PATIENT-CONTROLLED analgesia (PCA) has proven to be an important concept and therapeutic tool in the quest to improve acute pain management. The pharmacologic and nonpharmacologic benefits of PCA have been studied extensively and discussed widely. Despite these benefits, some acute pain therapists are reluctant to offer PCA to older patients, having seen that some members of this group are unwilling or unable to use PCA effectively. Explanations for this failure of therapy have included lack of understanding of the technique by older patients, different attitudes among older patients with regard to pain relief, and patient roles and fears of complications associated with analgesics or PCA equipment. The possibility of differences in pain perception or pain reporting with advancing age has also been considered. In this issue of Anesthesiology, Gagliese et al. 1have provided further insight into the influence of patient age on PCA therapy. The authors have systematically compared postoperative PCA use in two adult populations with mean ages of 39 and 67 yr. In addition to the anticipated findings related to opioid consumption and pain scores, this work includes evaluation of the effects of age on preoperative psychologic factors, concerns regarding PCA therapy, and treatment satisfaction.
Gagliese et al. 1observed that, on the first postoperative day, PCA morphine consumption averaged 66.6 mg in the younger group, compared with 39.1 mg in the older group (see table 5). These values are remarkably similar to the morphine requirements predicted by Macintyre and Jarvis in 1996. 2Those authors recommended the following formula for estimating average morphine requirements based on patient age:
In the current study, it was further shown that older patients did not self-administer less opioid than did younger patients on the basis of their concerns about pain relief, adverse drug effects (including opioid addiction), or PCA equipment use or malfunction. In fact, with the lower doses the older patients chose to use, they reported levels of analgesia at rest and with movement that were similar to those of their younger counterparts. By contrast, lower pain scores after surgery in older patients has also been reported. 3Another finding in the current study was that older patients preferred less information about and less direct involvement in their health care, but, compared with the younger group, they had similar attitudes toward PCA, similar confidence in their ability to use it successfully, and similar satisfaction with the technique.
Overall success in using PCA is a function of the inherent benefits of the technique, in combination with the expertise and knowledge of the supervising therapists. 4It can be argued that, because older patients tend to be medically more complex and more vulnerable to complications, they may benefit more from such expertise. All patients in this study received medical supervision from an anesthesiology-based acute pain service. One wonders whether outcomes would have differed more in the two study groups if they had less expert medical and nursing supervision.
It should be remembered that all patients in this study were screened and selected on the basis of absence of confusion and an ability to understand and participate in their own care. It would be interesting to know how many octogenarians were excluded from the study because they did not meet those criteria.
Finally, as the authors have emphasized, this study compared groups with average ages of 39 and 67 yr. Although it is reassuring to see that the older group was as successful as the younger group in effectively using PCA, we must await further studies to learn how effective PCA would be in a group with an average age of 80 yr or older. To this reader, the age of 67 does not seem nearly as “old” as it once did.