Older patients make up a large and increasing proportion of surgical patients. Effective postoperative pain control is critical in this group of patients because of the potential to develop postoperative confusion and high rates of morbidity and mortality associated with inadequate pain control. Frequently, postoperative pain management is inadequate despite the availability of a wide variety of treatment options. PCA is an effective modality for younger patients. Numerous studies have found advantages of using PCA opioids in elderly adults, including decreased pulmonary and cognitive complications as compared to intramuscular injections and decreased opiate use with increasing age. The decreased use of intravenous opiates by elderly adults has been attributed to a number of factors. One possibility is that the elderly self-administer less drug because they experience less intense postoperative pain. Other possibilities may be that elderly patients may be less willing or less able to use the PCA equipment. The elderly may also fear opioid addiction, adverse events or have age related differences in beliefs regarding medical care and pain. The study performed by Gagliese et al. was designed to identify factors that facilitate and hinder effective use of PCA by younger and older patients.

Preoperatively, young (mean age � SD, 39 � 9 yr; n = 45) and older (mean age � SD, 67 � 8 yr; n = 44) general surgery patients completed measures of attitudes toward an expectation of postoperative pain and PCA, psychological distress, health opinions, self-efficacy, and optimism. On the first two postoperative days, pain at rest and with movement and satisfaction with pain control were assessed using visual analog scales. Daily opioid intake was recorded. When PCA was discontinued, satisfaction and concerns about it were assessed.

The older patients expected less intense pain (P0.003) and preferred less information about (P0.02) and involvement in (P0.002) health care than young patients. There were no age differences with regard to pain at rest (P0.22) or with movement (P0.68). The older group self-administered less opioid than the young group (P0.0001) and received PCA for more days than the young group (P0.004). The groups did not differ in concerns about pain relief, adverse drug effects, including opioid addiction, and equipment use or malfunction. Satisfaction with PCA was high and did not differ between the groups.

Patient-controlled analgesia use was not hindered by age differences in beliefs about postoperative pain and opioids. Younger and older patients attained comparable levels of analgesia and were equally satisfied with their pain control.

Many discussions regarding pain control in the in-patient and out-patient setting revolve around barriers to adequate pain control. As our society ages, the barriers to adequate control resulting from generational differences as well as altered physiology with age have been only minimally evaluated. These authors set out to provide an answer to the question of whether or not age is impediment to effective use of PCA by surgical patients. Although the elderly group in this study only has a mean age of 67 years, it begins to address the problem on at least one level. The results may not be immediately extrapolated to incorporate all older adults; however, it is useful to begin to evaluate the effects of age on the use of these pain control tools. In addition, patients who are acutely or chronically confused were ineligible for this study. As the authors so accurately point out, a future study evaluating the use of PCA by older patients and cognitively impaired elderly may provide further valuable insight into the issue of pain control amongst the elderly. The editorial written by L. Brian Ready from the University of Washington Medical Center Pain Service accurately points out that the morphine requirements predicted by Macintyre and Jarvis in 1996 very closely match those obtained in this study by Gagliese et al. PCA morphine consumption averaged 66.6 mg per 24 hours in the younger group compared to 39.1 mg in the older group. The Macintyre and Jarvis formula predicts that average morphine use in 24 hours is equal to 100 minus the age in years. As we encounter an increasingly aged population, new knowledge regarding the best treatment options for pain in the elderly patients undergoing surgery will become increasingly important in our daily practice.

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