The MOBID-2 pain scale: reliability and responsiveness to pain in patients with dementia

Long-Term Pain Treatment Did Not Improve Sleep in Nursing Home Patients with Comorbid Dementia and Depression: A 13-Week Randomized Placebo-Controlled Trial

Objective: Previous research indicates that pain treatment may improve sleep among nursing home patients. We aimed to investigate the long-term effect of pain treatment on 24-h sleep patterns in patients with comorbid depression and dementia.

Design: A 13-week, multicenter, parallel-group, double-blind, placebo-controlled randomized clinical trial conducted between August 2014 and September 2016.

Setting: Long-term patients from 47 nursing homes in Norway.

Participants: We included 106 patients with comorbid dementia and depression according to the Mini Mental Status Examination (MMSE) and the Cornell Scale for Depression in Dementia (CSDD).

Intervention: Patients who were not using analgesics were randomized to receive either paracetamol (3 g/day) or placebo tablets. Those who already received pain treatment were randomized to buprenorphine transdermal system (maximum 10 μg/h/7 days) or placebo transdermal patches.

Measurements: Sleep was assessed continuously for 7 days by actigraphy, at baseline and in week 13. Total sleep time (TST), sleep efficiency (SE), sleep onset latency (SOL), wake after sleep onset (WASO), early morning awakening (EMA), and number of wake bouts (NoW) were evaluated. In addition, daytime total sleep time (DTS) was estimated. Pain was assessed with Mobilization-Observation-Behavior-Intensity-Dementia-2 Pain Scale (MOBID-2).

Results: The linear mixed model analyses for TST, SE, SOL, WASO, EMA, NoW and DTS showed no statistically significant differences between patients who received active pain treatment and those who received placebo. Post hoc subgroup analyses showed that there were no statistically significant differences between active treatment and placebo from baseline to week 13 in patients who were in pain (MOBID-2 ≥ 3) at baseline, or in patients who had poor sleep (defined as SE < 85%) at baseline. Patients who received active buprenorphine showed an increase in TST and SE compared to those who received active paracetamol.

Conclusion: The main analyses showed that long-term pain treatment did not improve sleep as measured with actigraphy. Compared to paracetamol, TST and SE increased among patients who received buprenorphine. This could indicate that some patients had beneficial effects from the most potent pain treatment. However, based on the present findings, long-term pain treatment is not recommended as a strategy to improve sleep. Clinical Trial https://clinicaltrials.gov/ct2/show/NCT02267057.

Feasibility of a staff training and support programme to improve pain assessment and management in people with dementia living in care homes

OBJECTIVES

The objective of this study was to establish the feasibility and initial effectiveness of training and support intervention for care staff to improve pain management in people with dementia living in care homes (PAIN-Dem).

METHODS

PAIN-Dem training was delivered to care staff from three care homes in South London, followed by intervention support and resources to encourage improved pain management by staff over 4 weeks. Feasibility was assessed through fidelity to intervention materials and qualitative approaches. Focus group discussions with staff explored the use of the PAIN-Dem intervention, and interviews were held with six residents and family carers. Pain was assessed in all residents at baseline, 3 and 4 weeks, and goal attainment scaling was assessed at 4 weeks.

RESULTS

Delivery of training was a key driver for success and feasibility of the PAIN-Dem intervention. Improvements in pain management behaviour and staff confidence were seen in homes where training was delivered in a care home setting across the care team with good manager buy-in. Family involvement in pain management was highlighted as an area for improvement. Goal attainment in residents was significantly improved across the cohort, although no significant change in pain was seen.

CONCLUSIONS

This study shows good initial feasibility of the PAIN-Dem intervention and provides valuable insight into training and support paradigms that deliver successful learning and behaviour change. There is a need for a larger trial of PAIN-Dem to establish its impact on resident pain and quantifiable staff behaviour measures. Copyright © 2017 John Wiley & Sons, Ltd.

Evaluation of a Pain Assessment Procedure in Long-Term Care Residents With Pain and Dementia

BACKGROUND

The management of pain in long-term care (LTC) residents with dementia is complex. A prospective exploratory study was conducted to describe the course of pain and pain management strategies following a guideline-based pain assessment procedure in LTC residents with pain and dementia.

MEASURES

Pain observations with the Mobilization Observation Behaviour Intensity Dementia (MOBID-2) Pain Scale, a review of the electronic patient file and pharmacy files and physical examination of LTC residents with pain and dementia.

INTERVENTION

Communication of the assessment results to the attending physician including guideline-based treatment recommendations.

OUTCOMES

After three months, complete follow-up data were obtained for 64 residents. Pain intensity was significantly reduced (P < 0.001). The proportion of residents with persistent pain was 58% and the total number of analgesic prescriptions did not change significantly.

CONCLUSIONS

There is room for improvement regarding pain management in LTC residents with pain and dementia, and performance feedback seems a promising strategy to explore further.

Pain in Dementia: Use of Observational Pain Assessment Tools by People Who Are Not Health Professionals

Objective

Pain is prevalent among older adults but is often underestimated and undertreated, especially in people with severe dementia who have limited ability to self-report pain. Pain in patients with moderate to severe dementia can be assessed using observational tools. Informal caregivers (relatives of seniors with dementia) are an untapped assessor group who often bear the responsibility of care for their loved ones. Our objective was to evaluate the ability of laypeople to assess pain using observational measures originally developed for use by health care professionals.

Design

We employed a quasi-experimental design and presented videos depicting patients with dementia (portrayed by actors) displaying pain behaviors or during a calm relaxed state (no pain) to long-term care nurses and laypeople. Participants rated the pain behaviors observed in each video by completing two standardized observational measures that had been previously developed for use by long-term care staff.

Results

As expected, both laypeople and nurses were able to effectively differentiate painful from nonpainful situations using the standardized tools. Both groups were also able to discriminate among gradations of pain (i.e., no pain, mild, moderate, severe) and required comparable amounts of time to complete the assessments.

Conclusions

We conclude that, as hypothesized, the instruments under study can be used for the assessment of pain by laypeople. This is the first study to validate these instruments for use by laypeople. The use of these tools by laypeople (under the guidance of health professionals) has the potential of facilitating earlier detection and treatment of pain in older adults with dementia who live in community settings.

Associations between pain and depression in nursing home patients at different stages of dementia

BACKGROUND

Pain is associated with depression in nursing home patients with dementia. It is, however, unclear whether pain increases depression. Therefore we evaluated the prospective associations between pain and depressive symptoms in nursing home patients at different stages of cognitive impairment.

METHODS

Two longitudinal studies were combined, including 931 patients (≥65 years) from 65 nursing homes. One study assessed patients at admission, with 6-month follow-up (2012-2014). The other study assessed residents with varying lengths of stay, with 4-month follow-up (2014-2015). Patients were assessed with the Mini-Mental State Examination, the Mobilisation-Observation-Behaviour-Intensity-Dementia-2 Pain Scale, and the Cornell Scale for Depression in Dementia.

RESULTS

At baseline, 343 patients (40% of 858 assessed) had moderate to severe pain, and 347 (38% of 924) had depression. Pain increased the risk of depression (OR 2.35, 95% CI 1.76-3.12). Using mixed model analyses, we found that a 1-point increase in pain was associated with a .48 increase in depression (p<.001). This association persisted in mild, moderate, and severe cognitive impairment. In those recently admitted, depressive symptoms decreased over time, and having less pain at follow-up was associated with a decrease in depressive symptoms (within-subject effect; p=.042).

LIMITATIONS

The two cohorts had different inclusion criteria, which may reduce generalisability. The study design does not allow conclusions on causality.

CONCLUSIONS

Pain and depressive symptoms are associated in patients with dementia. Because reduced pain is associated with less depressive symptoms, these patients should be assessed regularly for untreated pain. The benefit of analgesic treatment should be weighed carefully against the potential for adverse effects.

Associations between Pain and Quality of Life in Severe Dementia: A Norwegian Cross-Sectional Study

Background/Aims

Many variables influence the quality of life in older adults with dementia. We aim to quantify how the relationship between pain and quality of life in nursing home residents with severe dementia can be explained by neuropsychiatric symptoms, depressive symptoms, and activities of daily living.

Methods

This article presents cross-sectional baseline data from a cluster randomised controlled trial.

Results

The total and direct effects of pain on quality of life were statistically significant. Both neuropsychiatric and depressive symptoms partially mediated the relationship between pain and quality of life. Activities of daily living acted as a mediator only when modelled together with depressive symptoms.

Conclusion

Pain, neuropsychiatric symptoms, and depressive symptoms appear to be important factors that influence the quality of life for nursing home residents with severe dementia. Therefore, multidimensional interventions may be beneficial for maintaining or improving quality of life in this population.

[Pain measurement in cognitively impaired patients with the Doloshort scale]

BACKGROUND

Until recently the measurement of pain in cognitively impaired patients represented a neglected field in the diagnostics and treatment of pain. Investigations indicate a prevalence of pain in nursing home residents of between 45 % and 80 %.

MATERIAL AND METHODS

This study investigated the reliability of the German translation of the Doloshort scale and compared it with the visual analog scale (VS). The aim of this study was to determine the practical applicability of this scale in the clinical routine and to calculate the intrarater reliability (retest) and interrater reliability.

RESULTS

The interrater and intrarater reliability of the Doloshort scale was between 0.949 and 0.970. There was a highly significant correlation between the values of the Doloshort scale and the VAS.

CONCLUSION

The Doloshort scale is a well suited measurement instrument for the evaluation of pain in cognitively impaired patients. Because of the short form only simple instructions are necessary and it has a high acceptance with users.

Staff Distress Improves by Treating Pain in Nursing Home Patients With Dementia: Results From a Cluster-Randomized Controlled Trial

CONTEXT

Most people with dementia develop neuropsychiatric symptoms (NPSs), which are distressing for their carers. Untreated pain may increase the prevalence and severity of NPSs and thereby staff burden.

OBJECTIVES

We investigated the association between NPSs and the impact of individual pain treatment on distress in nursing home staff.

METHODS

Nursing home (NH) units were cluster-randomized to an intervention group (33 NH units; n = 175) or control group (27 NH units; n = 177). Patients in the intervention group received individual pain treatment for eight weeks, followed by a four-week washout period; control groups received care as usual. Staff informants (n = 138) used the Neuropsychiatric Inventory-NH version (including caregiver distress) as primary outcome to assess their own distress. Other outcomes were pain (Mobilization-Observation-Behavior-Intensity-Dementia-2 Pain Scale) and cognitive functioning (Mini-Mental State Examination).

RESULTS

Using hierarchical regression analysis, all NPS items at baseline were associated with staff distress (P < 0.01) apart from euphoria; agitation had the largest contribution (β = 0.24). Using mixed models, we found significantly lower staff distress in the intervention group compared to the control group. Moreover, we also found significantly reduced distress in the control group, and there were still effects in both groups throughout the washout period.

CONCLUSION

Individual pain treatment reduced staff distress in the intervention group compared to control group especially in regard to agitation-related symptoms and apathy. Furthermore, our results indicated a multifactorial model of staff distress, in which enhanced knowledge and understanding of NPSs and pain in people with advanced dementia may play an important role.

Pain assessment tools for older adults with dementia in long-term care facilities: a systematic review

AIM

The aim of this review is to document pain assessment tools used primarily for older adults in long-term care facilities and compare self-report and observer-rated tools.

METHODS

A literature search was conducted in Ovid MEDLINE^®, Embase, Cochrane and PsycINFO. Keywords included 'dementia', 'pain management' and 'managing pain'.

RESULTS

Of 1033 references, 23 articles were selected for inclusion. Six tools were self-rated and 18 tools were administered by an observer. 13 studies evaluated the reliability/validity of their scales; four studies compared different scales against each other.

CONCLUSION

Self-report should be the first-line approach when possible, with observational assessment used as a supplementary tool. Reliable observational tools have been shortened, and shown to maintain high reliability/validity, and positive psychometric properties.

TIME - Targeted interdisciplinary model for evaluation and treatment of neuropsychiatric symptoms: protocol for an effectiveness-implementation cluster randomized hybrid trial

BACKGROUND

Nearly all persons with dementia will experience neuropsychiatric symptoms (NPS) during the course of their disease. Clinicians and researchers emphasize the need for an evidence-informed standardized approach to managing NPS that integrates pharmacological and nonpharmacological treatments for real-world implementation. The Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) represents such an approach and is a multicomponent intervention based on the theoretical framework of cognitive behavioural therapy.

METHODS/DESIGN

The trial is a 3-month cluster randomized trial conducted in 30 nursing homes including 168 participants with dementia and a high level of agitation. Each nursing home defined as a cluster will be randomized to receive either the TIME intervention (the intervention group) or a brief education-only intervention regarding dementia and NPS (the control group). TIME is a manual-based, multicomponent programme that includes a rigorous assessment, one or more case conferences and the treatment and evaluation of NPS. Patient-level measurements are taken at baseline (prior to randomization) and 8 and 12 weeks later. The primary outcome measure is the change in agitation, as defined by the Neuropsychiatric Inventory-Nursing Home Version, at 8 weeks from baseline. Secondary outcome measures include change in agitation at 12 weeks from baseline, and change from baseline at 8 and 12 weeks in other NPS, quality of life, and the use of psychotropic and analgesic medications. Mixed methods will be used to follow, measure and explore the implementation process and the effect of the intervention at the individual staff level and the organization level. Combining measurements of clinical effectiveness and implementation outcomes define this trial as an effectiveness-implementation hybrid trial.

DISCUSSION

Measuring the implementation and effect of complex interventions aimed at reducing NPS in nursing homes is challenging. In this study protocol, we describe a multicomponent program, TIME, and discuss how an effectiveness-implementation cluster randomized hybrid trial can meet these challenges.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02655003 . Registered 6 January 2016.

Pain treatment for nursing home residents differs according to cognitive state - a cross-sectional study

Background

Communication skills are known to decrease with advancing cognitive impairment. Analgesic treatment in long-term care may be deficient due to the residents’ impaired ability to communicate their pain and needs. Undertreated pain frequently leads to rising BPSD in residents with cognitive impairment, resulting in a treatment with antipsychotics. Aim of this study was the analysis of differences in assessment and pharmacological treatment of pain in nursing home residents relative to their cognitive state and ability to articulate pain.

Methods

Data stems from the baseline of a non-experimental pre-post-study in 12 Austrian nursing homes. Residents’ pain prevalence in relation to pain assessment and cognitive decline was assessed, data on medical diagnoses and prescriptions were retrieved from the nursing homes’ documentation (n = 425). Residents were first divided into two groups: Residents with MMSE ≥ 18 were selected into group CUS (cognitively unimpaired/slightly impaired), residents with MMSE ≤ 17 were selected into group CI (cognitively moderately to severely impaired). CI residents were then sub-grouped according to their ability to communicate pain via the Verbal Rating Scale (VRS) (i.e. group CI-V, group CI-NV). Pain behavior of CI residents was assessed with a modified German version of PAINAD. Group differences were tested with ANOVA and H-test, 95 % confidence intervals were calculated and associations were tested with log-binomial regression.

Results

Pain prevalence in CI residents irrespective of their ability to communicate pain was 80 % and exceeded the CUS group prevalence significantly by 14 %. CI residents had significantly less analgesic prescriptions. Furthermore, CI residents have a significantly higher risk of getting no analgesics when in pain than CUS residents (CI-V: RR =2.6, CI-NV: RR =3.4). Use of antipsychotics was high in all groups (49 – 65 %) with more prescriptions in the cognitively impaired group.

Conclusion

Results point toward an underuse of pain medication in cognitively impaired residents, especially those unable to communicate pain verbally. The implementation of standardized pain assessments adapted to the cognitive abilities of residents may foster the recognition of pain, warrant optimized pain management, reduce inadequate medication and consequently raise the chance of equally effective pain treatment regardless of cognitive state.

Signs of Imminent Dying and Change in Symptom Intensity During Pharmacological Treatment in Dying Nursing Home Patients: A Prospective Trajectory Study

OBJECTIVES

To investigate whether it is possible to determine signs of imminent dying and change in pain and symptom intensity during pharmacological treatment in nursing home patients, from day perceived as dying and to day of death.

DESIGN

Prospective, longitudinal trajectory trial.

SETTING

Forty-seven nursing homes within 35 municipalities of Norway.

PARTICIPANTS

A total of 691 nursing home patients were followed during the first year after admission and 152 were assessed carefully in their last days of life.

MEASUREMENTS

Time between admission and day of death, and symptom severity by Edmonton symptom assessment system (ESAS), pain (mobilization-observation-behavior-intensity-dementia-2), level of dementia (clinical dementia rating scale), physical function (Karnofsky performance scale), and activities of daily living (physical self-maintenance scale).

RESULTS

Twenty-five percent died during the first year after admission. Increased fatigue (logistic regression, odds ratio [OR] 1.8, P = .009) and poor appetite (OR 1.2, P = .005) were significantly associated with being able to identify the day a person was imminently dying, which was possible in 61% of the dying (n = 82). On that day, the administration of opioids, midazolam, and anticholinergics increased significantly (P < .001), and was associated with amelioration of symptoms, such as pain (mixed-models linear regression, 60% vs 46%, P < .001), anxiety (44% vs 31%, P < .001), and depression (33% vs 15%, P < .001). However, most symptoms were still prevalent at day of death, and moderate to severe dyspnea and death rattle increased from 44% to 53% (P = .040) and 8% to 19% (P < .001), respectively. Respiratory symptoms were not associated with opioids or anticholinergics.

CONCLUSION

Pharmacological treatment ameliorated distressing symptoms in dying nursing home patients; however, most symptoms, including pain and dyspnea, were still common at day of death. Results emphasize critical needs for better implementation of guidelines and staff education.

TRIAL REGISTRATION

ClinicalTrials.govNCT01920100.

Pain monitoring and medication assessment in elderly nursing home residents with dementia

Objective:

To monitor pain intensity, pain symptoms, and medication use in elderly with dementia.

Methods:

Nursing home residents above 65 years of age, diagnosed with dementia, and showing pain symptoms were included in the study. The patients’ mental status was monitored through a mini-mental state examination score and observations of pain symptoms using Part 1 of the Mobilization-Observation-Behaviour-Intensity-Dementia-2 (MOBID-2) pain scale. Community pharmacists reviewed the patients’ medication use, and the prescriptions were compared with guidelines for treatment of geriatric patients. Alterations to the patients’ medicine use were forwarded to the general practitioners.

Findings:

Sixty-one nursing home residents diagnosed with dementia were identified, 15 of these fulfilled the inclusion criteria, and 12 agreed to participate in the study. The mean age was 87 years of age (range: 77-96), and 42% of the residents were males. The patients’ overall pain intensity was 83% for observations on the numeric pain rating scale (NRS) >0 and 67% for NRS ≥3. Most painful were the situations in which the residents were to mobilize their legs, turn around to both sides of the bed, and when sitting on the bed. The medication reviews identified a total of 95 individual prescriptions, and 33% of these were for nervous system medications, followed by medicines for the treatment of alimentary tract and metabolism disorders (31% of total). Eleven prescriptions for pain medicine were identified; the majority of these were for paracetamol and opioids. Seventeen proposals to patients’ medication use were suggested, but the general practitioners accepted only 6% of these.

Conclusion:

This study indicates that the MOBID-2 pain scale in combination with medication reviews can be used as a tool for optimization of patients’ medication use. However, we recommend the conduction of a larger-scale study in multiple settings, to validate our results and the generalizability of the findings.

The Interactive Relationship between Pain, Psychosis, and Agitation in People with Dementia: Results from a Cluster-Randomised Clinical Trial

Background. Neuropsychiatric symptoms are common in people with dementia, and pain is thought to be an important underlying factor. Pain has previously been associated with agitation, and pain treatment has been shown to ameliorate agitated behaviour. So far, the association between pain and psychosis and the effect of pain treatment on psychotic symptoms is unclear. Furthermore, the impact of opioid treatment on psychosis is not established. Aim. To investigate the efficacy of a stepwise protocol for treating pain (SPTP) on psychosis and agitation measured with the Neuropsychiatric Inventory, Nursing Home version, and to explore the impact of opioid analgesics on psychosis. Method. Secondary analyses are from a cluster-randomised controlled trial including 352 patients with advanced dementia and agitation from 18 nursing homes in Western Norway. The intervention group received pain treatment according to SPTP. Results. Pain was associated with disinhibition (adjusted OR: 1.21, 95% CI: 1.10–1.34) and irritability (adjusted OR: 1.10, 95% CI: 1.01–1.21) at baseline. Pain treatment reduced agitation (p < 0.001, df = 1; 300) and aberrant motor behaviour (p = 0.017, df = 1; 300). Psychosis was reduced in people with at least one symptom at baseline (p = 0.034, df = 1; 135). The use of opioid analgesics did not increase psychotic symptoms. Study Registration. This trial is registered with ClinicalTrials.gov (NCT01021696), Norwegian Medicines Agency, EudraCT (EudraCTnr: 2008-007490-20).

Analgesic prescribing patterns in Norwegian nursing homes from 2000 to 2011: trend analyses of four data samples

BACKGROUND

the analgesic drug use has been reported to increase in general in nursing home patients. However, there is insufficient evidence in terms of what agents are used, variations of use over time and to whom these drugs are prescribed.

OBJECTIVE

we investigated the prescribing patterns of scheduled analgesic drugs in Norwegian nursing home patients from 2000 to 2011, with the association to age, gender, cognitive function and type of nursing home unit.

DESIGN

secondary analyses of four study samples (three observational studies and one randomised controlled trial).

SETTING AND SUBJECTS

nursing home patients included in study samples from 2000 (n = 1,926), 2004 (n = 1,163), 2009 (n = 850) and 2011 (n = 1,858) located in 14 Norwegian counties.

METHODS

trend analyses of analgesic drug prescriptions. Percentages were described using t-test, χ(2) and Mann-Whitney U test and multivariate logistic regression.

RESULTS

the odds ratio for receiving any pain medication in 2011 compared with 2000 was 2.6 (95% CI 2.23-2.91), this is corresponding to a 65% increase from 34.9 to 57.6%. The paracetamol prescription increased by 113%, from 22.7% in 2000 to 48.4% in 2011. Strong opioids (fentanyl, buprenorphine, morphine, oxycodone) increased from 1.9% in 2000 to 17.9% in 2011 (P < 0.001), whereas non-steroidal anti-inflammatory drug prescription decreased, from 6.8 to 3.2%. In 2000, 2004 and 2009, people with dementia received fewer analgesics compared with patients without dementia; no differences in analgesic drug use between the groups were found in 2011.

CONCLUSIONS

the analgesic drug prescription increased significantly from 2000 to 2011, especially the use of paracetamol and strong opioids. We also highlight a possible change from under-prescription of analgesic medication in people with dementia, to an equal amount compared with patients without cognitive impairment.

Identifying and Managing Pain in People with Alzheimer's Disease and Other Types of Dementia: A Systematic Review

BACKGROUND AND OBJECTIVE

Pain in patients with Alzheimer's disease is a complex issue; these patients suffer from the common causes of acute and chronic pain, and some also have neuropathic or nociceptive pain. Whatever the mechanism of pain in these patients, their pain will require careful assessment and management, to insure the correct type and level of analgesia is given. The objective of this systematic review was the identification of studies that have investigated the efficacy of different analgesics on pain intensity or pain-related behavior during nursing home stay and at the end of life.

METHODS

A search using pain, pain treatment, and dementia MESH terms and keywords was conducted (October 15, 2015) in MEDLINE, EMBASE, PsychINFO, CINAHL, and Cochrane libraries.

RESULTS

Our search yielded 3138 unique hits, published between 1990 and October 2015. We read titles and abstracts, identified 124 papers for full-text evaluation, and included 12 papers to reflect and synthesize the following questions: (1) Which pain assessment tools for people with dementia are responsive to change in pain intensity scores? (2) Which analgesics are efficacy-tested by controlled trials including people with dementia living in nursing homes, including at the end of life? (3) Which outcome measures have been used to identify pain, pain behavior, and/or treatment efficacy in people with dementia?

CONCLUSION

Despite increased use of analgesics, pain is still prevalent in people with dementia. Validated pain tools are available but not implemented and not fully tested on responsiveness to treatment. Official guidelines for pain assessment and treatment addressing people with dementia living in a nursing home are lacking. The efficacy of analgesic drug use on pain or neuropsychiatric behavior related to dementia has been hardly investigated.

COSMOS--improving the quality of life in nursing home patients: protocol for an effectiveness-implementation cluster randomized clinical hybrid trial

BACKGROUND

Nursing home patients have complex mental and physical health problems, disabilities and social needs, combined with widespread prescription of psychotropic drugs. Preservation of their quality of life is an important goal. This can only be achieved within nursing homes that offer competent clinical conditions of treatment and care. COmmunication, Systematic assessment and treatment of pain, Medication review, Occupational therapy, Safety (COSMOS) is an effectiveness-implementation hybrid trial that combines and implements organization of activities evidence-based interventions to improve staff competence and thereby the patients' quality of life, mental health and safety. The aim of this paper is to describe the development, content and implementation process of the COSMOS trial.

METHODS/DESIGN

COSMOS includes a 2-month pilot study with 128 participants distributed among nine Norwegian nursing homes, and a 4-month multicenter, cluster randomized effectiveness-implementation clinical hybrid trial with follow-up at month 9, including 571 patients from 67 nursing home units (one unit defined as one cluster). Clusters are randomized to COSMOS intervention or current best practice (control group). The intervention group will receive a 2-day education program including written guidelines, repeated theoretical and practical training (credited education of caregivers, physicians and nursing home managers), case discussions and role play. The 1-day midway evaluation, information and interviews of nursing staff and a telephone hotline all support the implementation process. Outcome measures include quality of life in late-stage dementia, neuropsychiatric symptoms, activities of daily living, pain, depression, sleep, medication, cost-utility analysis, hospital admission and mortality.

DISCUSSION

Despite complex medical and psychosocial challenges, nursing home patients are often treated by staff possessing low level skills, lacking education and in facilities with a high staff turnover. Implementation of a research-based multicomponent intervention may improve staff's knowledge and competence and consequently the quality of life of nursing home patients in general and people with dementia in particular.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02238652.

Treating Pain in Dementia--Are We Good Enough?

Up to 80% of nursing home residents may be experiencing pain; however, in many cases their pain is not diagnosed and/or treated. People with moderate to severe dementia may have impaired communication, and this can impact on their self-report of pain. Drug treatment should be used cautiously. --This report is adapted from paineurope 2015; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be viewed via the Web site: www.paineurope.com , at which health professionals can find links to the original articles and request copies of the quarterly publication and access additional pain education and pain management resources.

Effective pain management in patients with dementia: benefits beyond pain?

This current opinion aims to provide a literature overview of the associations between pain and neuropsychiatric symptoms and the efficacy of pain management for both pain and neuropsychiatric symptoms in patients with dementia. In addition, international guidelines and recommendations for pain management have been collated, and important developing research areas are highlighted. Pain is, in general, under-recognized and undertreated in people with dementia and may therefore trigger or exacerbate neuropsychiatric symptoms. While there is an abundance of pain assessment instruments intended for people with dementia, few have been adequately tested for their feasibility, reliability and validity. In patients with dementia, vocalizations, facial expressions and body movements may be the only valid expressions of pain. Further, pain has been related to the neuropsychiatric symptoms of agitation, aggression, mood syndrome and sleep problems. Unfortunately, health personnel may misinterpret these symptoms as neuropsychiatric symptoms of dementia. A differential assessment of dementia, its presenting neuropsychiatric symptoms and the potential presence of pain is crucial to provide the correct treatment. To achieve this, use of pain assessment tools that are responsive to change and are validated for use in patients with dementia is a prerequisite. To date, there have been few studies, with inconsistent findings on the association between pain and neuropsychiatric symptoms. To ensure a better differential assessment of pain and neuropsychiatric symptoms, and consequently more accurate treatment for patients with dementia, studies with adequate statistical power and high-quality study designs, including randomized controlled trials, are needed.

Pain and psychological well-being among people with dementia in long-term care

OBJECTIVE

To examine the relationship between self-reported pain and psychological well-being of people with dementia (PWD) living in residential long-term care as indicated by displays of observed emotional expression over the daytime period.

DESIGN

Secondary analysis using repeated measures of self-report and observational data.

SETTING AND SUBJECTS

A total of 177 PWD were included from 17 nursing homes and six assisted living facilities in Michigan and Pennsylvania.

METHODS

Negative emotional expression was used as an indicator of reduced psychological well-being. Pain was assessed through PWD's response to a question about presence of pain obtained at each observation. Cognitive impairment was assessed using the Mini-Mental Status Examination. Linear mixed models were used that accounted for correlation of negative emotional expression measurements over time for each participant and between participants within the same facility.

RESULTS

Among 171 participants who were able to express their pain, 44% of PWD reported pain once or more during the daytime period. Severity of cognitive impairment was related to expression of negative emotion. PWD with pain displayed more negative emotional expression than PWD without pain.

CONCLUSIONS

Routine pain assessment is feasible among PWD with moderate to severe dementia and positive report of pain is associated with greater observed negative emotional expression, an indicator of reduced psychological well-being. Improving pain management holds potential for enhancing psychological well-being among PWD living in residential long-term care.

Association between pain, neuropsychiatric symptoms, and physical function in dementia: a systematic review and meta-analysis

Background

Pain, neuropsychiatric symptoms (NPS) and functional impairment are prevalent in patients with dementia and pain is hypothesized to be causal in both neuropsychiatric symptoms (NPS) and functional impairment. As the exact nature of the associations is unknown, this review examines the strength of associations between pain and NPS, and pain and physical function in patients with dementia. Special attention is paid to the description of measurement instruments and the methods used to detect pain, NPS and physical function.

Methods

A systematic search was made in the databases of PubMed (Medline), Embase, Cochrane, Cinahl, PsychINFO, and Web of Science. Studies were included that described associations between pain and NPS and/or physical function in patients with moderate to severe dementia.

Results

The search yielded 22 articles describing 18 studies, including two longitudinal studies. Most evidence was found for the association between pain and depression, followed by the association between pain and agitation/aggression. The longitudinal studies reported no direct effects between pain and NPS but some indirect effects, e.g. pain through depression. Although some association was established between pain and NPS, and pain and physical function, the strength of associations was relatively weak. Interestingly, only three studies used an observer rating scale for pain-related behaviour.

Conclusions

Available evidence does not support strong associations between pain, NPS and physical function. This might be due to inadequate use or lack of rating scales to detect pain-related behaviour. These results show that the relationship between pain and NPS, as well as with physical function, is complicated and warrants additional longitudinal evaluation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0048-6) contains supplementary material, which is available to authorized users.

Impact of a stepwise protocol for treating pain on pain intensity in nursing home patients with dementia: a cluster randomized trial

Background

Pain is frequent and distressing in people with dementia, but no randomized controlled trials have evaluated the effect of analgesic treatment on pain intensity as a key outcome.

Methods

Three hundred fifty-two people with dementia and significant agitation from 60 nursing home units were included in this study. These units, representing 18 nursing homes in western Norway, were randomized to a stepwise protocol of treating pain (SPTP) or usual care. The SPTP group received acetaminophen, morphine, buprenorphine transdermal patch and pregabalin for 8 weeks, with a 4-week washout period. Medications were governed by the SPTP and each participant's existing prescriptions. We obtained pain intensity scores from 327 patients (intervention n = 164, control n = 163) at five time points assessed by the primary outcome measure, Mobilization-Observation-Behaviour-Intensity-Dementia-2 (MOBID-2) Pain Scale. The secondary outcome was activities of daily living (ADL). We used a linear intercept mixed model in a two-way repeated measures configuration to assess change over time and between groups.

Results

The SPTP conferred significant benefit in MOBID-2 scores compared with the control group [average treatment effect (ATE) −1.388; p < 0.001] at week 8, and MOBID-2 scores worsened during the washout period (ATE = −0.701; p = 0.022). Examining different analgesic treatments, benefit was conferred to patients receiving acetaminophen compared with the controls at week 2 (ATE = −0.663; p = 0.010), continuing to increase until week 8 (ATE = −1.297; p < 0.001). Although there were no overall improvements in ADL, an increase was seen in the group receiving acetaminophen (ATE = +1.0; p = 0.022).

Conclusion

Pain medication significantly improved pain in the intervention group, with indications that acetaminophen also improved ADL function.

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