Stage : Moderately Severe Dementia
When the patient begins to forget the names of their children, spouse, or primary caregivers, they are most likely entering stage 6 of dementia and will need full time care. In the sixth stage, patients are generally unaware of their surroundings, cannot recall recent events, and have skewed memories of their personal past. Caregivers and loved ones should watch for:
- Delusional behavior
What Do We Know Of Pain In The Different Subtypes Of Dementia
Dementia is a syndrome that can lead to confusion, memory loss, neuropsychiatric symptoms, and sometimes physical challenges. The Diagnostic and Statistic Manual of Mental Disorders Fifth Edition does not mention dementia, but instead uses the term neurocognitive disorders, and classifies it as mild or major, on how severely the symptoms impact a person’s ability to function independently in everyday activities.
In a recent U.S. study, most patients with dementia were diagnosed with dementia not otherwise specified, with Alzheimer’s disease being the most prevalent subtype. In the early stages, people with AD may find it hard to remember recent events, conversations, and names of people. In time, it becomes harder to communicate and judgment may become impaired. The person may feel disoriented and confused. Their behavior can change, and physical activities, such as swallowing and walking, will become harder. Vascular dementia is another highly prevalent cause of dementia, followed by Lewy body dementia and frontotemporal dementia . Often, people have mixed types of dementia, with both aspects of AD and VD . Also, other neurodegenerative diseases such as Parkinson disease and Huntington disease often are accompanied by dementia in the last stages of the disease. To know what the effects of pain are in different subtypes of dementia, several things have to be taken into account:
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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Altered Pain Processing In Patients With Cognitive Impairment
- Wolters Kluwer Health: Lippincott Williams and Wilkins
- People with dementia and other forms of cognitive impairment have altered responses to pain, with many conditions associated with increased pain sensitivity, concludes a new research review.
People with dementia and other forms of cognitive impairment have altered responses to pain, with many conditions associated with increased pain sensitivity, concludes a research review in PAIN®.
The available evidence questions the previous notion that people with CI have reduced pain sensitivity to pain. Rather, “It appears that those with widespread brain atrophy or neural degeneration…all show increased pain responses and/or greater pain sensitivity,” write Ruth Defrin, PhD, of University of Tel Aviv, Israel, and colleagues.
Differences in Pain Sensitivity with Cognitive Impairment
Dr. Defrin and colleagues analyzed previous studies on pain responses in cognitively impaired patients. The topic is an important one, as many patients with CI — which can result from a wide range of neurological and neurodegenerative diseases, or even normal aging — have “sustained and complex healthcare needs” involving pain.
Evidence suggests that even normal, healthy aging may be associated with increased vulnerability to pain, as well as slightly reduced cognitive performance. These changes may set up a “vicious circle,” with pain leading to a decline in cognitive function and vice versa.
Ethics Consent And Permissions
Ethical approval was obtained both in England and Scotland . The process to recruit patients was informed by the Mental Capacity Act 2005 and the Adults with Incapacity Act 2000; it included written consent by patients or agreement from a carer consultee, patients capacity assessment to consent, consultation with staff and assent of carers . Interviewees gave their written consent and were informed of the audio-recording. The NHS trusts participating in this study granted access to the researchers, who complied with local requirements for data collection. Data were anonymised at the time of data collection.
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Are There Any Treatments
There are treatments that can help with the symptoms of some forms of dementia for a period of time, but there are currently no treatments that slow, halt or reverse the changes in the brain caused by the diseases. There are currently no treatments specifically for vascular dementia or frontotemporal dementia.
In the case of vascular dementia, a doctor may prescribe medication to treat underlying cardiovascular risk factors like high blood pressure or diabetes. Physiotherapy, speech therapy or occupational therapy may be offered to help with speech or movement problems. Non-drug treatments such as cognitive therapies may be available and can help some people with dementia to manage their symptoms.
Alzheimer’s Society ; has more information on treatments for dementia.
Exercise And Outdoor Activities For Dementia
Exercise and;outdoor activities;can have numerous benefits for;people with dementia. They can help improve brain function and thinking skills, regulate their sleep, and can help maintain a positive mood in;dementia patients;and lower the risk of them developing depression. Physical activities help overall cardiac and breathing health as well.
;Exercise and;outdoor activities;dementia patients;can engage in include:
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Pain Assessment In Patients With Dementia
Competent pain assessment is a necessary prerequisite for good pain management and ideally considers several pain dimensions, namely intensity, location, affect, cognition, behavior, and social accompaniments. In case of patients with dementia, many cognitive and linguistic barriers prevent individuals from focusing on all these aspects. Those responsible for pain management must be adequately informed at the least about the presence and intensity of pain. Thus, limited and one-sided pain assessment is almost the rule in individuals with dementia, leading to deleterious consequences for their pain treatment or lack thereof. The best-possible forms of pain assessment will be briefly reviewed in the next paragraphs.
Chronic Pain In The Elderly Population
- Persistent pain is present in 2550% of older adults, and increases with age. Nursing home patients may have prevalence as high as 4580%.33
- Chronologic markers for old age are arbitrary; however, various factors such as socioeconomic impacts, health-style choices and medical comorbidities may all factor into a patients physiologic age.
Studies Of Pain In Cognitively Impaired Elderly Persons
A number of studies in elderly persons comparing pain and cognitive ability have been performed. Such studies vary widely in their patient population, methods of pain assessment, and control populations. Many of these studies excluded patients who were noncommunicative, and most examined cognitively impaired elderly persons in general as opposed to patients with specific diagnoses, for example, DAT. However, consistent trends with regard to the relationship between pain and cognitive function seem to persist across many of these studies despite the significant differences in methodology and patient population.
Why Do People With Dementia Receive Poor Pain Relief
There are a number of reasons why people with dementia typically receive poor pain relief. The most obvious is that the person with dementia may lose the ability to tell us they are in pain.
Additionally, carers and care staff often do not recognise when a person is in pain or do not know how to help. People may think that some behaviours are due to the dementia rather than to pain. For example, calling out for help repeatedly. See the features in the Difficult situations section. Some believe that people with dementia do not experience pain or that because their memory is so poor they forget the experience.
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Biological Perspective: The Effect And Consequences Of Neuropathological Changes In Dementia On Pain
Both neuropathological and neuroimaging studies have described interconnected brain areas that are important in the mediation of pain processing.,, Most studies describe two neuronal networks, the medial and lateral pain systems. The medial pain system comprising the amygdala, medial thalamus, hippocampus, anterior cortex cinguli, and prefrontal cortex is a pathway that mediates cognitiveevaluative and motivational-affective aspects of pain. In addition, autonomicendocrine aspects are also mediated by the medial system., The lateral pain system comprises, among others, the primary somatosensoric areas and the lateral thalamic nuclei. The sensorydiscriminative aspects are mediated by the lateral pain system. Overlap of the two systems might occur in the insula. Recently, the existence of a third pathway mediating other critical aspects of pain has been proposed. This is thought to be a rostral, or limbic, pain system, which mediates behavioral aspects of pain for example, agitated behavior as a reaction to pain.
How Dementia Locks People Inside Their Pain
When a person feels pain but doesnt understand it, they can end up silently suffering.
On her first night home from the hospital, between bouts of writhing in pain, my grandmother stopped to ask me, over and over, Quest-ce que jai fait?: What did I do?
My grandmother, Denise, is 82 and in the late stages of Alzheimers disease, which means she can no longer form new memories. Late last summerits impossible to say when, exactlyshe fell and fractured a vertebra. Immediately, she forgot it had happened. Pain became the falls only remnant evidence. It took my family weeks, and two hospital trips, to understand why shed stopped eating or getting out of bed.
In anticipation of her second discharge from the hospital, I traveled to France to take care of her. When I arrived at the apartment where she lived alone, I was entirely unprepared for how intensely the Alzheimers could amplify her suffering.
My grandmothers throat rattled with every breath. She moaned in her sleep. In childlike tantrums, she kicked her legs and flailed her arms when I tried to get her out of bed to eat. She developed a cough so intense that it sounded, from a room away, like vomiting, and sometimes did turn into vomiting as her body tried to convulse the pain away. She couldnt tell day from night, and she got lost in her own home, even in her own bedroom.
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Language And Cognitive Impairment
Patients with severe dementia showed significant communication difficulties. Interviewees explained that questions about pain should be rephrased to account for this. For example, when questions were asked for the purpose of gathering and recording a pain score in a form structured with the three options mild, moderate and severe, these were to be translated into words patients could understand, taking into account the ability of each individual:
somebody might have no concept of what moderate means, for example .
Patients appeared to be using various gestures, postures, bodily movements, behavioural prompts, metaphorical expressions and a combination of these in what was interpreted as an expression and communication of pain. Data from interviews suggested that nurses and clinicians also looked at physical and behavioural signs to understand patients pain. One interviewee commented that the identification of these non-verbal communication cues depended largely on staff skills, experience, knowledge and perceptions and added that we need to get staff to think differently .
Good Advice For Handling Pain:
- Start by finding out why the person is in pain.
- You could try relieving the pressure.
- Use aids such as a heated cushion if, for example, the person has pain in the stomach.
- Massage and touch can alleviate pain. Find out more about touch therapy here.
- If necessary, use painkilling medication after taking advice from your doctor.
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Linking Pain And Dementia Stroke Risk
In an interview with Medical News Today, Dr. Rebecca Edelmayer, senior director of scientific engagement for the Alzheimers Association, called the Chongqing Medical University study a very first step in trying to understand whether theres any relationship between pain and increased risk for developing all types of dementia and having a stroke.
I was actually excited to read this paper because I was hoping to see a really in-depth study looking at the different types of pain that might put people at more risk for dementia, said Dr. Edelmayer, who completed her Ph.D. and postdoctoral training in medical pharmacology with a focus on neuropharmacology. I think this paper brings up more questions actually than answers.
Dr. Edelmayer also pointed out that widespread pain is a broad category. She told MNT:
What causes pain is very different across the body. It could be cancer-induced pain, inflammatory pain like arthritis, bone pain like osteoarthritis, neuropathic pain, which is sort of abnormal pain signaling and damaged nerves. Theres so many different reasons for people to be in pain.
Additionally, one type of pain may play more of a role in changing cognition than other types of pain, according to Edelmayer. I think much more research is still needed, she said.
Pain Management In Practice
Some studies have suggested that pain is less prevalent in patients with dementia because they suffer from less comorbidity, although several other studies have found that people with dementia do not have less painful conditions., Taken together, the literature indicates that about 50% of patients with dementia are regularly in pain. The largest study, which included over 5,000 home-care patients, also found no difference in pain prevalence in patients with or without dementia.
Studies on the prevalence of analgesic use in patients with dementia compared with in cognitively unimpaired patients .
The insufficient management of pain in patients with dementia can be explained by several factors. This uncertainty is partly due to the scarcity of pharmacological studies, which limits understanding of the pharmacodynamics of analgesic medication in this group of people. The optimal treatment in these patients is therefore predominantly experience based. Clinicians must make decisions on type and dosage of analgesia without clear knowledge of the impact of the cognitive comorbidity of their patient. This lack of knowledge extends among the range of health professionals who work with people with dementia, including nurses and pharmacists. It is likely that this results in both under- and overtreatment. Efficacy studies of analgesics in patients with dementia are challenging but feasible and there is an urgent need for more research in this area.
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Challenges And Future Directions
Figure 6 details the challenges reported by Spanish professionals in assessing pain in cognitive impairment , and the solutions and recommendations for its improvement . In an open question, there was a consensus among the different professionals that the difficulties were found at three levels: the patient, the professional knowledge and the tools. They pointed out pain management in severe cognitive impairment, due to its complexity and diverse etiology, like raising more concern. The difficulties are currently found in the poor or absent verbal communication and level of comprehension in such severe cognitive conditions ; the scarce time availability for pain assessment and monitoring confronted to low feasible and time-consuming tools ; the lack of specialized pain education and poor knowledge of specific tools for this population ; as well as the poor standardization and reliability of the tools, mostly for severe cognitive impairment. Also, the professionals referred to difficulties due to the presence of confounding factors, general lack of guidelines and recommendations, low awareness among the health professionals.
Figure 6. Challenges and Future directions in the pain assessment and management in the cognitively impaired/dementia population.
Support For People With Dementia And Carers
UCL covid-19 decision aid ; – a tool to support carers of people living with dementia to make difficult decisions during covid-19
Alzheimers Society ; end of life care information for patients and families;
Alzheimers Society ; ; information and fact sheets on all aspects of dementia including what is dementia, types of dementia and living well with dementia
Alzheimer Scotland ; specialist services for patients and carers;;
Dementia UK ;; expert one-on-one advice and support to families living with dementia via Admiral Nurses
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Pain Assessment In Advanced Dementia Scale
PAINAD is a commonly suggested tool to assess people with dementia or any cognitive impairment that prevents them from communicating their pain. roper use of the PAINAD scale as part of a comprehensive pain management plan can help reduce the likelihood of a patient experiencing unrecognized and untreated pain. This is an easy to use, simple, reliable and valid tool to assess pain in non-communicative people. Studies confirm that using a self-report tool such as Numeric Rating Scare is insufficient and inaccurate when used to assess people with dementia. Hence, an observational tool like PAINAD is more reliable. This tool that consists of 5 behaviors which need to be observed; breathing, negative vocalization, facial expression, body language and consolability. The total score ranges from 0-10 and it is interpreted as follows:
- 1-3=mild pain