1
|
Collins JT, Walsh DA, Gladman JRF, Patrascu M, Husebo BS, Adam E, Cowley A, Gordon AL, Ogliari G, Smaling H, Achterberg W. The Difficulties of Managing Pain in People Living with Frailty: The Potential for Digital Phenotyping. Drugs Aging 2024; 41:199-208. [PMID: 38401025 PMCID: PMC10925563 DOI: 10.1007/s40266-024-01101-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2024] [Indexed: 02/26/2024]
Abstract
Pain and frailty are closely linked. Chronic pain is a risk factor for frailty, and frailty is a risk factor for pain. People living with frailty also commonly have cognitive impairment, which can make assessment of pain and monitoring of pain management even more difficult. Pain may be sub-optimally treated in people living with frailty, people living with cognitive impairment and those with both these factors. Reasons for sub-optimal treatment in these groups are pharmacological (increased drug side effects, drug-drug interactions, polypharmacy), non-pharmacological (erroneous beliefs about pain, ageism, bidirectional communication challenges), logistical (difficulty in accessing primary care practitioners and unaffordable cost of drugs), and, particularly in cognitive impairment, related to communication difficulties. Thorough assessment and characterisation of pain, related sensations, and their functional, emotional, and behavioural consequences ("phenotyping") may help to enhance the assessment of pain, particularly in people with frailty and cognitive impairment, as this may help to identify who is most likely to respond to certain types of treatment. This paper discusses the potential role of "digital phenotyping" in the assessment and management of pain in people with frailty. Digital phenotyping is concerned with observable characteristics in digital form, such as those obtained from sensing-capable devices, and may provide novel and more informative data than existing clinical approaches regarding how pain manifests and how treatment strategies affect it. The processing of extensive digital and usual data may require powerful algorithms, but processing these data could lead to a better understanding of who is most likely to benefit from specific and targeted treatments.
Collapse
Affiliation(s)
- Jemima T Collins
- University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David A Walsh
- University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
- Sherwood Forest Hospitals NHS Foundation Trust, Nottinghamshire, UK
- Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | | | - Monica Patrascu
- Centre for Elderly and Nursing Home Medicine, University of Bergen, 5007, Bergen, Norway
- Neuro-SysMed Center, University of Bergen, 5007, Bergen, Norway
- Complex Systems Laboratory, University Politehnica of Bucharest, 60042, Bucharest, Romania
| | - Bettina S Husebo
- Centre for Elderly and Nursing Home Medicine, University of Bergen, 5007, Bergen, Norway
- Neuro-SysMed Center, University of Bergen, 5007, Bergen, Norway
| | - Esmee Adam
- Department of Public Health and Primary Care, Leiden University Medical Center, 2300 RC, Leiden, The Netherlands
| | - Alison Cowley
- University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Adam L Gordon
- University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
- University Hospitals of Derby and Burton NHS Trust, Derby, UK
| | - Giulia Ogliari
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Hanneke Smaling
- Department of Public Health and Primary Care, Leiden University Medical Center, 2300 RC, Leiden, The Netherlands
| | - Wilco Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, 2300 RC, Leiden, The Netherlands.
- LUMC Center for Medicine for Older People (LCO), Leiden University Medical Center, Leiden, The Netherlands.
| |
Collapse
|
2
|
Smith TO, Lockey D, Johnson H, Rice L, Heard J, Irving L. Pain management for people with dementia: a cross-setting systematic review and meta-ethnography. Br J Pain 2023; 17:6-22. [PMID: 36815066 PMCID: PMC9940246 DOI: 10.1177/20494637221119588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Pain management for people with dementia is challenging. There is limited understanding on the experiences of pain management from people with dementia, but also from those who support them. This study synthesised the qualitative evidence to explore the perspectives of people with dementia, their family, friends, carers and healthcare professionals to pain management. Methods A systematic literature review was undertaken of published and unpublished literature databases (to 01 November 2021). All qualitative research studies reporting the perspectives of people with dementia, their family, friends, carers and healthcare professionals to managing pain were included. Eligible studies were appraised using the Critical Appraisal Skills Programme (CASP) qualitative appraisal tool. A meta-ethnography analysis approach was adopted, with findings assessed against the GRADE-CERQual framework. Results Of the 3994 citations screened, 33 studies were eligible. Seven themes were identified from the data. There was moderate evidence from six studies indicating inequity of pain management for people with dementia. There was moderate evidence from 22 studies regarding anxieties on cascading pain information. There was moderate evidence from nine studies that familiarisation of the person with pain, their preferences, routines and behaviours were key factors to better pain management. Consistently, carers and healthcare professionals had a low opinion of the management of pain for people with dementia, with tensions over the 'best' treatment options to offer. This was associated with poor training and understanding on how pain 'should' be managed. Conclusion The findings highlight the challenges faced by people with dementia and pain, and those who support them. Improvements in education for people who support these individuals would be valuable across health and social care pathways. Supporting family members and relatives on pain experiences and treatment options could improve awareness to improve quality of life for people with dementia and pain and those who support them.
Collapse
Affiliation(s)
- Toby O Smith
- School of Health Sciences, University of East Anglia, Norwich, UK,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dawn Lockey
- Physiotherapy Department, South Tyneside and Sunderland NHS Foundation Trust, Sunderland Royal Hospital, Sunderland, UK
| | - Helen Johnson
- Physiotherapy Department, South Tyneside and Sunderland NHS Foundation Trust, Sunderland Royal Hospital, Sunderland, UK
| | - Lauren Rice
- Physiotherapy Department, South Tyneside and Sunderland NHS Foundation Trust, Sunderland Royal Hospital, Sunderland, UK
| | - Jay Heard
- Physiotherapy Department, Lewisham and Greenwich NHS Trust, Lewisham, University Hospital Lewisham, London, UK
| | - Lisa Irving
- Physiotherapy Department, South Tyneside and Sunderland NHS Foundation Trust, Sunderland Royal Hospital, Sunderland, UK
| |
Collapse
|
3
|
Collins JT, Harwood RH, Cowley A, Di Lorito C, Ferguson E, Minicucci MF, Howe L, Masud T, Ogliari G, O'Brien R, Azevedo PS, Walsh DA, Gladman JRF. Chronic pain in people living with dementia: challenges to recognising and managing pain, and personalising intervention by phenotype. Age Ageing 2023; 52:6974848. [PMID: 36626322 DOI: 10.1093/ageing/afac306] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 10/27/2022] [Indexed: 01/11/2023] Open
Abstract
Pain is common in people with dementia, and pain can exacerbate the behavioural and psychological symptoms of dementia. Effective pain management is challenging, not least in people with dementia. Impairments of cognition, communication and abstract thought can make communicating pain unreliable or impossible. It is unclear which biopsychosocial interventions for pain management are effective in people with dementia, and which interventions for behavioural and psychological symptoms of dementia are effective in people with pain. The result is that drugs, physical therapies and psychological therapies might be either underused or overused. People with dementia and pain could be helped by assessment processes that characterise an individual's pain experience and dementia behaviours in a mechanistic manner, phenotyping. Chronic pain management has moved from a 'one size fits all' approach, towards personalised medicine, where interventions recommended for an individual depend upon the key mechanisms underlying their pain, and the relative values they place on benefits and adverse effects. Mechanistic phenotyping through careful personalised evaluation would define the mechanisms driving pain and dementia behaviours in an individual, enabling the formulation of a personalised intervention strategy. Central pain processing mechanisms are particularly likely to be important in people with pain and dementia, and interventions to accommodate and address these may be particularly helpful, not only to relieve pain but also the symptoms of dementia.
Collapse
Affiliation(s)
- Jemima T Collins
- University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre (BRC), Nottingham, UK.,University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rowan H Harwood
- University of Nottingham, Nottingham, UK.,Nottingham University Hospitals NHS Trust, Nottingham, UK.,NIHR Applied Research Collaboration-East Midlands, Leicester, UK
| | - Alison Cowley
- University of Nottingham, Nottingham, UK.,Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Eamonn Ferguson
- University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre (BRC), Nottingham, UK
| | | | | | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK.,NIHR Applied Research Collaboration-East Midlands, Leicester, UK
| | - Giulia Ogliari
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Paula S Azevedo
- Botucatu Medical School, São Paulo State University, São Paulo, Brazil
| | - David A Walsh
- University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre (BRC), Nottingham, UK.,Sherwood Forest Hospitals NHS Foundation Trust, Nottinghamshire, UK
| | - John R F Gladman
- University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre (BRC), Nottingham, UK.,Nottingham University Hospitals NHS Trust, Nottingham, UK
| |
Collapse
|
4
|
Garrone B, Durando L, Prenderville J, Sokolowska E, Milanese C, Di Giorgio FP, Callaghan C, Bianchi M. Paracetamol (acetaminophen) rescues cognitive decline, neuroinflammation and cytoskeletal alterations in a model of post-operative cognitive decline (POCD) in middle-aged rats. Sci Rep 2021; 11:10139. [PMID: 33980934 PMCID: PMC8115335 DOI: 10.1038/s41598-021-89629-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/22/2021] [Indexed: 11/09/2022] Open
Abstract
Post-operative cognitive dysfunction (POCD) is a debilitating clinical phenomenon in elderly patients. Management of pain in elderly is complicated because analgesic opiates elicit major side effects. In contrast, paracetamol (acetaminophen) has shown analgesic efficacy, no impact on cognition, and its side effects are well tolerated. We investigated the efficacy of paracetamol, compared to the opioid analgesic buprenorphine, in a model of POCD by investigating cognitive decline, allodynia, peripheral and hippocampal cytokines levels, and hippocampal microtubule dynamics as a key modulator of synaptic plasticity. A POCD model was developed in middle-aged (MA) rats by inducing a tibia fracture via orthopaedic surgery. Control MA rats did not undergo any surgery and only received isoflurane anaesthesia. We demonstrated that cognitive decline and increased allodynia following surgery was prevented in paracetamol-treated animals, but not in animals which were exposed to anesthesia alone or underwent the surgery and received buprenorphine. Behavioral alterations were associated with different peripheral cytokine changes between buprenorphine and paracetamol treated animals. Buprenorphine showed no central effects, while paracetamol showed modulatory effects on hippocampal cytokines and markers of microtubule dynamics which were suggestive of neuroprotection. Our data provide the first experimental evidence corroborating the use of paracetamol as first-choice analgesic in POCD.
Collapse
Affiliation(s)
- B Garrone
- Angelini Pharma S.p.A., Viale Amelia, 70, 00181, Rome, Italy
| | - L Durando
- Angelini Pharma S.p.A., Viale Amelia, 70, 00181, Rome, Italy
| | - J Prenderville
- Transpharmation Ireland Ltd., Trinity College Dublin-Institute of Neuroscience (TCIN), Lloyd Institute, Trinity College, Dublin 2, Ireland
| | - E Sokolowska
- Transpharmation Ireland Ltd., Trinity College Dublin-Institute of Neuroscience (TCIN), Lloyd Institute, Trinity College, Dublin 2, Ireland
| | - C Milanese
- Angelini Pharma S.p.A., Viale Amelia, 70, 00181, Rome, Italy
| | - F P Di Giorgio
- Angelini Pharma S.p.A., Viale Amelia, 70, 00181, Rome, Italy
| | - C Callaghan
- Ulysses Neuroscience Ltd, Room 3.57B, Trinity College Dublin-Institute of Neuroscience (TCIN), Lloyd Institute, Trinity College, Dublin 2, Ireland
| | - M Bianchi
- Ulysses Neuroscience Ltd, Room 3.57B, Trinity College Dublin-Institute of Neuroscience (TCIN), Lloyd Institute, Trinity College, Dublin 2, Ireland.
| |
Collapse
|
5
|
Dexmedetomidine in combination with morphine improves postoperative analgesia and sleep quality in elderly patients after open abdominal surgery: A pilot randomized control trial. PLoS One 2018; 13:e0202008. [PMID: 30106963 PMCID: PMC6091958 DOI: 10.1371/journal.pone.0202008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 07/25/2018] [Indexed: 12/20/2022] Open
Abstract
Background Dexmedetomidine in combination with opioids has been used for postoperative analgesia. The purpose of this study was to investigate the impacts of dexmedetomidine supplemented intravenous analgesia on morphine consumption and subjective sleep quality in elderly patients after open abdominal surgery. Methods This was a pilot randomized controlled trial. 58 elderly patients (age ≥ 60 years) who underwent open abdominal surgery were randomized to receive either dexmedetomidine supplemented morphine analgesia (0.5 mg/ml morphine plus 2 μg/ml dexmedetomidine in 100 ml normal saline, DEX group) or morphine analgesia (0.5 mg/ml morphine in 100 ml normal saline, CTRL group) for 72 hours after surgery. Patient-controlled analgesia pump was programmed to deliver a 2ml bolus with a lockout interval of 8 minutes and a background infusion at a rate of 1 ml/h. The primary endpoint was 72-hour morphine consumption. Secondary endpoints included pain intensity, subjective sleep quality, and 30-day complications and mortality after surgery. Results The 72-hour morphine consumption was lower in the DEX group than in the CTRL group (median 39.0 mg [interquartile range 37.3, 41.0] in the DEX group vs. 49.0 mg [45.5, 50.0] in the CTRL group; median difference -9.0 mg [95% CI -10.0, -6.0], P < 0.001). The intensity of pain within 48 hours was lower (P<0.001 at 4, 12 and 48 hours, P = 0.007 at 24 hours) whereas the subjective quality of sleep was higher (P = 0.031 during the night of surgery and P<0.001 during the 1st night after surgery, respectively) in the DEX group than in the CTRL group. The incidence of 30-day complications did not differ significantly between groups, but it was slightly lower in the DEX group (P = 0.060). There were no significant differences between groups regarding 30-day mortality and the incidences of adverse events. Conclusions For elderly patients after open abdominal surgery, dexmedetomidine supplemented analgesia decreases morphine consumption, improves analgesic effects and subjective sleep quality without increasing adverse events. Trial registration Chinese Clinical Trial Registry ChiCTR-IPR-14005620.
Collapse
|
6
|
Consensus multidisciplinaire d’experts en douleur et gériatrie : utilisation des antalgiques dans la prise en charge de la douleur de la personne âgée (hors anesthésie). ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.douler.2017.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
7
|
Fry M, Chenoweth L, Arendts G. Can an observational pain assessment tool improve time to analgesia for cognitively impaired older persons? A cluster randomised controlled trial. Emerg Med J 2017; 35:33-38. [PMID: 28780493 DOI: 10.1136/emermed-2016-206065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/03/2017] [Accepted: 07/16/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The primary objective of the study was to measure the impact of an observational pain assessment dementia tool on time from ED arrival to first dose of analgesic medicine. METHODS A multisite cluster randomised controlled trial was conducted to test the Pain Assessment in Advanced Dementia (PAINAD) tool. Patients aged 65 years or older suspected of a long bone fracture were screened for cognitive impairment using the Six-Item Screening (SIS) tool. Patients scoring 4 or less on SIS (intervention sites) were assessed for pain using PAINAD. Control sites, assessed pain using standard methods. The primary outcome was time to first dose of analgesia and was analysed on an intention-to-treat basis with a sensitivity analysis. RESULTS We enrolled 602 patients, of which 323 (54%) were at intervention sites (n=4). The median time to analgesia was 82 min (IQR 45-151 min). There was no statistically significant difference in median time to analgesia for intervention 83 (IQR 48-158 min) and non-intervention 82 min (IQR 41-147 min) sites (p=0.414). After adjusting for age, fracture type, arrival mode and triage category, there remained no significant difference in time to analgesia (HR 0.97, 95% CI 0.80 to 1.17, p=0.74). Of the 602 patients enrolled, 273 actually had cognitive impairment. A sensitivity analysis demonstrated patients at intervention sites received analgesia 13 min sooner (90 vs 103 min, p=0.91). CONCLUSION Use of the PAINAD was not associated with a shorter time to analgesia, although there was a clinically important but non-significant improvement in the cognitively impaired patient group. Further research is needed to address this clinically important and complex issue.
Collapse
Affiliation(s)
- Margaret Fry
- Faculty of Health, University of Technology, Sydney, New South Wales, Australia.,Director Research and Practice Development, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Lynn Chenoweth
- Centre for Healthy Brain Ageing, University of New South Wales, Sydney, New South Wales, Australia
| | - Glenn Arendts
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| |
Collapse
|
8
|
|