Evaluation and Treatment of Acute Trauma Pain in Older Adults.

In the context of an ageing population, the demographic sands of trauma are shifting. Increasingly, trauma units are serving older adults who have sustained injuries in low-energy falls from a standing height. Older age is commonly associated with changes in physiology, as well as an increased prevalence of frailty and multimorbidity, including cardiac, renal and liver disease. These factors can complicate the safe and effective administration of analgesia in the older trauma patient. Trauma services therefore need to adapt to meet this demographic shift and ensure that trauma clinicians are sufficiently skilled in treating pain in complex older people. This article is dedicated to the management of acute trauma pain in older adults. It aims to highlight the notable clinical challenges of managing older trauma patients compared with their younger counterparts. It offers an overview of the evidence and practical opinion on the merits and drawbacks of commonly used analgesics, as well as more novel and emerging analgesic adjuncts. A search of Medline (Ovid, from inception to 7 November 2022) was conducted by a medical librarian to identify relevant articles using keyword and subject heading terms for trauma, pain, older adults and analgesics. Results were limited to articles published in the last 10 years and English language. Relevant articles' references were hand-screened to identify other relevant articles. There is paucity of dedicated high-quality evidence to guide management of trauma-related pain in older adults. Ageing-related changes in physiology, the accumulation of multimorbidity, frailty and the risk of inducing delirium secondary to analgesic medication present a suite of challenges in the older trauma patient. An important nuance of treating pain in older trauma patients is the challenge of balancing iatrogenic adverse effects of analgesia against the harms of undertreated pain, the complications and consequences of which include immobility, pneumonia, sarcopenia, pressure ulcers, long-term functional decline, increased long-term care needs and mortality. In this article, the role of non-opioid agents including short-course non-steroidal anti-inflammatory drugs (NSAIDs) is discussed. Opioid selection and dosing are reviewed for older adults suffering from acute trauma pain in the context of kidney and liver disease. The evidence base and limitations of other adjuncts such as topical and intravenous lidocaine, ketamine and regional anaesthesia in acute geriatric trauma are discussed.

Tetanus presenting as painful muscle spasms, dysphagia and delirium in an older adult.

While tetanus is now a rare disease in the UK, it remains an important differential diagnosis for trismus and muscle spasms. Even more so in older adults, as this population is less likely to have received full vaccination. Hence, the highest incidence of tetanus in England is seen in older adults. Written informed consent for publication of their clinical details was obtained from the patient proxy.

Ankle pressures in UK South Asians with diabetes mellitus: a case control study.

OBJECTIVES: To study ethnic differences in ankle pressures in South Asians versus Europeans and in those with and without diabetes mellitus (DM). DESIGN: Case control. SETTING: Primary care. PARTICIPANTS: 391(DM=154) South Asian and 252(DM=72) European adults. INTERVENTION: None. MAIN OUTCOME MEASURES: Systolic blood pressure of the left (L) and right (R) brachial, posterior tibial (PT) and dorsalis pedis (DP) arteries were measured using a Doppler probe. RESULTS: In comparison with Europeans, in young South Asians, DM was diagnosed 12 years earlier but pressures were lower, p ≤ 0.0001 for all (RPT (146 vs 157 mm Hg), LPT (143 vs 154 mm Hg), RDP (138 vs 150 mm Hg) and LDP (137 vs 149 mm Hg)). Pack year was greater in Europeans. Odds ratios of cardiovascular disease in relation to ankle pressure were increased in South Asians with ankle brachial index between 0.9 and 1.3 or >1.3. Linear regression in South Asians identified age was an independent predictor of increased pedal pressures, DM of increased RPT and LDP, and sex of LPT and LDP. In Europeans, age was an independent predictor of increased pedal pressures, and sex and pack years were independent predictors of decreased pedal pressures. In South Asians, all ankle pressure and in Europeans, RPT, LPT and LDP were increased in subjects with DM versus without. Ankle pressures and cardiovascular disease in South Asians with DM were similar to those of 10 years older Europeans with DM. CONCLUSIONS: South Asians with DM had higher ankle pressures versus without and were similar to 10 years older Europeans with DM. Prospective studies on ankle pressures for development of diabetes or cardiovascular disease are warranted in South Asians.