The patients most likely to undergo some of the most painful procedures and have comorbidities that make them especially vulnerable to pain are the patients most often undertreated for pain. We're of course talking about the elderly.

Seniors are less likely than other adult patients to communicate their pain to you. One, they might feel as though they're supposed to feel pain after orthopedic surgery, hernia repair and varicose vein ligation, and thus be reluctant to express it. Two, they might have cognitive impairments that make communication difficult. Here are six strategies to help your facility meet the challenge of assessing post-operative pain in elderly patients.

1 Educate pre-operatively
Pave the way for a smooth recovery, in the PACU and at home, by performing a thorough pre-operative assessment and educating your elderly patients and their families about what they'll be experiencing post-op. Emphasize that if they do have pain, they shouldn't hesitate to ask for medication. It might also help to familiarize patients with numerical or pictorial pain-assessment tools.

Make sure patients are prepared to manage their pain at home. A few tips:

• Discuss the timeline of the pain; if a regional anesthetic was used, explain that because pain might not start until several hours after patients return home, they should have pain medications on hand and take them preemptively.
• If patients will be receiving opioids, they'll probably experience constipation (which affects most elderly people anyway). Suggest that they buy an over-the-counter laxative such as Senekot, which stimulates peristalsis in the digestive tract.
• All patients should know exactly whom to call if pain becomes severe. Go over all pertinent phone numbers and emphasize that they shouldn't hesitate to call if there's a problem.

2 Address medication concerns
Many patients might be reluctant to take prescription pain pills because they fear becoming addicted to them. You could address this concern by explaining that the risk of addiction is less than 1 percent, or you could suggest that patients recall a previous experience when they took pain medication for acute pain. Then ask if, in that case, they wanted to keep taking the medication once the pain had stopped - in most cases, the answer will be no. Explain that, in all likelihood, this experience will be exactly the same.

Some patients might already be on several medications and will resist taking pain pills simply because they feel like they're taking too many pills. If this is the case, carefully explain, preferably with a family member present, what each pill is for and why it's important to take the medication as prescribed.

3 Get the family involved
Make family or caregivers part of the pre-operative screening, particularly if your patient has trouble communicating. Ask if the patient is normally reluctant to express pain and how he might express pain non-verbally. Let family members know their presence in the PACU will be a great help - patients are more likely to be forthcoming if people they know are with them.

4 Ensure the continuation of a daily medication regimen
If patients are already taking medications to manage chronic conditions, make sure they understand that they should adhere to their regimens up to the day of surgery, unless otherwise directed. Patients might have to stop taking certain medications, such as some NSAIDs, because they can interfere with blood clotting or cause other complications. In accordance with American Society of Anesthesiologists guidelines, patients can continue to take clear liquids and approved medications for up to two hours before receiving a general anesthetic.

5 Use a variety of pain assessment tools and methods
In the PACU, as soon as the patient is responsive, start assessing pain by asking the patient to verbally rate or describe it. If you're not getting a clear picture, progress to large-print numerical or pictorial assessment tools. Also look for non-verbal cues, such as agitation and restlessness, and call on the family or caregivers for support.

6 Treat presumptively
Don't wait for patients to request medication - keep assessing pain and offering pain medications regularly in the PACU, even if patients don't seem uncomfortable. Constantly reinforce the idea that if they're in pain, you can do something about it.

Excellent post-op pain control
By following these tips and taking care to select and administer the analgesics and doses best suited to your elderly patients, you'll make sure you're doing all you can to keep them from suffering in silence.