrations secondary to poor patient

2-subunit calcium channel

Valproic acid

Another commonly used group of drugs for the treatment

of neuropathic pain and included in multimodal therapy for
acute pain management are anticonvulsant medications
(Table 11). The effectiveness of this drug class for pain relief
appears to be related to its pathophysiology toward the
treatment of epilepsy; with both conditions being
characterized by neuronal hyper-excitability. The
hyper-excitable state of neuropathic pain and epilepsy are
marked by sensitization along with dysfunctional discharges
at the dorsal root ganglion or the spinal dorsal horn. 64
There is Food & Drug Administration (FDA) approval for
anticonvulsants that have been directed toward a host of
neuropathic pain syndromes (ex. carbamazepine for
trigeminal neuralgia and gabapentin for post-herpetic
neuralgia) with mechanisms of action including inhibition of
gamma-aminobutyric acid receptors and modulation of
voltage-gated sodium and calcium channels.Anticonvulsants
such as gabapentin and pregabalin are excreted by the renal
system, have few drug-to-drug interactions, allow for rapid
titration and thus provide for earlier onset of analgesia, and
have linear pharmacokinetics.However, there are dose
dependent side effects such as dry mouth, somnolence,
dependent edema, and dizziness that can occur.

Universal Journal of Medical Science 1(2): 36-49, 2013

Table 12. Muscle relaxants


Table 14. Topical agents





Skeletal muscle relaxants are another adjunct in pain

management regimens and have multiple modes of action
(Table 12). The comparative efficacy of these drugs is not
well known in the elderly, however, evidence from clinical
trials is limited and a distinction that needs to be understood
is that skeletal muscle relaxants consist of anti-spasticity and
antispasmodic agents. Anti-spacticity medications such as
baclofen, diazepam, tizanidine, and dantrolene may aid in
improving muscle hyper-tonicity and involuntary jerking
cyclobenzaprine are used to treat musculoskeletal conditions
(ex. fibromyalgia) in the elderly. Therefore, skeletal muscle
relaxant choice should be based on indication, patient
tolerability, and potential AEs profile.
An early animal study by Commissiong and colleagues
suggested that cyclobenzaprine activates the locus ceruleus
in the brainstem, increases the release of norepinephrine in
the ventral horn of the spinal cord, and inhibits alpha motor
neurons. [65] Caution should be exercised when prescribing
cyclobenzaprine to elderly patients with arrhythmias, acutely
following a myocardial infarction, and in congestive heart
Tizanidine, an alpha 2-receptor agonist and centrally
acting skeletal muscle relaxant inhibits the release of
excitatory amino acids from spinal neurons and is chemically
related to clonidine with less antihypertensive
effect.However, caution is recommended in patients with
impaired renal function.Tizandine can be helpful in elderly
patients with spasticity due to spinal cord injury and
traumatic brain injury as well as multiple sclerosis.
Table 13. Corticosteroids
Methylprednisolone Acetate (Depo-medrol)
TriamcinaloneAcetonide (Kenalog)
TriamcinaloneDiacetate (Aristocort)
Betamethasone (Celestone)
Dexamethasone (Decadron)

Corticosteroids that are useful in clinical practice for pain

management include those with large anti-inflammatory
activity components and a low water balance
profile.Glucocorticoids act by suppressing the inflammatory
response and mineralocorticoids act by modifying both salt
and water balance.These steroid preparations are used as
injection for intra-articular, epidural, periarticular, and
intramuscular administration (Table 13).Studies demonstrate
lower postoperative pain scores, decreased length of hospital
stay and diminished morphine consumption in patients who
had lumbar spine surgery and received a steroid
preparation.66 However, a potential problem and continued
controversy still exists as to the extent which corticosteroids
may influence wound healing.


Topically applied single- or multi-agent analgesics are

available as an adjunct in pain management scenarios (Table
14). For example, a lidocaine patch can reduce ectopic
activity in the voltage-gated sodium channels of damaged
sensory nerves and also acts as a mechanical barrier to
relieve allodynia. Capsaicin stimulates transient receptor
vanilloid receptors that can subsequently deplete substance P
from sensory nerve fibers. Some additional uses include low
back pain and treatment of painful diabetic peripheral
Non-pharmacologic methods that may also be useful in
elderly perioperative pain medicine include heat or ice
therapy as well as psychological support.Pain is a complex
experience that is influenced not only by the surgical insult,
but also by the individuals cognition and behavior.Patients
can learn coping mechanisms such as relaxation and imagery
to decrease muscle tension, reduce emotional distress and
distract from pain. 67
6.3. Influence of Regional Anesthesia/Analgesia and
Multimodal Pain Therapy in Older Patients
Regional techniques can provide targeted pain relief and
may reduce dependence upon or minimize amounts of
systemic opioids in the perioperative period.Multimodal
non-opioid medication regimens provide analgesia and
reduce reliance on opioids and their many associated
AEs.Optimal postoperative analgesia is achieved when
regional analgesics are placed in close proximity to the
corresponding dermatome distribution of the surgical site
or with utilization of multimodal medication
therapy and permitting less reliance on opioid analgesics.
Choice of analgesic agents used with regional (local
anesthetics with or without opioids and other adjuncts) will
influence patient outcome.Central-neuraxial opioids prove
effective in controlling postoperative pain, but only epidural
local anesthetics have the ability to attenuate adverse
pathophysiological responses that can contribute to
perioperative morbidity.70Neuraxial local anesthetics are
effective through prevention of spinal reflex inhibition of
diaphragmatic and gastrointestinal function, suppression of
responses to surgical stress, and through blockade of efferent
and afferent nerve signals to and from the spinal
cord.Perioperative regional techniques in the elderly will
influence and control perioperative pathophysiologic events
by decreasing respiratory complications, reduce the
neuroendocrine stress response, improving effective pain
control, promote return of gastrointestinal function, and
facilitate earlier patient mobilization.These factors play an
integral role in management of recuperating patients. 71,72
The following studies demonstrate improved patient


Perioperative Pain Management in the Elderly Surgical Patient

outcome, amelioration of negative pathophysiologic events,

and improved analgesia with the use of perioperative
regional modalities as part of a multimodal pathway for
rehabilitation: 1. Postoperative regional analgesia as part of a
perioperative multimodal approach in patients undergoing
abdominal-thoracic esophagectomy can result in a shorter
time to patient extubation, earlier return of bowel function,
superior analgesia, and earlier fulfillment of discharge
criteria from an ICU73; 2. Patients participating in a
perioperative multimodal pathway following major surgery
had a decrease in metabolic and hormonal stress along with
improvement in convalescence 74; and 3. Patients undergoing
colon resection incorporating epidural analgesia and
receiving a multimodal approach to surgical rehabilitation
showed a decreased length of hospitalization from 6-to-10
days to a median of 2 days.75 Therefore, incorporating
perioperative regional techniques and utilizing a multimodal
anesthetic approach to surgical rehabilitation may aid in
attenuation of pathophysiological surgical responses, reduce
the length of hospitalization, and result in accelerated patient
recovery for the elderly.76

7. Anesthesia and Analgesic Techniques:

Impact on Perioperative Pain
There are many theories that RA in the elderly will reduce
the incidence of POCD, as well as other negative factors
related to morbidity and mortality.22, 26, 38, 40, 41, 49 Timely
implemented, there is a lower incidence of acute
postoperative pain, less sleep disruption, and reduced
confusion in elderly patients following hip fracture surgery
under RA.[23] High delirium risk surgery (ex. femoral neck
fracture repair) performed under spinal anesthesia (without
perioperative premedication or sedation) has reported no
incidence of delirium in elderly patients.24 In addition, higher
degrees of postoperative pain has been associated with an
increased incidence of cognitive dysfunction 25, so it would
appear that adequate control of postoperative pain would
decrease the incidence of postoperative cognitive
providing different postoperative analgesic levels, may result
in a varying incidence of postoperative cognitive
dysfunction.This was demonstrated in a study by Block et al.
in which analgesic regimens consisting of regional
techniques using local anesthetics were shown to provide
superior pain control over systemic opioids 26 and also to
reduce systemic adverse effects of opioids that have been
associated with the occurrence of POCD.27In addition,
epidural analgesia has been shown to reduce the incidence of
postoperative pulmonary complications that has been linked
to an increased occurrence of POCD.16,28,29 Even with results
such as described above, there is no statistically conclusive
evidence that regional anesthesia and analgesia are
associated with a lower incidence of POCD in the long
term.The problems in evaluating studies surrounding
cognitive preservation in elderly surgical patients are design

flaws and methodological variability contained in the

literature. Attempts at interpreting past and current evidence
provides conflicting results and even in the hierarchy of
evidence (meta-analysis of randomly controlled trials and
large randomized trials), there is lack of data to demonstrate
preservation of cognition beyond the first few hours to a
week after surgery when selecting regional techniques.30,31
Results from meta-analysis demonstrate significant
improvement in mortality when neuraxial blockade is used
without GA 32,33, but until POCD predictors and
consequences are determined, it remains difficult to make
recommendations for appropriate treatment and prevention
of POCD.
Acute pain should always be expected in postoperative
elderly patients regardless of the degree of cognitive
dysfunction. Perioperative pain has become a costly and
significant public health concern due to associated costs of
treatment and resources consumed due to patient
readmission for treatment of perioperative pain.With aging
of the U.S population, more surgeries are being performed
annually that translates into a higher absolute number of
older surgical patients where pain management continues to
pose a challenge for clinicians.As discussed, inadequate pain
management can have profound and even long-lasting
negative implications (stresses of surgery & postoperative
stress, poor surgical outcome, etc.).Increasing evidence
shows that uncontrolled or inadequately controlled pain after
surgery serves as a risk factor for the development of chronic
pain and that efforts to manage pain in the perioperative
period may be very effective in reducing such a burden.

8. Conclusion
Pain management in the elderly and cognitively impaired
is associated with specific complicating elements
surrounding perioperative events.Geriatric patients typically
suffer from a greater number of co-morbid diseases, have
lower organ function reserve, and demonstrate altered
physiologic and pharmacologic reactions.There are also
unique challenges in pain assessment.For example, it may
require more time for older patients to understand the pain
scale due to barriers such as vision, hearing or cognitive
defects.In addition, elderly patients also tend to underreport
pain and effective perioperative pain management requires
careful assessment of pain and sensible dosing of
analgesics.It is also crucial to be aware of potential AEs
secondary to analgesic options and to keep a close watch for
adverse effect development.
Incorporating perioperative regional anesthesia/analgesia
and multimodal drug therapy may prove to be the most
effective approach to perioperative pain management in the
elderly and cognitively impaired with the least amount of
physiological compromise.Regional anesthesia may benefit
older patients by reducing postoperative neurological,
pulmonary, cardiac and endocrine complications and.to
potentially improve immediate postoperative pain control,

Universal Journal of Medical Science 1(2): 36-49, 2013

but it has not been proven to improve long-term

morbidity.Multimodal drug therapy is another potentially
advantageous choice toward perioperative pain management
that utilizes a variety of analgesics in order to minimize
dosages and adverse effects of any single agent while
maximizing analgesic effect.
Perioperative pain management in the elderly, despite
several real and potential advantages in addition to newer
non-opioid analgesic advances continues to be an issue of
concern.Studies have demonstrated many reports of
inadequate postoperative pain management, sometimes
necessitating readmission to the hospital.77,78,79Therefore, it
remains necessary to implement carefully thought out
postoperative pain medicine therapies and to continue to
develop new methods of pain management for all patients,
especially the growing elderly surgical population.

Commercial or institutional resources did not sponsor this
article and author received no financial support.The author
has no conflict of interest with regard to this manuscript.



study of regional versus general anaesthesia in 438 elderly

patients. ActaAnaesthesiolScand 2003; 47: 260-66.
[10] White P, Kehlet H. Improving postoperative pain
management; what are the unresolved issues? Anesthesiology.
2010; 112: 220-25.
[11] Moore, J, Kelz, M. Opioids, sleep and pain: the adrenergic
link. Anesthesiology. 2009; 111:1175-76.
[12] Kam PC, Calcroft RM. Perioperative stroke in general
surgery patients. Anaesthesia. 1997;52:879-83.
[13] Olfosson B, Lundstrom M, et al. Delirium is associated with
poor rehabilitation outcome in elderly patients treated for
femoral neck fractures. Scand J Caring Sci. 2005;19:119-27.
[14] Murkin JM, Martzke JS, et al. A randomized study of the
influence of perfusion technique and pH management
strategy in 316 patients undergoing coronary artery bypass
surgery. II. Neurologic and cognitive outcomes. J
ThoracCardiovasc Surg. 1995;110:349-62.
[15] Lawrence VA, Hilsenbeck SG, et al. Incidence and hospital
stay for cardiac and pulmonary complications after abdominal
surgery. J Gen Intern Med. 1995;10:671-78.
[16] Moller JT, Cluitmans P, et al. Long-term postoperative
cognitive dysfunction in the elderly: ISOPCD study 1. Lancet.
[17] Marcantonio ER, Goldman L, et al. A clinical prediction rule
for delirium after elective noncardiac surgery. JAMA.


Warfield C, Kahn C. Acute pain management. Programs in

US hospitals and experiences and attitudes among US adults.
Anesthesiology. 1995; 83(5): 1090-1094.

[18] Monk TG, Weldon BC, et al. Predictors of Cognitive

Dysfunction after Major Noncardiac Surgery. Anesthesiology
2008; 108:18-30.


Haljamae H, Stromberg M. Postoperative pain

management-clinical practice is still not optimal.
CurrAnaesthCrit Care. 2003; 14:207-10.

[19] Zakriya K, Sieber FE, et al. Brief postoperative delirium in

hip fracture patients affects functional outcome at three
months. AnesthAnalg. 2004;98:1798-1802.


Leung JM, Dzankic S. Relative importance of preoperative

health status versus intraoperative factors in predicting
postoperative adverse outcomes in geriatric surgical patients.
J Am Ger Soc. 2001;49:1080.

[20] Inouye SK, Peduzzi PN, et al. Importance of functional

measures in predicting mortality among older hospitalized
patients. JAMA. 1998;279:1187-93.


Bettelli G. Anaesthesia for the elderly outpatient:

preoperative assessment and evaluation, anaesthetic
management .CurrOpinAnesthesiol. 2010;23:726-731.


Buvanendran A, Kroin J. Multimodal analgesia for

controlling acute postoperative pain. CurrOpinAneastheiol.
2009; 22(5): 588-93.


Sinatra, R. Opioids and Opioid Receptors. In Sinatra RS, Jahr

JS, Watkins-Pitchford JM, eds. The Essence of Analgesia and
Analgesics, Cambridge University Press, 2011, pp 73-80.


Brambrink A, Evers A, Avidan M, et al. Isoflurane induced

neuroapoptosis in the neonatal Rhesus macaque brain.
Anesthesiology. 2010; 112: 843-41.


Cully D, Xie Z, Crosby G. General anesthetic induced

neurotoxicity: an emerging problem for the young and old?
CurropinAnaesthesiol. 2007; 20: 408-13.


Rasmussen L, Johnson T, Kuipers H, et al. Does anaesthesia

cause postoperative cognitive dysfunction?: a randomized

[21] Inuoye SK, Schlesinger MJ, et al. Delirium: A symptom of

how hospital care is failing older persons and a window to
improve quality of hospital care. Am J Med.
[22] Mackensen GB, Gelb AW. Postoperative cognitive deficits:
more questions than answers. Eur J Anaesthesiol.
[23] Parker MJ, Handol HH, et al. Anaesthesia for hip fracture
surgery in adults. Cochrane Database Syst Rev.
[24] Inouye SK, Viscoli CM, et al. A predictive model for delirium
in hospitalized elderly patients based on admission
characteristics. Ann Intern Med. 1993;119:474-7.
[25] Lynch EP, Lazor MA, et al. The impact of postoperative pain
on the development of postoperative delirium. AnesthAnalg.
[26] Block BM, Lui SS, et al. Efficacy of postoperative epidural
analgesia: a meta-analysis. JAMA. 2003;290:2455-2463.
[27] Hodgson PS, Liu SS. Thoracic epidural anaesthesia and


Perioperative Pain Management in the Elderly Surgical Patient

analgesia for abdominal surgery: Effects on gastrointestinal

[28] Ballantyne JC, Carr DB, et al. The comparative effects of
postoperative analgesic therapies on pulmonary outcomes:
cumulative meta-analysis of randomized controlled trials.
AnesthAnalg. 1998;86:598-612.
[29] Rodgers A, Walker N, et al. Reductions of postoperative
mortality and morbidity with epidural or spinal anesthesia:
results from overview of randomized trials. Br Med J.
[30] Williams-Russo P, Sharrock NE, et al. Cognitive effects after
epidural vs general anesthesia in older adults. A randomized
trial. JAMA. 1995;274:44-50.
[31] Riis J, Lomholt B, et al. Immediate and long term mental
recovery fro general versus epidural anesthesia in elderly
patients. ActaAnaesthesiol Scand. 1983;27:44-49.
[32] Peters A. Structural changes in the normally aging cerebral
cortex of primates. Prog Brain Res. 2002;136:455-65.
[33] Alexander-Bloch A, Raznahan et al. The convergence of
maturational change and structural covariance in human
cortical networks. J neurosci. 2013: 33: 2889-99
[34] Wright RM, Warpular RW. Geriatric pharmacology: safer
prescribing for the elderly patient. J Am Podiatr Med Assoc.
2004:94: 90-7.
[35] Turnheim K. When drug therapy get old: pharmacokinetics
and pharmacodynamics in the elderly. ExpGerontol.

Roy RC. Choosing general versus regional anesthesia for the

elderly. AnesthesiolClin North America. 2000;18:91-104.

[37] Park WY, Thompson JS, et al. Effect of epidural anesthesia

and analgesia on perioperative outcome: a randomized
controlled Veterans Affairs cooperative study. Ann Surg.
[38] Matot I, Oppenheim-Eden A, et al. Preoperative cardiac
events in elderly patients with hip fracture randomized to
epidural or conventional analgesia. Anesthesiology.
[39] Beattie WS, Badner NH, et al. Epidural analgesia reduces
postoperative myocardial infarction: a meta-analysis.
AnesthAnalg. 2001;93:853-58.
[40] Mangano DT, Hollenberg M, et al. Perioperative myocardial
ischemia in patients undergoing non-cardiac surgery-I:
Incidence and severity during the 4 day perioperative period.
J Am CollCardiol. 1999;17:843-50.
[41] Badner NH, Knill RL, et al. Myocardial infarction after
noncardiac surgery. Anesthesiology. 1998;88:572-78.
[42] Trip MD, Volkert MC, et al. Platelet hyper-reactivity and
prognosis in survivors of myocardial infarction. N Engl J Med.
[43] Wu CL, Hurley RW, et al. Effect of postoperative analgesia
on morbidity and mortality following surgery in Medicare
patients. RegAnesth Pain Med. 2004;29:525-33.
[44] Beattie WS, Bander NH, et al. Meta-analysis demonstrates
statistically significant reduction inpostoperative myocardial

infarction with the use of thoracic epidural analgesia.

AnesthAnalg. 2003;97:919-20.
[45] Peterson DD, Pack AI, et al. Effects of aging on ventilatory
and occlusion pressure responses to hypoxia and hypercarbia.
Am Rev Respir Dis. 1981;124:387-391.
[46] Gruber EM, Tschernko EM. Anaesthesia and postoperative
analgesia in older patients with chronic obstructive
pulmonary disease: special considerations. Drugs Aging.
[47] Don HF, Wahba M, et al. The effects of anesthesia and 100%
oxygen on the functional residual capacity of the lungs.
Anesthesiology. 1970;32:521-529.
[48] Rigg JR, Jamrozik K, et al. MATS: epidural anaesthesia and
analgesia and outcome of major surgery: a randomized trial.
Lancet. 2002;13:1276-82.
[49] Werawatganon T, Charuluxananan S. Patient controlled
intravenous opioid analgesia versus continuous epidural
analgesia for pain after intra-abdominal surgery. Cochrane
Database of Systematic Reviews 2005, Issue 1. Art. No.:
CD004088. DOI: 10.1002/14651858.CD004088.pub2.
[50] Craig DB. Postoperative recovery of pulmonary function.
AnesthAnalg. 1981;60:46-52.
[51] Savas JF, Litwack r, et al. Regional anesthesia as an
alternative to general anesthesia for abdominal surgery in
patients with severe pulmonary impairment. Am J Surg.
[52] Moraca RJ, Sheldon DG, Thirby RC. The role of epidural
anesthesia analgesia in surgical practice. Ann Surg.
[53] Kehlet H, Holte K. Effect of postoperative analgesia on
surgical outcome. Br J Anaesth. 2001;87:62-72.
[54] [54] Nishimori M, Ballantyne JC, Low JHS. Epidural pain
relief versus systemic opioid-based pain relief for abdominal
aortic surgery. Cochrane Database of Systematic Reviews
[55] Liu S, Carpenter RL, et al. Epidural anesthesia and analgesia:
their role in postoperative outcome. Anesthesiology.
[56] Carli F, Halliday D. Continuous epidural blockade arrests the
postoperative decrease in muscle protein fractional synthetic
rate in surgical patients. Anesthesiology. 1997;86:1033-40.
[57] Holte K, Kehlet H. Epidural anesthesia and analgesia-effects
on surgical stress responses and implications for
postoperative nutrition. ClinNutr. 2002;21:199-206.
[58] Horlocker T, Wedel D, Rowlingson J, et al. Regional
Anesthesia in the patient receiving antithrombotic or
thrombolytic therapy: American Society of Regional
Anesthesia and Pain Medicine Evidence-Based Guidelines
(Third Edition). RegAnesth Pain Med. 2010; 35(1): 64-101.
[59] Knotkova H, Pappagallo M. Adjunct
AnesthesiolClin. 2007; 25(4): 775-86.


[60] McDaid C, Maunde E, Rice S, et al. Paracetamol and

selective and non-selective nonsteroidal anti-inflammatory
drugs (NSAIDs) for the reduction of morphine-related side

Universal Journal of Medical Science 1(2): 36-49, 2013

effects after major surgery: a systemic review. Health

Technol Assess. 2010; 14(17): 1-153.
[61] White P, Tang J, Wender R, et al. The effects of oral
ibuprofen and celecoxib in preventing pain, improving
recovery outcomes and patient satisfaction after ambulatory
surgery. AnesthAnalg. 2011; 112(2): 323-29.
[62] Buvanendran A, Kroin J. Multimodal analgesia for
controlling acute postoperative pain. CurrOpinAnaesthesiol.
2009; 22(5): 588-93.
[63] Gloth, FM. AGS 2009 Guidelines for Pharmacological
Management of Persistant Pain in Older Adults. Handbook of
Pain Relief in Older Adults: An Evidence-Based Approach,
Aging Medicine, DOI 10.1007/978-1-60761-618-4_4.
Springer Science and Business Media, LLC 2011.
[64] ] Han H, Lee d, Chung J. Characteristics of ectopic discharges
in a rat neuropathic pain model. Pain. 2000; 84(2-3): 253-61.
[65] Commissiong J, Karoum F, Neff N, et al. Cyclobenzaprine: a
possible mechanism of action for it muscle relaxant effect.
Can J PhysiolPharmacol. 1981; 59: 37-44.


[71] Liu SS, Carpenter RL, et al. Effects of perioperative analgesic

technique on the rate of recovery after colon surgery.
Anesthesiology. 1995;83:757-65.
[72] Kehlet H. Multimodal approach to control postoperative
pathophysiology and rehabilitation. Br J Anaesth.
[73] Brodner G, Pogatzki E, et al. A multimodal approach to
control postoperative pathophysiology and rehabilitation in
patients undergoing abdominalthoracicesophagectomy.
AnesthAnalg. 1998;86:228-34.
[74] Brodner G, Van Aken H, et al. Multimodal perioperative
management-combining thoracic epidural analgesia, forced
mobilization, and oral nutrition-reduces hormonal and
metabolic stress and improve convalescence after major
urologic surgery. AnesthAnalg. 2001;92:1954-1600.
[75] Basse L, Jacobsen D, et al. A clinical pathway to accelerate
recovery after colonic resection. Ann Surg. 2000;232:51-7.
[76] Kehlet H, Wilmore DW. Multimodal strategies to improve
surgical outcome. Am J Surg. 2002;183:630-41.

[66] Pobereskin L, Sneyd J. Does wound irrigation with

triamcinalone reduce pain after surgery to the lumber spine?
Br J Anaesth. 2000; 84:731-34.

[77] Wu CL, Caldwell MD. Effect of post-operative analgesia on

patient morbidity. Best Pract Res ClinAnaesthesiol. 2002

[67] Archer KR, Motzny N, et al. Cognitive-Behavioral Based

Physical Therapy to Improve Surgical Spine Outcomes: A
Case Series. PhysTher. 2013 Apr 18.

[78] Coley KC, Williams BA, et al. Retrospective evaluation of

unanticipated admissions and readmissions after same day
surgery and associated costs. J ClinAnesth. 2002;14:349-53.

[68] Kahn L, Baxter FJ, et al. A comparison of thoracic and lumbar

epidural techniques for post-thoracoabdominal
esophagectomy analgesia. Can J Anaesth. 1999;46:415-422.

[79] Apfelbaum JL, Cehn C, et al. Postoperative pain experience:

results from a national survey suggest postoperative pain

[69] Kock M, Blomberg S, et al. Thoracic epidural anesthesia

improves global and regional left ventricular function during
stress-induced myocardial ischemia in patients with coronary
artery disease. AnesthAnalg. 1990;71:625-30.
[70] Kehlet H. Modification of responses to surgery by neural
blockade: Clinical implication. In Cousins MJ, Bridenbaugh
PO (eds): Neural Blockade in Clinical Anesthesia and
Management of Pain, 3rd ed. Lippincott Raven, 1998,

[80] Block BM, Liu SS, Rowlingson AJ, Cowan AR. Efficacy of
postoperative epidural analgesia: a meta-analysis. JAMA.
2003 Nov 12;290(18):2455-63.
[81] Cartin-Ceba, R, Sprung, J, et al. The Aging Respiratory
System: Anesthetic Strategies to Minimize Perioperative
Pulmonary Complications. Silverstein, JH(ed): Geriatric
Anesthesiology, 2008, pp149-164.