The frequent comorbidities seen in the elderly often results in polypharmacy. The effect of drug interactions and the altered handling of drugs in the elderly increases the risk of complications. Caution has to be exercised in developing a management plan with appropriate consideration to side effects and potential interactions.56 Other chapters detail the management of specific conditions and discuss the pharmacology of individual drug groups. In a general sense, the World Health Organization (WHO) analgesic ladder can guide initial pain management. There is a principle in prescribing, particularly in the elderly, to start with a low dose and slowly titrate to benefit or side effects. The aim of pain management is to improve pain and optimize function, particularly with regard to daily activities. The eradication of pain is usually unrealistic and the lowest drug dose will often not provide optimal analgesia. Optimal treatment typically combines pharmacological and nonpharmacological interventions, including the home remedies that patients utilize for themselves. Most elderly patients use a variety of pain management methods, including prescribed medication, rest, and distraction and identify cold, exercise, hot bath/shower, and alcohol as effective.57 Longitudinal studies of nursing home residents suggest that the use of long-acting opioids in a nursing home setting is relatively safe.58
A qualitative study looking at elderly patients preference for pain management strategies and barriers to management found that patients wanted to be actively involved in their management and make informed decisions. They were happy to try new methods and interventions. Conventional medication, exercise, and physiotherapy were the least liked options.59 These studies suggest a need to involve patients more closely and discuss management options with regard to the patient's perspective and preferred strategies.
The use of nondrug interventions is of great importance in optimizing management. Many patients are aware of the interventions they can use at home to ease their pain and optimize function. These may include the use of heat and cold, position, and mobility, as well as aids for moving, dressing, or performing activities of daily living. There is also a role for physical therapy.
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