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.
Pain In Advanced Dementia
This section gives some ideas for what you can do to recognise pain in people living with dementia, and what you can do to help them better manage pain.
Pain is one of the most common symptoms that people with dementia experience. However, often it is poorly recognised and undertreated in dementia. The main reason for this is that, as dementia progresses, the persons ability to communicate their needs becomes more difficult.
Pain is what the person says hurts.
International Association of Hospice and Palliative Care.
Evaluation Of Pain Management: Responsiveness
To perform valid responsiveness studies, RCTs with appropriate sample sizes are a prerequisite, but most of the current controlled studies did not include a representative sample of elderly with dementia. Further, it is vital that the final evaluation of the psychometric qualities of a scale considers the criterion of responsiveness against the criterion of reliability. Focusing only on the volatile and state-like aspects of pain in an instrument may increase its responsiveness, because every change is detected, but may neglect resistant and trait-like pain features . The result might be a premature all-clear when pain has not been fully addressed.
Reviews Findings The Pain Assessment Tools
In total, 28 pain assessment tools were assessed in the eight reviews nine tools were assessed in five or more reviews one tool was assessed in three reviews three tools were assessed in two reviews and the remaining 15 tools were assessed in one review each .
It should be noted that there seem to be different versions of PACSLAC: a preliminary 60 items one, then modified to 36 items. There seems to be ambiguity about which version of the tool the data are reported about . Similar ambiguity was found in relation to PADE, being unclear which version or which of its subscales – was studied for psychometric properties. Similarly, the MOBID tool has been studied in two different versions. It is also unclear how much the Abbey Pain Scale had been refined across the studies carried out to evaluate it .
Assessing Pain In Older Adults With Dementia
Issue #2 of Dementia Series
WHY: Pain in older adults is very often undertreated, and it may be especially so in older adults with severe dementia. Changes in a patients ability to communicate verbally present special challenges in treating pain, since self-report is considered the gold standard of pain assessment. As with all older adults, those with dementia are at risk for multiple sources and types of pain, including chronic pain from conditions such as osteoarthritis and acute pain from surgery, injury, and infection. Untreated pain in cognitively impaired older adults can delay healing, disturb sleep and activity patterns, reduce function, reduce quality of life, and prolong hospitalization
BEST TOOLS: The best tool for use in this population is a comprehensive pain assessment that includes self-report and objective measures of pain. Reid and colleagues provide a comprehensive protocol and geriatric pain assessment form. For patients with dementia, The American Society for Pain Management Nursings Task Force on Pain Assessment in the Nonverbal Patient recommends a comprehensive, hierarchical approach to pain assessment that incorporates the following steps:
TARGET POPULATION: Older adults with cognitive impairment who cannot be assessed for pain using standardized pain assessment instruments. Pain assessment in older adults with cognitive impairment is essential for both planned or emergent hospitalization.
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Description Of Nh Residents
The mean age of the residents was 70. 32 years and 46.3% were men. The mean length of stay for the residents was 31.2 months. Thirty-four percent of the residents had severe dementia the mean MMSE score was 14.44 and the mean Mini-Cog score was 1.6 . Nurses certainty was compromised after conducting a brief assessment of 21% of 104 residents and after conducting an additional assessment of 45% of 104 residents.
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 she’s 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 she doesn’t receive it, or she gets it later than would have been ideal and her 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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The Bolton Pain Assessment Tool
A new tool for patients with communication difficulties , the Bolton Pain Assessment Tool was produced. It combines aspects of the Abbey Pain Scale and the PAINAD. As a result of feedback from patients, relatives and carers , it includes a section for comments by usual carers and family members.
Scores between 0 and 3 are attributed in six categories and pain is rated as follows:
- 0-2 = no pain
- > 14 = severe pain.
Clinical Implication For Practitioners
It is imperative that practitioners use a consistent approach to prevent, detect, and manage physical discomfort, and to recognize that pain may worsen behavioral disturbances. This differentiation is critically important to allow selection of the most appropriate pharmacotherapeutic regimens, specifically an analgesic regimen in lieu of an antipsychotic agent. Because of frequent tracers and penalties against nursing facilities with regard to antipsychotic use, it may be prudent for facilities to assess pain and possibly treat with an analgesic trial before administering antipsychotics for agitation and aggressive-type behaviors.
Herr and colleagues suggest a consistent process for the assessment and management of pain in patients unable to self-report pain, including infants/preverbal toddlers, and critically ill/unconscious, dementia, intellectual disability, and end-of-life patients. Specific considerations for dementia and end-of-life populations are as follows:
In summary, patients with advanced dementia approaching the end of life have a high symptom burden. Pain is often underreported in this patient population because of their cognitive impairment. However, health care providers must anticipate this challenge and screen for and treat potential pain when possible.
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Data Extraction And Management
Data were extracted by two reviewers independently using a set of data extraction forms which was developed for the meta-review: 1) the AMSTAR checklist , 2) two forms for data about the reviews and 3) one form for data about the tools . The latter included a field for data extraction on the user-centredness of the tools, informed by Dixon and Longs work on the development of health status instruments . The data extraction forms were both paper-based and built into a MS Access database. At the time of data extraction, the reviews eligible for inclusion were screened further on the basis of availability of psychometric data of tools. At this point, we found that some of the reviews initially identified as being eligible for inclusion in the meta-review did not provide psychometric data of tools and were subsequently excluded . Data about the characteristics of the tool were extracted from the reviews we did not search for, nor retrieve, the original tools. The reviews were synthesised using a narrative synthesis approach.
S Of Pain Assessment In Cognitively Impaired Elderly Persons
Whereas a small collection of studies have surfaced regarding pain in cognitively impaired elderly patients able to communicate, patients whose dementing illnesses are so severe that they preclude meaningful communication have typically been excluded from studies because of the difficulty of objective pain assessment in this population. Despite the inherent difficulties of such assessment in this population, a number of methods and scales have been developed that measure pain in noncommunicative patients. In addition, in studies of significantly demented patients who are able to communicate, researchers have attempted to find the most effective methods to accurately and reproducibly determine pain in these patients. In this section we review the literature on pain assessment in both communicative and noncommunicative elderly persons.
A study of communicative patients with moderate to severe dementia found that 62% of patients reported pain with the remainder denying pain or unable to respond. Of those patients reporting pain, 83% were able to use at least one of five available scales to quantify their pain, showing that when healthcare providers are patient, allowing time for demented patients to assimilate clues and using visual cueing techniques to aid their patients, quantification of pain is often possible, even in this difficult population .
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Openuse A Tested Tool To Assess Pain
A number of different resources are available to help care staff establish whether a person with dementia is in pain, especially if the person cannot tell you in words. One example is the Abbey Pain Tool . The tool asks us to look for other ways in which the person may be letting us know they are in pain, perhaps through screwing up their face or rocking back and forth.
The Abbey Pain Tool can be used by care staff and suggests six possible signs of pain in a person with dementia:
Using a tool like this can help in your assessment of the persons pain. It can guide you to the cause of the pain, its severity, when it occurs and what helps to make the pain better or worse. It will also give you evidence to show a nurse or doctor if the pain is present or gone. If the pain is still present, always inform a doctor or nurse to review the persons medication.
Assessing Pain In The Confused Elderly Patient
Am Fam Physician. 2001 Jul 15 64:311.
Although frail older patients are likely to have painful conditions, managing pain in elderly patients whose cognitive impairment prevents them from communicating well about their pain may be difficult. Krulewitch and associates conducted a prospective, observational study to determine how nonprofessional caregivers recognize pain in the confused elderly patient and to compare their reports with those of the patient. Specifically, they sought to compare standard pain assessment instruments .
Researchers enrolled community-dwelling patients with Alzheimer’s disease, vascular dementia and other forms of dementia. The caregiver also was included in the study. Patients with Mini-Mental State Examination scores of 27 and above were excluded from participation.
Twenty-four of the pairs reported no pain or minimal pain, and 46 pairs reported at least moderate pain. In 16 pairs, the patient reported moderate to severe pain while the caregiver reported minimal or no pain. The Hospice Approach Discomfort Scale had low correlation with the other tools, but there were few patients in this study with extremely low MMSE scores.
The authors conclude that the PIS is the instrument most likely to determine the existence and magnitude of pain in a cognitively impaired older adult. A cognitively impaired patient is also more likely to be able to complete this instrument.
Read the full article.
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Pain In Dementia: Use Of Observational Pain Assessment Tools By People Who Are Not Health Professionals
Funding sources: This work was supported, in part, through a grant from the Saskatchewan Health Research Foundation.
Conflict of interest: Thomas Hadjistavropoulos acknowledges that he is one of the developers of the PACSLAC-II which is one of the scales discussed in this article. Nonetheless, he has no commercial interest in the PACSLAC-II. The authors have no other conflicts of interest to declare.
Overall Assessment Of The Tools
There seemed to be a general consensus among the reviewers that the current evidence on validation and clinical utility of the tools is insufficient . The overall conclusion was that there is a need for further psychometric testing of each tool. Two reviews recommended that the focus should be on studying existing scales rather than creating new ones , although one review also suggested that there may be a need to revisit the tools conceptual foundations .
Recommendations for further research and testing of the tools included the involvement of culturally diverse populations and the provision of scoring methods and guidelines for interpretation in the evaluation of the scale . Finally, a need for research emerged to link assessment with treatment algorithms .
Some of the reviews also concluded with recommendations for practice, for example: the use of at least two different pain assessment approaches at the same time in clinical practice and two different tools in research the importance of a comprehensive approach to pain assessment beyond the use of tools the need to involve social workers in regular holistic multidisciplinary pain assessment , with training in the use of the scales .
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Pain In Older Adults With Dementia: A Survey In Spain
- 1Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- 2Institut de Neurociències, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- 3Department of Pharmacology and Physiology, University of Zaragoza, Zaragoza, Spain
- 4Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
- 5Abertay University, Dundee, United Kingdom
- 6Sheffield Hallam University, Sheffield, United Kingdom
Common Causes Of Pain In Dementia
People with dementia are usually older and therefore many of the causes of pain will be the same for all older people:
- pressure sores
- muscle rigidity
People often experience pain when a part of the body is moving. For example, a person is most likely to experience pain when they are being helped to turn in bed, get dressed or undressed or when a wound dressing is being cleaned or removed.
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Strategies For Pain Assessment In Adult Patients With Delirium: A Scoping Review
- Annmarie HosieAffiliationsIMPACCTImproving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
- Tim LuckettAffiliationsIMPACCTImproving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
- Meera AgarAffiliationsIMPACCTImproving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
Pros And Cons Of Pain Scales
Williamson and Hoggart described the three main pain assessment scales as easy-to-use, highly valid and reliable. They did not recommend one above the others, and pointed out that what matters is to look at a pain score against previous ones. Gregory and Richardson conducted a small pilot study of nurses in the North West of England to identify which of the three scales is more commonly used. None appeared to be used consistently, but the NRS and VDS were used more often than the VAS.
Layman Young et al described the need for a single pain assessment scale that is practical and known to everyone to be used consistently across a particular setting, as using more than one scale could cause confusion and inconsistencies. Some participants in the study by Gregory and Richardson used two or more scales, but none indicated that they would use more than one scale to assess pain in one individual patient. This suggests a patient-centred approach where a scale suitable for the individual patient is chosen, as advocated by Mohan et al .
Pain scales only measure the intensity of pain, not other characteristics such as quality, duration and provoking or exacerbating factors the PQRST mnemonic can be used for a more comprehensive assessment .
Box 1. PQRST mnemonic for pain assessment
Ability To Differentiate No Pain Periods From Pain Expression Periods
Our first main hypothesis was that both groups of participants would be able to differentiate pain from nonpain video segments using the PACSLAC-II and the PAINAD. Means and SDs of PACSLAC-II and PAINAD scores during pain and no pain conditions are presented in . To test this hypothesis and to determine whether nurses and laypeople differed in their ratings, we conducted 2 x 2 mixed-methods MANOVAs with repeated measures, with the PACSLAC-II and the PAINAD as dependent measures. Regarding the possibility of differences between nursing staff and laypeople, for one out of the four sets of videos , the MANOVA yielded a significant between-groups multivariate effect using the Wilks criterion =18.67, P< 0.05, partial 2=0.12). All four sets of videos yielded significant within-subjects multivariate effects 689.01, P< 0.05, partial 2s0.92). Two out of the four sets of videos yielded significant interaction effects 3.87, P< 0.05, partial 2s0.06).
Next, univariate analyses were conducted involving PAINAD scores. For all four of the video sets, the within-subjects effects were significant 1236.83, P< 0.05, partial 2s0.91), demonstrating greater pain scores for the pain condition than for the no pain condition. No between-subjects or interaction effects were significant . The findings were consistent with our hypothesis concerning the ability of participants to differentiate pain from nonpain videos.