Chapter 58 Geriatric Pain Flashcards Preview

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Flashcards in Chapter 58 Geriatric Pain Deck (128):

Practitioners should be guided by two overarching principles when evaluating
the older adult with pain.

First, the rules of multiplicity rather than Occam’s razor should drive the assessment of
the causes and contributors to pain. That is, pain should be
conceptualized as a syndrome potentially “caused by a multiplicity
of pathologies in multiple organ systems. The second principle follows in that the symptom with which a patient presents may represent the
weakest link, but not necessarily the treatment target


Low back pain in older adults commonly contributed to by

hip osteoarthritis, fibromyalgia syndrome, and myofascial pain


Myofascial pain may be contributed to by

axial spondylosis, degenerative scoliosis, leg length discrepancy, and anxiety


pain may present subtly as

loss of function, or change in mood or cognition.


Treatment may require

biomechanics, insomnia, depression, and/or other
long-standing chronic disease often coexisting with persistent
pain to optimize function and quality of life.


Older patients with persistent pain conditions should be screened routinely for

concurrent mental
health conditions (e.g., depression, anxiety, and dementia). Failure to treat comorbid psychiatric illness will likely result in ineffective analgesia


Other diseases common in older adults that may cause or exacerbate pain include

osteoporosis and osteoarthritis,
diabetes, cancer, cardiovascular disease, and dementia.


Alzheimer’s disease (AD) may pose a significant
challenge to the treating practitioner for a number of reasons:

(1) Patients with AD may have difficulty communicating their pain. (2) Anxiety/fear of pain may amplify the experience and expression of pain in patients with AD,
thus the most appropriate treatment may be uncertain.
(3) Patients with AD may perseverate on, but not suffer from, their pain, thus use of pain self-report as the gold standard
for guiding treatment becomes complicated.
(4) As dementia progresses, patients with AD may lose treatment
expectancy that may compromise analgesic efficacy.


Risk factors for the
development of disability include

high burden of medical
comorbidities, depression, sensory impairments related to vision and hearing, and musculoskeletal disorders such as arthritis. Smoking, level of alcohol use, inactivity, and lack
of social support also contribute significantly


morphologic and functional changes in the peripheral and central
nervous system that may impact pain processing

decline in the number of myelinated and unmyelinated fibers, an increase in the number of damaged nerve fibers,
slowed nerve conduction velocity, loss of serotonergic and
noradrenergic neurons in the dorsal horn, and a reduction in serotonergic receptor density in the anterior cingulate and prefrontal cortex, among others


performance (NP)

declines with age and brain volume
loss, senile plaques, and neurofibrillary tangles occur in the absence of AD. Persistent pain itself is associated with
deterioration of NP and evidence indicates that pain reduction is associated with improved NP


Because provider–patient communication is an essential component in the treatment of pain

impairments in vision
and hearing may alter treatment efficacy and require modified assessments. Vision and hearing change both
structurally and functionally with age


Common eye diseases

cataract, glaucoma, macular degeneration, and
diabetic retinopathy) associated with aging may result in moderate to severe vision loss.



loss of hearing with age. Assistive technologies such as hearing aids and a frequency modulation (FM) device for those patients with speech
recognition difficulty, may be helpful when practitioners evaluate these patients, as they afford the opportunity to
engage in more meaningful conversation and improved care.


Postural control abnormalities leading to

increased risk of falls. pain adds to this risk. assessment of balance should be a routine part of assessing the older adult with pain.


Common changes in the musculoskeletal system include

sarcopenia (i.e., progressive loss of lean body mass associated
with muscle cell atrophy and infiltration of fat),
degenerative arthritis, and decreased bone density. Pain practitioners need to be acutely aware of the fact that
radiographic evidence of degeneration without pain is exceedingly common


Management of changes in the musculoskeletal system

Over half of older adults with radiographic evidence of hip osteoarthritis (OA) are without hip pain. Thus, the history and
physical examination should provide strong evidence of disease before imaging is ordered to avoid unnecessary
procedures such as injections and surgery that carry the potential for morbidity.


majority of older adults with chronic low back with or without leg pain have a combination of pathologies responsible for their symptoms. Ex

hip OA, fibromyalgia, iliotibial band pain


Vertebral compression

occur in the absence of acute pain, but
as kyphosis develops, they may contribute to pain in the upper and lower back


vitamin D deficiency

common in older adults and may contribute to muscular pain and falls. Assessment of serum 25-OH vitamin D may be considered as part of pain
assessment in older adults and correction of insufficiency a
routine part of treatment.




Remains unchanged
Increase Gastric pH

Decrease Secretory capacity and GI blood flow




Decrease Plasma albumin, Protein affinity, Total body water

Increase alpha 1-acid glycoprotein, Expression and activity of
P-glycoprotein in live




Decrease Liver volume, Hepatic blood flow, First-pass metabolism, Phase I metabolism, Phase II metabolism in frail

Increase Interindividual variability with age,




Measurable and predictable decline
in renal function with age
Decrease Glomerular filtration rate and Renal plasma flow


Body Composition

Increase Body fat
Decrease Lean and total body mass


Central Nervous System

Decrease Blood supply to brain and Baroreceptor activity


Cardiovascular Function

Decrease Resting heart rate, stroke volume, and cardiac output


Aldosterone System

Decrease Plasma renin and Urine aldosterone


Medications that have a high hepatic extraction ratio may undergo

decreased clearance and experience a longer half life in older adults because of diminished liver size and blood flow


Meperidine and Morphine use in older patient

Meperidine (contraindicated in older adults because of its renally cleared active metabolite that can
cause seizures) and morphine are high extraction ratio analgesics whose first-pass effect and clearance is reduced with age.


long half-life nonsteroidal antiinflammatory drugs are hepatically metabolized and their clearance may be reduced in older adults:

celecoxib, diflunisal,
naproxen, oxaprozin, prioxican, salsalate, and sulindac.


Analgesics that are affected by aging-associated decline in
renal function include

codeine, duloxetine, gabapentin, meperidine,
pregabalin, propoxyphene, salicylate, tramadol,
and the opioids morphine, oxycodone, hydromorphone,
fentanyl, and methadone


Cockcroft-Gault equation,
shown below, to estimate creatinine clearance
(CrCl) that helps to guide dose adjustment of renally cleared medications

CrCl = ( (140 - age) * (Wt in kg) * (0.85 if female)) /
(72 *Cr)


Pharmacodynamics refers to

tissue sensitivity and how a drug interacts with its end organ. The body’s response to
medications may be therapeutic or adverse


Opioid sensitivity increases with associated decline

in mu opioid receptor density and increase in
opioid affinity. Thus older adults may respond to opioid doses that are significantly smaller than those in younger individuals.


The purpose of pain assessment is twofold:

(1) to identify contributors to pain that are usually multiple, and (2) to identify outcome measures to follow during the course of treatment, that is, each patient’s individual “pain signature


Pain assessment in older adults

Pain assessment should be an ongoing process to measure change in pain over time as this will affect any necessary
modifications in the treatment course. Assessment of pain alone is not sufficient; providers should inquire about
changes in appetite, sleep, and/or mood, loss of mobility, and diminished activity level.


indicative of an acute
pain event

Abnormalities in traditional vital signs such as abrupt changes
in respiratory rate or heart rate


For cognitively intact older adults, there are many pain rating tools from which to choose

Numeric rating scales (NRS) and verbal descriptor scales (VDS)


Medication that enhance fall risk

opioids, tricyclic antidepressants, gabapentin, and pregabalin


How to manage patient who are taking Medication that enhance fall risk

it is prudent to optimize mobility (e.g., by referring the patient to a physiatrist or physical therapist for instruction in using the appropriate assistive device and gait/balance training) prior to prescribing medications that may further increase this risk


Assessment of cognitive function is critical. Mini-Cognitive Assessment Instrument

Step 1 Ask the patient to repeat three unrelated words, such as “ball,” “dog,” and “television.”
Step 2 Ask the patient to draw a simple clock set to 10 min after 11 o’clock (11:10). A correct response is a drawing of a circle with all of the
numbers placed in approximately the correct positions, with the hands point to the 11 and 2.
Step 3 Ask the patient to recall the three words from Step 1. One point is given for each item that is recalled correctly.


On Mini-Cognitive Assessment Instrument
(Mini-Cog) If there is evidence of dementia

in addition to treating the patient’s pain, the provider should refer the
patient for neuropsychological testing or to a specialist who can address this important problem such as a geriatrician or neurologist.


Cognitively impaired older adults are at increased risk of pain undertreatment because of

the belief among many
health-care workers that their pain ratings are unreliable. In fact, patients with mild to moderate cognitive impairment can reliably report pain using verbal descriptor scales. In patients with more advanced dementia who
have difficulty using self-report instruments, caregivers rely on behavioral cues to determine the presence and severity of pain


one of the most sensitive and reliable behavioral indicators of pain in patients with dementia or poor verbal communication.

Facial grimacing


other indicators of pain in patients with dementia or poor verbal communication.

guarding, bracing, rubbing and sighing


Common Pain Behaviors in Cognitively Impaired
Elderly Persons

Facial expressions
Verbalizations, vocalizations
Body movements

Facial expressions
- Frown; sad, frightened face, Grimace, wrinkled forehead, tightened eyes

Verbalizations/ vocalizations
- Sighing, moaning, groaning, grunting
Calling out, asking for help
Noisy breathing; verbally abusive

Body movements
Rigid, tense body posture; guarding, fidgeting
Pacing, rocking; restricted movement
Gait or mobility changes


Common Pain Behaviors in Cognitively Impaired
Elderly Persons

Changes in interpersonal interactions
Changes in activity patterns or routines
Mental status changes

Changes in interpersonal interactions
Aggressive, combative, resisting care
Decreased social interactions, withdrawn
Socially inappropriate, disruptive

Changes in activity patterns or routines
Refuses food, appetite change
Sleep, rest pattern changes
Sudden cessation of common routines

Mental status changes
Crying, tears
Increased confusion
Irritability or distress


For all patients presenting with pain ruling out serious
conditions (i.e., red flag symptoms) that require immediate attention is paramount

fever, sudden unexplained weight loss, acute onset of severe pain, neural
compression, loss of bowel or bladder function, jaw claudication, new headaches, bone pain in a patient with a history of malignancy or that awakens the patient from
sleep, and sudden pain in an extremity that is associated with pallor, pulselessness, and paresthesias


After determining the older adult’s pain signature, multifaceted
treatment should be designed

an antidepressant, cognitive behavioral
therapy, and physical therapy may be the most appropriate components of the treatment regimen.


For the older adult with dementia and excessive fear of pain because of social isolation

placement in an assisted living facility may most
effectively improve quality of life. If the practitioner determines that pain itself requires treatment, a stepped care approach should be utilized.



participation in regular
exercise improves psychological well-being, reduces pain, and increases functional capacity in older adults with persistent pain. A combination of endurance, resistance, balance, and flexibility exercises may yield important health benefits.


exercise prescribed for treating osteoarthritic pain

individualized programs should be created to meet the patient’s unique
needs. It has been demonstrated in older adults with knee OA that both low-intensity and high-intensity stationary
bicycling for 25 min three times a week promote decreased pain and improved function


Goal of Physical therapy

Reducing pain, optimizing fitness, and promoting functional dependence should be the goals of treatment. It is critical
that the patients view themselves as taking an active role in treatment rather than as a passive recipient.


key to successful pain rehabilitation in Physical therapy

being committed to maintaining a home exercise program,
learning how to pace activities and self-manage pain flares


Assistive devices for older adults with pain serve the following purposes:

(1) pain relief, (2) enhancement of mobility
and stability, and (3) modification of painful activities.


Assistive devices

canes and walkers exert their analgesic effect by reducing load (e.g., canes for lower extremity
arthritis, walkers for low back pain). Canes are generally used for those patients with mild to moderate mobility impairment; walkers tend to be prescribed for those patients with “generalized weakness, extreme inability for lower-limb weight bearing, debilitating conditions or poor balance control


Upper extremity assistive devices can help
to modify painful activities

Reachers, jar openers, button aids, and zipper pulls are often prescribed for patients with osteoarthritis


Topical therapies for pain are an attractive option for older adults given

their mild side effect profile, less systemic
absorption compared to oral medications, and ease of application


Topical therapies for pain

capsaicin cream and a topical lidocaine patch 5%
for joint and low back pain, postherpetic neuralgia, and
other neuropathic symptoms; diclofenac gel for osteoarthritis;
and a topical diclofenac epolamine patch for acute
pain associated with minor strains and sprains.


side effects of Topical therapies

local irritation or rash and a burning sensation,
the latter occurring most commonly with capsaicin


corticosteroid and/or hyaluronic acid injections may be beneficial

patients with pauciarticular joint pain associated with inflammatory and noninflammatory arthritides


Patient with neuropathic pain (e.g., postherpetic neuralgia) treated with

nerve blocks may aid in
reducing pain but their benefits are typically shortlived, lasting only a few days or weeks


Trigger-point injections with local anesthetic have proven effective in alleviating

myofascial pain


Epidural steroid injections
(ESI) have been used to treat pain conditions associated with

lumbar spinal stenosis involving the central
and/or lateral canal. Patients with herniated discs, spondylolisthesis, scoliosis, and degenerative disc disease may see benefits following ESI


Two of the most commonly
used medications in the older adult with mild to moderate
pain are

acetaminophen (APAP) and nonsteroidal anti-inflammatory drugs (NSAIDs)


first-line treatment in patients with osteoarthritis and other types of musculoskeletal pain



a risk of unintentional acetaminophen

>4000 mg/day


treatment of patients with inflammatory pain (e.g., gout, pseudogout

NSAIDs may be indicated for short-term use although
intra-articular corticosteroid injections may be used when one or two joints are involved.


Chronic use of NSAIDs may be fraught
with a number of risks including

congestive heart failure,
exacerbation of hypertension, renal insufficiency, and
gastrointestinal bleeding.


risk factors for GI bleeding

age 75 and older, peptic ulcer disease, GI bleed, and use of glucocorticosteroids.


Risk factors associated with renal insufficiency include

age 75 and older, diabetes mellitus,
hypertension, and use of angiotension-converting enzyme
inhibitor or diuretics.


NSAIDs in patients with congestive heart failure due to

the possibility of exacerbation and in patients with renal dysfunction who have serum Cr concentration over 150 mmol or glomerular filtration rate of less than 50 ml/hr.


Corticosteroids are commonly prescribed in older adults with

inflammatory disorders (e.g., giant cell arteritis, polymyalgia rheumatica, rheumatoid arthritis).


Corticosteroids are indicated for pain associated with malignancy
because they

reduce tumor-associated edema that
can cause spinal cord compression, brain herniation, and
compressive neuropathy


Corticosteroids common side effects include

glucose intolerance,
hypertension, psychosis, and osteoporosis,


using opioids for the treatment of

moderate to severe pain
(both nociceptive and neuropathic), earlier in the course
of disease than previously recommended to avoid the
multiple potential toxicities associated with NSAIDs


A general rule is
that long-acting opioids should

never be initiated in the
older adult who is opioid-naïve. A short-acting preparation
should always be initiated and once the total daily dose
requirement is determined, the patient can then be switched to a long-acting preparation, supplemented with
an as-needed short-acting drug for breakthrough pain


adverse effects of opioids

constipation, falls and fractures, urinary retention (e.g., in the patient with prostatic enlargement) and delirium.


Buprenorphine has been shown to be both effective
and well-tolerated in patients with

cancer and nonmalignant
persistent pain such as neuropathic pain


Fentanyl patches vs. transdermal buprenorphine

Fentanyl patches have been
used increasingly to treat persistent pain in the older
adult; while it appears that transdermal buprenorphine
may have a better side effect profile, therapeutic index,
and ease of titration, inadequate data exist to support
recommending its use in older adults


Contraindications of using

Patients with opioid
dependence, myasthenia gravis, respiratory depression, and delirium tremens


methadone may be very useful.

Given its low cost, long-acting properties, and efficacy when used in small doses in frail older adults


Risk of metahdone

its very long and variable half-life. In addition to having all of the same potential adverse effects as the other opioids, patients on methadone may suffer from QTc prolongation. patients being started on methadone
should receive an EKG at baseline, 30 days after initiating
methadone, and then annually
and sleep-disordered breathing.


first-line treatment for Neuropathic Pain

antidepressants with both norepinephrine and serotonin reuptake inhibition properties (SNRIs), calcium channel a2-d ligands, and topical lidocaine


second line treatment for Neuropathic Pain

opioids and tramadol


commonly studied SNRI antidepressants for treating neuropathic

duloxetine and venlafaxine. Both have evidence of efficacy for painful diabetic neuropathy



used in cases of painful polyneuropathies,
although caution should be exercised in patients
with cardiovascular disease.


Treatment of trigeminal neuralgia
is different from that of other neuropathic pain states.

For this disorder, carbamazepine or oxcarbazepine are recommended as first line


Treatment of postherpetic

pregabalin, and tricyclic antidepressants


Tertiary amines should be avoided
in older adults because of

Tertiary amines (amitriptyline, imipramine, trimipramine, doxepin, clomipramine) should be avoided in older adults because of their anticholinergic side effects (sedation, delirium, urinary retention, constipation,
glaucoma exacerbation, and dizziness).


amines have been shown to have more tolerable side
effect profiles

nortriptyline, desipramine, protriptyline, amoxapine)


a baseline EKG should be obtained prior to starting
a tricyclic antidepressant and monitored periodically with
dose titration

Because of their potential for QT prolongation,


For Neuropathic pain opioids
have proved efficacious in patients with

postherpetic neuralgia
and painful peripheral neuropathy.



weak mu-opioid receptor agonist that also inhibits the reuptake of norepinephrine and serotonin, may fare better in older adults at reducing neuropathic pain.


Benzodiazepines have been used to treat

spasms, neuropathic pain, and anxiety related to pain


Benzodiazepines should generally be avoided in older adults for the treatment of neuropathic pain because of

the risk of symptomatic rebound, dizziness, falls, and confusion.



symptoms occurring for longer than 3 months varying
from morning stiffness, fatigue, and nonrestorative sleep to
headaches, myofascial pain, and pelvic pain


Treatments for fibromyalgia

low-dose tricyclic antidepressants, cyclobenzaprine, aerobic
exercise, cognitive behavioral therapy, or a combination
of these treatment methods


Food and Drug Administration (FDA) approved for the treatments of fibromyalgia

Duloxetine, pregabalin, and


Outcomes used
to monitor treatment efficacy in patients with fibromyalgia

pain intensity and physical and emotional functioning.


complementary and alternative medicine (CAM) approaches to persistent pain

Meditation, vitamin and mineral supplements, herbs, and chiropractic medicine are commonly used in older adults with back pain, arthritis, and
mental illness.


eight common behavioral modalities in treating
persistent pain in older adults

biofeedback, progressive muscle relaxation, meditation, guided imagery, hypnosis, tai chi, qi gong, and yoga. The benefits of complementary therapies such as these improve not only the self-reported pain but also pain related comorbidities such as depression, anxiety, and disability.


In the practice of
interdisciplinary pain medicine

it is important to consider geriatricians, geriatric psychiatrists, physiatrists, rheumatologists,
neurologists, and endocrinologists as important potential collaborators in the care of frail older adults with
complex conditions.


Carbamazepine (Tegretol)

100 mg daily
SE: Monitor hepatic transaminases (aspartate transaminase, alanine
transaminase), complete blood count, creatinine, blood urea nitrogen, electrolytes, serum carbamazepine levels.
Multiple drug-drug interactions


Gabapentin (Neurontin)

100 mg at bedtime
Monitor sedation, ataxia, edema.


Pregabalin (Lyrica)

50 mg at bedtime Monitor sedation, ataxia, edema.


Lamotrigine (Lamictal)

25 mg at bedtime Monitor sedation, ataxia, cognition.
Associated with rare cases of Stevens-Johnson syndrome.


Mexiletine (Mexitil)

150 mg twice daily Monitor electrocardiogram at baseline and after dose stabilization.
Avoid use in patients with conduction block, bradyarrhythmia


Corticosteroids (prednisone,
methylprednisolone, e.g.,
Deltasone, Medrol dose pak Liquid Pred, Orasone)

5 mg prednisone daily
and taper as soon as feasible.
Use lowest possible dose to prevent steroid effects. Anticipate fluid retention and glycemic effects in short-term use
and cardiovascular and bone demineralization with long-term use.


Lidocaine (topical)
(Lidoderm 5%)

1–3 patches for 12 hr per day
Monitor for rash or skin irritation.


Muscle Relaxants
Baclofen (Lioresal)

5 mg up to 3 times daily Monitor muscle weakness, urinary function, cognitive effects,
Avoid abrupt discontinuation because of central nervous system
Older persons rarely tolerate doses greater than 30 to 40 mg
per day


Muscle Relaxants
Tizanidine (Zanafex)

2 mg up to 3 times daily Monitor muscle weakness, urinary function, cognitive effects, sedation, orthostasis. Potential for many drug–drug interactions.


Muscle Relaxants
Clonazepam (Klonopin)

0.25–0.5 mg at bedtime Monitor sedation, memory, complete blood count.


Nabilone (Cesamet)

1 mg 1 or 2 times daily Monitor ataxia, cognitive effects, sedation.
High incidence of dizziness or drowsiness.
Cardiovascular effects with tetrahydrocannabinol or cannabidiol.
Older persons may be prone to postural hypotension.
Nabilone is approved for nausea and vomiting but may help with
some pain syndromes.


Dronabinol (Marinol)

2.5 mg 1 or 2 times daily Dizziness, somnolence, cognitive impairment, dysphoria.


Tramadol (Ultram/Ultram ER)

12.5–25 mg every 4–6 hr Mixed opioid and norepinephrine or serotonin reuptake inhibitor mechanisms of action. Monitor for opioid side effects, including drowsiness, constipation,
and nausea. Risk of seizures if used in high doses or in predisposed patients. May precipitate serotonin syndrome if used with selective serotonin reuptake inhibitors.


Tapentadol (Nucynta)

50 mg every 4–6 hr by mouth
(equivalent to oxycodone 10 mg every 4–6 hr by mouth) Clinical trials of tapentadol suggest lower incidence of gastrointestinal adverse events than comparator opioids.


Immediate release (MSR,

2.5–10 mg every 4 hr Available in tablet form and as concentrated oral solution, which
is most commonly used for episodic or breakthrough pain and for patients unable to swallow tablets.


Sustained release (Avinza,
Kadian, MSContin,
Oramorph SR)

15 mg every 8–24 hr
Usually started after initial dose determined by effects of immediate-release opioid or as an alternative in a different long-acting opioid due to indications for opioid rotation. Toxic metabolites of morphine may limit usefulness in patients
with renal insufficiency or when high-dose therapy is required. Continuous-release formulations may require more-frequent
dosing if end-of-dose failure occurs regularly.
Significant interactions with food and alcohol toxicity


Hydromorphone (Dilaudid,
Methadone (Dolophine)

1–2 mg every 3–4 hr For breakthrough pain or for around-the-clock dosing.
Highly variable half-life and nonlinear dose equivalencies when
switching from other opioids. Not recommended as first-line agent.


Immediate release (Opana IR)

5 mg every 6 hr Typical opioid side effects.
Significant interactions with food and alcohol toxicity.


Extended release (Opana ER)

5 mg every 12 hr Usually started after initial dose determined by effects of
immediate-release opioid or as an alternative to a different long-acting opioid because of indications for opioid rotation.


Transdermal fentanyl

12–25 mcg/hr patch every 72 hr Started after initial dose determined by effects of immediate-release opioid or as an alternative to a different
long-acting opioid because of indications for opioid rotation.
Current available lowest-dose patch recommended for patients who require ,60 mg per 24-hr oral morphine equivalents.
Peak effects of first dose take 18 to 24 hr. Duration of effect is usually 3 days but may range 48 hr to 96 hr. May take two to three patch changes before steady-state blood
levels reached.


Tricyclic Antidepressant

Desipramine (Norpramine),
Nortryptyline (Aventyl,
Pamelor), Amitriptyline (Elavil)

10 mg at bedtime Significant risk of adverse effects in older patients. Anticholinergic effects (visual, urinary, gastrointestinal);
cardiovascular effects (orthostasis, atrioventricular blockade).
Older persons rarely tolerate doses greater than 75 to 100 mg
per day.


Duloxetine (Cymbalta)

20 mg daily Monitor blood pressure, dizziness, cognitive effects, and memory. Has multiple drug-drug interactions.


Venlafaxine (Effexor)

37.5 mg daily Venlafaxine associated with dose-related increases in blood pressure
and heart rate.


Milnacipran (Savella)

50 mg 2 times daily/starting dose
12.5 mg once a day. See package insert for titration recommendations.
Discontinuation requires tapering. Caution in renal insufficiency with creatinine clearance less than 30 ml/min, reduce dose by 50%. Common reactions include nausea, constipation, hot flashes,
hyperhidrosis, palpitations, dry mouth, hypertension.
Contraindicated with monoamine oxidase inhibitors and narrow-angle glaucoma.

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