Home > Uncategorized > Treatment of Pain in Dementia

Treatment of Pain in Dementia

doctorThere has been a lot written about the various causes of pain experienced by persons with dementia, and what can be done to 1) recognize that these people are in pain, and 2) treat that pain.  But today I found a discussion of some empirical studies that have been conducted on that subject, which I found quite interesting.  Even though the studies are several years old, I thought it worth-while to share them here.

Quite a few studies have shown that, as we age, we are more and more likely to experience pain.  It can be expected that, as we grow older, we will have an increasingly greater opportunity of coming into contact with some disease or health condition that will cause us to have pain — either chronic or in the short-term.  Even the “healthy aged” often report some level of discomfort from arthritis or other common conditions.  This percentage is presumed to be even higher in the nursing home population, at least partly because these individuals often have some sort of chronic and/or debilitating condition that makes it impossible for them to live independently.

Ferrell, B.A., et al, conducted a study, in 1995, of pain as experienced by a large number of skilled nursing home residents, looking at the prevalence of complaints of pain, as well as its etiology and management.  Cognitive impairment was also measured.  Subjects consisted of 325 randomly-selected residents of ten local nursing homes.  However, approximately one-third of subjects were excluded because they were comatose, non-English-speaking, too ill to participate, or refused to do so.  Their mean age was 84.9%, 85% were women, and most of the were dependent in all activities of daily living.  Mean score on the Folstein Mini-Mental State exam was 12.1, with some participants scoring as high as 20,0 or as low as 4.2.  Sixty-two percent of subjects complained of having pain, mostly attributed to musculoskeletal or neurogenic causes.  However, researchers noted that there was a discrepancy in the amount of pain that was actually documented, and most attempts at managing pain were not altogether successful. It was noted that 83% of the subjects could complete one of the pain reporting methods utilized in the study.  So, while researchers agreed that pain assessment and management were difficult in individuals who were mild to moderately impaired from a cognitive standpoint, it was possible to do so using tools that are currently available.

Another study was conducted in 1999, by Won. A, et al, that was published in the Journal of the American Geriatric Society.  Subjects consisted of almost 50,000 residents of nursing homes in four U.S. states, with information obtained from a pre-existing database.  (the Systematic Assessment of Geriatric drug use via Epidemiology).  Information was collected through the Minimum Data Set (MDS), a tool that nurses use to gather information about their patients, as well as figures on nursing home drug use. Researchers attempted to look at the correlation between nonmalignant pain, psychological and functional health, and pain management practices in the nursing home.

According to test results, daily pain was reported in 26% of nursing home residents. This number was likely to be lower among men, among those over 86 years of age, and of racial minorities.  The number of people experiencing daily pain was likely to be higher among those who were dependent on others for ADLs (activities of daily living), more symptoms of depression, and less frequent involvement in activities.  A statistic that I, personally, found rather interesting was that at least 25% of those persons with daily pain were given no analgesics.  Those subjects who fell into this latter group, who were less likely to be given analgesics, included those over 86 years of age (seems to be a magical number here), were cognitively impaired, were men, or belonged to a racial minority.  It was noted that those who were in pain used physical and/or occupational therapy.

One thing that I have often suspected, in my work with persons who have dementia, is that they are not given the benefit of pain relief as often as their peers who have more intact cognition.  After doing some reading on this topic, I discovered that this is a concern to the medical community as well.  One reason that has been proposed for this is the difficulty that medical personnel have in recognizing that individuals with dementia are in pain.  Another possibility is that the pain is under-treated.  I found a couple of references to studies involving older persons who had suffered hip fractures.  What bothered me the most was the finding that, during one study, those who were cognitively intact received opioid pain management three times as often as those who had dementia to some degree.

There are a number of possible explanations for this discrepancy in how pain is managed between the two groups.  One is that persons with dementia are unable to communicate to their caregivers that they are in pain.  As the person grows closer to the latter stages of the disease, he loses the ability to formulate his thoughts and to express them.  However, it has also been speculated that these individuals do indeed perceive pain differently than others.  For example, the brain may be unable to differentiate painful stimuli from, for example, other noxious stimuli such as a bad smell.

Individuals with mild to moderate dementia have typically been able to self-report their pain levels with a fairly good degree of accuracy.  Various observational scales have been put together, using behaviors and facial expressions, in an attempt to better assess pain in those with more severe dementia.  However, it has been difficult to ascertain whether a person is reacting to actual pain, or rather to some other internal sensation such as fear or constipation.  This remains an area which needs further assessment.

When it comes to the management of pain, the World Health Organization developed a pain relief ladder in 2006, which shows some promise.  This tool promotes a gradual, or stepped, approach to pain control.  First should come the use of non-opioid medications or NSAIDs, to provide a low level of pain control.  Then, if this doesn’t work, the person should receive a progression to weak and then strong opioids, with adjuvant anagesics at any step along the way as needed.  Non-pharmacological treatments should also be attempted, including heat, massage, TENS, or acupuncture, since there is a strong possibility of side effects with this population.

There’s another problem related to pain control that I have seen come up occasionally in my work in nursing homes.  Often physicians will order that a particular medication be given on a PRN basis — in other words, when the patient feels a need for it.  (This is true for other types of medications as well as those used for pain control.)  A person who is cognitively intact has no difficulty determining when to take a dosage of a particular medication.  (For instance, a person who has recently had some dental work done can take a Tylenol after eating a heavy meal, for tooth and gum pain.)  However, a person who is cognitively impaired may not be able to judge when it is appropriate to take such medications, or even remember that they have been prescribed for his benefit.  Unfortunately, in a nursing home the nurse’s hands are tied.  She can’t offer the medication to the patient; it has to be requested by the patient or his family.  The order should better be written for the medication to be given routinely, or at the nurse’s discretion.

As a person who has dementia nears the end of his life, palliative care becomes more and more of a concern.  His care becomes focused on providing comfort, rather than recovery — or even maintenance — of previously-held skills.  This is a topic that I will deal with in more detail in a later post.


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