Pain in persons with dementia: complex, common, and challenging

Pain management inequities by demographic and geriatric-related variables in older adult inpatients

BACKGROUND

Pain is ubiquitous, yet understudied. The objective of this study was to analyze inequities in pain assessment and management for hospitalized older adults focusing on demographic and geriatric-related variables.

METHODS

This was a retrospective cohort study from January 2013 through September 2021 of all adults 65 years or older on the general medicine service at UCSF Medical Center. Primary exposures included (1) demographic variables including race/ethnicity and limited English proficiency (LEP) status and (2) geriatric-related variables including age, dementia or mild cognitive impairment diagnosis, hearing or visual impairment, end-of-life care, and geriatrics consult involvement. Primary outcomes included (1) adjusted odds of numeric pain assessment versus other assessments and (2) adjusted opioids administered, measured by morphine milligram equivalents (MME).

RESULTS

A total of 15,809 patients were included across 27,857 hospitalizations with 1,378,215 pain assessments, with a mean age of 77.8 years old. Patients were 47.4% White, 26.3% with LEP, 49.6% male, and 50.4% female. Asian (OR 0.75, 95% CI 0.70-0.80), Latinx (OR 0.90, 95% CI 0.83-0.99), and Native Hawaiian or Pacific Islander (OR 0.77, 95% CI 0.64-0.93) patients had lower odds of a numeric assessment, compared with White patients. Patients with LEP (OR 0.70, 95% CI 0.66-0.74) had lower odds of a numeric assessment, compared with English-speaking patients. Patients with dementia, hearing impairment, patients 75+, and at end-of-life were all less likely to receive a numeric assessment. Compared with White patients (86 MME, 95% CI 77-96), Asian patients (55 MME, 95% CI 46-65) received fewer opioids. Patients with LEP, dementia, hearing impairment and those 75+ years old also received significantly fewer opioids.

CONCLUSION

Older, hospitalized, general medicine patients from minoritized groups and with geriatric-related conditions are uniquely vulnerable to inequitable pain assessment and management. These findings raise concerns for pain underassessment and undertreatment.

Pain-Reducing Effects of Physical Therapist-Delivered Interventions: A Systematic Review of Randomized Trials Among Older Adults With Dementia

BACKGROUND AND PURPOSE

Pain is common among older adults with dementia. There are nonpharmacological options for managing pain in this population. However, the effects of physical therapist-delivered interventions have not been summarized. The purpose of this systematic review was to summarize the literature on physical therapist-delivered interventions in randomized trials for reducing pain among older adults with dementia.

METHODS

A systematic search of MEDLINE/PubMed, CINAHL, PsycINFO, and Web of Science was conducted for randomized trials of pain management in individuals 60 years or older with medically diagnosed dementia of any severity. Included studies addressed the effects of nonpharmacological physical therapist-delivered interventions on pain outcomes. Pain outcomes included patient or caregiver self-report, observational or interactive measures. Independent reviewers extracted relevant data and assessed methodological quality using the PEDro scale.

RESULTS AND DISCUSSION

Three studies (total = 222 participants; mean age range = 82.2-84.0 years; 178 [80.2%] females) met inclusion criteria. PEDro scores ranged from 4 to 8/10. Interventions included passive movement and massage. Pain outcomes included the observational measures Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC), Pain in Advanced Dementia (PAINAD), and Doloplus-2 Scale. Passive movement did not show better results when compared with no treatment, while massage showed pain-reducing effects in 1 study compared with no treatment.

CONCLUSIONS

The evidence supporting pain-reducing physical therapy interventions for patients with dementia is limited. There is a clear gap in knowledge related to evidence-based physical therapy for managing pain in this population. Future studies should examine active physical therapist-delivered interventions and utilize interactive pain measures.

Factors influencing trends in opioid prescribing for older people: a scoping review

Aim:

The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people.

Background:

Chronic pain occurs in 45%–85% of older people, but appears to be under-recognised and under-treated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group.

Methods:

This review included all study types, published 1990–2017, which focused on opioid prescribing for pain management among older adults. Arksey and O’Malley’s framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database, and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends.

Findings:

A total of 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven, or system-driven. Patient factors included age, gender, race, and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA.

Conclusions:

A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain management in older adults, but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden.

Patterns and predictors of chronic opioid use in older adults: A retrospective cohort study

Background

Given the controversy around the effectiveness of opioid treatment for chronic pain and the lack of detailed guidance for prescribing opioids in older adults, the objectives of this study were to estimate the trajectories and predictors of opioid use in older adults.

Methods

Data were extracted from the National Alzheimer’s Coordinating Center (2005–2017). Group-based trajectory modeling was used to identify the patterns of opioid use (any or strong) among participants age 65+. We used multivariable logistic regression with backward selection to evaluate demographics and comorbidities as potential predictors of trajectory membership.

Results

Among 13,059 participants, four trajectories were identified for the use of both any opioids and strong opioids (minimal-users, incident chronic-users, discontinuing-users, and prevalent chronic-users). For any opioids, female sex (adjusted odds ratio = 1.23; 95% confidence interval = 1.03–1.46), black vs. white (1.47; 1.18–1.82), year of education (0.96; 0.94–0.99), type of residence (independent group vs. private: 1.77; 1.38–2.26, care facility vs. private: 1.89; 1.20–2.97), hypertension (1.44; 1.20–1.72), cardiovascular disease (1.30; 1.09–1.55), urinary incontinence (1.45; 1.19–1.78), dementia (0.73; 0.57–0.92), number of medications (1 to 4 vs. none: 0.48; 0.36–0.64, 5 or more vs. none: 0.67; 0.50–0.88), and antidepressant agent (1.38; 1.14–1.67) were associated with incident chronic-use vs. non-use. For strong opioids, female sex (1.27; 1.04–1.56), type of residence (independent group vs. private: 1.90; 1.43–2.53, care facility vs. private: 2.37; 1.44–3.90), current smoking (1.68; 1.09–2.60), hypertension (1.49; 1.21–1.83), urinary incontinence (1.45; 1.14–1.84), dementia (0.73; 0.55–0.97), number of medications (1 to 4 vs. none: 0.46; 0.32–0.65, 5 or more vs. none: 0.59; 0.42–0.83), and antidepressant agent (1.55; 1.24–1.93) were associated with incident chronic-use vs. non-use.

Conclusion

Given that chronic opioid use was more prevalent in participants who were more vulnerable (i.e., older age, with multiple comorbidities, and polypharmacy), further studies should evaluate the safety and efficacy of using opioids in this population.

Association of Comorbid Burden and Patient Outcomes of Residents With Dementia in Jordanian Nursing Homes

Medical and psychiatric comorbidity in individuals with dementia is often associated with serious adverse health outcomes. Using a convenience sample of 76 residents with dementia in Jordanian nursing homes, the current study aimed to examine the relationship among comorbid burden, ability to verbally self-report symptoms, severity of dementia, and patient outcomes of pain and agitation. Comorbid burden and ability to verbally self-report symptoms were found to be significant predictors of patient outcomes of pain and agitation. However, the ability to verbally self-report symptoms did not explain the relationship between comorbid burden and patient outcomes. Nurses must understand the impact of comorbid burden and the ability to verbally self-report symptoms regarding pain and agitation in individuals with dementia. [Journal of Gerontological Nursing, 44(7), 50-58.].

Validity of the Korean Version of the Face, Legs, Activity, Cry, and Consolability Scale for Assessment of Pain in Dementia Patients

Pain is often associated with a more rapid progression of cognitive and functional decline, and behavioral disturbance in dementia. Therefore, it is essential to accurately assesses pain for proper intervention in patients with dementia. The Face, Legs, Activity, Cry, and Consolability (FLACC) scale is an excellent behaviour scale which includes most of the domains that are recommended by the American Geriatrics Society to evaluate when assessing pain in patients with dementia. The purpose of this study was to develop the Korean version of the FLACC (K-FLACC) and to verify its reliability and validity in assessing pain of elderly patients with dementia. We developed the K-FLACC to consist of the five domains (face, legs, activity, cry, and consolability) with scores of 0, 1, and 2 for each domain and a total score ranging from 0 to 10 as in the original FLACC. Eighty-eight patients with dementia who visited Konkuk University Medical Center were evaluated. The K-FLACC revealed good validity as compared to the Numeric Rating Scale (NRS; r = 0.617, P < 0.001) and the Face Pain Scale (FPS; r = 0.350, P = 0.001). All of the five domains of the K-FLACC were related to the NRS and FPS, in which the activity domain showed the highest correlation. Test-retest reliability was excellent, as the intra-class correlation coefficient comparing the retest to test was 0.73 (95% confidence interval, 0.59-0.82). Our results show that the K-FLACC is a suitable and valuable scale to assess pain in patients with dementia in Korea.

Infrared pupillometry helps to detect and predict delirium in the post-anesthesia care unit

This study evaluates the capability of pupillary parameters to detect and predict delirium in the post-anesthesia care unit (PACU-D) following general anesthesia. PACU-D may complicate and prolong the patient's postoperative course, consequently increasing hospital costs. After institutional approval, 47 patients undergoing surgical interventions with general anesthesia were included in the study. We measured the pupillary reflexes at signing of informed consent, during surgery 20 min after intubation and when the primary inhaled anesthetic was turned off, and 15 and 45 min after PACU admittance and upon discharge from the PACU. We evaluated patients for delirium using the confusion assessment method for the intensive care unit (CAM-ICU) score after 15 and 60 min in the PACU. We chose receiver operating curve (ROC) and area under the curve (AUC) to compare the performance of non-pupillary parameters to pupillary parameters, such as pupil diameter, percent constriction, and dilation velocity, to detect and predict PACU-D. Percent constriction (AUC = 0.93, optimal threshold = 18.5%) and dilation velocity (AUC = 0.93, optimal threshold = 0.35 mm/s) showed excellent ability to detect and predict delirium persisting throughout the PACU stay. These pupillary measures showed superior performance compared to other pupillary measures and features commonly associated with delirium, e.g., age (AUC = 0.73), total opioids (AUC = 0.56), or length of surgery (AUC = 0.40). Our results suggest that pupillometry and the parameters derived from the recording may identify delirious patients in the PACU. This information can help to efficiently structure their care in a timely manner, and potentially avoid adverse complications for the patient and financial consequences for the hospital.

Problem Adaptation Therapy for Pain (PATH-Pain): A Psychosocial Intervention for Older Adults with Chronic Pain and Negative Emotions in Primary Care

Chronic pain is highly prevalent in older adults, contributes to activity restriction and social isolation, disrupts family and interpersonal relationships, and poses a significant economic burden to society. Negative emotions such as sadness, anxiety, helplessness, and hopelessness are associated with chronic pain and contribute to poor quality of life, impaired interpersonal and social functioning, and increased disability. Psychosocial interventions for older adults with chronic pain have been historically developed for, and are almost exclusively delivered to, cognitively intact patients. Therefore, many older adults with chronic pain and comorbid cognitive deficits have limited treatment options. Our multidisciplinary team developed Problem Adaptation Therapy for Pain in Primary Care (PATH-Pain), a psychosocial intervention for older adults with chronic pain, negative emotions, and a wide range of cognitive functioning, including mild-to-moderate cognitive impairment. In the current article, we describe the principles underlying PATH-Pain, review the steps taken to adapt the original PATH protocol, outline the treatment process, and present a case illustrating its potential value.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part XI: Dementia

OBJECTIVE : To present the 11th in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributions to pain and disability in older adults with CLBP. This article focuses on dementia.

METHODS

A modified Delphi technique was used to develop an algorithm for an approach to treatment for older adults living with CLBP and dementia. A panel of content experts on pain and cognition in older adults developed the algorithm through an iterative process. Though developed using resources available within Veterans Health Administration (VHA) facilities, the algorithm is applicable across all health care settings. A case taken from the clinical practice of one of the contributors demonstrates application of the algorithm.

RESULTS

We present an evidence-based algorithm and biopsychosocial rationale to guide providers evaluating CLBP in older adults who may have dementia. The algorithm considers both subtle and overt signs of dementia, dementia screening tools to use in practice, referrals to appropriate providers for a complete a workup for dementia, and clinical considerations for persons with dementia who report pain and/or exhibit pain behaviors. A case of an older adult with CLBP and dementia is presented that highlights how an approach that considers the impact of dementia on verbal and nonverbal pain behaviors may lead to more appropriate and successful pain management.

CONCLUSIONS

Comprehensive pain evaluation for older adults in general and for those with CLBP in particular requires both a medical and a biopsychosocial approach that includes assessment of cognitive function. A positive screen for dementia may help explain why reported pain severity does not improve with usual or standard-of-care pain management interventions. Pain reporting in a person with dementia does not always necessitate pain treatment. Pain reporting in a person with dementia who also displays signs of pain-associated suffering requires concerted pain management efforts targeted to improving function while avoiding harm in these vulnerable patients.Key Words. Dementia; Chronic Pain; Low Back Pain; Lumbar; Primary Care.

The assessment and management of pain in patients with dementia in hospital settings: a multi-case exploratory study from a decision making perspective

BACKGROUND

Pain is often poorly managed in people who have a dementia. Little is known about how this patient population is managed in hospital, with research to date focused mainly on care homes. This study aimed to investigate how pain is recognised, assessed and managed in patients with dementia in a range of acute hospital wards, to inform the development of a decision support tool to improve pain management for this group.

METHODS

A qualitative, multi-site exploratory case study. Data were collected in four hospitals in England and Scotland. Methods included non-participant observations, audits of patient records, semi-structured interviews with staff and carers, and analysis of hospital ward documents. Thematic analysis was performed through the lens of decision making theory.

RESULTS

Staff generally relied on patients' self-report of pain. For patients with dementia, however, communication difficulties experienced because of their condition, the organisational context, and time frames of staff interactions, hindered patients' ability to provide staff with information about their pain experience. This potentially undermined the trials of medications used to provide pain relief to each patient and assessments of their responses to these treatments. Furthermore, given the multidisciplinary environment, a patient's communication about their pain involved several members of staff, each having to make sense of the patient's pain as in an 'overall picture'. Information about patients' pain, elicited in different ways, at different times and by different health care staff, was fragmented in paper-based documentation. Re-assembling the pieces to form a 'patient specific picture of the pain' required collective staff memory, 'mental computation' and time.

CONCLUSIONS

There is a need for an efficient method of eliciting and centralizing all pain-related information for patients with dementia, which is distributed in time and between personnel. Such a method should give an overall picture of a patient's pain which is rapidly accessible to all involved in their care. This would provide a much-needed basis for making decisions to support the effective management of the pain of older people with dementia in hospital.

Pain assessment in elderly with dementia: Brazilian validation of the PACSLAC scale

Objective

To validate the Pain Assessment Checklist for Seniors with Limited Ability to Communicate – Portuguese in demented elderly and to analyze its measurement properties.

Methods

We evaluated 50 elderly with dementia, residing in a nursing home and with limited communication ability, when exposed to potentially painful situations. The tool was applied at two different moments. First, two interviewers applied it simultaneously, and the intensity of pain was asked based on the caregiver’s opinion. After 14 days, with no analgesic intervention, one of the interviewers applied it again.

Results

The sample comprised more females, aged over 80 years, with dementia due to Alzheimer, presenting musculoskeletal pain of moderate to severe intensity. The psychometric properties of the tool demonstrated appropriate internal consistency (Cronbach’s alpha coefficient of 0.827). The scale had excellent reproducibility, according to the intraclass correlation coefficient, and the tool has been duly validated.

Conclusion

The Pain Assessment Checklist for Seniors with Limited Ability to Communicate – Portuguese had adequate measuring properties for use with elderly presenting limited communication.

Identification, assessment, and management of pain in patients with advanced dementia

Patients with advanced dementia have a high symptom burden at end of life. Many of those with dementia have reports of symptoms similar to those without dementia, yet are treated less frequently. Pain is a prevalent symptom that can be underrecognized because of the ability of the patient to self-report. Several tools are available to help with the identification of pain, but they should only be one aspect in the overall assessment. Health care providers must anticipate this and screen for and treat potential pain. This includes obtaining a self-report, searching for potential causes for pain, observing patient behavior, gaining proxy reporting of pain, and attempting an appropriate analgesic trial. It is beneficial for all those involved with a patient's care to screen for pain because of the potential benefits in decreasing behaviors and subsequent antipsychotic use.

Pain in Community-Dwelling Older Adults with Dementia: Results from the National Health and Aging Trends Study

OBJECTIVES

To report prevalence, correlates, and medication management of pain in community-dwelling older adults with dementia.

DESIGN

Cross-sectional.

SETTING

In-person interviews with self- or proxy respondents living in private residences or non-nursing home residential care settings.

PARTICIPANTS

Nationally representative sample of community-dwelling Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study 2011 wave.

MEASUREMENTS

Dementia status was determined using a modified previously validated algorithm. Participants were asked whether they had had bothersome and activity-limiting pain over the past month. A multivariable Poisson regression model was used to determine the relationship between bothersome pain and sociodemographic and clinical characteristics.

RESULTS

Of the 7,609 participants with complete data on cognitive function, 802 had dementia (67.2% aged ≥80, 65.0% female, 67.9% white, 49.7% proxy response, 32.0% lived alone, 18.8% lived in residential care); 670 (63.5%) participants with dementia experienced bothersome pain, and 347 (43.3%) had pain that limited activities. These rates were significantly higher than in a propensity score-matched cohort without dementia (54.5% bothersome pain, P < .001, 27.2% pain that limited activity, P < .001). Proxies reported slightly higher rates of pain than self-respondents, but differences were statistically significant only for activity-limiting pain (46.6% proxy vs 40.1% self, P = .03). Correlates of bothersome pain included arthritis, heart and lung disease, less than high school education, activity of daily living disability, depressive and anxiety symptoms, and low energy. Of those reporting pain, 30.3% stated that they rarely or never took any medications for pain.

CONCLUSION

Community-living older adults with dementia are at high risk of having pain. Creative interventions and programs are needed to manage pain adequately in this vulnerable population.

Non-opiate pharmacotherapy options for the management of pain in older adults

Pain is highly prevalent, costly, and disabling in later life, especially when undertreated. In this article, we aim to describe the risks and benefits of non-opioid medication options for the management of pain in adults aged 65 years and older in order to provide additional options in a practitioner's tool box when designing a pain management regimen for an older adult. Non-opiate pharmacologic therapies, such as acetaminophen, nonsteroidal anti-inflammatory drugs, topicals, and antidepressants have an important role in pain management of older adults. When designing a pain regimen, taking an individualized approach that considers the patient's functional status, comorbidities, and treatment goals will maximize pain management.

The relationship between patient age and pain management of acute long-bone fracture in the ED

OBJECTIVE

Certain patient populations may be unable to communicate their needs in the emergency department (ED) setting, and the ability to communicate varies between age groups. We aim to determine if there are differences in pain management of acute long-bone fracture (ALBF) among age groups presenting to the ED.

METHODS

This study was a retrospective chart review of a consecutive sample of subjects over 13 months. Fracture site, subject age, arrival time, whether pain medication was administered, and time to initial administration were recorded. Subjects were categorized into 3 groups based on age: pediatric (<18 years), adult (≥18 and <65 years), and geriatric (≥65 years).

RESULTS

A total of 1255 patients were included in analysis. One hundred seventy-seven (78.0%) pediatric, 364 (86.5%) adult, and 486 (80.1%) geriatric patients received pain medication during their ED stay. Median and average times to initial pain medication administration with 95% confidence intervals were 44 and 52.0 minutes (45.9-58.1), 39 and 53.6 minutes (48.8-58.4), and 55 and 73.2 minutes (68.1-78.3) for pediatric, adult, and geriatric groups, respectively. A single-factor analysis of variance indicated a significant difference between the groups (P<.01). Student t tests revealed significant differences between pediatric and geriatric groups (P<.01) and adult and geriatric groups (P<.01).

CONCLUSIONS

Although most patients presenting to the ED with ALBF were geriatric, these patients were the least likely to have their pain addressed in a timely fashion. Subgroup analysis of pediatric and geriatric populations indicates significant delay, especially for those ages younger than 3 and 85 years and older. We believe that patients within these groups experience the greatest difficulty communicating their needs effectively due to age-related issues.

Caregiver's perceptions of the relationship of pain to behavioral and psychiatric symptoms in older community-residing adults with dementia

OBJECTIVES

Pain is underrecognized and undermanaged in older adults with dementia. Because dementia patients have a diminished capacity to communicate discomfort, untreated pain may be expressed in the form of behavioral and psychiatric symptoms. The goal of the present study was to examine the relationship between pain and behavioral and psychiatric symptoms of dementia in community-residing older adults from the perspective of the family caregiver.

MATERIALS AND METHODS

Dyads composed of 272 dementia patients, and their family caregivers were assessed to determine dementia patient's mental status; family caregiver's assessment of care recipient's pain, functional dependence, and number of behavioral symptoms; analgesic use; and demographic information.

RESULTS

Hierarchical multiple regression analysis controlling for age, marital status, race, functional disability, and analgesic use showed that pain explained a small but significant percent of variance in the number of behavioral symptoms (3%, P<0.001). Pain had a stronger influence on the number of behavioral and psychiatric symptoms of dementia among those with severe cognitive impairment (F1,69=11.75, P<0.001) compared with those with low to moderate cognitive impairment (F1,199=4.543, P=0.034.).

DISCUSSION

The findings indicate that pain is a risk factor for behavioral symptoms in individuals with dementia and suggest that pain is a more significant predictor of behavior for individuals with severe dementia, compared with those with mild/moderate stage dementia. These results reinforce the importance of proper pain assessment and its management as part of dementia care planning.

Pain and dementia: an overview of the literature

This paper discusses how pain and its undertreatment impacts upon older people with dementia. It outlines how the contributing factors to the underassessment of pain are numerous and includes dementia-related factors (such as loss of communication ability) and health professional-related factors (such as inappropriate or non-application of a pain-assessment tool and deficit knowledge regarding pain mechanisms and/or dementia). Pharmacological and non-pharmacological treatment options for pain are noted as important but are not the focus of this paper.

Older US emergency department patients are less likely to receive pain medication than younger patients: results from a national survey

STUDY OBJECTIVE

The purpose of this study is to determine whether older adults presenting to the emergency department (ED) with pain are less likely to receive pain medication than younger adults.

METHODS

Pain-related visits to US EDs were identified with reason-for-visit codes from 7 years (2003 to 2009) of the National Hospital Ambulatory Medical Care Survey. The primary outcome was the administration of an analgesic. The percentage of patients receiving analgesics in 4 age groups was adjusted for measured covariates, including pain severity.

RESULTS

Pain-related visits accounted for 88,031 (46.9%) ED visits by patients aged 18 years or older during the 7-year period. There were 7,585 pain-related ED visits by patients aged 75 years or older, representing an estimated 3.65 million US ED visits annually. In comparing survey-weighted unadjusted estimates, pain-related visits by patients aged 75 years or older were less likely than visits by patients aged 35 to 54 years to result in administration of an analgesic (49% versus 68.3%) or an opioid (34.8% versus 49.3%). Absolute differences in rates of analgesic and opioid administration persisted after adjustment for sex, race/ethnicity, pain severity, and other factors and multiple imputation of missing pain severity data, with visits by patients aged 75 years and older being 19.6% (95% confidence interval 17.8% to 21.4%) less likely than visits by patients aged 35 to 54 years to receive an analgesic and 14.6% (95% confidence interval 12.8% to 16.4%) less likely to receive an opioid.

CONCLUSION

Patients aged 75 years and older with pain-related ED visits are less likely to receive pain medication than patients aged 35 to 54 years.

Persistent pain and frailty: a case for homeostenosis

OBJECTIVES

To compare the association between self-reported moderate to severe pain and frailty.

DESIGN

Cross-sectional analysis of the Canadian Study of Health and Aging Wave 2.

SETTING

Community.

PARTICIPANTS

Representative sample of persons aged 65 and older in Canada.

MEASUREMENTS

Pain (exposure) was categorized as no or very mild pain versus moderate or greater pain. Frailty (outcome) was operationalized as the accumulation of 33 possible self-reported health attitudes, illnesses, and functional abilities, subsequently divided into tertiles (not frail, prefrail, and frail). Multivariable logistic regression assessed for the association between pain and frailty.

RESULTS

Of participants who reported moderate or greater pain (35.5%, 1,765/4,968), 16.2% were not frail, 34.1% were prefrail, and 49.8% were frail. For persons with moderate or greater pain, the odds of being prefrail rather than not frail were higher by a factor of 2.52 (95% confidence interval (CI) = 2.13-2.99; P < .001). For persons with moderate or greater pain, the odds of being frail rather than not frail were higher by a factor of 5.52 (95% CI = 4.49-6.64 P < .001).

CONCLUSION

Moderate or higher pain was independently associated with frailty. Although causality cannot be ascertained in a cross-sectional analysis, interventions to improve pain management may help prevent or ameliorate frailty.

Neurological diseases and pain

Chronic pain is a frequent component of many neurological disorders, affecting 20-40% of patients for many primary neurological diseases. These diseases result from a wide range of pathophysiologies including traumatic injury to the central nervous system, neurodegeneration and neuroinflammation, and exploring the aetiology of pain in these disorders is an opportunity to achieve new insight into pain processing. Whether pain originates in the central or peripheral nervous system, it frequently becomes centralized through maladaptive responses within the central nervous system that can profoundly alter brain systems and thereby behaviour (e.g. depression). Chronic pain should thus be considered a brain disease in which alterations in neural networks affect multiple aspects of brain function, structure and chemistry. The study and treatment of this disease is greatly complicated by the lack of objective measures for either the symptoms or the underlying mechanisms of chronic pain. In pain associated with neurological disease, it is sometimes difficult to obtain even a subjective evaluation of pain, as is the case for patients in a vegetative state or end-stage Alzheimer's disease. It is critical that neurologists become more involved in chronic pain treatment and research (already significant in the fields of migraine and peripheral neuropathies). To achieve this goal, greater efforts are needed to enhance training for neurologists in pain treatment and promote greater interest in the field. This review describes examples of pain in different neurological diseases including primary neurological pain conditions, discusses the therapeutic potential of brain-targeted therapies and highlights the need for objective measures of pain.

The fragmented story of pain: a saga of economic discourse, confusion and lack of holistic assessment in the residential care of older people

The long-standing problem of overlooked and/or undertreated pain experienced by so many older people living in Australian residential care facilities condemns these people to a life robbed of quality. Such a degree of suffering experienced by older people calls into question the pain assessment skills of staff who work in residential care. However, the problem of undetected and unresolved pain experienced by older people is not simply a skill or knowledge issue. It is much broader than that. In this paper we portray pain as likened to a story; a narrative that only the older person, as the author, can impart and one in which only they can communicate their experience of pain. Nevertheless, as opposed to seeking the older person's pain narrative, nurses attempt to measure the immeasurable. In part, their actions relate to the confusing terminology which envelops pain assessment. However, political policy and economic discourse also influences nurses' pain assessment practises to the detriment of older people and the profession of gerontological nursing. Discussion in this paper includes the experience of pain for the older person, an overview of the specific role of pain-screening tools compared with the requirements of a person-centred pain assessment, and person-centred pathways to help nurses and others interpret and heed the older person's pain story. Analysis also incorporates the argument that current and previous Federal Government funding tools for residential care subtly impact on holistic pain assessment causing confusion for caregivers and fragmentation of the older person's pain story.

Pain in communication impaired residents with dementia: Analysis of Resident Assessment Instrument (RAI) data

Background: Pain has been identified as a significant and under-reported problem in the older adult and those persons with dementia who may face an impaired ability to communicate that they are in pain. Their pain, under-diagnosed and under-treated, has functional implications, such as decreased ambulation, mood and sleep disturbances, impaired appetite and exacerbation of cognitive functioning. Methods: Resident Assessment Instrument (RAI) data were analyzed in order to 1) identify a pain profile of all of the residents living in the facility across two sampling periods (December 2005 and December 2006) and 2) compare the pain profile of residents categorized into two subgroups (intact communication/impaired communication). Findings: Consistent with the literature, clear differences were demonstrated between pain reporting and management for communication impaired residents with dementia and residents with intact communication. Several incongruent findings were also demonstrated. Conclusions: The RAI is useful to identify patterns but insufficient in itself for pain management purposes in this vulnerable group. Pain assessment tools developed for this population must be employed.

Self-reported pain in persons with dementia predicts subsequent decreased psychosocial functioning

OBJECTIVES

Pain self-report is the assessment gold standard in cognitively intact populations but has been discouraged in persons with dementia because of significant evidence that pain intensity is often underreported by persons with dementia. However, most community-dwelling persons with dementia are cared for in primary care settings where a more in depth pain assessment is unlikely. Therefore, it is vital to know the clinical predictive value of self-report pain assessment in this population. Psychosocial functioning is a meaningful focus for clinical prediction, because psychosocial constructs are integrally related to quality of life, physical functioning, and one's ability to function in the presence of pain. The purpose of this study was to investigate the degree to which answers to simple self-report pain questions can predict changes in psychosocial functioning 4 months later in community-dwelling older adults with dementia.

DESIGN

Longitudinal. Patients and caregivers were assessed every 4 months for 24 months.

SETTING

Veterans Affairs Medical Center, Houston, TX.

PARTICIPANTS

One hundred seventy-one patients over age 60 years diagnosed with dementia in the previous year and with no previous aggression were recruited from Veterans Administration clinics.

MEASUREMENTS

Pain, agitation, depression, involvement in pleasant events, caregiver burden, psychosis, and patient/caregiver relationship quality (mutuality).

RESULTS

Pain scores at each time period were predictive of increased agitation and depression and decreased pleasant event frequency 4 months later.

CONCLUSIONS

Our results suggest that persons with dementia who affirmatively respond to pain questions are at higher risk for developing negative psychosocial states.

Pain, Ageing and Dementia: The Crisis is Looming, but are We Ready?

Pain in older people, and particularly for those people with dementia, is an underrecognised and undertreated problem of growing magnitude. Occupational therapists, although well positioned with a range of skills and resources to help older people with pain and their caregivers, must first become educated about the issues of pain assessment and management for this unique population.

Despite the fact that pain is a pervasive symptom of many occupational therapy clients, the occupational therapy educational curricula and professional literature fail to alert therapists to the urgent need for research and guideline development in this rapidly expanding practice area.

The assessment of musculoskeletal pain in the clinical setting

Pain is a primary symptom in musculoskeletal conditions, and aspects of the pain experience (eg, severity) are key considerations in clinical decision-making and in the outcome of trials and interventions. Consequently, appropriate assessment of pain is essential. This article reviews the measures most commonly used in rheumatology practice, arguing that many are significantly limited in their ability to reflect the complexity of the patient's experience. The authors provide examples of alternative approaches, concluding that there is real scope for improving assessment and measurement of musculoskeletal pain in the clinical setting.