Pain management in older adults

In older adults, the safest effective treatment is usually the least systemic one. Know the 2023 Beers listings, avoid stacking CNS-active drugs, prefer topicals, and dose-adjust NSAIDs and opioids for age, weight and kidney function.

1. Beers is the reference list. The 2023 AGS Beers Criteria flag drugs to avoid in adults 65 and older, including skeletal muscle relaxants, strongly anticholinergic antidepressants such as amitriptyline, meperidine, ketorolac and indomethacin ¹.
2. Avoid stacking CNS-active drugs. Beers advises avoiding any combination of three or more CNS-active drugs, such as opioids, gabapentinoids, hypnotics and benzodiazepines, because of falls and fractures; CDC also cautions against combining opioids with sedatives ¹².
3. Prefer topical and low-exposure therapy. For knee osteoarthritis, topical NSAIDs are strongly recommended and should be considered before oral NSAIDs ³. For localized neuropathic pain, a lidocaine 5% patch avoids systemic anticholinergic and sedative effects ⁴.
4. NSAIDs need limits. Beers advises avoiding chronic use of nonselective NSAIDs unless alternatives fail and a gastroprotective agent is used ¹. Ketorolac at 65 or older is reduced to 15 mg every 6 hours, maximum 60 mg/day, for no more than 5 days ⁵.
5. Choose and dose opioids carefully. Meperidine is a poor oral analgesic with neurotoxicity and delirium risk and should be avoided ¹. Tramadol adds seizure and serotonergic risks and needs dose reduction as renal function declines ⁶.
6. Osteoporotic fractures: stay mobile. For osteoporotic compression fractures, a Cochrane review found high- to moderate-quality evidence that vertebroplasty gives no important benefit over placebo for pain, disability or quality of life; analgesia, mobility and osteoporosis treatment are the mainstay ⁷.

Falls on several CNS-active drugs is a deprescribing problem: remove Beers-listed sedatives first, and never substitute a first-generation antihistamine, which is itself strongly anticholinergic ¹.

• Muscle relaxants are poorly tolerated in older adults (anticholinergic effects, sedation, fractures), and their effectiveness at tolerated doses is questionable ¹.
• Amitriptyline's Beers listing reflects anticholinergic effects, sedation and orthostatic hypotension ¹.
• Ketorolac is avoided altogether; naproxen is avoided only for chronic use ¹.
• Beers flags antidepressants in patients with a history of falls or fractures ¹.
• Topical diclofenac is kinder to the kidneys than oral, but at-risk patients still need monitoring ⁸.
• The 2023 update added skeletal muscle relaxants to the drug classes counted in the three-or-more CNS-active drug criterion ¹.

• Reading "avoid" in Beers as "use only short courses" ¹.
• Starting oral NSAIDs first in an older adult with CKD when a topical NSAID fits ³.
• Adding a sedating drug to fix sleep in a patient who is already falling ¹.
• Assuming vertebroplasty is the standard fix for a painful osteoporotic fracture ⁷.