What are the alternatives for pain management in an 89-year-old lady with hip dislocation who cannot take Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Pain Management for Hip Dislocation in an 89-year-old Patient Unable to Take NSAIDs

For an 89-year-old lady with hip dislocation who cannot take NSAIDs, a multimodal analgesic approach should be implemented with intravenous acetaminophen as first-line treatment, supplemented with peripheral nerve blocks and carefully titrated opioids only for breakthrough pain. 1

First-Line Treatment Options

Acetaminophen

• Administer intravenous acetaminophen 650 mg every 6 hours regularly as baseline treatment 1
• Maximum daily dose should not exceed 3-4g/day 1
• Provides effective baseline analgesia with minimal side effects in elderly patients
• Particularly important when NSAIDs are contraindicated

Regional Anesthesia Techniques

• Peripheral nerve blocks are strongly recommended as they:

  • Significantly reduce opioid requirements 1
  • Provide excellent pain relief for hip injuries 1
  • Have fewer side effects than systemic analgesics in elderly patients 1

• Specific nerve block options:

  • Femoral nerve block (recommended based on efficacy in hip fracture) 1
  • Posterior lumbar plexus block (greater efficacy than femoral blocks but higher risk of complications) 1
  • Consider continuous infusion via catheter rather than single-shot approach for extended analgesia 1

Second-Line/Adjunct Options

Opioids (Use with Caution)

• Reserve for breakthrough pain only, at the lowest effective dose for the shortest duration 1
• For elderly patients over 75 years, total daily dose should not exceed 300 mg/day for tramadol 2
• Start with lower doses (50% reduction) and extend dosing intervals to 12 hours in patients with renal dysfunction 1
• Avoid codeine as it causes constipation, nausea and cognitive dysfunction in the elderly 1
• If using tramadol:
  • Start at lowest dose (50 mg) and titrate slowly
  • Maximum 200 mg/day in patients with renal impairment 2
  • Initiate with a slow titration regimen to improve tolerability 2

Other Adjunctive Therapies

• Gabapentinoids may be considered as part of multimodal analgesia 1
• Lidocaine patches for localized pain 1
• Non-pharmacological measures:
  • Proper immobilization of the affected limb
  • Ice packs applied to reduce local inflammation and pain 1
  • Positioning to minimize stress on the affected hip

Special Considerations for Elderly Patients

Monitoring

• Regular assessment of pain using appropriate scales for elderly patients
• Close monitoring for side effects, especially cognitive changes, sedation, and respiratory depression
• Monitor renal function when using any medications with renal clearance

Cautions

• Avoid opioids when possible due to increased risk of:
  • Respiratory depression
  • Confusion and delirium
  • Falls
  • Constipation
• If opioids are necessary, use the lowest effective dose with careful titration

Algorithm for Pain Management

1. Start with IV acetaminophen 650 mg every 6 hours
2. Implement peripheral nerve block (femoral or lumbar plexus) if expertise available
3. For breakthrough pain only:
   • Consider low-dose tramadol (start at 50 mg every 12 hours)
   • Titrate slowly based on response and tolerability
4. Add non-pharmacological measures (proper positioning, ice packs, immobilization)
5. Reassess pain control frequently and adjust regimen as needed

This approach prioritizes safety while providing effective pain control for an elderly patient with hip dislocation who cannot take NSAIDs, focusing on minimizing morbidity and mortality while maintaining quality of life.