The Quality of Pain Treatment in Community-Dwelling Persons with Dementia

Patterns of cognitive decline and somatosensory processing in a mouse model of amyloid accumulation

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Despite copious amyloid plaques, 5XFAD mice show modest signs of cognitive decline.

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At ages 2 to 13 months old 5XFAD mice show no signs of sensory or pain dysfunctions.

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5XFAD mice may not be a valid model for pain abnormalities in the context of AD.

Pain and cognitive decline increase with age. In particular, there is a troubling relationship between dementia and pain, with some studies showing higher prevalence and inadequate treatment of pain in this population. Alzheimer’s disease (AD) is one of the most common causes of dementia in older adults. Amyloid plaques are a hallmark of AD. The downstream processes these plaques promote are believed to affect neuronal and glial health and activity. There is a need to better understand how the neuropathological changes of AD shape neural activity and pain sensitivity. Here, we use the 5XFAD mouse model, in which dense amyloid accumulations occur at early ages, and in which previous studies reported signs of cognitive decline. We hypothesized that 5XFAD mice develop sensory and pain processing dysfunctions. Although amyloid burden was high throughout the brain, including in regions involved with sensory processing, we identified no functionally significant differences in reflexive or spontaneous signs of pain. Furthermore, expected signs of cognitive decline were modest; a finding consistent with variable results in the literature. These data suggest that models recapitulating other pathological features of Alzheimer’s disease might be better suited to studying differences in pain perception in this disease.

Translation and Psychometric Evaluation of the Mahoney Pain Scale Among Iranian Elderly With Dementia: A Methodological Study

Valid and reliable measurement tools are necessary for pain assessment among the elderly with dementia. This study aimed to translate the Mahoney Pain Scale (MPS) into Persian and evaluate its psychometric properties among Iranian elderly with dementia. In this methodological study, after translating and assessing the face and content validity of MPS, 100 elderly with dementia were selected via convenience sampling from nursing homes and clinics in Kashan in 2018-19; then, MPS was completed for them both at rest and during a movement pain protocol. MPS was assessed by exploratory factor analysis, known-group comparison, convergent validity, internal consistency, equivalence, and stability. The factor analysis revealed a one-factor structure, which explained 57.11% of the total variance. The Persian MPS differentiated patients with and without known painful conditions, as well as pain at rest and during the movement pain protocol (p < .0001). There was a significant positive correlation between the scores of MPS and PACSLAC-II (r = .87, p < .0001). The Cronbach's α, intraclass correlation coefficient and standard error of measurement of MPS were .91, .79, and ±1.37, respectively. As a valid and reliable tool, the Persian MPS can be used for pain assessment among Iranian elderly with dementia.

The challenge of pain identification, assessment, and management in people with dementia: a qualitative study

BACKGROUND

Painful conditions are common in older adults, including people with dementia. The symptoms associated with dementia (for example, diminished language capacity, memory impairment, and behavioural changes), however, may lead to the suboptimal identification, assessment, and management of pain. Research has yet to qualitatively explore pain management for community-dwelling people with dementia.

AIM

To explore pain identification, assessment, and management for community-dwelling people with dementia.

DESIGN & SETTING

A qualitative study was undertaken, set in England.

METHOD

Semi-structured interviews took place with people with dementia, family caregivers, GPs, and old-age psychiatrists. Data were analysed thematically.

RESULTS

Interviews were conducted with eight people with dementia, nine family caregivers, nine GPs, and five old-age psychiatrists. Three themes were identified that related to pain identification and assessment: gathering information to identify pain; the importance of knowing the person; and the use of pain assessment tools. A further three themes were identified that related to pain management: non-drug strategies; concerns related to analgesic medications; and responsibility of the caregiver to manage pain.

CONCLUSION

Identifying and assessing the pain experienced by people with dementia was challenging. Most people with dementia, family caregivers, and healthcare professionals supported non-drug strategies to manage pain. The minimal concerns associated with non-drug strategies contrasted the multifactorial concerns associated with analgesic treatment for people with dementia. Given the complexity of pain identification, assessment, and management, primary care should work together with family caregivers and community services, with case finding for pain being considered in all assessment and management plans.

Pain assessment and pain treatment for community-dwelling people with dementia: A systematic review and narrative synthesis

OBJECTIVES

To describe the current literature on pain assessment and pain treatment for community-dwelling people with dementia.

METHOD

A comprehensive systematic search of the literature with narrative synthesis was conducted. Eight major bibliographic databases were searched in October 2018. Titles, abstracts, and full-text articles were sequentially screened. Standardised data extraction and quality appraisal exercises were conducted.

RESULTS

Thirty-two studies were included in the review, 11 reporting findings on pain assessment tools or methods and 27 reporting findings on treatments for pain. In regard to pain assessment, a large proportion of people with moderate to severe dementia were unable to complete a self-report pain instrument. Pain was more commonly reported by informal caregivers than the person with dementia themselves. Limited evidence was available for pain-focused behavioural observation assessment. In regard to pain treatment, paracetamol use was more common in community-dwelling people with dementia compared with people without dementia. However, non-steroidal anti-inflammatory drugs (NSAIDs) were used less. For stronger analgesics, community-dwelling people with dementia were more likely to receive strong opioids (eg, fentanyl) than people without dementia.

CONCLUSION

This review identifies a dearth of high-quality studies exploring pain assessment and/or treatment for community-dwelling people with dementia, not least into non-pharmacological interventions. The consequences of this lack of evidence, given the current and projected prevalence of the disease, are very serious and require urgent redress. In the meantime, clinicians should adopt a patient- and caregiver-centred, multi-dimensional, longitudinal approach to pain assessment and pain treatment for this population.

Opioid use and the presence of Alzheimer's disease and related dementias among elderly Medicare beneficiaries diagnosed with chronic pain conditions

Introduction

There is scant literature on the use of opioids among community-dwelling elderly with Alzheimer's disease and related dementias (ADRD).

Methods

We adopted a retrospective, cross-sectional study design using Medicare Current Beneficiary Survey data from 2006 to 2013. The study sample included elderly community-dwelling Medicare beneficiaries who were diagnosed with chronic pain conditions and had Medicare fee-for-service plans for the entire year. We conducted bivariate χ² test and multivariate logistic regression to examine the relationship between opioid use and ADRD status.

Results

The study sample included 19,347 Medicare beneficiaries; 7.7% of them had ADRD. We found no statistically significant difference in opioid use by ADRD status in the unadjusted analysis; however, controlling for various factors, those with ADRD had lower odds of opioid use (adjusted odds ratio = 0.81, 95% confidence interval = 0.71, 0.93) than those without ADRD.

Discussion

This population-based study suggests that elderly Medicare beneficiaries with ADRD and chronic pain conditions may have undertreatment of pain.

Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem

Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilization, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimize prescribing for this vulnerable patient group. Although there has been a considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life expectancy is limited. The development of tools to assess medication appropriateness in people with mild to moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes, including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities, and to examine the impact of PIP on health outcomes.