ProfessorDepartment of AnesthesiologyDirectorUniversity of Washington Medical Center Pain ServiceUniversity of Washington School of Medicine Seattle, Washington 98195-6540lbready@u.washington.eduPATIENT-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.

In most healthy individuals, dexamethasone suppresses adrenal cortisol production. However, in patients with major depression, non-suppression frequently occurs and thus may be a marker for depression. The purpose of the present study was to examine the relationship of dexamethasone suppression test (DST) non-suppression to clinical variables such as major depression, site and duration of pain, prior surgery, and medication use in 81 chronic pain patients beginning inpatient pain treatment (Inpt. Pain), and 33 medication-restricted outpatients with chronic back pain and depression (Outpt. Back). In the Inpt. Pain group, the specificity of DST non-suppression for depression was 82% and for sensitivity 24%. In the Outpt. Back group, its sensitivity was 18%. Within the diverse inpatient samples, there was 69% non-suppression in patients with headache pain only, compared to 15% in patients with other sites of pain (P < 0.01), but there was no significant difference in depression rate between these two groups. In the Inpt. Pain group, non-suppressors also had significantly less prior surgery. In the Outpt. Back group, opioid use was significantly higher in non-suppressors (33%) than in suppressors (11%). In chronic pain populations, the DST appears not to be useful clinically for the detection of depression and may be significantly affected by clinical variables other than depression.

Regional Anesthesia Division, Department of Anesthesiology, University of Washington, School of Medicine, Seattle, WA 98195 U.S.A.

John Barsa Constantino Benedetti John A. Bokan Monte S. Buchsbaum Stephen H. Butler Donald A. Calsyn William H. Calvin Amiram Carmon C. Richard Chapman Andrew C.N. Chen Willie K. Dong Samuel F. Dworkin Steven G. Fey B. Raymond Fink Wilbert E. Fordyce Gerald F. Gebhart Lawrence M. Halpern John F. Howe Bernard Kenton John C. Liebeskind John D. Loeser Richard F. Martin Harold Merskey Terence Murphy L. Brian Ready Ronald R. Tasker Arnold L. Towe Judith A. Turner Donald C. Tyler