As people age, they experience life-altering events, such as serious illnesses, that can create a sense of hopelessness and lead to a loss of meaning in their lives and in the lives of their families. Often, patients and families may find themselves in a state of despair, finding it difficult to cope. Clinicians who provide care to older adults in any care setting can play a critical role in restoring order to devastated patients and families. In this article, the author provides his perspective on creating both empathy and a compassionate presence and describes a methodology for building the cognitive and emotional foundation for a physician–patient relationship and a framework for shared decision-making.
Frailty and multimorbidity may be regarded as a homeostatic failure of a complex system, and these conditions are commonly encountered in elderly people. The concept of “frailty” has been used to d ...
Opioid medications are considered key therapeutic interventions in the management of both acute pain and cancer-related pain among patients of all ages; however, their role in treating patients with chronic noncancer pain remains controversial. While the debate about the appropriate role of opioids in the treatment of chronic pain continues, the fact remains that many clinicians prescribe opioids to patients in the outpatient setting or treat patients already taking an opioid. These patients include those with acute pain, those receiving palliative care (eg, patients with advanced heart or renal disease), as well as those with persistent noncancer pain disorders, such as postherpetic neuralgia, spinal stenosis, and osteoarthritis. While many factors must be considered when treating the primary care patient receiving an opioid in accordance with clinical practice guidelines,1,2 clinical decision-making must take into account the unique considerations for treating older adults, including age-related physiologic changes, multimorbidity, frailty, sensory and/or cognitive impairment, and polypharmacy—all of which can increase the risk for adverse treatment outcomes.3 This review describes four approaches to managing opioid-induced side effects that can be implemented both before and during opioid treatment: dose reduction, opioid rotation, altering the route of opioid administration, and symptomatic management of adverse effects. More than a decade ago, these four approaches were formulated and published by the Expert Working Group of the European Association of Palliative Care (EAPC) with specific attention paid to managing adverse effects of oral morphine; however, this set of guidelines continues to be a timely and valuable resource that can be used to manage the side effects of any opioid analgesic.4 Successful implementation of these approaches can lead to improvements in medication adherence, opioid tolerability, and analgesic effect. A summary of the evidence-based rationales for each approach and our recommendations for how to implement these strategies in the clinical care of geriatric patients are provided.
