Pain reports and pain medication treatment in nursing home residents with and without dementia

AIM

The purpose of this pilot study was to determine if a diagnosis of dementia influenced pain self-reports and pain medication use in a group of verbally communicative nursing home (NH) residents.

METHODS

The study design was a between groups, cross-sectional chart audit and a seven-question structured pain interview comparing outcomes in residents with and without a diagnosis of dementia. The study was carried out at a large metropolitan NH in the southern USA. The participants consisted of 52 long-stay NH residents capable of self-consent with at least one order for pain medication (opioid or non-narcotic) either pro re nata, scheduled or both. Approximately 40% (n = 20) had a diagnosis of dementia.

RESULTS

Although each group had similar pain-related diagnoses, residents without a dementia diagnosis were significantly more likely to have a medication order for an opioid (OR 4.37,95% CI 1.29-14.73, P = 0.018). Based on self-reported pain interview responses, no statistically significant differences were identified between the groups for chronic pain symptoms. However, among residents who reported current pain, those with a dementia diagnosis reported greater pain intensity (based on a 0-10 numeric rating scale) than did those without dementia (median 8.0 vs 6.0, respectively; P = 0.010).

CONCLUSIONS

Verbally communicative NH residents with mild and moderate cognitive impairment can report their pain symptoms and pain intensity. Nurses in long-term care might assume that residents with dementia cannot reliably self-report their pain; however, suffering from untreated severe pain could exacerbate cognitive impairment, worsen functional impairment and severely impair sleep. A brief, focused pain interview might be one method for increasing the detection of moderate to severe pain in verbally communicative NH residents with dementia.

Would the elderly be better off if they were given more placebos?

Placebos are useful in the medical care of the elderly, although the exact definition of a "placebo" or "placebo effect" is difficult to define precisely. They have an important role as control treatments in research trials, but a non-specific "placebo effect" may also be beneficial part of many physician-patient interactions. Physicians also give them deliberately according to several studies worldwide to satisfy patient demands or because they believe in a "placebo effect" among other reasons. A significant placebo effect has been observed among older patients in clinical trials of antidepressants (12-15%), and in treatments of Parkinson's disease (16%). Placebos activate serotonergic pathways in the brain used by antidepressants. In Parkinson's disease, the administration of a placebo stimulates dopamine release in the dorsal (resulting in motor effects) and ventral striatum (which influences expectation of reward). Much of our understanding of the placebo effect comes from studies of placebo analgesia which is influenced by conditioning, expectation, meaning and context of the treatment for the patient, and patient-physician interaction. It is anatomically medicated by brain opioid pathways. Response to "sham" acupuncture in osteoarthritis may be an example of its use in the elderly. Placebos have often been considered a deception and thus unethical. On the other hand, some physicians and ethicists have suggested conditions for appropriate uses for placebos. A placebo might offer the theoretical advantage of an inexpensive treatment that would not cause adverse drug reactions or interactions with other medications, potentially avoiding complications of polypharmacy.

Successful treatment of spondylolisthesis with medicinal herbs

It has been reported that some herbal medicines may be effective for acute episodes of chronic nonspecific lower back pain. Spondylolisthesis is one of the causes of lower back or neck pain. To our knowledge, successful treatment of symptomatic spondylolisthesis with medicinal herbs has not been previously reported in the published work. A 63-year-old female had suffered from back pain for 4 years. Radiographs revealed spondylolisthesis at the L3 level. In another case, an 82-year-old female suffered from neck pain. X-ray examinations revealed cervical spondylolisthesis at the C4 level. Several herbs were administered to these patients with symptomatic spondylolisthesis according to the guidelines for herbal medicine. Significant improvements in pain were obtained within 4 weeks in both patients. The pain completely disappeared after 20 weeks (case 1) and 6 weeks (case 2) of treatment. Although surgical treatment is often performed for symptomatic spondylolisthesis, the findings of the present cases imply the therapeutic potential of herbal medicine in selected patients.

Postherpetic Neuralgia in Older Adults

The purpose of this article is to describe current knowledge and standards of care for postherpetic neuralgia (PHN) among older persons. Three influencing factors are considered: cultural implications, quality of life (QOL), and current practice of alternative/complementary therapy. A review of literature published between 2001 and 2006 was conducted. The findings indicate that PHN has debilitating effects on older adults regardless of culture. The impact of PHN on culture and ethnicity, particularly on the relationship between culture and patient's self-report of herpes zoster and/or PHN, has not been well investigated as evidenced in the literature. PHN is found to be associated with decreased health-related QOL among the elderly, with the most affected domains being sleep, mood, and general activity. Alternative and complementary therapy offers many advantages such as ease of use, availability, and low cost. However, due to lack of controlled trials and insufficient evidence, alternative therapy is not currently used widely and recommended. As the US population ages, the incidence of herpes zoster and PHN is expected to rise. Clinical trials that explore the response of the culturally diverse older adults to current treatment guidelines, strategies for prevention of PHN and its corresponding decrease in QOL, as well as controlled trials of alternative/complementary remedies should be considered.

Acupuncture treatment for opiate addiction: A systematic review

A review of the efficacy of acupuncture as treatment for opiate addiction, covering 33 years of reported literature in western scientific journals, was systematically undertaken. Some abstracts from Chinese language journals were also briefly reviewed. Supportive evidence often came from non-controlled nonblinded methodologies. When well-designed clinical trials (randomized, controlled, single-blind methodologies) were used, there was no significant evidence for acupuncture being a more effective treatment than controls. Some of the current supportive evidence for efficacy came from Chinese journals that have not been translated into English yet.