Severe pain and morphine in the elderly patient in the emergency department

Management of severe pain in the elderly patient in the emergency department continues to be inadequate despite recent progress and recommendations for use of opiates in the acute situation. The vulnerability of patients in this age group is a feared consequence of pain. An appreciation of the mechanisms of hyperalgesia in the elderly, of the effect of ageing on the pathophysiology of pain, and of the tendency of the elderly not to express to the full their experience of severe pain helps to facilitate the identification of such pain (commoner in the old than in the young) by the use of appropriate scales to measure its intensity. The use of hetero-evaluation whenever self-evaluation is impossible should become routine. New scales which are more appropriate in the emergency medicine setting are making it easier to do this currently. The treatment of severe acute pain in the emergency department requires use of step 3 of the pain relief ladder from the outset and, as in the young, morphine remains the reference agent. The difficulty is in being effective without causing iatrogenic problems in these frail, polymedicated patients. Safety can still be ensured by using a method of intravenous titration, most frequently without adjustment of dose level, although age-related increase in sensitivity to morphine has been described. The subcutaneous route, by contrast, carries greater risks than in the young. It should be reserved for follow-up analgesia, with a reduction of 25 to 50% in the usual dose regime, as applies also to oral administration. PCA (patient controlled analgesia) is not contraindicated, but is reserved for special cases. Finally, data for the recommended analgesic strategies taken as a whole are lacking in the very elderly (more than 85 years of age) and in patients who are unable to communicate. But careful and well-monitored administration of major analgesics should, nevertheless, facilitate pain relief in these patients. Morphine remains the only effective and safe treatment of acute severe pain in the emergency department. Assessment of the pain is carried out qualitatively, taking into account its intensity and the patient's cognitive function. A strict protocol and monitoring should be employed by a trained team.