Psychosocial interventions for pain management in older adults with dementia: a systematic review of randomised controlled trials

Perception, behavior and experience of nursing assistants towards pain of older adults with dementia: A qualitative study

Nursing assistants are strategically positioned to detect and interpret behavioral alterations indicative of pain in residents suffering from dementia. Despite this, extant literature is scarce regarding their experiences in administering pain care to this demographic. Utilizing a phenomenological approach, this study engaged 17 nursing assistants selected via purposive sampling for semi-structured interviews. Data analysed by the Colaizzi 7-step method. Four emergent themes were discerned: perception of pain; strategies for coping with pain; emotional and psychological responses to pain-related caregiving; challenges and needs in pain-related caregiving. Nursing assistants play a unique and crucial role in the identification of pain, reporting and providing feedback to healthcare professionals, and implementing non-pharmacological interventions. However, these roles have not been fully utilized. Enhancements in pain management could be facilitated by decreasing staff turnover, augmenting educational and training programs, and incorporating empathy-focused situational training. The provision of mental health services is also recommended to ameliorate caregiving-induced stress.

Occupational Therapy Practice Guidelines for Adults Living With Alzheimer's Disease and Related Neurocognitive Disorders

IMPORTANCE

There are currently 55 million adults living with declining functional cognition-altered perception, thoughts, mood, or behavior-as the result of Alzheimer's disease (AD) and related neurocognitive disorders (NCDs). These changes affect functional performance and meaningful engagement in occupations. Given the growth in demand for services, occupational therapy practitioners benefit from consolidated evidence of effective interventions to support adults living with AD and related NCDs and their care partners.

OBJECTIVE

These Practice Guidelines outline effective occupational therapy interventions for adults living with AD and related NCDs and interventions to support their care partners.

METHOD

We synthesized the clinical recommendations from a review of recent systematic reviews.

RESULTS

Twelve systematic reviews published between 2018 and 2021 served as the foundation for the practice recommendations.

CONCLUSION AND RECOMMENDATIONS

Reminiscence, exercise, nonpharmacological behavioral interventions, cognitive therapy, sensory interventions, and care partner education and training were found to be most effective to support adults living with AD and related NCDs. Plain-Language Summary: These Practice Guidelines provide strong and moderate evidence for occupational therapy practitioners to support adults living with Alzheimer's disease (AD) and related neurocognitive disorders (NCDs) and their care partners. They provide specific guidance for addressing the decline in cognition, behavioral and psychological symptoms of dementia, and pain experience of adults living with AD and related NCDs. The guidelines also describe interventions to support care partners. With support from the evidence, occupational therapy practitioners are better equipped to address the unique needs of adults living with AD and related NCDs and their care partners.

Interventions Within the Scope of Occupational Therapy to Manage Pain in Individuals With Dementia (2018-2022)

Systematic review briefs provide a summary of the findings from systematic reviews evaluated in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings related to interventions within the scope of occupational therapy to manage pain in individuals with dementia.

Family Involvement in Pain Management for People Living With Dementia: An Integrative Review

This review aimed to synthesize current evidence on family involvement in pain management for people living with dementia from the perceptions of family carers and health care professionals. An integrative review was conducted using CINAHL, Embase, PubMed, PsycINFO and Cochrane Library electronic databases. The Mixed Methods Appraisal Tool was used to appraise the articles, followed by thematic analysis. Twelve studies were included and four themes were identified: (1) The roles and responsibilities of family carers; (2) Enablers and barriers for pain identification; (3) Strategies and concerns for pain management; and (4) Lack of staff education and communication with health care providers. Family carers play an important role in pain assessment and management for people living with dementia, but they cannot be actively involved in this process due to a lack of communication with health care providers. An integrated approach that includes education and communication with family carers and health care providers is needed.

Comparison of the effect of psychosocial skills training on acute and chronic musculoskeletal pain intensity: The effectiveness of early intervention in the reduction of acute musculoskeletal pain

BACKGROUND

Pain, as a psychological experience, is caused by complex interactions among sensory-discriminative, motivational-affective, and cognitive-evaluative dimensions. The psychosocial approach is one of the important approaches in managing musculoskeletal pain in patients. Therefore, this study aimed to determine and compare the effects of psychosocial skills training on pain intensity in patients with acute and chronic musculoskeletal pain.

METHODS

In this quasi-experimental study, 64 patients with acute and chronic musculoskeletal pain were selected using convenience sampling. Both groups received psychosocial training in pain management in groups of 8-10 people over six 1-h sessions. The data were collected at baseline, after the intervention, and 3 months later using a numerical rating scale (NRS). Then, the data were entered into the SPSS 22 software and were analysed using descriptive and inferential statistics.

RESULTS

In this study, the mean age of the participants was 50.10 ± 10.63 years and 60.9% of them were female. Based on the results, time had a significant effect on pain intensity (p < 0.001), but the effect of group on pain intensity was not statistically significant (p = 0.07). The group × time effect on pain intensity was also statistically significant (p < 0.001).

CONCLUSION

Psychosocial training had a positive impact on the reduction of pain among the patients with acute and chronic musculoskeletal pain. Additionally, the training was more effective in patients with acute pain due to early training. These findings can help healthcare providers in the field of musculoskeletal pain management, especially in patients with acute pain.

Scientific Publication Patterns of Systematic Reviews on Psychosocial Interventions Improving Well-being: Bibliometric Analysis

Background

Despite numerous empirical studies and systematic reviews conducted on the effectiveness of interventions improving psychological well-being, there is no holistic overview of published systematic reviews in this field.

Objective

This bibliometric study explored the scientific patterns of the effectiveness of different psychosocial interventions improving well-being among various categories of individuals with mental and physical diseases, to synthesize well-being intervention studies, and to suggest gaps and further studies in this emerging field.

Methods

The bibliometric analysis included identifying the most productive authors, institutions, and countries; most explored fields and subjects of study; most active journals and publishers; and performing citation analysis and analyzing publication trends between 2014 and 2022. We focused on data retrieved from known databases, and the study was conducted with a proven bibliometric approach.

Results

In total, 156 studies were found concerning the research domains and retrieved using LENS software from high-ranking databases (Crossref, Microsoft Academic, PubMed, and Core). These papers were written in English by 100 authors from 24 countries, among which, the leading country was the United Kingdom. Descriptive characteristics of the publications involved an increased number of publications in 2017 (n=35) and 2019 (n=34) and a decreased number in 2021 (n=4). The top 2 leading authors by citation score are James Thomas (3 papers and 260 citations) and Chris Dickens (3 papers and 182 citations). However, the most cited study had 592 citations. BMJ Open (n=6 articles) is the leading journal in the field of medicine; Clinical Psychology Review (n=5), in psychology; and Frontiers in Psychology, in psychological intervention (n=5) and psychology (n=5). The top 2 publishers were Wiley (n=28) and Elsevier (n=25).

Conclusions

This study indicates an overall interest in the declared domains within the last decade. Our findings primarily indicate that psychosocial interventions (PIs) were evaluated as being effective in managing mental and physical problems and enhancing well-being. Cognitive behavioral therapy was assessed as being effective in treating anxiety, psychoeducation in relapse prevention, and gratitude interventions in improving overall health, and the mindfulness approach had a positive impact on decreasing distress and depression. Moreover, all these intervention types resulted in an overall increase in an individuals’ well-being and resilience. Integrating social and cultural factors while considering individual differences increases the efficiency of PIs. Furthermore, PIs were evaluated as being effective in managing symptoms of eating disorders, dementia, and cancer. Our findings could help provide researchers an overview of the publication trends on research domains of focus for further studies, since it shows current findings and potential research needs in these fields, and would also benefit practitioners working on increasing their own and their patients' well-being.

Efficacy of non-pharmacological interventions to reduce pain in people with dementia: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To identify the efficacy of non-pharmacological interventions designed to reduce pain in people with dementia.

BACKGROUND

Pain is prevalent among patients with dementia but frequently remains untreated. Although non-pharmacological interventions have been used to reduce pain in people with dementia, the efficacy of these interventions for pain management in people with dementia has not been thoroughly synthesised.

DESIGN

Systematic review and meta-analysis.

METHODS

The study was conducted in accordance with PRISMA guidelines and Cochrane criteria for systematic reviews. A comprehensive search was performed using the Academic Search Complete, CINAHL, Cochrane Library, EMBASE, MEDLINE, PubMed, OVID and Web of Science databases, from databases inception to 13 March 2022. The modified Cochrane risk-of-bias tool (ROB-2) was used to evaluate the methodological quality of each included study. Standardised mean differences (SMDs) with 95% confidence intervals (CIs) were synthesised using a random-effects model to assess the efficacy of non-pharmacological interventions for reducing pain in people with dementia (using Stata 16.0).

RESULTS

The final analysis assessed 12 studies, including 989 persons with dementia. Non-pharmacological interventions were found to reduce pain in 4-8 weeks after the interventions (SMD: -0.32; 95% CI: -0.62 to -0.02). However, the effects of intervention frequency and patient age remain unknown.

CONCLUSIONS

Non-pharmacological interventions are effective for reducing pain in people with dementia. Further investigations remain necessary to explore the effectiveness of specific non-pharmacological therapies for pain reduction in people with dementia (e.g. aromatherapy, play activity, singing or robotic care).

RELEVANCE TO CLINICAL PRACTICE

The findings of this study can guide healthcare practitioners when considering the use of non-pharmacological pain management methods for people with dementia and may improve the implementation of these methods in clinical practice.

PATIENT OR PUBLIC CONTRIBUTIONS

The study suggests non-pharmacological interventions to reduce pain and underlines the relevance of health provider's viewpoints. The types, duration and length of follow-up of non-pharmacological interventions can be offered based on patient's conditions and the standard of clinical practice.

Feasibility study protocol of the PainChek app to assess the efficacy of a social robot intervention for people with dementia

AIM

This study aims to test the feasibility of the PainChek app to assess pain for people with dementia living in residential aged care facilities (RACFs). It will also identify the optimal dosage and efficacy of a social robot (personal assistant robot [PARO]) intervention on chronic pain for people with dementia.

DESIGN

This is a feasibility randomized controlled trial with three groups.

METHODS

Forty-five residents living with dementia and chronic pain will be recruited from one RACF. The intervention consists of an individual 15-min non-facilitated session with a PARO robot twice a day (Group 1), a PARO robot once a day (Group 2), or a Plush-Toy (non-robotic PARO) once a day (Group 3) from Monday to Friday for 4 weeks. Participants will be followed at 4 and 8 weeks after baseline assessments. The primary outcome will be the feasibility of using the PainChek app to measure changes in pain levels before and after each session. Secondary outcomes include staff-rated pain levels, neuropsychiatric symptoms, quality of life and changes in psychotropic and analgesic medication use. Participants, staff and family perceptions of using PARO and the PainChek app will be collected after the 4-week intervention.

DISCUSSION

This study will test the use of the PainChek app and PARO to improve pain management for people with dementia. Results from this study will help determine its usefulness, feasibility and acceptability for pain management in people with dementia living in RACFs.

IMPACT

As pain is a significant problem for people with dementia, this project will generate evidence on the use of the PainChek to measure the efficacy of a social robot intervention that has the potential to improve the quality of pain care in people with dementia.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry number (ACTRN12621000837820) date registered 30/06/2021.

A Latent Approach to Understanding Pain in Nursing Home Residents Who are Unable to Self-Report Pain

Context

Pain assessment in people with cognitive impairment is challenging.

Objective

The study sought to 1) identify pain subgroups based on staff-assessed pain, agitated and reactive behavior, functional status, and symptoms of depression; and 2) understand if cognitive impairment was associated with transitions between pain subgroups at nursing home admission, 3 months, and 6 months.

Methods

Using national Minimum Data Set 3.0 data (2011–2016), we included 26,816 newly admitted residents with staff-assessed pain at admission, 3 months, and 6 months. Pain subgroups were identified by latent class analysis at each time point. Transitions between pain subgroups were described using latent transition analysis.

Results

Five latent statuses of pain were identified at admission: “Behavioral and Severe Depression” (prevalence stable, severe or worsening cognitive impairment: 11%, mild/moderate or improved cognitive impairment: 10%), “Functional” (21%; 25%), “Physical” (22%; 23%), “Behavioral” (23%, 19%), and “Low” (23%; 24%). Regardless of change in cognitive status, most residents remained in the same pain latent class. Among residents with stable, severe or worsening cognitive impairment, 11% in the “Behavioral” class transitioned to the “Behavioral and Severe Depression” class by 3 months. Fewer residents transitioned between latent classes in the 3- to 6-month period (>80% remained in their 3-month class).

Conclusion

For nursing home residents unable to self-report pain, consideration of additional indicators including functioning, depressive symptoms, and agitation may be useful in identifying pain subgroups. Longitudinal changes in the pain subgroups over 6 months post-admission highlight that residents with severe cognitive impairment may be at risk for worsening pain.

Non-pharmacological interventions for pain management in patients with dementia: A mixed-methods systematic review

AIMS AND OBJECTIVES

To systematically identify, summarise and compare evidence from studies related to the non-pharmacological interventions used to manage pain in patients with dementia. Secondly, this study aims to provide evidence on the effectiveness of non-pharmacological interventions used to manage pain in patients with dementia.

BACKGROUND

The number of people diagnosed with dementia is rising rapidly in the context of ageing. Pain is considered to be one of the most common neuropsychiatric symptoms of dementia. To date, little research has focused on non-pharmacological interventions to manage pain in patients with dementia. Therefore, a systematic review on the non-pharmacological interventions used to manage pain in patients with dementia and how effective these interventions are, is warranted.

METHOD

The extensive search strategy included electronic database searches for CINAHL, MEDLINE and PsycINFO from January 2009 to February 2020. A mixed-methods systematic review was undertaken in accordance with the PRISMA statement and relevant papers were chosen based on inclusion criteria and quality assessment measures. Eligibility criteria defined the characteristics of inclusion studies using the PICO framework. Results were extracted to a synthesis table. The quality appraisal was conducted using JBI and CASP checklist.

RESULTS

Eight studies met the inclusion criteria. These included six randomised controlled trials, one quasi-experimental study and one qualitative descriptive study. The current review identified various non-pharmacological interventions for pain management in patients with dementia including singing, painting, massage, ear acupressure, play activities program and robot. The most common intervention was massage while the most effective intervention was play activities program. All studies provided evidence that non-pharmacological interventions have an effect on pain management in patients with dementia or that there was a tendency for non-pharmacological intervention to reduce pain in patients with dementia. Overall, the quality of the included studies was interpreted as strong (n = 8).

CONCLUSIONS

Overall, interactive pharmacological interventions were more effective than non-interactive non-pharmacological interventions. While this review highlighted a limited number of studies investigating the use of non-pharmacological interventions to manage pain in patients with dementia, it did however uncover a range of non-pharmacological interventions used to manage pain in these patients along with their level of effectiveness.

RELEVANCE TO CLINICAL PRACTICE

Further research is required to explore which non-pharmacological interventions are most effective in the management of pain in patients with varying degrees of cognitive impairment. Further qualitative research is also needed to explore nurses' views on the use of non-pharmacological interventions to manage pain in patients with dementia.

The effectiveness of interventions to improve pain assessment and management in people living with dementia: A systematic review and meta-analyses

AIMS

To synthesize and evaluate the effectiveness of interventions for nurses to improve the assessment and management of pain in people living with dementia.

DESIGN

Systematic review and meta-analyses of randomized controlled trials.

DATA SOURCES

CINAHL, Joanna Briggs Institute (JBI) EBP, Cochrane Library, PubMed, and Scopus databases were searched for all journal articles published between 2009 -2019.

REVIEW METHODS

Papers were included under population intervention comparator outcome (PICO) framework for: (a) people living with dementia aged 65 years and over; (b) interventions developed for nurses or other health professionals; (c) comparison group of standard care or control; and (d) outcome that measures the intervention effects on nurses and people living with dementia. Independent reviewers undertook critical appraisal, data abstraction, and synthesis. Meta-analyses were performed to determine the effectiveness of interventions.

RESULTS

Of 2099 titles and abstracts screened, six interventions with low-to-moderate risk of bias met inclusion criteria. Studies that implemented a routine pain assessment tool showed no effect on nurses' analgesic management. Studies that developed a comprehensive pain model involving multidisciplinary health professionals showed overall effects on pain assessment and management in dementia care. Physician involvement had an impact on analgesic management.

CONCLUSION

Comprehensive pain models improve nurses' pain assessment and management. A lack of balance between analgesia use and non-pharmacological pain management in dementia care is evident. Multidisciplinary health professionals' involvement is essential for effective intervention design for pain management in dementia.

IMPACT

Various pain assessment tools have been considered to assist identification and management of pain in people living with dementia. Nevertheless, challenges exist when caring for people living with dementia in pain. These findings support the development of a comprehensive pain model, which may be a more effective strategy than routine use of a pain tool alone for nurses to improve pain management in dementia care.

Pain and delirium: mechanisms, assessment, and management

PURPOSE

Pain and delirium are common problems for older people. Both conditions are prevalent in acute hospital settings. In people living in the community, delirium often precipitates presentation to the emergency department. Pain and delirium are known to interact in a complex and multidirectional way. This can make it challenging for staff to recognize and treat pain in people with delirium.

METHODS

This paper aims to explore the complex relationship between pain and delirium and on pain assessment in delirium, drawing together evidence from a range of settings including acute medical, cardiac and orthopaedic post-operative cohorts, as well as from aged care.

RESULTS

A limited number of studies suggest there is an association between pain and delirium; however, this is a complex, particularly where analgesics which may-themselves cause delirium are prescribed. Factors acting on the pathway between pain and delirium may include depression, sleep deprivation and disturbance of the cholinergic system. Delirium affects the ability to self-report pain. The fluctuating nature of delirium as well as reduced awareness and attention may challenge practitioners in recognizing, assessing and treating pain. Evidence concerning the reliability and validity of current observational and self-assessment tools in people with delirium is unclear but some show promise in this population.

CONCLUSION

The current evidence base regarding assessing pain in people with delirium is lacking. Tentative recommendations, drawing on current guidelines require robust testing. Guidelines for people with pain and dementia require adaptations regarding the unique characteristics of delirium. The complex interplay between dementia, pain and delirium warrants further investigation across a range of settings.