Acute Pain Care for Older Adults in the 

Emergency Department Setting

HSR&D cyberseminars – Spotlight on Pain Management

July 2, 2013

Ula Hwang, MD, MPH

Associate Professor, Core Investigator

Geriatrics Research, Education and Clinical Center 

HSR&D Research Enhancement Award Program

James J. Peters Department of Veterans Affairs Medical Center

Department of Emergency Medicine 

Brookdale Department of Geriatrics and Palliative Medicine

Icahn School of Medicine at Mount Sinai 
VETERANS HEALTH ADMINISTRATION

No financial conflicts of interest to report

Research funding by: 

 NIH/National Institute on Aging 

 VA HSR&D

Department of Emergency Medicine

Disclosures
VETERANS HEALTH ADMINISTRATION

Today’s talk...

• Acute ED pain care for older adults 

• Constraints of pain care in the ED setting

– ED crowding

– Hip fracture care (geriatric condition)

– General pain care (comparison with younger adults) 

– Prelim VA ED pain care findings
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Survey Question #1

• What best describes your VA role?

1. Researcher

2. Clinician/Patient-Aligned Care Team

3. Clinician/Other

4. Administrator/Policymaker

5. Other (including non-VA)

3 
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Survey Question #2

• What department/division are you affiliated with?

1. Internal Medicine

2. Family Medicine

3. Medicine Subspecialty

4. Surgery 

5. Surgical Subspecialty

6. Neurology

7. Anesthesia

8. Emergency Medicine 

9. Psychiatry/Psychology/Mental Health

10. Ob/Gyn

11. Radiology

12. Pathology

13. Other

4 
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Survey Question #3

• How do you define acute pain care?

1. Documentation of pain assessment

2. Treatment of pain

3. Both 1 & 2

4. Other

5 
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Older Adults in the ED

• In 2035, patients ≥ 65 yo will make up 26% of total ED visits

(US Census Bureau, National Population Projections)

• ≥ 75 yo most likely to have 1 ED visit over 1 yr

(NCHS Data Brief, May 2010)

• Atypical presentations

• Cognitive and/or functional 

impairments

• Co-morbidities (multimorbidity) 

• Polypharmacy

6 

 VULNERABLE POPULATION
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Geriatric Care in the ED

• Quality of care for older adults in the ED limited to focus group 

interviews and small surveys

• Slowly growing body of evidence

• Limited research evaluating the factors impacting clinical care and 

outcomes for geriatric ED patients

• Acute pain care as a model to evaluate general quality of care they 

receive 
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Pain in the ED

• Pain as 5th vital sign

• Identified as an area for quality 

improvement

• Pain is common ED cc

– 70% of ED conditions 

– 34% of all medications in ED for pain

• Inconsistent & inadequate analgesia (oligoanalgesia) 

8 
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Disparities in Analgesia

• Geriatric ED patients have greater rates of oligoanalgesia

- Less likely to receive analgesics (any and opioid) (older vs. younger)

 

• Unrelieved acute pain is associated with adverse 

outcomes.

 - Development of persistent pain

 - Longer hospital lengths of stay

 - Delays to ambulation

 - Development of delirium
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Pain in Older Adults

• High prevalence of pain in older adults

– Self-doubt, reluctant, and reticent to complain

• Co-morbidities, drug-drug interactions, age-related drug 

metabolism changes, and fear of adverse reactions makes giving 

analgesia a challenge 

• 50% ED MDs uncomfortable giving analgesia to elderly
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Polypharmacy

• 90% older adults on ≥ 1 medications

• 40% on >5 medications

• 30-50% receive new prescription at ED discharge

• Risk adverse drug reaction with

– Multiple meds

– Severity of illness

– Multiple comorbidities

– Changes in physiologic reserve
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Physiologic Reserve Loss

Lower body mass, total body water, hepatic and renal function, 

increased fatty tissue

– Pharmacodynamics

(how drugs act at receptor sites and affect the body)

– Pharmacokinetics 

(drug distribution/elimination)

 Caution and awareness in analgesia choice and dosing 

(do no harm...start low and go slow...)

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Geriatric ED Pain Care 

• Frequent assessments

• Do no harm

• Start low and go slow

Akin to management of DKA...

Without frequent assessments of fingersticks (pain level), 

no way to titrate insulin (analgesics)
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Geriatric ED Pain Care 

Quality Indicators

– Pain assessed <1 hour arrival

– F/U assessment <6 hours

– F/U prior to discharge if received pain med

– Pain med if mod-sev pain

– Avoid meperidine

– Bowel regimen if discharged with opioid Rx

(Terrell KM, et.al. Quality indicators for geriatric emergency care. 

Acad Emerg Med. 2009)
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The Emergency Department (ED)

• Unique environment where 

specialized care delivered to 

acutely ill and injured

• Safety net care for 

disenfranchised and 

vulnerable populations
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IOM report on Emergency Care

• Hospital-Based Emergency Care: At 

the Breaking Point, June 2006

– ↑ charity care and ↑ costs related to 

“elder and sicker patients” threaten 

academic medical centers as a safety 

net

– Crowding has disproportionate impact 

on tertiary referral centers' ability to 

provide timely clinical care 
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ED Crowding Outcomes

• Increase

– Mortality rates with higher weekly visits 

– Inpatient mortality, LOS, costs

– Thrombolytic delays for AMI with network ambulance 

diversion 

• Decreased

– CAP antibiotics in <4hours with greater numbers of 

boarders and ED LOS

– Patient satisfaction
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Is ED crowding associated with poorer pain care 

for older adults? 

Are there differences in pain management for 

older adults in the ED?
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Hip fracture

• Condition relatively unique to older adults

• Model for evaluation of pain management 

Hwang U, Richardson LD, Sonuyi TO, Morrison RS. The effect of emergency 

department crowding on the management of pain in older adults with hip fracture. J 

Amer Geriatr Soc. 2006;54:270-275 
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Methods

Design: Review of ED care for 158 patients, 

>50yo, admitted for hip fracture (8/97-7/98)

Variables collected: 

Age, gender, NH residence, triage level, dementia, APACHE critical 

care score, RAND co-morbidity score, ED crowding factors (census)

Outcomes: 

Documentation of pain assessment, time to assessment, analgesia 

given, and time to pain treatment

20
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Findings

• 81% patients with documented complaint of pain

• Mean times to 

– pain assessment was 40 minutes

– pain treatment was 141 minutes

– Delay to treatment was 122 minutes

• Of those with pain:

– 36% received no analgesia

– 7% non-opioids

– 57% opioids

• 33% of these as meperidine
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Findings

• ED census levels >120% bed capacity associated with no pain 

documentation (p=0.05) and longer times to pain assessment 

(p=0.01)
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Implications

• Hip fracture patients received relatively poorer pain management 

that is worsened during ED crowding

• By studying a condition relatively unique to the geriatric patient, it 

may be possible to develop models for future studies and target 

areas of quality improvement 
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What about general pain care?
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The Quality of Older Adult 

Pain Care in the ED Setting

Observational study of pain assessment and treatment for adult 

patients in the ED 

Hwang U, Richardson LD, Livote E, Harris B, Spencer N, Morrison RS. Emergency 

department crowding and decreased quality of pain care. Acad Emerg Med. 

2008;15:1248-1255.
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Research Objective

• To determine if older age and greater ED census are associated 

with poorer process of care measures for pain management 

within the ED setting
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Methods

Design:

• Retrospective cohort review of adult patients with conditions 

warranting analgesia
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Methods

Design:

• Retrospective cohort review of adult patients with conditions 

warranting analgesic 

• [No chest pain (cardiac)]
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Time:

7/05 & 12/05

Setting: 

Mount Sinai ED

• Urban, academic, 

tertiary care ED

• 76,000 visits/annually

• Comprehensive electronic 

ED medical record (patient tracking, MD, 

RN documentation and order entry)
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Subjects: 

• Adults (≥ 18 yo) with a chief complaint involving pain AND a 

final ED diagnosis of a painful condition

Examples:

• CC: toe pain, Final dx: gout  Included

• CC: toe pain, Final dx: CHF  Excluded
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Methods

Data: 

• Electronic ED medical record for patient demographic, clinical, 

and pain care data

• ADT (admission, discharge, transfer) registration data ED 

crowding factors during the 1st hour of the index patient’s 

arrival
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Variables

• Primary independent variables:

– ED census (total # all ED patients)

– Age

• 18-64 years (Younger (REF))

• 65-84 years (Older)

• ≥85 years (Oldest) 

• Covariates:

– Gender

– Race/Ethnicity

– Triage score (Emergency Severity Index)

– Degree of pain (none, mild, mod, sev) 

– Comorbidity (Charlson score)

– Number of prior medications
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Primary Outcome Measures

• Process of pain care measures:

– Documented pain assessment 

• Any by MD

• Any follow-up

– Pain treatment

• Any analgesia

• Opioids

• NSAIDs

– Times of activities:

• Triage to first MD documented pain assessment

• Triage to first analgesia ordering

• Triage to first analgesia administration
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ED Census, 

During 1st hour of Index Pain Patient

Characteristic N=1031

ED square footage 4500 sq.ft.

Number of beds available 41

ED census, median=50%ile (iqr) 54 (40, 68)
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ED Census

p=0.99

p=0.11

*p<0.0001

*p=0.03

*p=0.01

*Adjusted for age, gender, race/ethnicity, ESI, comorbidity, 

number of medications and significant pain
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Pain management times

125

104

106

167

136

174

0 50 100 150 200

Time to first

analgesia

administered

Time to first

analgesia

ordered

Time to first

clinician pain

assessment

Time in minutes

HIGH

Census

(>=50%ile)

LOW

Census

(<50%ile)

*p<0.0001

*p=0.0003

*p<0.0001

*Adjusted for age, gender, race/ethnicity, comorbidity, number medications, 

and reporting significant pain
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Findings

• Periods of HIGH ED census (above median levels) was associated 

with less analgesic treatment and significantly longer times to pain 

assessment and treatment 
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Implications

• Identifying factors associated with quality of 

pain care can help identify and target 

interventions to improving care for older 

adults in the ED 

• Managing ED volume 

– Interventions to get earlier pain treatment to 

patients (e.g., FNB for hip fracture patients, nurse 

initiated analgesics for select conditions)
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What about patient-related factors?
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Characteristics of Study Sample

Patient 

characteristics

N=1031

Younger 

(<65 

years)

n=813 

Older 

(65-84 

year)

n=168

Oldest

(≥85 

years)

n=50 

 pvalue

Female 63% 73% 76% 0.02

Race ethnicity

 White

 Black 

 Hispanic 

 Other

 22%

32

37

9 

 31%

30

33

6 

 53%

26

16

5 

<0.01

 

Emergency Severity 

Index, mean SD 

[1=acute, 5=non-acute], 

3.27 (0.65) 3.09 (0.54) 3.00 (0.55) <0.0001 
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Characteristics of Study Sample

Patient 

characteristics

N=1031

Younger 

(<65 

years)

n=813 

Older 

(65-84 

year)

n=168

Oldest

(≥85 

years)

n=50 

 pvalue

Charlson score, 

mean (SD) 0.70 (1.68) 1.58 (1.82) 1.22 (1.25) <0.0001 

Number of prior meds, 

mean (SD) 1.77 (2.49) 4.44 (4.16) 5.12 (3.44) <0.0001 

ED pain diagnoses

 Muscuoloskeletal 

 Abdominal 

 Back 

 Fall

 Renal 

 Head 

 

 25% 

47 

15 

1 

5 

7 

 42% 

38 

5 

6 

5 

4 

 44% 

36 

8 

8 

0 

4 

<0.0001 
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Characteristics of Study Sample

Patient 

characteristics

N=1031

Younger 

(<65 

years)

n=813 

Older 

(65-84 

year)

n=168

Oldest

(≥85 

years)

n=50 

 pvalue

Difference initial to final 

pain score, mean (sd) 1.89 (4.45) 0.83 (4.69) 0.20 (4.56) <0.01 

Times to pain 

assessment, 

median (iqr)

91 (55,153) 96 (64, 151) 77 (55, 148) 0.42 

Time to analgesic 

administration, 

median (iqr) 112 (68, 175) 124 (73, 185) 112 (94, 259) 0.35 
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Pain Assessment

Pain care

All patients

N=1031

Age Category*

Younger

(<65 years) 

 

Older 

(65-84 year)

OR (95% CI) 

Oldest 

(≥85 years)

OR (95% CI) 

Documented pain 

assessment* 92% Ref 1.19 

0.60, 2.33)

1.88 

(0.38, 9.25)

Follow-up pain 

assessment † 

(excluding those 

reporting no pain)

41% Ref 1.09 

(0.74, 1.63)

1.16 

(0.58, 2.33)

* Adjusted for comorbidity, number of medications, gender, race/ethnicity, ESI, final 

diagnoses, and clustering effects of treating clinician

† Adjusting for * plus degree of pain
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Pain Treatment

Pain care* 

(excluding those 

with “no pain”)

All patients

N=926*

Age Category

Younger

(<65 years) 

 

Older 

(65-84 year)

OR (95% CI) 

Oldest 

(≥85 years)

OR (95% CI) 

Received pain 

medication (n=515) 61% Ref 1.28 

(0.83, 1.96)

1.15 

(0.65, 2.03)

Initially received 

Opioid 57% Ref 0.59 

(0.35, 0.98)

0.81 

(0.37, 1.76)

Initially received 

NSAID 25% Ref 1.70

(0.91, 3.19)

1.85

(0.68, 5.03)

Initially received 

nonNSAID 18% Ref 1.31 

(0.73, 2.34)

0.72

(0.25, 2.07)

* Adjusted for comorbidity, number of medications, gender, race/ethnicity, 

ESI, final diagnoses, degree of pain & clustering effects of treating clinician
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Pain Treatment

Pain care* 

Age Category

Younger

(<65 years) 

 

Older 

(65-84 year)

OR (95% CI) 

Oldest 

(≥85 years)

OR (95% CI) 

Initially received NSAID 

for mild pain

(1-3 of 10) (n=180)

Ref 1.42 

(0.49, 4.14)

3.72 

(0.97, 14.24)

Initially receive opioid for 

moderate to severe pain 

(4-10 of 10) (n=335)

Ref 0.44 

(0.22, 0.88)

1.21 

(0.41, 3.5)

* Adjusted for comorbidity, number of medications, gender, race/ethnicity, 

ESI, final diagnoses & clustering effects of treating clinician
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Findings

• Older adults had lower reduction of pain scores and decreased 

opioid use 

• Trend with preferential use of NSAIDs in the initial treatment of 

mild pain for older adults
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Implications

• With acute pain, older adults had lower 

reduction of pain scores and decreased opioid

use 

• Do these differences represent disparities or 

inadequate ED pain care?
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Survey Question #4

• What medications do preferentially use to treat acute pain?

1. Acetaminophen (Tylenol)

2. NSAIDs

3. Opioids

4. Others

5. None

48
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What about multicenter studies?
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The Quality of Acute Pain Care 

for Older Adults in the ED

Multicenter observational study of pain assessment and 

treatment for adult patients in the ED 
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Research Objectives

 Questions: 

1. ED pain care processes:

 - geriatric vs. younger adult patients?

2. Patient-related characteristics: 

 - which ones unique to geriatric patients

 - influence the quality of ED pain care? 

 Hypothesis: Pain care is poorer for geriatric patients than for 

younger patients:

 - ↓ pain assessments

 - ↓ analgesic medications 

 - ↓ opioids, ↑ NSAIDs

 - ↓ reduction in pain scores

 - Dependent on type of presenting pain?
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Methods

 Study design: 

 - Retrospective observational cohort review

 - Adult (≥18 years age) ED visits

 - Chief complaint of pain

 - Final diagnosis of abdominal or fracture pain

 Setting: 

- Five US EDs

 - 2009 

 (Jan, Apr, Jul, Oct)
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Methods

 Outcome measures: 

1. ED documentation of initial pain assessment and follow-up 

2. Analgesic medications administered

3. Reduction in pain scores

 Primary predictor: 

 - Age: young (18-64 years), older (65-84 years), oldest (≥85 years) 

 Covariates: 

 - Gender - Race/ethnicity 

 - Triage severity - Initial reported pain 

 - Comorbidity - Number of medications

 - Clustering by clinician - Clustering by site level

53
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N=6944

Young

(<65 years)

N=5892 (85%)

Older 

(65-84 years)

N=828 (12%)

Oldest

(≥85 years)

N=224 (3%)

Female 58% 64% 73% 

Race/ethnicity

 White

 Black 

 Hispanic 

 Other/Unknown

43% 

22% 

23% 

12% 

47% 

19% 

22% 

12% 

64% 

12% 

17% 

7% 

ESI, mean (SD) [1=acute, 5=non-acute] 3.07 (0.53) 2.93 (0.54) 2.73 (0.48)

Number of current medications, mean 

(SD) 1.95 (3.28) 4.02 (4.08) 4.90 (4.22)

Charlson score, mean (SD) 0.56 (1.40) 1.31 (1.66) 1.38 (1.54)

Cohort Characteristics by Age Category

Results in RED indicate statistically significant differences (p<0.05) 
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N=6944 

Young

(<65 years)

N=5892 (85%)

Older 

(65-84 years)

N=828 (12%)

Oldest

(≥85 years)

N=224 (3%)

Had initial pain assessment 

documentation, n (%) 5650 (96) 780 (94) 205 (92)

Had any pain assessment 

documentation, n (%) 5834 (99) 818 (99) 221 (99)

Had follow-up pain 

documentation, n (%) 5030 (86) 732 (89) 206 (93)

Received analgesia, n (%) 4367 (74) 570 (69) 143 (63)

Results in RED indicate statistically significant differences (p<0.05) 

Results: Pain Care Outcomes by Age Category
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49

13 12

26

48

6 

14

31

45

4 

15

36

0 

10 

20 

30 

40 

50 

60 

Opioids NSAIDs Other None

Percentage of patients

Younger (ages 

18-64)

Older (ages 65-

84)

Oldest (ages 85 

and older)

p < 0.0001 

*Results remain 

significant in 

adjusted 

hierarchical 

modeling

Results: Analgesics Given to Cohort
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7.45

6.67 6.34

4.27

3.17

2.27

0 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10

Young Older Oldest

Mean Pain Score

Initial 

recorded 

pain score

Final 

recorded 

pain score

p < 0.0001

Reduction in pain score 

(final-initial), mean (SD) -3.12 (3.56) -3.42 (3.82) -3.84 (3.64)

Results: Initial vs. Final Pain Scores
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N=6944 

Fracture

N=1720 (25%)

Abdominal Pain

N=5224 (75%)

Young 

N=1335 

(78%)

Older 

N=278 

(16%)

Oldest 

N=107 

(6%)

Young 

N=4557 

(87%)

Older 

N=560 

(11%)

Oldest 

N=117 

(2%)

Had initial pain 

assessment 

documentation, n (%)

1288 

(96)

266 

(96)

100

(93)

4362

(96)

514

(93)

105

(90)

Had any pain 

assessment

documentation, n (%)

1308 

(98)

274 

(99)

104 

(97)

4526 

(99)

544

(99)

117 

(100)

Had follow-up pain 

documentation, n (%)

840 

(63)

205 

(75)

92 

(88)

4190 

(93)

527

(97)

114

(97)

Results in RED indicate statistically significant differences (p<0.05) 

Results: 

Pain Care Outcomes by Condition and Age Category
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N=6944

Fracture

N=1720 (25%)

Abdominal Pain

N=5224 (75%)

Young 

N=1335 

(78%)

Older 

N=278 

(16%)

Oldest 

N=107 

(6%)

Young 

N=4557 

(87%)

Older 

N=560 

(11%)

Oldest 

N=117 

(2%)

Received

analgesic, n (%)

859

(63)

184 

(66)

78

(73)

3508 

(77)

386 

(70)

65 

(56)

Reduction in pain 

score (final–initial), 

mean (sd) 

-1.42

(2.73)

-1.79 

(3.32)

-3.64 

(3.59) 

-3.62

(3.63)

-4.62 

(3.79)

-4.03 

(3.70)

Results in RED indicate statistically significant differences (p<0.05) 

Results: 

Pain Care Outcomes by Condition and Age Category
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45

15

3 

37

54

6 8 

33

63

1 

6 

21

0 

10

20

30

40

50

60

70

Opioids NSAIDs Other None

Percentage of fracture pain patients

Young (ages 

18-64)

Older (ages 

65-84)

Oldest (ages 

85 and over)

p < 0.0001

Results: Analgesics Given to Fracture Pain
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51

11 13

26

46

6 

16

32

29

6 

22

43

0 

10

20

30

40

50

60

Opioids NSAIDs Other None

Percentage of abdominal pain patients

Young (ages 

18-64)

Older (ages 

65-84)

Oldest (ages 

85 and over)

p < 0.0001

Results: Analgesics Given to Abdominal Pain
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• Older adults receive poorer pain care

• Less likely to receive initial pain assessment

• Less likely to receive analgesics overall

• Results are dependent on the type of 

presenting pain

• Overall, older adults had better reduction in 

pain scores

Conclusions
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• Could improvement of pain care lead to even 

greater pain score reductions?

• Why are different types of pain not treated 

equally?

• What should be the benchmark for pain care 

quality?

Implications
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Survey Question #5 & 6

• Have you treated acute pain care in the ED setting?

1. Yes

2. No

• If Yes to the above, did you routinely document a pain assessment 

in your clinical note ?

1. Yes

2. No

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What about the quality of VA ED pain care?
VETERANS HEALTH ADMINISTRATION

Studying Veteran ED Pain Care with an 

Electronic Pain Care Abstraction Tool

Pilot project assessing the feasibility of collecting Veteran ED pain 

care data to develop an electronic medical record abstraction 

technique for pain care data 

66 
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Specific Aim 1

To assess the feasibility of extracting process of pain care 

measures with HUMAN RECORD REVIEW
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Specific Aim 2

To explore sources and types of data required to extract process 

of pain care measures using ELECTRONIC ABSTRACTION data by:

1. Identifying alternate data sources of VA ED pain care from local (X), regional 

(Y), and national (Z) VA sources

2. Identifying the data types available (non-structured, semi-structured, 

structured) and how to efficiently and effectively access them
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Specific Aim 3

• To provide recommendations on improving, modifying, or 

structuring VA data for accurate and consistent electronic 

abstraction of process of pain care data

• [Future grant for long-term development of the electronic medical 

record abstraction instrument]
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Method

Time:

Randomly selected adult ED visits 2009 at:

Settings: 

• West Haven (10,000 annual ED visits)

• West Los Angeles (25,000 )

• Bronx VA (10,000)

Review of ED CPRS medical records each site

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Method

Exploration and comparison of alternate data sources:

• Veterans’ Informatics, Information & Computing 

Infrastructure (VINCI)

• Corporate Data Warehouse (CDW)

• VistA Data

• National VHA Data – Austin Automation Center

• National Patient Care Database (NPCD)

• Decision Support System (DSS)

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Results

• 435 randomly selected ED visits reviewed

(trained research assistant, 2 investigators)

• 61% involved chief complaint of painful condition

– 80% of these had pain scores from national database sources

– Mean score 5.85 (0 – 10 scale)

– 38% had physician documentation of pain assessment in text note

– 45% received analgesics

– Mean time to analgesics 101 min (sd 101) 

• By site, significant variation in pain assessment documentation 

(range 8 to 64%) and receiving analgesics (range 14 to 41%)

• No differences in acute pain care by age, race, gender

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VETERANS HEALTH ADMINISTRATION

Implications

• Difficulty for natural language processing automated evaluation of 

pain documentation

• Earlier steps to improve pain assessment in ED setting

• Future (later) steps to then focus on interventions to improve pain 

treatment

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VETERANS HEALTH ADMINISTRATION

Summary

• Acute pain care involves both the assessment and treatment of 

patient pain

• Without pain assessment, we cannot treat the pain

• Acute pain care in the ED setting is influenced by environmental 

factors and patient-related characteristics

• ED crowding worsens the quality of pain care

• Older adults receive disparate acute pain care

• Differences in pain care based not only on age (surrogate for 

comorbidities, polypharmacy), but also presenting condition

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VETERANS HEALTH ADMINISTRATION

Many thanks to

• Icahn School of Medicine at Mount Sinai

– R. Sean Morrison, MD (Geriatrics and Palliative Medicine)

– Lynne Richardson, MD (Emergency Medicine)

• Oregon Health Sciences University

– Daniel Handel, MD, MPH

• George Washington University Medical Center

– Kabir Yadav, MDCM, MD

• University of Colorado Medical Center

– Kennon Heard, MD

• James J. Peters VAMC

– Nicole Moodhe

– Daniel Signor

• VACHS Connecticut

– Cynthia Brandt, MD (Informatics, PRIME)

– Robert Kerns, PhD

– Woody Levin

• The American Geriatrics Society, Hartford Foundation, and Atlantic Philanthropies 

• National Institute on Aging

• VA HSR&D
VETERANS HEALTH ADMINISTRATION

Thank you for your attention!

?’s

Ula.Hwang@mountsinai.org

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VETERANS HEALTH ADMINISTRATION

Beers Criteria

• Consensus based pharmacologic guidelines for older adults 

• Defines potentially “inappropriate use of medications”

• 53 medications to avoid 

• Most recent update in 2012
VETERANS HEALTH ADMINISTRATION

Beers Analgesics and Muscle Relaxants to 

Avoid

– Meperidine (Demerol)

– Non-COX-selective NSAIDs (avoid chronic use) • ASA >325md/d

• Ibuprophen

• Naproxen

• Diclofenac

• Meloxicam

– Ketorolac (Toradol) (GI bleed)

– Indomethacin (Indocin) (GI bleed)

– Petazocine (Talwin) (Confusion and hallucinations)

– Muscle relaxants/antispamodics (sedation and risk of fracture)

– Long-acting benzodiazepines

– High-doses of short-acting benzodiazepines

– GI ulcers or on anticoagulation, avoid NSAIDS and ASA

– Heart Failure, Stage IV and V chronic kidney disease, avoid NSAIDS 

– Cognitive Impairment, falls/fractures avoid benzodiazepines 
VETERANS HEALTH ADMINISTRATION

Non-Opioid Analgesia

• Acetaminophen

– Highest safety profile

– Drug of first choice for mild-moderate pain

• [NSAIDS]

– Effective for mild-moderate inflammation pain

– Risk of azotemia, GI toxicity, worsen HTN and CHF for elderly

– Ceiling effect
VETERANS HEALTH ADMINISTRATION

Opioid Analgesia

• Opioids drug of choice for moderate-severe pain

• Mild opioids (e.g. hydrocodone) as 2nd line

• Stronger opioids (e.g. morphine, hydromorphone) as 3rd line

• Avoid:

– Meperidine

– Codeine (delirium, hip fracture, cognitive fx.)