Painkillers and Older Adults: Why Some Common Ones Need Care

Why older adults are different

• Kidney function falls with age, so medicines stay in the body longer and may damage the kidneys. Dehydration, diabetes and high blood pressure add to the risk; see chronic kidney disease home care.
• The liver clears drugs more slowly, and alcohol, illness or poor nutrition increase the risk.
• The stomach and gut lining are more fragile, and ulcers and bleeding are more likely and may be painless until severe.
• The heart and blood vessels are more vulnerable. Some painkillers raise blood pressure, cause fluid retention and increase the risk of heart failure or heart attack in susceptible people; see heart failure at home guide and hypertension home care guide.
• The brain is more sensitive. Some painkillers and related medicines cause drowsiness, confusion, dizziness and falls; see delirium in older adults and dizziness and low blood pressure when standing.
• Body composition changes, with less water and more fat, altering how drugs act.
• Many older adults take several medicines, which can interact. Taking five or more is common; see polypharmacy and deprescribing.
• Falls and fractures have serious consequences for fragile bones; see osteoporosis home care guide.
• Pain may be under-reported and under-treated, and then self-treated in a hurry.

Main groups of painkillers, and their general cautions

Doctors speak of several groups. Naming a group is not a recommendation; it helps you understand why advice differs.

Simple pain-relief tablets (the commonest first choice). Usually the first-line option for mild to moderate pain in older adults, but taken in excess they can damage the liver, particularly with alcohol, poor nutrition or liver disease. The main danger is accidental overdose through taking several products that contain the same ingredient, such as cold and flu remedies, fever tablets and combination pain products. Always check labels, and ask a pharmacist about total daily limits for your parent.

Anti-inflammatory painkillers (NSAIDs), in tablets, injections or sachets. Often used for arthritis and back pain. They can cause stomach irritation, ulcers and bleeding, kidney damage, fluid retention, high blood pressure, heart failure flare-ups, and interact with blood thinners, blood pressure medicines, water tablets and steroids. Risks are higher in older adults, in those with kidney, heart or stomach problems, and in those who are dehydrated. They should be used only when a doctor judges the benefit outweighs the risk, at the lowest effective amount for the shortest time, often with stomach protection. Do not combine two such products. Gels and creams applied to the skin generally expose the body to less drug, but are not risk-free.

Opioid-type painkillers (both milder and stronger ones). Used for severe pain under medical supervision. In older adults they can cause drowsiness, confusion, constipation, nausea, slowed breathing, falls, urinary retention and dependence. They must be prescribed and monitored; never share or use leftover tablets. See constipation in older adults.

Medicines used for nerve pain, such as some antiepileptic and antidepressant-type drugs. They can cause drowsiness, dizziness, confusion, swelling and falls, and need careful dosing and review.

Muscle relaxants and sedatives sold with painkillers. These raise the risk of drowsiness, confusion and falls. Avoid unless clearly advised.

Steroid tablets and injections. Powerful anti-inflammatories that can raise blood sugar, blood pressure, fluid retention, weaken bones, thin skin, increase infection risk and affect mood; they must be supervised by a doctor.

Creams, gels, patches and sprays. Skin products can contain anti-inflammatory ingredients, warming agents or numbing agents. They can irritate or burn skin, especially if combined with heat or tight bandages. Patches may contain strong drugs. Use as directed, on intact skin; ask a pharmacist.

Herbal, ayurvedic and traditional products. Some are useful and some are not; some contain hidden steroids, anti-inflammatory drugs or heavy metals, or interact with prescribed medicines such as blood thinners. Tell the doctor about everything used; see supplements and medicine interactions and joint supplements evidence.

Combination products. Cold and flu remedies, headache powders and "pain-relief" sachets often contain more than one active drug, including sedating antihistamines or decongestants that are problematic in older adults. Read labels.

Warning signs of trouble

Stop and seek urgent medical help if an older person on any painkiller develops:

• Black, tarry or bloody stools, vomiting blood or coffee-ground material, severe stomach pain: possible bleeding.
• Marked drowsiness, confusion, slow or shallow breathing: emergency.
• Swelling of legs or face, sudden weight gain, breathlessness: fluid retention or heart problems; see swollen legs in older adults.
• Passing much less urine, or very dark urine, or new nausea and weakness: possible kidney problem.
• Rash, itching, swelling of lips or face, wheeze: allergy.
• Fainting, severe dizziness, a fall.
• Yellowing of eyes or skin, dark urine, abdominal pain: possible liver injury.
• Chest pain, palpitations, sudden weakness on one side or trouble speaking: emergency; see stroke warning signs and first hour.
• Severe constipation, inability to pass urine.
• New agitation or hallucinations.

Safer habits

1. Do not self-medicate for pain that lasts. Pain that goes on for more than a few days, or is new or severe, needs diagnosis. 2. Tell every doctor and pharmacist every medicine, including over-the-counter, herbal and supplements. Carry a list; see keeping a health record at home. 3. Do not share or use leftover medicines. 4. Read labels for active ingredients and avoid duplicates. 5. Use the lowest effective amount for the shortest time, as your doctor advises, and review regularly. 6. Take with food or as directed, and with a glass of water; stay upright after taking. 7. Keep well hydrated, particularly in hot weather and illness, since dehydration raises kidney risk; see hydration for older adults and heat stroke and dehydration in seniors. 8. Avoid alcohol with painkillers. 9. Use a pill organiser and a chart to avoid double doses, particularly if memory is poor; see pill organiser guide, setting up a weekly medicine box and medicine reminders for forgetful parents. 10. Store safely, out of reach of confused people and children; see giving medicines safely at home. 11. Check expiry dates and discard old medicine. 12. Ask about blood tests for kidney and liver function when medicines are used long term. 13. Do not stop certain medicines suddenly, such as steroids or some nerve-pain tablets, without advice. 14. Keep a pain diary to see what works; see keeping a pain diary and talking to the doctor. 15. Plan for constipation if using strong painkillers. 16. Use fall precautions if drowsiness or dizziness occurs; see falls risk assessment at home. 17. Ask regularly: is this still needed? Medicines started for a short problem often continue for years.

Non-drug options that can reduce the need for medicine

Pain control works best when several approaches are combined.

• Exercise and movement, the cornerstone for arthritis and back pain; see exercise with arthritis, gentle exercises for knee and hip pain and chair exercises for seniors.
• Physiotherapy.
• Weight management where appropriate.
• Heat and cold, with skin care; see heat or cold for joint pain and hot pack safety for older skin.
• TENS, with medical advice; see TENS units for pain.
• Supports and aids such as sticks, knee sleeves, wrist supports and gadgets; see knee support buying guide, wrist supports and arthritis daily living gadgets.
• Pacing and activity planning.
• Good sleep and mood care; see sleep problems in older adults, depression in older adults and chronic pain in older adults.
• Relaxation, breathing, music, prayer and meditation; see breathing techniques for relieving stress and anxiety.
• Social contact and meaningful activity; see loneliness and isolation in older adults.
• Treating the cause, where possible, such as gout, infection, nerve compression or fractures.
• Procedures, such as injections or surgery, when appropriate.

Talking to the doctor or pharmacist

Ask:

• Is this painkiller safe for my parent, given the heart, kidney, stomach, blood pressure, diabetes and other medicines?
• What are the risks and signs to watch?
• How long should it be used, and when should we stop or review?
• Is there a safer alternative or a non-drug option?
• Do we need blood tests?
• Can it be taken with the blood thinner or other tablets?
• What should we do if pain is not controlled?
• What do we do if a dose is missed?

See preparing for a doctor's visit with a parent and medicine side effects families should watch.

When to ask a professional

Ask a doctor or pharmacist before starting, stopping or combining any painkiller, cream, herbal product or supplement in an older adult, and before using leftover medicines. Seek urgent care for the warning signs listed above. A geriatrician can review all medicines and aim to reduce unnecessary ones. A pain clinic can help with persistent pain. A physiotherapist and occupational therapist can help with non-drug approaches.