Pain In Alzheimers Disease And Other Dementias
Pain is a complex perceptual and subjective experience that has sensory, affective and cognitive dimensions. In vegetative and minimal states of consciousness there is a residual cortical response to nociceptive experimental stimuli , thus the perception of pain seems essential for survival and deserves evaluation in the absence of valid subjective reports, such as in people with severe cognitive impairment.
Neuropathological changes that occur in people with dementia are considered responsible for alterations in pain perception . Although these alterations could be common in different types of dementia, the vast majority of clinical and experimental studies investigating pain assessment or treatment in dementia are focused on patients with Alzheimers disease .
Conversely, other studies have provided different results . For example, after nociceptive stimuli administration a functional brain neuroimaging study did not show more reduced activity of specific brain areas involved in the medial pain pathway in AD patients than in healthy controls . This indicates that the emotional aspects of the experience and emotional pain are not selectively reduced in these patients . These data are still consistent with the results of previous works indicating that sensory-discriminative pain is preserved even in the advanced stages of AD , whereas pain tolerance is enhanced with increasing severity of the disease .
Ne Turnover Influences Microglial Activation And Neuroinflammation
Homeostasis of the LC-NE system is important for controlling central inflammation because numerous studies have shown that NE can effectively inhibit inflammation, including microglia-related neuroinflammation . On the other hand, recent studies indicate that NE could be pro-inflammatory . Therefore, when the homeostasis of LC-NE system is destroyed, either excessive or insufficient NE may lead to neuroinflammation.
Microglia are well equipped to respond to NE signaling by expressing the noradrenergic 1A, 2A, 1, and 2 receptors and strong interactions exist between NE and microglia . Some evidence supports that pro-inflammatory activation of microglia may be due to activation of the LC and abnormal and excessive release of NE . NE enhances A-mediated IL-1 secretion through action at -adrenoceptors in THP-1 cells . NE also increases COX-2 and prostaglandin E2 production induced by LPS via -adrenoreceptors in rat primary microglia . NE plays both roles as a facilitator or a suppressor for microglial pro-inflammatory reactions via activating cAMP and modulating downstream MAPK and NF-B signaling . Therefore, chronic pain-induced LC-NE neuron hyperactivity and increased supply of NE to brain areas such as PFC may result in microglial pro-inflammatory activation and exacerbate neuroinflammation in these areas in AD .
Stay At A Healthy Weight
The New York Times reported on the connection between dementia and a healthy weight just last year: “Compared with people of normal weight , overweight people with a B.M.I. of 25 to 29.9 were 27 percent more likely to develop dementia, and the obese, with a B.M.I. of 30 or higher, were 31 percent more likely to become demented.” It continued: “The researchers also found that women with central obesity a waist size larger than 34.6 inches were 39 percent more likely to develop dementia than those with normal waist size. Fat around the middle was not associated with a higher dementia risk in men.”
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Widespread Pain Linked To Heightened Dementia And Stroke Risk
Findings independent of age, sex, general health and lifestyle
Widespread pain is linked to a heightened risk of all types of dementia, including Alzheimers disease, and stroke, finds research published online in the journal Regional Anesthesia & Pain Medicine.
And this association is independent of potentially influential factors, such as age, general health, and lifestyle, the findings indicate.
Widespread pain is a common subtype of chronic pain that may reflect musculoskeletal disorders. Several studies suggest that it can reliably predict cancer, peripheral arterial disease, and cardiovascular disease, and it has been linked to a heightened risk of death.
While chronic pain may be an early indicator of cognitive decline, its not clear if widespread pain might also be linked to a heightened risk of dementia and stroke.
To try and find out, the researchers drew on data from 2464 second generation participants of the US long term, multigenerational, community-based Framingham Heart Study, known as the Offspring Study.
Participants were given a comprehensive check-up, which included a physical exam, lab tests, and detailed pain assessments between 1990 and 1994.
They were divided into three pain groups: widespread paindefined according to American College of Rheumatology criteria as pain above and below the waist, on both sides of the body, the skull, backbone and ribs other painclassified as pain in one or more joint only or no pain in any joints .
Widespread Pain Linked To Cognitive Decline And Stroke
Using data from the United States community-based Framingham Heart Study, Drs. Wang and Liu assessed pain status of individuals at a single time point between 1990 and 1994. Participants were followed and assessed for incident dementia, Alzheimers disease and stroke a median of 10 years later.
A total of 347 participants met criteria for widespread pain at the start of the study while 2,117 did not. Widespread pain was defined in the Framingham study as pain above and below the waist, on the left and right-hand sides of the body and in the axial skeleton according to the American College of Rheumatology criteria.1 Previous studies suggest that chronic pain may be an early indicator of cognitive decline, but none has examined associations between widespread pain and adverse cognitive outcomes and stroke at the population level, they noted.
Over a 10-year follow-up period, widespread pain was associated with:
- a 43% increased risk of all-cause dementia
- a 47% increased risk of Alzheimers disease
- a 29% increased risk of stroke in multivariate analysis
During the follow-up period, 188 individuals developed dementia or AD and 139 individuals suffered a stroke, 31 with widespread pain and 108 without.
The associations were independent of variables including age, health, and sociodemographic factors, and results were similar in a subgroup of participants older than 65 years.
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Can Sinus Issues Cause Dementia
Longtime readers know that I often mention the many adverse effects of letting sinus troubles go untreated: sleep loss, headaches, and depression, to name just a few. In most of these cases, the cause is clear obstructed respiration robs the body of rest and oxygen, two things that are utterly essential to our overall wellbeing.
But the stakes were raised this month when a new study was released linking small issues like sinus complaints to one of the most debilitating diseases in medicine: dementia. As a New York Times article put it:
The findings, published on Wednesday in the journal Neurology, are based on an analysis of 7,239 people age 65 and older who took part in the Canadian Study of Health and Aging between 1992 and 2002. Investigators intentionally ignored traditional dementia risk factors like heart disease and diabetes and focused on seemingly inconsequential health issues often associated with aging, like sinus complaints, foot and ankle conditions, skin problems and trouble with vision, hearing or dental health.
Taken alone, none of these health conditions are related to a persons dementia risk. But when investigators combined these relatively minor physical ailments into a single frailty index, they found a significant cumulative effect on dementia risk.
Higher Risk Of Dementia Stroke
For their study, the Chongqing Medical University researchers pulled data from the Framingham Heart Study . FHS is a large cohort study that started in 1948, with 5,209 white men and women between the ages of 30 and 62 years from the town of Framingham, Massachusetts. Originally, the purpose of the study was to understand heart disease better.
Now studying its third generation of participants, the FHS has encompassed more than 15,000 participants. For their work, the Chongqing Medical University researchers looked at about 2,464 participants of the Framingham Offspring Study Cohort. Health practitioners examined these participants between 1990 and 1994.
The participants also underwent laboratory tests and received a questionnaire to determine whether or not they experienced pain. Of the participants, 347 reported experiencing widespread pain.
The researchers found that these participants had:
- a 43% higher risk for all-cause dementia
- a 47% higher risk of Alzheimers disease
- a 29% higher risk of stroke
The researchers presented three hypotheses for why individuals experiencing widespread pain might have an increased risk of developing dementia or having a stroke.
It could relate to lifestyle factors associated with experiencing chronic pain. For example, people who have chronic pain might not feel well enough to exercise regularly or shop for the groceries they need for a nutritious diet.
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Organizational And Educational Aspects That Challenge Pain Management In Dementia
Recommendations to improve pain assessment and management in nursing homes, including national guidelines, have stressed the importance of a well-trained, knowledgeable pain team., In addition, implementation of treatment algorithms and consultation, continuous education, and team building within the care team are seen as the cornerstones of better pain management . A Canadian study that consulted frontline staff and administrators in long-term care revealed overall a general attitude that is open to change in which staff acknowledged the need for better implementation of pain management. Stakeholders identified a number of barriers including a lack of resources and lack of support from funding bodies. Free evidence-based tools and best practices for nurses, who work in nursing homes, are available through www.geriatricpain.org. However, it is clear that to elicit change in practice it will be key to position an accountable professional or onsite leader to champion implementation of better care standards.
Medicating For Pain Control
While non-drug approaches are important, many people will still benefit from prescribed pain medications. If you’ve ruled out other causes of behaviors , and you’ve determined that the person is likely experiencing pain, getting a prescription for pain medicine is a good idea.
Be wary of pain medications that are ordered on a PRN basis. Because the person with dementia might not be able to express their pain well, or might not be aware of a gradual increase in discomfort until they’re in a lot of pain, PRN pain medications are more likely to result in poorly controlled pain.
Either the person doesn’t ask for it, so they don’t receive it, or they get it later than would have been ideal and their pain is beyond what’s normally controllable by the medication and dose prescribed. If at all possible, a routine order for pain medicine is preferable for the person with dementia.
Although family members may express the worry of possible addiction to pain medications, this is usually not a primary concern since drug-seeking behavior is not common in people with dementia. Additionally, many value quality of life, which is likely to improve with adequate pain control.
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Risk Of Bias Assessment
We constructed a risk of bias form based on relevant items from the Cochrane Collaboration risk of bias tool and relevant forms of bias relating to casecontrol study designs . Two coauthors completed the bias of each study. Any disagreements were resolved through discussion or by the inclusion of a third reviewer .
Better Managing Impact Of Chronic Pain
Doctors often struggle to manage their patients pain, since current therapies, in addition to being addictive, do not always work. But Whitlock said that even those patients who continue to suffer, and may be experiencing a more rapid cognitive decline as a result, can still be helped with assistive devices, physical and occupational therapy, or strategies, such as mindfulness techniques, that are aimed at increasing self-efficacy and curbing the emotional impact of chronic pain.
This is something I really feel we can do something about as clinicians, Whitlock said. Its part of taking care of the whole patient.
Other authors of the study include Grisell Diaz-Ramirez, MS W. John Boscardin, PhD Kenneth E. Covinsky, MD and Alexander K. Smith, MD, MPH, all of the Division of Geriatrics in the UCSF Department of Medicine and , ScD, MS, of the UCSF Department of Epidemiology and Biostatistics.
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Managing Pain For Individuals With Dementia
When you suspect that a person is going through dementia and pain, it is advisable to seek medical attention.
Doctors have special tools that they can use to detect pain in seniors who have dementia.
The health care workers are also in the best position to prescribe appropriate pain medication depending on the cause of pain.
Some of the drugs that doctors may prescribe include opioids, non-steroidal anti-inflammatory drugs, aspirin, laxatives, and analgesics.
There are also non-drug therapies that can help with dementia and pain.
Depending on doctors instructions they can be implemented alone or in combination with pain alleviating drugs.
Examples of therapies that can help include:
- Pet, music, or aromatherapy
If a person needs to be on long-term pain management, you can always consult different professionals like tissue viability nurses, a general practitioner, physiotherapist, or a pain specialist team in your locality to get expert advice on effective pain management strategies.
Detecting Pain In Persons With Dementia
As dementia progresses, it can affect a persons language skills to the extent that they are not able to express when they are in pain.
Some affected persons may not even remember how they hurt themselves or the source of their pain which adds to the challenges of trying to communicate about their pain.
Caregivers should, therefore, know how to detect when a person is suffering from dementia and pain so that it can be treated as soon as possible.
Because persons with dementia will experience pain differently, at times it may be possible to ask directly whether a person is in pain.
This is where you shoot direct questions like does it hurt, are you in pain? Is it sore? and they will give you an answer.
However, when a person is not able to communicate how they are feeling, perhaps because they have advanced dementia, their behaviors might give you a clue when they are experiencing pain.
Some of the behaviors include social withdrawal or becoming increasingly agitated. Other non-verbal cues that a person may use to communicate that they are in pain or distress include:
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Assessment Of Pain In Elderly With Cognitive Decline
Self-assessment scales are considered the gold standard for assessing pain, but the presence of cognitive impairment decreases their reliability. In 2002, the American Geriatrics Society established guidelines for the assessment of behavioral indicators of pain . More recently, the American Society for Pain Management, with the Nursing Task Force on the assessment of pain in patients unable to verbally communicate, recommended a comprehensive hierarchical approach, incorporating measures of self-evaluation and the observation of behaviors related to pain . On the basis of these recommendations, the assessment of pain in elderly patients affected by cognitive impairment should be carried out as follows:
Researching possible causes of pain. Common etiological factors should always be investigated in elderly persons: pathological conditions , treatment procedures or other causes are common etiologies of chronic pain.
Obtaining information from a caregiver. Sufficiently reliable information can be obtained from formal and informal caregivers who have adequate knowledge of the patients history and past and current behavior and may be adequately trained to assess pain. Pain assessment should be included in the training of all staff members involved in clinical care. There are discrepancies between patient self-assessment and that of family members and clinical staff, who tend to overestimate and underestimate the pain experienced by the individual .
Evidence For Cognitive Decline In Chronic Pain: A Systematic Review And Meta
- 1Department of Anesthesiology and Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China
- 2Precision Medicine Research Center, West China Hospital, Sichuan University, Chengdu, China
Background: People with chronic pain sometimes report impaired cognitive function, including a deficit of attention, memory, executive planning, and information processing. However, the association between CP and cognitive decline was still not clear. Our study aimed to assess the association of CP as a risk factor with cognitive decline among adults.
Methods: We included data from clinical studies. Publications were identified using a systematic search strategy from PubMed, Embase, and Cochrane Library databases from inception to October 10, 2020. We used the mean cognitive outcome data and the standard deviations from each group. The standardized mean difference or odds ratio , and 95% confidence intervals were performed for each cognitive decline outcome. I2-values were assessed to quantify the heterogeneities.
There may be an association between CP and the incidence of cognitive decline when some cognitive, evaluative methods were used, such as short-form 36 health survey questionnaire, Montreal cognitive assessment, performance validity testing, and operation span.
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Reasons Why Its Challenging To Detect Pain In Seniors With Dementia
1. Inability to describe, explain, recognize, or remember painOne reason we dont know when someone with dementia is in pain is that they lose the ability to recognize or describe whats happening with their body.
Even when asked specifically, they may not be able to explain how theyre feeling, where the pain is, when it started, how it feels, etc.
And even though they feel and are affected by it, they may not be able to recognize that what theyre feeling is pain.
Plus, if someone has problems with short-term memory, they may have forgotten about an episode of pain.
However, that doesnt mean that they werent affected by the pain at the time or that they wont be in pain again.
2. FearAnother reason someone with dementia may not say when theyre in pain is that theyre afraid.
They might be afraid that they would need surgery or a painful treatment, be sent to the hospital or a nursing home, or be given medication they dont want.
3. PrideEven if they can clearly communicate their thoughts and feelings, some people may have grown up with the belief that pain is to be endured silently.
Their pride tells them that people should never admit to or complain of pain.
Others may think that admitting to being in pain and needing help means that theyll lose respect or independence.