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.12 The best-possible forms of pain assessment will be briefly reviewed in the next paragraphs.
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Acute Injuries arise out physical trauma, they include fractures, dislocations, open wounds etc. The coverage of these injuries in this article will be limited as they all require the same treatment protocol, being first aid, and depending on the injury may require medical attention followed by physiotherapy. Lewy Body Dementia And Joint Pain
Symptoms indicate which tissue is involved, it can be one or all of those listed, in varying degrees of severity, and more than one tissue may be involved.
Nerve impingement refers to pressure placed on a nerve or nerve root by surrounding tissue, which may be bone, disc, muscle or fascia. Hernias and tumours can also increase pressure on nerves. Symptoms include numbness, tingling, pins and needles, weakness, and sometimes a degree of loss of control of an affected limb. It is for example, impingement of the sciatic nerve that leads to a temporary numbness in the buttocks, legs and feet, caused by muscles tightening around the nerve. This is often caused by sitting in an unnatural position for some time. Stretching the gluteal muscles and sports/remedial massage can help prevent and relieve these symptoms, however, if the symptoms persist after the activity which caused them has ceased, or they recur frequently, then medical advice should be sought. Your doctor may then recommend that you see an Osteopath, Chiropractor or Physiotherapist.
A Long Road To A Diagnosis Of Lewy Body Dementia
In addition to the initial pain, Maureen developed headaches and issues with her vision. I started getting some weird lights in the side of my eyes, just a bunch of crazy things, she says. Still, Maureen continued to put her children and other responsibilities first. As other symptoms came along, I would try to fit my kids in before me, she says.
Then one day in late 2009 when she was teaching, something felt wrong. She stopped by her doctors office on the way home from school. When they took her blood pressure, they told her, Youre going right to the hospital. Youre off the charts. Her list of symptoms expanded to include high blood pressure that was especially difficult to treat.
The disease also manifested in sleeping problems. At first, Maureens kids told her she was talking in her sleep. Then they told her she was yelling in her sleep. My son came in to try to wake me up one night, and somehow I had the remote control in my hand, and I threw it, Maureen says. I didnt know he was in the room.
Maureens neurologist referred her to a sleep doctor, who diagnosed her with an REM sleep behavior disorder. She had been acting out her dreams. It was then that Maureen heard about Lewy body dementia for the first time. But the doctor assured her Lewy body dementia wasnt the cause. No, no, no, not you, she remembers hearing. The sleep doctor told her she was too young. Instead, they believed she had Parkinsons disease.
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What Can I Expect If A Loved One Or I Have Lewy Body Dementia
Each persons experience with Lewy body dementia is unique to them. How slowly or quickly the disease progresses is impossible to know, but may be influenced by your general health and any existing conditions you may have.
Because LBD is a progressive disease, difficulties with mind and body functions get worse over time. Currently, theres no known way to stop the progression of the disease.
However, theres always hope. Research on dementia with Lewy bodies, Alzheimers disease and Parkinsons disease with dementia are ongoing. New medications are being developed and new treatment approaches are being investigated.
How To Help Someone Manage Lewy Body Dementia
When it comes to helping someone manage the symptoms of LBD, small things can often make a big difference.
Create a routine. It can help someone with LBD to have predictable routines, especially around meal times and sleep times.
Establish a nighttime ritual. Try to establish bedtime rituals that are calming and away from the noise of television, meal cleanup, and active family members. Limiting caffeine consumption and daytime napping, and encouraging exercise can help curb restlessness at night.
Modify tasks. Break tasks into easier steps and focus on success, not failure.
Walk together. Taking a walk with the patient with LBD is a win-win activity. Being outdoors and exercising is vital for the health and state of mind for both the patient and you.
Strengthen senses. Have a doctor evaluate each the patients five senses in order to identify and treat any abnormalities. Then ask about exercises to improve them.
Make lifestyle changes. To help minimize the risk of fall-related injuries, you can help stabilize blood pressure. Help your loved one stay well hydrated, exercise, take in adequate sodium , avoid prolonged bed rest, and stand up slowly.
Tips for managing behavioral changes
One of the major challenges of caring for a loved one with dementia can be coping with the troubling behavioral changes that often occur. As a caregiver, you cant change the person with dementia, but you can employ strategies to modify or better accommodate any problem behaviors.
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About Dr Melita Petrossian
Melita Petrossian, MD, is Director of Pacific Movement Disorders Center and is a fellowship-trained neurologist with clinical interests and expertise in movement disorders such as Parkinsons disease, essential tremor, dystonia, gait disorders, ataxia, myoclonus, blepharospasm, hemifacial spasm, Meige syndrome, spasticity, tics, and Tourettes syndrome.
She also specializes in Parkinsons-related conditions such as Dementia with Lewy Bodies, progressive supranuclear palsy, multiple system atrophy, corticobasal degeneration, primary freezing of gait, and Parkinsons disease dementia.
Pain In Other Types Of Dementia
There have been few studies on pain in different subtypes of dementia such as VaD, FTD, or Lewy body dementia. In VaD, white matter lesions lead to several disconnections between areas of the brain in a process known as deafferentiation. This is thought to be responsible for an increase in the motivationalaffective aspects of pain. This type of pain, also called central neuropathic pain, occurs frequently in patients who have had a stroke29 and there is some clinical evidence that this type of deafferentiation pain might also occur in VaD.17,30
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Practical Tips On Medications To Manage Difficult Behaviors In Dementia
You may be now wondering just how doctors are supposed to manage medications for difficult dementia behaviors.
Here are the key points that I usually share with families:
- Before resorting to medication: its essential to try to identify what is triggering/worsening the behavior, and its important to try non-drug approaches, including exercise.
- Be sure to consider treating possible pain or constipation, as these are easily overlooked in people with dementia. Geriatricians often try scheduling acetaminophen 2-3 times daily, since people with dementia may not be able to articulate their pain. We also titrate laxatives to aim for a soft bowel movement every 1-2 days.
- No type of medication has been clinically shown to improve behavior for most people with dementia. If you try medication for this purpose, you should be prepared to do some trial-and-error, and its essential to carefully monitor how well the medication is working and what side-effects may be happening.
- Antipsychotics and benzodiazepines work fairly quickly, but most of the time they are working through sedation and chemical restraint. They tend to cloud thinking further. It is important to use the lowest possible dose of these medications.
- Antidepressants take a while to work, but are generally well-tolerated. Geriatricians often try escitalopram or citalopram in people with dementia.
Restless Leg Syndrome And Periodic Limb Movement Disorder
These conditions often accompany the disorders of synuclein, and each other . The treatment options are identical for the two disorders however, periodic limb movement disorder does not require treatment unless it is disrupting sleep or sleep architecture. There are no trials of restless leg syndrome or periodic limb movement disorder treatment in the context of DLB. The dopamine agonists are not recommended in this setting for the reasons outlined earlier. Standard treatment of restless leg syndrome and limb movement disorder with carbidopa/levodopa, benzodiazepines , and the alpha-2-delta calcium channel ligands are effective in PD patients .
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No Easy Solutions But Improvement Is Usually Possible
As many of you know, behavior problems are difficult in dementia in large part because there is usually no easy way to fix them.
Many probably too many older adults with Alzheimers and other dementias are being medicated for their behavior problems.
If your family is struggling with behavior problems, I know that reading this article will not quickly solve them.
But I hope this information will enable you to make more informed decisions. This way youll help ensure that any medications are used thoughtfully, in the lowest doses necessary, and in combination with non-drug dementia behavior management approaches.
To learn about non-drug management approaches, I recommend this article: 7 Steps to Managing Difficult Dementia Behaviors
And if you are looking for a memory care facility, try to find out how many of their residents are being medicated for behavior. For people with Alzheimers and other dementias, its best to be cared for by people who dont turn first to chemical restraints such as antipsychotics and benzodiazepines.
This article was first published in 2016, and was last updated by Dr. K in May 2022.
Signs And Symptoms Of Lewy Body Dementia
As with Alzheimers disease or Parkinsons disease, the symptoms of Lewy body dementia worsen over time, with intellectual and motor functions deteriorating, typically over several years. Despite the overlaps, however, there are symptoms that indicate the disorder is indeed LBD and not another condition.
While patients with LBD lose cognitive function, they are less prone to the short-term memory loss associated with Alzheimers disease. More commonly, they experience greater problems with executive functions of planning, decision-making, and organization, as well as difficulties with visual perception, such as judging and navigating distances. This can cause you to fall or faint frequently or become lost in familiar settings. Lewy body dementia can also cause sleep disturbances, including insomnia and daytime sleepiness.
If you have Lewy body dementia, you will also exhibit at least two of four core features:
Changes or fluctuations in awareness and concentration. You swing from a state of alertness to appearing drowsy, confused, or staring into space. These episodes can be unpredictable and last anywhere from a few seconds to several hours.
Spontaneous Parkinsons-like motor symptoms, such as slowness of movement, rigid muscles, tremor, lack of facial expression, or abnormal gait.
Recurrent visual hallucinations or delusions, such as seeing shapes, colors, people, or animals that arent there or conversing with deceased loved ones.
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How Is Lewy Body Dementia Treated
Theres no cure for Lewy body dementia . Medications and nonmedical therapies, like physical, occupational and speech therapies, manage symptoms as much as possible.
Medications that can help manage the symptoms of LBD include:
- Cholinesterase inhibitors: This type of medication, which includes rivastigmine, galantamine and donepezil, helps manage the cognitive symptoms of LBD.
- Carbidopa-levodopa: Symptoms of parkinsonism, like tremors, are usually treated with levodopa, a drug commonly used to treat Parkinsons disease. However, it has serious side effects and can lead to delusions, hallucinations and confusion.
- Pimavanserin: This medication can be used to treat psychosis in people with Parkinsons disease dementia.
- Clonazepamandmelatonin: These medications can help treat REM sleep behavior disorder.
- Antidepressants: Depression is common in people with LBD and often requires antidepressant therapy with selective serotonin reuptake inhibitors .
- Memantine: This drug is typically used to treat dementia caused by Alzheimers disease, but its been investigated in clinical trials and may work in people with LBD who are in the early phases of the condition.
People with LBD can take part in different therapies to improve their quality of life, including:
- Individual and family psychotherapies .
Treating Chronic Pain In Dementia Patients
The U.S. population is steadily getting older, and thatmeans that health issues like chronic pain and dementia will become morewidespread. Due to improving health care,more Americans are living longer which means that the risk of developing aserious pain or a neurological condition is more likely. As these risks increasein the general population, more people are having to struggle with both kindsof health issues simultaneously.
Estimates suggest that pain lasting more than three months may be present in up to 50 percent of the senior population, while the number of seniors with dementia range from five to eight percent. Although it is unclear how many of the elderly suffer from both conditions, there is likely to be a significant population because recent studies suggest that there is a causal link between chronic pain and cognitive dysfunction.
What Is Dementia?
Almost everyone experiences some decline in cognitive abilitieslike memory, speech or problem solving as they age, but there is a starkcontrast between weakening cognitive function and the medical concept ofdementia. Dementia is not a single ailment but includes an entire class of neurologicaldiseases. By definition, all of these illnesses cause abnormal brain changesthat interfere with independent daily life.
Dementia includes the following conditions:
Treating Chronic Pain to Help Prevent Dementia
Chronic Pain Treatments for Seniors
The most commonly recommended pain therapies for seniorswith dementia include:
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> > > Best Joint Pain Solution Available
IMPORTANT DO NOT STRETCH THE MUSCLE IF ANY OF THE ABOVE SYMPTOMS ARE PRESENT. SEEK TREATMENT. Lewy Body Dementia And Joint Pain
One of the problems arising out of tendon injuries, long after the pain has gone, is a perceived weakness. You may have badly sprained an ankle and found thereafter, that you roll the ankle for no good reason i.e. on perfectly flat ground. The likely cause of this is damage to the proprioceptors in the tendon which relay spatial information pertaining to the limb, to the brain, When these receptors are damaged, the brain doesnt know where your foot is in space, so that you may be putting your foot down on its side rather than the sole, hence you keep rolling your ankle. Special exercises are required to re-program the proprioceptor cells to prevent the injury recurring over and over again. A physiotherapist will be able to provide this information.
Tenosynovitis is inflammation of the tendon sheath, occurring with or without tendonitis. The symptoms are similar to those of tendonitis, though the pain can be over a greater area. Again, seek immediate treatment from a physiotherapist. Massage is not usually appropriate. Acupuncture may be of benefit.
The Link To Parkinsons Disease
Most people with Parkinsons disease have Lewy bodies in their brains. Its these clusters that cause some or all of the motor symptoms of Parkinsons disease, as well as memory or cognitive problems, visual hallucinations, and problems with alertness.
We rarely know if a living patient has Lewy bodies with certainty, however. Its not until an autopsy that they can be seen, says Liana Rosenthal, M.D., assistant professor of neurology at the Johns Hopkins University School of Medicine. If we see Lewy bodies in someones brain during an autopsy, thats considered a pathologic certainty of Parkinsons disease, she says.
As with Parkinsons, Lewy body dementia is associated with a depletion of certain neurotransmitters in the brain. These are:
- Dopamine: This neurotransmitter helps transmit signals that control muscle movement. When the accumulation of Lewy bodies blocks dopamines production and transmission, the result is the hallmark movement issues of Parkinsons disease.
- Acetylcholine: This neurotransmitter does its work in the parts of the brain responsible for memory, thinking and processing. When Lewy bodies build up in these areas, they interfere with acetylcholine, causing symptoms of dementia.
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Lewy Body Dementia And Joint Pain
Nerve impingement is often neglected as the symptoms are not severe enough to prompt action, yet it can be a precursor to nerve inflammation, a very painful and serious condition.
Nerve inflammation Lewy Body Dementia And Joint Pain
An impinged nerve can become inflamed. The inflammation further increases pressure on the affected nerve and causes its dysfunction. This is symptomised by sudden sharp shooting or stabbing pain, which follows the nerve pathway, therefore it tends to radiate from an epicentre to another part of the body e.g. along a limb. It can cause muscle spasms and reduced function in the affected limb. In both nerve impingement and inflammation, the symptoms can occur with or without movement but are often worsened by specific positions. Sciatica for example, is inflammation of the sciatic nerve and causes pain down the side and back of the leg, the inner thigh and into the foot. Viral infections such as Shingles also cause nerve inflammation.Nerve inflammation can be excruciating. You should seek medical advice as soon as possible as permanent nerve damage can result if the cause is untreated.
Muscle spasms and strains
What Causes Lewy Body Dementia
A buildup of Lewy bodies causes both dementia with Lewy bodies and Parkinsons disease dementia. When Lewy bodies build up in neurons, they cause damage to certain areas of your brain.
Researchers dont know why some people develop LBD while others dont. Theres some thought that the combination of mutations in a persons genes, environmental risk factors and natural aging might lead to the development of LBD in some people. Research into specific causes is ongoing.
One of the more recent discoveries toward identifying a cause of Lewy body dementia is the finding of an increasing number of gene mutations. Two genetic risk factors recently discovered are variants in the APOE and GBA genes.
APOE is already known to increase the risk of developing Alzheimers disease. Theres growing evidence that it also increases the risk for dementia with Lewy bodies. Similarly, the GBA gene increases the risk for both Parkinsons disease and dementia with Lewy bodies. Despite these findings, genetic changes as a cause of LBD are still considered rare by scientists. Most cases of Lewy body dementia arent thought to be inherited .
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