Surgical oncology
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Postoperative pain is often underestimated in elderly patients, based on considerations of the limited function of kidney and liver with advancing age or presumed high threshold of pain sensation. Achieving adequate pain management for the older patient is complicated by comorbid diseases, increased risk of adverse drug reactions, and physician factors such as inadequate training and reluctance to prescribe opioid medications. Anticholinergic load has been related to impaired cognitive and physical function. ⋯ Patient-controlled analgesia (PCA) permits analgesic titration according to the patient's own needs and greatly reduces the risk of overdose because of increased individual sensitivity to analgesic drugs. The success of such a technique depends on close evaluation of all preoperative and intraoperative factors that can cause or contribute to acute delirium. In the present paper we review the literature on this pivotal field.
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Neuropathic pain, i.e., pain arising as a direct consequence of a lesion or disease affecting the somatosensory system, is a frequent complaint in the elderly. The frequency of herpes zoster and peripheral neuropathy, the commonest diseases that cause neuropathic pain, increases with age. More than half of all persons in whom herpes zoster develops are older than 60 years and about 30% of these patients will ultimately suffer from chronic postherpetic neuralgia. ⋯ This age-related nociceptive pathway degeneration probably explains why elderly patients tend to under-report pain in many medical conditions including myocardial infarction, fractures, and arthritis. This age-related impairment probably plays a key role in the development of neuropathic pain. In this report we describe the most reliable methods for assessing neuropathic pain such as laser evoked potential (LEP) recordings and skin biopsy, procedures that selectively assess nociceptive pathways in order to obtain a rapid diagnosis and hence determine treatment.