Pain in dementia: prevalence and associated factors: protocol of a multidisciplinary study

A Scoping Review on Nurse's Pain Management of Older Patients with Dementia in a Hospital Environment

OBJECTIVES

Hospitalized persons living with dementia often experience unrelieved pain. Unmanaged pain during hospitalization has a significant negative effect on quality of life for persons living with dementia. Despite the central role of nurses in pain management, little is known about how nurses manage pain in this patient population in the hospital environment.

DESIGN

A scoping review explored the nurses' pain management practices when caring for persons living with dementia in a hospital setting.

DATA SOURCES AND REVIEW/ANALYSIS METHODS

After an extensive search for all available evidence on how nurses manage pain in hospitalized persons living with dementia, data were extracted on pain management methods that included assessment, intervention, effectiveness of pain management, and the barriers nurses encountered when managing pain. A descriptive content analysis was used to extract data from qualitative studies.

RESULTS

Six articles published between 2016 and 2021 met the inclusion criteria; four utilized qualitative methods, and the others used mixed-methods and quantitative study designs. A narrative description of the findings was summarized after data were categorized into pain management data elements and barriers nurses encountered when managing pain. Barriers were grouped into the subcategories of communication challenges (nurse to patient), information sharing (nurse to nurse), lack of knowledge, time constraints, and nursing stressors.

CONCLUSION

We identified six articles that met our inclusion criteria, highlighting a noticeable gap in the literature. Managing pain in this population is complex and lacks organizational support. Review findings indicate that pain management methods lack consistency and standardization, making it difficult to assess their effectiveness. Nurses also described knowledge deficits resulting in practice gaps that, when combined with barriers and challenges, result in underrecognized and undermanaged pain.

Nursing-sensitive quality indicators for quality improvement in Norwegian nursing homes - a modified Delphi study

BACKGROUND

Use of nursing-sensitive quality indicators (QIs) is one way to monitor the quality of care in nursing homes (NHs). The aim of this study was to develop a consensus list of nursing-sensitive QIs for Norwegian NHs.

METHODS

A narrative literature review followed by a non-in-person, two-round, six-step modified Delphi survey was conducted. A five-member project group was established to draw up a list of nursing-sensitive QIs from a preliminary list of 24 QIs selected from Minimum Data Set (2.0) (MDS) and the international Resident Assessment Instrument for Long-Term Care Facilities (interRAI LTCF). We included scientific experts (researchers), clinical experts (healthcare professionals in NHs), and experts of experience (next-of-kin of NH residents). The experts rated nursing-sensitive QIs in two rounds on a seven-point Likert scale. Consensus was based on median value and level of dispersion. Analyses were conducted for four groups: 1) all experts, 2) scientific experts, 3) clinical experts, and 4) experts of experience.

RESULTS

The project group drew up a list of 20 nursing-sensitive QIs. Nineteen QIs were selected from MDS/interRAI LTCF and one ('systematic medication review') from the Norwegian quality assessment system IPLOS ('Statistics linked to individual needs of care'). In the first and second Delphi round, 44 experts (13 researchers, 17 healthcare professionals, 14 next-of-kin) and 28 experts (8 researchers, 10 healthcare professionals, 10 next-of-kin) participated, respectively. The final consensus list consisted of 16 nursing-sensitive QIs, which were ranked in this order by the 'all expert group': 1) systematic medication review, 2) pressure ulcers, 3) behavioral symptoms, 4) pain, 5) dehydration, 6) oral/dental health problems, 7) urinary tract infection, 8) fecal impaction, 9) depression, 10) use of aids that inhibit freedom of movement, 11) participation in activities of interest, 12) participation in social activities, 13) decline in activities of daily living, 14) weight loss, 15) falls, and 16) hearing loss without the use of hearing aids.

CONCLUSIONS

Multidisciplinary experts were able to reach consensus on 16 nursing-sensitive QIs. The results from this study can be used to implement QIs in Norwegian NHs, which can improve the quality of care.

Family Caregiver Challenges in Pain Management for Patients with Advanced Illnesses: A Systematic Review

Although pain management is integral to the caregiving role, there is a paucity of evidence synthesizing specific challenges family caregivers (FCs) face when managing pain for their care partners. This review comprehensively identified and summarized such challenges in the setting of advanced illnesses. Electronic databases (PubMed, CINAHL, PsycINFO, Scopus, and Health and Psychosocial Instruments) were searched using index and keyword methods for all articles published before April 2021. Fifty-five studies were included in this review. Most articles were published within the last 10 years (54%) in community settings, with home hospice care comprising the majority (50%). Most studies included patients with an advanced cancer diagnosis (84%), and 16% of the studies included patients with a noncancer diagnosis. Four major categories of challenges were identified: (1) caregiver-related issues (e.g., fears, beliefs, function), (2) caregivers' limited knowledge and skills in pain management (e.g., verbal and nonverbal pain assessment skills, pharmacological knowledge, documentation, safe management of medication), (3) communication challenges with health care providers, and (4) patient-related issues (e.g., inability to report pain). Many of these challenges have not been fully addressed in prior literature. Thus, this review provides a framework for needed future research to develop interventions that target FCs' specific challenges in providing pain management. The results also highlight a significant lack of research surrounding challenges faced by caregivers of care partners having a noncancer, dementia, or multimorbidity diagnosis.

Non-pharmacological interventions for pain in people with dementia: A systematic review

CONTEXT

Pain commonly occurs in people living with dementia but is often undertreated. Non-pharmacological interventions are a safer first-line option for pain management, but evidence-based interventions for people living with dementia have not been established. An increasing number of studies have examined the effect of non-pharmacological interventions in pain management. However, the evidence that specifically focuses on people living with dementia has not been systematically reviewed.

OBJECTIVES

This review aimed to systematically synthesize current evidence on non-pharmacological interventions to manage pain in people living with dementia.

METHODS

A comprehensive search of the literature was conducted in PubMed, CINAHL, Scopus, and Web of Science databases. Studies were included if they were 1) peer-reviewed original quantitative research, 2) tested the effect of non-pharmacological interventions on pain in people with dementia, and 3) English language. Studies were excluded if they 1) included both pharmacological and non-pharmacological interventions and did not report separate results for the non-pharmacological interventions; 2) enrolled participants with and without dementia and did not have separate results reported for individuals with dementia; 3) tested dietary supplements as the intervention; and 4) were not original research, such as reviews, editorials, commentaries, or case studies. Title, abstract, and full text were screened. Quality assessment was conducted using the Cochrane Risk of Bias tool and Johns Hopkins Level of Evidence. Pain assessment tools, participant characteristics, study designs, intervention condition, and results were extracted. Results were synthesized through grouping the type of the interventions and weighting evidence based on quality and design of the studies.

RESULTS

A total of 11 articles and 12 interventions were identified. A total of 486 participants were included. Interventions that have shown a positive impact on pain include ear acupressure, music therapy, reflexology, tailored pain intervention, painting and singing, personal assistive robot, cognitive-behavioral therapy, play activity, and person-centered environment program. Nevertheless, a majority of the interventions were only evaluated once. Moreover, most studies had similar sample characteristics and setting.

CONCLUSION

Overall, the quality of included studies were mostly low to mixed quality and most participants only had mild to moderate baseline pain, which limits detection of the intervention's effect. Hence, these findings need to be duplicated in studies with a greater sample size, a more diverse population (race, gender, and settings), and a more rigorous design to validate the results.

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.

Advance Requests for Medical Assistance in Dying in Dementia: a Survey Study of Dementia Care Specialists

Background

Current Canadian Medical Assistance in Dying (MAiD) legislation requires individuals to have the mental capacity to consent at the time of the procedure. Advance requests for MAiD (ARs for MAiD) could allow individuals to document conditions where MAiD would be desired in the setting of progressive dementia.

Methods

Greater Vancouver area dementia care clinicians from family practice, geriatric medicine, geriatric psychiatry, and palliative care were approached to participate in an online survey to assess attitudes around the appropriateness of ARs for MAiD. Quantitative analysis of survey questions and qualitative analysis of open-ended response questions were performed.

Results

Of 630 clinicians approached, 80 were included in the data analysis. 64% of respondents supported legislation allowing ARs for MAiD in dementia. 96% of respondents articulated barriers and concerns, including determination of capacity, protecting the interests of the future individual, navigating conflict among stakeholders, and identifying coercion. 78% of respondents agreed with a mandatory capacity assessment to create an AR, and 59% agreed that consensus between clinicians and substitute decision-makers was required to enact an AR.

Conclusion

The majority of Vancouver dementia care clinicians participating in this study support legislation allowing ARs for MAiD in dementia, while also articulating ethical and logistical concerns with its application.

Oral function and its association with nutrition and quality of life in nursing home residents with and without dementia: A cross-sectional study

Background

Oral health problems increase with age, and are common in nursing home residents, especially in those with dementia. These problems can lead to tooth loss, diminished oral function and malnutrition.

Objectives

To compare oral function, nutritional status and quality of life (QoL) between residents with and without dementia, and to examine associations between these variables.

Methods

Cross‐sectional study conducted in four UK nursing homes. Residents aged 65 + with and without dementia were included. Information was collected on demographics, dental status, quality of swallowing and chewing, xerostomia and orofacial pain. During oral examination, information was collected on number of teeth and occlusal units (OU), and functional categories (eg, OU combined with dentures). Multiple linear regression was used for statistical analysis.

Results

Of 84 residents with and 27 without dementia participated. Residents with dementia had significantly fewer teeth (Dementia median (IQR) = 14 (6‐21), vs No dementia 22 (12.75‐24.25); P = .021), fewer OU (Dementia median (IQR) = 0 (0‐3), vs No dementia 4 (0‐7); P = .001) and poorer functional categories (Z = −3.283; P = .001), and nutritional status was significantly poorer than those without (Dementia Mean (SD) = 8.3 (2.7), vs No dementia 10.4 (2.0); P = .002). In the regression model, quality of chewing (Coef (95% CI) = −1.27 (−2.22, −0.31); P = .010) was significantly correlated with nutritional status.

Conclusion

Oral function and nutritional status of residents with dementia was poorer than those without. Almost half of all residents had insufficient oral function, which was negatively associated with QoL and nutritional status.

The objectivity and subjectivity of pain practices in older adults with dementia: A critical reflection

Providing nursing care for people with dementia residing in long-term care facilities poses specific challenges regarding pain practices. With underlying communication barriers unique to dementia pathologies, this population is often unable to communicate verbal sentiments and descriptions of pain. In turn, nurses caring for older persons with dementia have difficulty assessing, managing and treating pain. Objectivity is an imperative factor in healthcare pain practices; however, it is difficult to objectively evaluate someone who cannot accurately communicate their experience of pain. Therefore, the authors believe that subjectivity is also an essential part of evaluating the person with dementia's experience of pain. In this critical reflection, the authors explore objectivity and subjectivity in relation to pain practices for dementia in long-term care. A historical summary of pain is provided outlining the evolution of objectivity and subjectivity related to pain practices. The authors discuss the complexities of assessing and managing pain and offer a new perspective about the role of objectivity (and co-existence of subjectivity) for nurses treating pain in the older adults with dementia.

Holistic pain assessment in older people and older people living with dementia

Pain occurs in a wide range of diseases and long-term conditions associated with ageing and can affect every aspect of an individual's life, reducing their ability to recover, their independence and their quality of life. The assessment of pain is an important aspect of nurses' role and requires them to obtain detailed information on how the older person experiences pain and how pain is affecting their life. However, there are many challenges to effective pain assessment in older people, including challenges concerning communication and cognition. This article provides an overview of pain assessment in older people, particularly those living with dementia, based on the author's expertise and on relevant literature, notably the recently revised UK national guidelines on the assessment of pain in older people.

Chewing Efficiency, Global Cognitive Functioning, and Dentition: A Cross-sectional Observational Study in Older People With Mild Cognitive Impairment or Mild to Moderate Dementia

Introduction: Previous studies suggest an association between poor mastication and cognitive impairment. The role of chewing efficiency and dentition in this relation is unclear. The aim was to examine global cognitive functioning and dentition as predictors for chewing efficiency, in older people with mild cognitive impairment (MCI) or dementia.

Methods: In this observational cross-sectional study, 136 people with MCI or dementia were included. The chewing efficiency was assessed with a two-colored chewing gum and analyzed with the Chewing Efficiency Analysis software. The level of global cognitive functioning was measured with the Mini Mental State Examination (MMSE) by trained clinical staff. An oral examination was performed by a dentist and included the number of present teeth, the number of occluding pairs, and the presence of prostheses. Age, gender, and educational years were derived from the medical records. Univariate and multivariate backward stepwise linear regression analyses were used to evaluate global cognitive functioning and dentition as predictors for chewing efficiency.

Results: The mean age of the participants was 82.1 (SD 5.8) years, and 74 (54.4%) were female. The participants had a median MMSE score of 22.4 (IQR 18.0–26.0) and a median Chewing Efficiency Analysis score of 0.46 (IQR 0.14–0.59). The median number of teeth was 13.0 (IQR 0.0–23.0), and the median number of occluding pairs was 0.0 (IQR 0.0–7.0). Sixty-four (47.4%) of the participants wore full prosthesis in the upper jaw. In univariate linear regression analyses, predictive factors for the Chewing Efficiency Analysis score were age, MMSE score, full prosthesis in the upper jaw, number of present teeth, and number of occluding pairs. In the multivariate model, full prosthesis in the upper jaw and number of occluding pairs were significant predictors for the Chewing Efficiency Analysis score. Participants with full prosthesis in the upper jaw had a lower Chewing Efficiency Analysis score than participants with natural dentition in the upper jaw.

Conclusion: Better mastication is associated with a higher number of occluding pairs. Full prosthesis in the upper jaw is related to a lower chewing efficiency. Global cognitive functioning is not associated with mastication in older people with MCI or mild-to-moderate dementia. This might be explained by sufficient capacity for compensation of reduced mastication in this group.

Model of Empathic Pain Assessment and Treatment in Persons With Dementia

The current article presents an evidence-based model for understanding clinical empathy's relationship with the assessment and treatment of pain in persons with advanced dementia. A literature review informed creation of an interdisciplinary conceptual framework of clinician empathy in pain assessment and treatment among persons with advanced dementia. Driven by observation of behaviors indicating pain in persons with dementia unable to self-report, the model represents the cognitive, affective, ethical, and behavioral components of clinical empathy involved in assessing and treating pain, relevant patient outcomes, and contextual factors influencing empathy and outcomes; and provides a framework for testing clinical empathy interventions to improve adverse outcomes in persons with advanced dementia. Understanding the relationship between clinician empathy and the assessment and treatment of pain in persons with advanced dementia may improve care quality and help reduce pain behaviors in this patient population. This model may be used to inform pain research in persons with dementia and develop clinical interventions and clinician education programs. [Research in Gerontological Nursing, 13(5), 264-276.].

Interventions to Support Family Caregivers in Pain Management: A Systematic Review

CONTEXT

Family caregivers encounter many challenges when managing pain for their loved ones. There is a lack of clear recommendations on how to prepare caregivers in pain management.

OBJECTIVES

To evaluate existing interventions that support family caregivers in providing pain management to patients with all disease types.

METHODS

Four electronic databases were systematically searched (PubMed, Cumulative Index for Nursing Allied Health Literature, PsycINFO, and Scopus) using index and keyword methods for articles published before December 2019. The Mixed Methods Appraisal Tool was used to assess the quality.

RESULTS

The search identified 6851 studies, and 25 studies met the inclusion criteria. Only two studies exclusively focused on noncancer populations (8%). Three types of interventions were identified in this review: educational interventions, cognitive-behavioral interventions, and technology-based interventions. Both educational and cognitive-behavioral interventions improved family caregiver and patient outcomes, but the content and intensity of these interventions in these studies varied widely, and there was a limited number of randomized clinical trials (68%). Hence, it is unclear what strategies are most effective to prepare family caregivers in pain management. Technology-based interventions were feasible to support family caregivers in providing pain management.

CONCLUSION

Providing adequate pain management training can improve patient and family caregiver outcomes. However, the most effective interventions for family caregivers are still unclear. More rigorous and replicable clinical trials are needed to examine the effects of educational interventions, cognitive-behavioral interventions, and technology-based interventions. Also, more studies are needed in patients with a noncancer diagnosis or multimorbidity.

Prevalence and associations of orofacial pain and oral health factors in nursing home residents with and without dementia

OBJECTIVES

determine and compare the prevalence of orofacial pain in older nursing home residents with and without dementia and explore the association between orofacial pain and health factors.

METHODS

cross-sectional study conducted in four UK nursing homes. We used the Orofacial-Pain Scale for Non-Verbal Individuals (OPS-NVI) to identify orofacial pain in residents with dementia. Residents who were able to communicate self-reported orofacial pain. A brief oral examination was conducted. Information on demographics, Clinical Dementia Rating, Charlson Comorbidity Index, Cohen Mansfield Agitation Inventory, Barthel Index, 5-level Euroqol 5 Dimension, Oral Health Impact Profile 14, Mini Nutritional Assessment Short Form and medication was collected. Chi-squared tests, independent sample t-tests and Mann-Whitney U-tests were used to compare outcomes between groups. Multivariable logistic regression was used to evaluate predictors of orofacial pain.

RESULTS

orofacial pain, assessed with the OPS-NVI, was present in 48.8% (95% confidence interval [C.I.] 36.1-50.7) of residents with dementia. Self-reported orofacial pain was present in 37.8% (95% C.I. 20.4-53.7) of residents with dementia and in 14.8% (95% C.I. 0.5-30.4) residents without dementia. Orofacial pain was significantly more prevalent in residents with dementia than those without (OPS-NVI; P = 0.002, self-report; P = 0.04). Having a soft diet, xerostomia, being dentate, and poor oral hygiene in dentate residents were significant predictors of orofacial pain in residents with dementia.

CONCLUSION

orofacial pain was more prevalent in residents with dementia. Oral health care should be part of routine care for residents, especially for those with dementia, to improve oral health and decrease the risk of developing orofacial pain.

Do Health-Related Quality of Life and Pain-Coping Strategies Explain the Relationship between Older Women Participants in a Pilates-Aerobic Program and Bodily Pain? A Multiple Mediation Model

This study (1) analyzes the differences between non-participating and participating older women in terms of clinical characteristics, pain coping strategies, health-related quality of life and physical activity (PA); (2) studies the associations between non-participants and participants, clinical characteristics, pain coping strategies, HRQoL and bodily pain and PA; and (3) determines whether catastrophizing, physical role, behavioural coping, social functioning and emotional role are significant mediators in the link between participating in a Pilates-aerobic program (or not) and bodily pain. The sample comprised 340 older women over 60 years old. Participants of the present cross-sectional study completed measures of clinical characteristics: HRQoL using the SF-36 Health Survey, pain-coping strategies using the Vanderbilt Pain Management Inventory (VPMI) and PA using the International Physical Activity Questionnaire (IPAQ). Significant differences between non-participants and participants, were found in clinical characteristics, pain-coping strategies (both, p < 0.05), HRQoL (p < 0.01), and PA (p < 0.001). Moreover, catastrophizing support mediated the link between non-participants and participants and bodily pain by 95.9% of the total effect; 42.9% was mediated by PA and 39.6% was mediated by behavioural coping. These results contribute to a better understanding of the link between PA and bodily pain.

Sex Differences in Associations of Cognitive Function with Perceptions of Pain in Older Adults

BACKGROUND

Sex differences in pain have been shown to exist in older adults with normal cognition and people with Alzheimer's disease. It is unknown if sex differences in pain in older adults exist in a range of communicative older adults with varying cognitive ability from no impairment to moderately severe cognitive impairment.

OBJECTIVE

This study proposes to compare the association between psychophysical responses to experimental thermal pain between males and females to determine if sex differences in pain exist across the cognitive spectrum.

METHODS

We conducted a secondary analysis of data from an age- and sex-matched between-groups cross-sectional study examining the psychophysical response to contact heat in people with and without dementia.

RESULTS

Median age of males (n = 38) and females (n = 38) was 73 (range: 68-87) with similar distributions of Mini-Mental State Examination (MMSE) scores (range: 11-30). Findings revealed inverse statistically significant associations with the threshold temperature of warmth (females: r = -0.41, p = 0.010; males: r = -0.33, p = 0.044). There was an apparent divergent pattern of MMSE associations with unpleasantness ratings between the groups. At the moderate pain threshold, that difference became statistically significant (p = 0.033). Females demonstrated a positive association of MMSE with unpleasantness (r = 0.30, p = 0.072), while males demonstrated an inverse association at that respective threshold (r = -0.20, p = 0.221).

CONCLUSIONS

Between-group findings suggest that patterns of responses to thermal stimulus intensity may differ between males and females with worsening cognition with females reporting significantly less unpleasantness with the percept of moderate pain and males reporting significantly higher unpleasantness with moderate pain perception.

Orofacial pain and its potential oral causes in older people with mild cognitive impairment or dementia

Background

The number of people with dementia and natural dentition is growing. As dementia progresses, the degree of self‐care decreases and the risk of oral health problems and orofacial pain increases.

Objectives

To examine and compare the presence of orofacial pain and its potential causes in older people with Mild Cognitive Impairment (MCI) or dementia.

Methods

In this cross‐sectional observational study, the presence of orofacial pain and its potential causes was studied in 348 participants with MCI or dementia with all levels of cognitive impairment in two outpatient memory clinics and ten nursing homes.

Results

Orofacial pain was reported by 25.7% of the 179 participants who were considered to present a reliable pain self‐report (Mini‐Mental State Examination score ≥14 points), while it could not be determined in people with more severe cognitive impairment. The oral health examination of the 348 participants indicated that potential painful conditions, such as coronal caries, root caries, tooth root remnants or ulcers were present in 50.3%. There was a significant correlation between the level of cognitive impairment and the number of teeth, r = 0.185, P = 0.003, teeth with coronal caries, r = −0.238, P < 0.001, and the number of tooth root remnants, r = −0.229, P = 0.004, after adjusting for age.

Conclusions

This study indicated that orofacial pain and its potential causes were frequently present in participants with MCI or dementia. Therefore, a regular oral examination by (oral) healthcare providers in people with MCI or dementia remains imperative, even if no pain is reported.

Pain, Neuropsychiatric Symptoms, and Quality of Life of Nursing Home Residents With Advanced Dementia in The Netherlands: A Cross-sectional Study

BACKGROUND

Many studies have investigated factors associated with quality of life (QoL) in nursing home residents with dementia. Both pain and neuropsychiatric symptoms (NPS) are clinically relevant and individually associated with a lower QoL; however, there are no studies that investigated pain and NPS together in relation to QoL.

PURPOSE

In this study, we explored the relationship of pain and NPS with QoL in nursing home residents with dementia by investigating the association between pain concurrently with NPS, and QoL.

METHODS AND PATIENTS

Secondary data analyses of cross-sectional data from 199 residents were collected by observations at dementia special care units of 10 nursing homes. QoL was measured with Qualidem, pain with the Mobilization Observation Behavior Intensity Dementia (MOBID-2) Pain Scale and NPS with the Neuropsychiatric Symptoms Inventory. The relation of pain and NPS to QoL was studied using multiple linear regression analyses. Analyses were adjusted for age, sex, activities of daily living, comorbidity, medication use, and dementia severity.

RESULTS

Regression models with pain and NPS, showed no independent relationship between pain and QoL subdomains, but NPS, in particular agitation and depressive symptoms, were significantly associated with lower QoL subdomain scores. Agitation was related to lower scores on the subdomains "relationship" [95% confidence interval (CI), -0.083 to -0.059], "positive affect" (95% CI, -0.037 to -0.013), "restless tense behavior" (95% CI, -0.003 to -0.004), and "social relations" (95% CI, -0.033 to -0.009), whereas depression was related to lower scores on the subdomains "positive affect" (95% CI, -0.054 to -0.014), "negative affect" (95% CI, -0.114 to -0.074), "restless tense behavior" (95% CI, -0.075 to -0.025), and "social relations" (95% CI, -0.046 to -0.002).

CONCLUSIONS

Only NPS were significantly associated with QoL in nursing home residents with dementia. Further longitudinal research is needed to estimate the nature of the relationship between pain, NPS, and QoL.

An Iceberg Phenomenon in Dementia: Pain

BACKGROUND

Pain is one of the most frequent symptoms in older adults. It severely impairs quality of life, increases delirium risk, and may lead to progression of dementia. Assessment of pain performed by taking anamnesis from the patient is not reliable in patients with dementia due to cooperation and communication problems. The aim of this study was to assess pain and its consequences in patients with dementia.

METHODS

Seventy-five nursing home residents with dementia were enrolled. After comprehensive geriatric assessment, presence of pain was asked to patients, and Pain Assessment in Advanced Dementia (PAINAD), Discomfort Scale for Dementia of the Alzheimer's Type (DS-DAT), Pain Assessment for the Dementing Elderly (PADE), Wong-Baker Faces Pain Rating Scale, and Numeric Rating Scale tests were performed.

RESULTS

Mean age was 81.1 (7.0), and 46.7% (n = 35) were female. Thirty-two percent of the patients were at early stage, 24% at moderate stage, and 44% at severe stage. Although the number of patients declaring pain was lower in moderate and severe stage, scores of PADE, PAINAD, and DS-DAT were significantly higher in severe stage showing the presence of pain ( P < .001). Furthermore, scores of PADE, PAINAD, and DS-DAT were negatively correlated with comprehensive geriatric assessment test scores.

CONCLUSION

These results demonstrate that pain is not rare in patients with dementia, but they are not usually capable of expressing it, especially in the severe stage. Therefore, objective pain assessment scales developed for patients with dementia should be routinely used and management of pain should be done regarding the association of pain with other geriatric syndromes.

Oral health and orofacial pain in people with dementia admitted to acute hospital wards: observational cohort study

Background

Orofacial pain in people with dementia is difficult to detect, and often under-treated. Our aim was to investigate the prevalence of orofacial pain in people with dementia in acute hospitals in the UK. Secondary aims were to examine oral health status and explore associations between orofacial pain and oral health factors.

Methods

This cross-sectional observational study was carried out in two UK hospitals. Using the Orofacial Pain Scale in Non-Verbal Individuals (OPS-NVI) to identify orofacial pain, 101 participants with dementia, admitted to acute medical wards, were observed for at least 3 min during rest and chewing. Verbal participants were then asked about presence of orofacial pain, using self-report pain scales. Finally, a brief oral assessment was performed.

Results

Orofacial pain, assessed with the OPS-NVI, was present in 11.9% (95% C.I. 5.9, 18.8) of participants at rest and 21.9% (95% C.I. 14.6, 31.3) whilst chewing. Participants who were no longer able to self-report pain were significantly more likely to experience orofacial pain. Oral health in both dentate and edentate participants was poor. Brush frequency, indication of chewing quality, consistency of the food, presence of extra-oral abnormalities, person who performed mouth care, and oral hygiene in dentate participants were significant predictors for the presence of orofacial pain.

Conclusion

Improving oral care in acute hospital patients with dementia, particularly those who cannot self-report pain, may significantly reduce pain and suffering in this population.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0810-7) contains supplementary material, which is available to authorized users.

Shifting Paradigms: Advance Care Planning for Pain Management in Older Adults With Dementia

Ensuring effective pain management is an important quality of life (and death) issue for older adults with dementia, particularly since they are more vulnerable to under-assessment and under-treatment of pain. Yet, pain management decisions are often made by health care providers and caregivers with little to no input on the older adult's with dementia values for pain management. The Institute of Medicine (IOM) has recognized the revolutionary imperative to change the manner in which pain care is planned and coordinated. Implementing advance care planning (ACP) prior to advanced stages of dementia may assist in developing a person-centered pain management plan and improve pain care for this population throughout the dementia trajectory. This forum overviews the current state of pain management in dementia, discusses the significance of ACP in a pain management context, and offers practical solutions for common challenges in ACP. Dementia in this article is an umbrella term referring to the many forms of dementiathat cause cognitive impairment.

Psychometric evaluation of the Orofacial Pain Scale for Non-Verbal Individuals as a screening tool for orofacial pain in people with dementia

OBJECTIVE

The aim of this study was to describe the psychometric evaluation of the Orofacial Pain Scale for Non-Verbal Individuals (OPS-NVI) as a screening tool for orofacial pain in people with dementia.

BACKGROUND

The OPS-NVI has recently been developed and needs psychometric evaluation for clinical use in people with dementia. The pain self-report is imperative as a reference standard and can be provided by people with mild-to-moderate cognitive impairment.

METHODS

The presence of orofacial pain during rest, drinking, chewing and oral hygiene care was observed in people with mild cognitive impairment (MCI) and dementia using the OPS-NVI. Participants who were considered to present a reliable self-report were asked about pain presence, and in all participants, the oral health was examined by a dentist for the presence of potential painful conditions. After item-reduction, inter-rater reliability and criterion validity were determined.

RESULTS

The presence of orofacial pain in this population was low (0%-10%), resulting in an average Positive Agreement of 0%-100%, an average Negative Agreement of 77%-100%, a sensitivity of 0%-100% and a specificity of 66%-100% for the individual items of the OPS-NVI. At the same time, the presence of oral problems, such as ulcers, tooth root remnants and caries was high (64.5%).

CONCLUSION

The orofacial pain presence in this MCI and dementia population was low, resulting in low scores for average Positive Agreement and sensitivity and high scores for average Negative Agreement and specificity. Therefore, the OPS-NVI in its current form cannot be recommended as a screening tool for orofacial pain in people with MCI and dementia. However, the inter-rater reliability and criterion validity of the individual items in this study provide more insight for the further adjustment of the OPS-NVI for diagnostic use. Notably, oral health problems were frequently present, although no pain was reported or observed, indicating that oral health problems cannot be used as a new reference standard for orofacial pain, and a regular oral examination by care providers and oral hygiene care professionals remains indispensable.

The Factors Associated With Anxiety Symptom Severity in Older Adults Living in Nursing Homes and Other Residential Aged Care Facilities

Objective: This study aimed to identify the biopsychosocial factors associated with anxiety among a residential aged care sample. Method: A total of 178 residents ( M age = 85.4 years, SD = 7.4 years) with mild cognitive impairment or normal cognition participated. Participants completed the Geriatric Anxiety Inventory (GAI) and a set of measures assessing cognition, depression, self-perceived health, mastery, attachment, perceived social support, social engagement, functional status, the experience of a fall, and other negative life events. Results: Unique correlates of GAI scores were depression, a preoccupied attachment style, lower mastery, cognitive impairment, and lower self-perceived health. Discussion: Most correlates that were uniquely associated with anxiety had little to do with the current environment. More variance was accounted for by stable and lifelong factors. This provides new insights into the characteristics of anxiety within aged care populations, and although preliminary, provides possible targets to prevent and treat anxiety within this setting.

Revealing brain mechanisms of mTOR-mediated translational regulation: Implications for chronic pain

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mTOR is a major regulator of protein translation.

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mTOR serves an important role in neural plasticity.

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mTOR signalling in the brain as a pathology for neurological disorder is known.

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mTOR signalling in the brain as a chronic pain mechanism is understudied.

In the spinal cord, altered protein transcription and translation have received a lot of recent attention for their role in neural plasticity, a major mechanism leading to the development of chronic pain. However, changes in brain plasticity are also associated with the maintenance of pain symptoms, but these cellular mechanisms remain less clear. The mechanistic/mammalian target of rapamycin (mTOR) is a master regulator of protein synthesis, and controls several neuronal functions, including neural plasticity. While aberrant changes in mTOR signaling are associated with sensitization of the pain pathway (sensory neurons and spinal cord), there are various nervous system diseases that have pain as a comorbidity and altered mTOR activity in the brain. Here, we provide a brief review of mTOR changes in the brain that are associated with some neurological disorders and focus on how these changes may be relevant to the pain of the underlying condition and chronic pain itself.

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.

Chronic Monoarthritis Pain Accelerates the Processes of Cognitive Impairment and Increases the NMDAR Subunits NR2B in CA3 of Hippocampus from 5-month-old Transgenic APP/PS1 Mice

Many factors impact cognitive impairment; however, the effects of chronic pain and the mechanisms underlying these effects on cognitive impairment are currently unknown. Here we tested the hypothesis that chronic pain accelerates the transition from normal cognition to mild cognitive impairment (MCI) in 5-month-old transgenic APP/PS1 mice, an animal model of Alzheimer’s disease (AD), and that neurotoxicity induced by N-methyl-D-aspartic acid receptor (NMDAR) subunits may be involved in this process. Chronic monoarthritis pain was induced in transgenic APP/PS1 mice and 5-month-old wild-type (WT) mice by intra- and pre-articular injections of Freund’s complete adjuvant (FCA) into one knee joint. Pain behavior, learning and memory function, and the distribution and quantity of NMDAR subunits (NR1, NR2A and NR2B) in hippocampal CA1 and CA3 regions were assessed. Our results showed that although persistent and robust monoarthritis pain was induced by the FCA injections, only the transgenic APP/PS1 mice with chronic monoarthritis pain exhibited marked learning and memory impairments. This result suggested that chronic monoarthritis pain accelerated the cognitive impairment process. Furthermore, only transgenic APP/PS1 mice with chronic monoarthritis pain exhibited an overexpression of NR2B and an increased NR2B/NR2A ratio in the hippocampus CA3. These findings suggest that chronic pain is a risk factor for cognitive impairment and that increased neurotoxicity associated with NMDAR subunit activation may underpin the impairment. Thus, NMDARs may be a therapeutic target for the prevention of chronic pain-induced cognitive impairment.

Prevalence of Pain in Nursing Home Residents: The Role of Dementia Stage and Dementia Subtypes

OBJECTIVES

To study pain prevalence, pain type, and its pharmacological treatment in Dutch nursing home residents in relation to dementia subtype and dementia severity.

DESIGN

Data were collected as part of the PAINdemiA study, an observational cross-sectional study conducted between May 2014 and December 2015.

SETTING

Ten nursing homes in the Netherlands.

PARTICIPANTS

A total of 199 nursing home residents in various stages of dementia.

MEASUREMENTS

We collected data on pain (by observation: MOBID-2 Pain Scale and by self-report scales), pain type, pain medication, dementia subtype, dementia severity (GDS), and demographic features.

RESULTS

In the whole sample, the prevalence of pain was 43% (95% confidence interval 36%-50%) using the MOBID-2 Pain Scale. Regardless of regularly scheduled analgesics, approximately one-third of the residents with pain suffered from moderate to severe pain. Pain assessment with the MOBID-2 Pain Scale showed no difference in pain between dementia subtypes, but residents with more severe dementia experienced pain more often than those with less severe dementia (27% vs 15%). The prevalence of self-reported pain was significantly higher in residents with vascular dementia (VaD) (54%) compared with those with Alzheimer disease (18%) and other dementia subtypes (14%). Nociceptive pain was the predominant type of pain (72%) followed by mixed pain (25%). Acetaminophen was the most prescribed analgesic (80%).

CONCLUSION

Most of the participating nursing home residents had no pain; however, pain was observed more often in residents with severe dementia, whereas residents in the early stages of VaD self-reported pain more often that those with other dementia subtypes. As one-third of the residents with clinically relevant pain had moderate to severe pain regardless of using pain medication, more focus should be on how pain management could use more tailored approaches and be regularly adjusted to individual needs.

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.

An Algorithm for Neuropathic Pain Management in Older People

Neuropathic pain frequently affects older people, who generally also have several comorbidities. Elderly patients are often poly-medicated, which increases the risk of drug-drug interactions. These patients, especially those with cognitive problems, may also have restricted communication skills, making pain evaluation difficult and pain treatment challenging. Clinicians and other healthcare providers need a decisional algorithm to optimize the recognition and management of neuropathic pain. We present a decisional algorithm developed by a multidisciplinary group of experts, which focuses on pain assessment and therapeutic options for the management of neuropathic pain, particularly in the elderly. The algorithm involves four main steps: (1) detection, (2) evaluation, (3) treatment, and (4) re-evaluation. The detection of neuropathic pain is an essential step in ensuring successful management. The extent of the impact of the neuropathic pain is then assessed, generally with self-report scales, except in patients with communication difficulties who can be assessed using behavioral scales. The management of neuropathic pain frequently requires combination treatments, and recommended treatments should be prescribed with caution in these elderly patients, taking into consideration their comorbidities and potential drug-drug interactions and adverse events. This algorithm can be used in the management of neuropathic pain in the elderly to ensure timely and adequate treatment by a multidisciplinary team.

Orofacial Pain during Mastication in People with Dementia: Reliability Testing of the Orofacial Pain Scale for Non-Verbal Individuals

Objectives. The aim of this study was to establish the reliability of the “chewing” subscale of the OPS-NVI, a novel tool designed to estimate presence and severity of orofacial pain in nonverbal patients. Methods. The OPS-NVI consists of 16 items for observed behavior, classified into four categories and a subjective estimate of pain. Two observers used the OPS-NVI for 237 video clips of people with dementia in Dutch nursing homes during their meal to observe their behavior and to estimate the intensity of orofacial pain. Six weeks later, the same observers rated the video clips a second time. Results. Bottom and ceiling effects for some items were found. This resulted in exclusion of these items from the statistical analyses. The categories which included the remaining items (n = 6) showed reliability varying between fair-to-good and excellent (interobserver reliability, ICC: 0.40–0.47; intraobserver reliability, ICC: 0.40–0.92). Conclusions. The “chewing” subscale of the OPS-NVI showed a fair-to-good to excellent interobserver and intraobserver reliability in this dementia population. This study contributes to the validation process of the OPS-NVI as a whole and stresses the need for further assessment of the reliability of the OPS-NVI with subjects that might already show signs of orofacial pain.