Nonopioid Analgesics for the Perioperative Geriatric Patient

A Narrative Review

Sylvia H. Wilson, MD; P. Ryan Wilson, MD; Kathryn H. Bridges, MD; L. Hannah Bell, MD; Carlee A. Clark, MD


Anesth Analg. 2022;135(2):290-306. 

In This Article

Abstract and Introduction


Management of acute perioperative pain in the geriatric patient can be challenging as the physiologic and pharmacokinetic changes associated with aging may predispose older patients to opioid-related side effects. Furthermore, elderly adults are more susceptible to postoperative delirium and postoperative cognitive dysfunction, which may be exacerbated by both poorly controlled postoperative pain and commonly used pain medications. This narrative review summarizes the literature published in the past 10 years for several nonopioid analgesics commonly prescribed to the geriatric patient in the perioperative period. Nonopioid analgesics are broken down as follows: medications prescribed throughout the perioperative period (acetaminophen and nonsteroidal anti-inflammatory drugs), medications limited to the acute perioperative setting (N-methyl-D-aspartate receptor antagonists, dexmedetomidine, dexamethasone, and local anesthetics), and medications to be used with caution in the geriatric patient population (gabapentinoids and muscle relaxants). Our search identified 1757 citations, but only 33 specifically focused on geriatric analgesia. Of these, only 21 were randomized clinical trials, and 1 was a systematic review. While guidance in tailoring pain regimens that focus on the use of nonopioid medications in the geriatric patient is lacking, we summarize the current literature and highlight that some nonopioid medications may extend benefits to the geriatric patient beyond analgesia.


The geriatric population, comprising adults ≥65 years, is projected to increase by almost 50% between 2015 and 2030.[1] This expanding population comprises roughly one-third of surgical procedures.[2,3] As surgery is often synonymous with pain, geriatric analgesic regimens are needed.

While acute and chronic pain are prevalent and complex in geriatric patients,[4] analgesic management is not simplistic. Physiological changes in the elderly patient impact pharmacokinetics including age-associated increases in body fat with decreased muscle mass and total body water (Table 1).[5]

The reduced volume of distribution (Vd) for hydrophilic drugs and increased Vd for lipophilic medications alter the onset and effective dose of medications. Age-associated changes in protein quantity and binding can alter drug bioavailability, while decreased hepatic and renal function can impact drug metabolism and elimination. As neural fiber density and transmission along pain fibers are altered,[6] overall analgesic requirements are decreased with aging.[7] Concurrently, geriatric patients are at increased risk of postoperative delirium (acute changes in cognition and attention) and postoperative cognitive dysfunction (POCD; more subtle cognitive decline after surgery persisting for several months to a year or more involving disorientation, language difficulties, and learning or memory impairment).[8,9] Opioids, the traditional mainstays of pain regimens, are associated with increased rates of delirium,[10] POCD,[11] and respiratory depression in geriatric patients.[5] Thus, pain management strategies incorporating nonopioid therapies should be strongly considered in aged patients.

Specific guidance regarding analgesic medication management in elderly patients remains inadequate as this population is frequently excluded from trials.[7,12] Limited geriatric-specific education for health care providers and concerns for medication-related harm may foster inadequate analgesic therapy for aged patients. This review aims to summarize the literature for nonopioid analgesics in the perioperative geriatric population, develop recommendations, and identify areas for future research.