Pain assessment in patients with possible vascular dementia

Separate and combined associations of cognitive impairment and body pain with functional and mobility disabilities among older women and men in India

This study examined the separate and combined associations of cognitive impairment and body pain with functional and mobility disabilities (FMDs) among older women and men in India. Multivariable linear regression models were applied using data from the Longitudinal Aging Study in India (2017-18) comprising 31,464 adults aged 60+. Older adults with cognitive impairment and pain reported higher levels of FMDs than peers without any pain and cognitive impairment. The likelihood of FMDs was significantly greater among older Indians enduring both cognitive impairment and pain (p < 0.05). Moreover, the association between cognitive impairment and functional disability was noticeably stronger in older women, particularly those with frequent pain, while the link between cognitive impairment and mobility disability was more pronounced in men with pain. Integrated cognitive rehabilitation and pain management programs, along with guided physical therapy, gender-specific support groups, and community-based health promotion activities, should be considered to reduce FMDs in older Indians.

Opioids in the Elderly Patients with Cognitive Impairment: A Narrative Review

Introduction

Assessment and management of pain in elderly people with cognitive impairment is particularly challenging. Physiological changes due to aging as well as comorbidities and polypharmacy are responsible for a complex clinical approach. Concomitantly, in cognitive impairment, including advanced dementia, changes in the central nervous system along with changes in the peripheral nervous system due to aging have a significant impact on pain perception. Sometimes clinicians decide to prescribe opioids to relieve pain, also without a clear indication. This review aims to investigate the effect of opioids in elderly patients with cognitive impairment.

Methods

A literature search of PubMed/Medline, Scopus, and Cochrane databases was conducted using keyword searches to generate lists of articles that were screened for relevance by title and abstract to give a final list of articles for full-text review. Further articles were identified by scanning the reference lists of the full-text articles.

Discussion

This review discusses the complex physiological and pharmacological changes in the elderly as well as the neurological changes that affect pain perception in this population. Additionally, it focuses on cognitive impairment and pain in Alzheimer’s disease and other dementias, the pain assessment in the elderly with cognitive impairment as well as the safety of opioid use in the elderly. Information regarding opioid prescription in nursing homes and recorded indications for opioid use, type and dosing of opioids, and compliance of treatment in advanced dementia are also provided.

Conclusions

Opioid prescription in the elderly population with cognitive impairment is particularly complex. All healthcare professionals involved in the care of such patients need to be aware of the challenges and strive to ensure analgesic use is guided by appropriate and accurate pain assessment.

A Cross-Sectional Study of Pain Sensitivity and Unpleasantness in People with Vascular Dementia

OBJECTIVE

Advanced age holds higher risk of both pain and dementia, with many studies finding dementia often heightens sensitivity to pain. VaD is the second most common type of dementia. Only a few observational or retrospective studies have examined pain responsiveness in VaD, suggesting it may increase pain unpleasantness (i.e., pain affect). This study compared thermal pain psychophysics between a cohort of vascular dementia (VaD) patients and healthy control (HC) subjects.

DESIGN

Single center, cross-sectional, between-subjects design.

SUBJECTS

Verbally communicative, probable VaD patients (N = 23) and age- and sex-matched HC (N = 23).

METHODS

A thermal psychophysics protocol assessed "mild pain" and "moderate pain" thresholds (oC temperature) and associated unpleasantness ratings (0-20 scale) in both VaD and HC groups. Psychophysics were compared between groups by way of a mixed-effects analysis, controlling for depressive symptoms.

RESULTS

There were no significant differences between groups for pain thresholds (main effect p = 0.086, Cohen's d: mild = 0.55, moderate = 0.27). However, unpleasantness ratings were higher in the VaD group compared to HC (main effect p = 0.003; mild pain p = 0.022, Cohen's d = 0.79; moderate pain p = 0.057, Cohen's d = 0.6).

CONCLUSIONS

These results are consistent with prior observational findings suggesting VaD may make patients more susceptible to pain, particularly its affective component.

Pain, cognition and disability in advanced multiple sclerosis

OBJECTIVES

In patients with multiple sclerosis (MS), a relationship between physical disability and pain has been observed. In addition a relationship between physical disability and cognition in MS has been suggested. However, cognitive functions and pain appear not to be correlated in MS patients. Therefore, we examined whether a possible relationship between pain and cognitive functioning may exist, and if so, if such a relationship is mediated by physical disability.

METHODS

Forty-five MS patients with chronic pain, and in an advanced stage of the disease were included. Physical disabilities were assessed by the Expanded Disability Status Scale (EDSS). Episodic memory was assessed by means of the Eight Words test, and Face and Picture Recognition. Executive functions (EF) were examined by Digit Span Backward for working memory, and the Rule Shift Cards and Category Fluency test for cognitive flexibility. Pain Intensity and Pain Affect were assessed by means of visual analogue scales and one verbal pain scale and mood (depression, anxiety) by the Beck Depression Inventory and the Symptom Check List (SCL-90). The research questions were analyzed by means of regression analyses and the Sobel test for mediation.

RESULTS

A significant relationship was found between Pain Affect and EF, but that relationship was not mediated by physical disabilities (EDSS). In addition, Pain Intensity and EF showed a significant relationship but only in combination with physical disabilities (EDSS). Finally, mood was related to pain affect.

DISCUSSION

The findings suggest that the lower the EF, exclusively or in combination with more physical disabilities, the more the patient may suffer from pain.

IMPLICATIONS

The more one is cognitively and physically impaired, the more one might suffer from pain, and, the less one is able to communicate pain. The latter could put MS patients at risk for underdiagnosing and undertreatment of pain.

White matter hyperintensities are related to pain intensity in an outpatient memory clinic population: preliminary findings

Background: The association between pain and dementia is complicated and may depend on underlying brain pathology. It was hypothesized that both medial temporal atrophy (MTA) and global cortical atrophy (GCA) predicted no/mild pain, while white matter hyperintensities (WMH) predicted moderate/severe pain.

Objectives: To study the association between pain intensity and measures of brain pathology, more specifically MTA, GCA, and WMH.

Methods: In total, 115 consecutive patients visiting an outpatient memory clinic were included. In total, diagnoses included dementia (N=70), mild cognitive impairment (N=30), and subjective cognitive impairment (N=15). Without administering stimuli, pain intensity was assessed with the Brief Pain Inventory. MTA, GCA, and WMH were measured with a MRI visual rating scale. Logistic regression analyses to examine the relationship between WMH, MTA, GCA, and self-reported pain intensity (no/mild pain versus moderate/severe pain) were adjusted for confounders.

Results: Mean age of the patients was 81 years (IQR: 78–85, 53% female). Moderate/severe pain was reported by 23.5% and associated with greater WMH (OR =3.34, 95% CI =1.01–10.97, p=0.047), but not MTA or GCA.

Conclusions: In contrast to the present results, earlier studies have reported either a positive or negative relationship between pain and brain volume. It is suggested that the presence of dementia may explain the absence of a relationship between pain and brain volume. WMH is positively related with pain in an older memory outpatient population. Considering the small sample size, our findings should be interpreted with caution. Hence, our conclusions are preliminary findings, warranting future replication.

Chronic Pain in the Elderly with Cognitive Decline: A Narrative Review

The presence of pain in elderly persons with cognitive decline is often neglected, under-reported, underestimated, misdiagnosed and not adequately treated, with consequences that have a strong impact on health, independence in activities of daily living and quality of life. There is no empirical evidence that people with dementia experience less pain; therefore, in patients with severe cognitive impairment the progression of cognitive decline dramatically affects the ability to verbalize the presence of pain. Self-assessment scales are considered the “gold standard” for pain assessment, but the presence of cognitive impairment is likely to reduce the reliability of these measures. Treatment of pain in elderly with cognitive decline or dementia is based on non-pharmacological and pharmacological strategies. Pharmacological treatment should consider physiological changes, high comorbidity and drug interactions that occur frequently in the elderly. This narrative review aims to describe current knowledge, methods of detection and treatment approaches for chronic pain in elderly persons with cognitive deficits.

Age-Related Changes in Headache Days across the Cognitive Spectrum

Introduction

Prior studies demonstrating age-related declines in headache prevalence have not accounted for the potentially confounding effects of cognitive impairment. Our primary goal was to assess the relationship between aging and self-reported monthly headache days across the cognitive spectrum.

Methods

A detailed headache questionnaire was included prospectively as part of an annual mailing to participants in the Sanders-Brown Center on Aging longitudinal cohort.

Results

The overall survey response rate was 58.6%, yielding a cohort of 332 cognitively normal, 71 mild cognitive impairment (median Mini-Mental Status Examination [MMSE] score = 27, interquartile range [IQR] = 25-28), and 51 demented (median MMSE score = 24, IQR = 19-26) individuals. Current headaches were reported by 22.8%, 25%, and 27.1%, respectively, across normal, mild cognitive impairment, and dementia subgroups. A negative correlation was observed between age and average headache days in cognitively normal (ρ = -0.163, 95% confidence interval [CI] = -0.246 to -0.022, P = 0.004), mild cognitive impairment (ρ = -0.255, 95% CI = -0.274 to 0.229, P = 0.0475), and dementia groups (ρ = -0.295, 95% CI = -0.457 to 0.159, P = 0.068). Ordinary least-squares regression with backward selection identified age alone, but not gender or MMSE, as predicting headache days in the overall cohort.

Conclusions

Aging is associated with a decline in headache days in the absence of any confounding cognitive pathology and is weakly predictive of headache days across the cognitive spectrum. Whether this represents a reporting bias due to dementia or has neurobiological significance warrants further investigation.

Palliative care in dementia: issues and evidence

Palliative care is an approach that stands well with the aims of person-centred dementia care. There is no doubt that the standards of care for many people with advanced dementia are poor. There is a lack of good-quality evidence, however, to support any particular approach for palliative care in dementia. Still, there are a number of areas in relation to caring for people with severe dementia where a palliative approach might be beneficial. In general, the relevant decisions have to be made on an individual basis but within a palliative framework. Advance care planning is likely to be crucial in encouraging this process. There is certainly a moral imperative behind the idea that care at the end of life for people with dementia should be improved.

A Review of Pain Prevalence in Alzheimer's, Vascular, Frontotemporal and Lewy Body Dementias

BACKGROUND

Numerous studies have reported on pain in dementia. It has been hypothesized that pain perception differs between dementia subtypes, and therefore, the prevalence of pain differs between dementia subtypes. However, there remains a paucity of evidence on the differences in the prevalence of pain in different dementia subtypes. This review aimed to determine the prevalence of pain for the major dementia subtypes: Alzheimer's disease (AD), vascular dementia (VaD), frontotemporal dementia (FTD) and dementia with Lewy bodies (DLB).

SUMMARY

We found 10 studies that met our inclusion criteria. Most of these studies reported on AD; studies reporting the prevalence of pain in people with DLB were scarce, and for FTD, we found no studies. The sample-weighted prevalence of pain could only be calculated for AD, VaD and mixed dementia: AD 45.8% (95% confidence interval, CI: 33.4-58.5%), VaD 56.2% (95% CI: 47.7-64.4%) and mixed dementia 53.9% (95% CI: 37.4-70.1%).

KEY MESSAGES

Studies investigating the prevalence of pain in dementia subtypes were scarce; however, we found a high prevalence of pain in dementia without significant differences between the dementia subtypes. More studies are required to draw firm conclusions on the differences in the prevalence of pain between dementia subtypes.

The use of facial expressions for pain assessment purposes in dementia: a narrative review

Facial expressions convey reliable nonverbal signals about pain and thus are very useful for assessing pain in patients with limited communicative ability, such as patients with dementia. In this review, we present an overview of the available pain observation tools and how they make use of facial expressions. Utility and reliability of facial expressions to measure pain in dementia are discussed, together with the effect of dementia severity on these facial expressions. Next, we present how behavioral alterations may overlap with facial expressions of pain, and may even influence the extent to which pain is facially expressed. The main focus is on disinhibition, apathy and emotional changes. Finally, an overview of theoretical considerations and practical implications is presented for assessing pain using facial expressions in clinical settings.

Chronic pain in "probable" vascular dementia: preliminary findings

BACKGROUND

In a previous study, the levels of pain reported by patients with "possible" vascular dementia (VaD) were higher than those reported by older individuals without dementia.

OBJECTIVE

To examine experienced pain in patients with "probable" VaD, confirmed by brain imaging.

STUDY DESIGN

Observational, cross sectional.

SETTING

Nursing home.

METHODS

The participants were 20 nursing home residents (14 females, 6 males) who met the NINDS-AIREN criteria for "probable" VaD and 22 nursing home residents with a normal mental status (18 females, 4 males). The patients were in a mild to moderate stage of dementia. All of the participants were suffering from arthritis/arthrosis or osteoporosis. Global cognitive functioning was measured by the Mini-Mental State Examination. Pain was assessed by the Coloured Analogue Scale (CAS: original and modified version) and the Faces Pain Scale. The Geriatric Depression Scale and the Symptom Checklist-90 were used to assess mood.

RESULTS

The main finding was that, after controlling for mood, the pain levels indicated by patients with "probable" VaD (M = 102.32; standard deviation [SD] = 53.42) were significantly higher than those indicated by the control group (M = 59.17; SD = 38.75), only according to the CAS modified version (F[1,29]) = 5.62, P = 0.01, η2  = 0.16).

CONCLUSION

As VaD patients may experience greater pain than controls, it is essential for prescribers to be aware of the presence of this neuropathology if these patients are to receive adequate treatment.

Impact of a stepwise protocol for treating pain on pain intensity in nursing home patients with dementia: a cluster randomized trial

Background

Pain is frequent and distressing in people with dementia, but no randomized controlled trials have evaluated the effect of analgesic treatment on pain intensity as a key outcome.

Methods

Three hundred fifty-two people with dementia and significant agitation from 60 nursing home units were included in this study. These units, representing 18 nursing homes in western Norway, were randomized to a stepwise protocol of treating pain (SPTP) or usual care. The SPTP group received acetaminophen, morphine, buprenorphine transdermal patch and pregabalin for 8 weeks, with a 4-week washout period. Medications were governed by the SPTP and each participant's existing prescriptions. We obtained pain intensity scores from 327 patients (intervention n = 164, control n = 163) at five time points assessed by the primary outcome measure, Mobilization-Observation-Behaviour-Intensity-Dementia-2 (MOBID-2) Pain Scale. The secondary outcome was activities of daily living (ADL). We used a linear intercept mixed model in a two-way repeated measures configuration to assess change over time and between groups.

Results

The SPTP conferred significant benefit in MOBID-2 scores compared with the control group [average treatment effect (ATE) −1.388; p < 0.001] at week 8, and MOBID-2 scores worsened during the washout period (ATE = −0.701; p = 0.022). Examining different analgesic treatments, benefit was conferred to patients receiving acetaminophen compared with the controls at week 2 (ATE = −0.663; p = 0.010), continuing to increase until week 8 (ATE = −1.297; p < 0.001). Although there were no overall improvements in ADL, an increase was seen in the group receiving acetaminophen (ATE = +1.0; p = 0.022).

Conclusion

Pain medication significantly improved pain in the intervention group, with indications that acetaminophen also improved ADL function.

What's already known about this topic?

What does this study add?

Pain management in patients with dementia

There are an estimated 35 million people with dementia across the world, of whom 50% experience regular pain. Despite this, current assessment and treatment of pain in this patient group are inadequate. In addition to the discomfort and distress caused by pain, it is frequently the underlying cause of behavioral symptoms, which can lead to inappropriate treatment with antipsychotic medications. Pain also contributes to further complications in treatment and care. This review explores four key perspectives of pain management in dementia and makes recommendations for practice and research. The first perspective discussed is the considerable uncertainty within the literature on the impact of dementia neuropathology on pain perception and processing in Alzheimer's disease and other dementias, where white matter lesions and brain atrophy appear to influence the neurobiology of pain. The second perspective considers the assessment of pain in dementia. This is challenging, particularly because of the limited capacity of self-report by these individuals, which means that assessment relies in large part on observational methods. A number of tools are available but the psychometric quality and clinical utility of these are uncertain. The evidence for efficient treatment (the third perspective) with analgesics is also limited, with few statistically well-powered trials. The most promising evidence supports the use of stepped treatment approaches, and indicates the benefit of pain and behavioral interventions on both these important symptoms. The fourth perspective debates further difficulties in pain management due to the lack of sufficient training and education for health care professionals at all levels, where evidence-based guidance is urgently needed. To address the current inadequate management of pain in dementia, a comprehensive approach is needed. This would include an accurate, validated assessment tool that is sensitive to different types of pain and therapeutic effects, supported by better training and support for care staff across all settings.

Assessment and management of pain, with particular emphasis on central neuropathic pain, in moderate to severe dementia

In patients with dementia, undertreatment of pain, irrespective of its aetiology, is widely recognized; the risk for undertreatment increases with the severity of dementia. We argue, however, that central neuropathic pain is by far the most undertreated type of pain in patients with dementia. Central pain is a type of neuropathic pain that is known to occur in stroke patients and is caused by white matter lesions. Although white matter lesions are also a neuropathological hallmark of dementia, central neuropathic pain has hardly been described in dementia. Therefore, the goal of this review was to address assessment and management of pain, with particular emphasis on central neuropathic pain, in moderate to severe dementia. Concerning pain assessment, the findings of this review suggest that self-report pain rating scales, in particular the Verbal Rating Scale, the Horizontal Visual Analogue Scale and the Faces Pain Scale can be administered to patients in a more advanced stage of dementia. For those who are no longer able to communicate pain, pain observation scales are most appropriate. Self-report and pain observation should be combined, if possible. For an overview of assessment tools to measure pain with older people unable to verbally communicate, we refer readers to the City of Hope Pain and Palliative Care Resource Center ( http://prc.coh.org/PAIN-NOA.htm ). The review further highlights that behavioural disturbances, e.g. agitation and physical inactivity, as well as autonomic responses, e.g. an increase in blood pressure and heart rate, may contribute to a more reliable assessment of pain. With respect to central neuropathic pain in particular, assessment of sensory abilities (touch, pinprick, temperature and vibration), mood (e.g. anxiety) and determination of the presence of a Babinsky reflex, accelerated tendon reflexes, and spasticity may contribute to reliable assessment. Management of pain, not of a central origin, starts with paracetamol (acetaminophen), which, together with opioids, is the most frequently prescribed analgesic drug in dementia. Non-steroidal anti-inflammatory drugs are hardly prescribed in a residential setting. Some authors advise starting treatment with a low dose of opioids. Antidepressants and antiepileptic drugs appear to have a positive effect on central neuropathic pain. In the review, advantages and disadvantages of amitriptyline, carbamazepine, lamotrigine, gabapentin and pregabalin are discussed; a negative effect of these drugs on liver and kidney functions, as well as on cognitive functions in patients who already suffer from cognitive impairment is highlighted. Next to pharmacotherapy, non-pharmacological treatment strategies such as transcutaneous electrical nerve stimulation may be effective as long as afferent pathways transmitting the electrical stimulus are still intact.

The neurologist facing pain in dementia

INTRODUCTION

Ageing, a common background in dementia, is usually associated with painful disorders. Nevertheless, the use of analgesics is limited due to poor communication. On the other hand, dementia lesions are placed in the nociceptive pathways. For this reason, the painful experience becomes different and distinctive for every lesional type.

COURSE

The lateral nociceptive pathway (lateral thalamic nuclei and primary parietal cortex), which is in charge of the primary pain perception, is preserved in dementia. Thereafter, the shear painful perception, including pain intensity and threshold, remains unmodified. Distinctly, the medial pain pathways are affected by dementia lesions. In this pathway are included: the intralaminar thalamic nuclei, the pons (locus ceruleus:LC), the mesencephalon (periaacueductal grey substance: PGS), the hypothalamus (paraventricular nuclei, mamilary tuberculum) and different areas of the parietal (primary, secondary, operculum), temporal (amigdala, hypoccampus) and frontal (anterior cingular: ACC). As a consequence, the features of pain executed by these areas will be compromised: the cognitive assessment, the mood and emotion inherent to pain, the pain memory or the autonomic responses are modified in dementia. Specifically, in Alzheimer's disease (AD) there is a reduction in the anticipatory and avoidance responses and also a flattening of the autonomic responses. These are essentially secondary to the degenerative changes in the medial temporal (pain memory) and ACC (cognitive and mood aspects) areas. In vascular dementias, there is a cortico-subcortical deafferentation secondary to the white matter lesions. The consequence is the presence of hyperpathy and hyperalgesia. In the frontotemporal dementias, there is a reduction in pain expressivity. It is linked to the lesions in the orbitofrontal and anterior temporal areas, which are responsible of the emotional aspects of pain. In Parkinson's disease, painful conditions are a common characteristic. They are attributed to an early lesion in the LC, which reduces its prominent antinociceptive activity. Finally, in the demented patients there is a lack of expectations to analgesic treatments. This means an absence of the placebo effect, which is, alongside the pharmacokinetic action, an inherent part of the analgesic response. The placebo response is related to activity in the ACC and PGS. Giving its lack, higher doses of analgesics are necessary in dementias.

CONCLUSIONS

The assessment of pain in dementia is rather complex, which is the main reason for the scarcity of the analgesic treatment in dementias. It must be specific and systematic. For this purpose, the pain scales are a useful tool. For communicative patients, simple visual scales are helpful, meanwhile in the non-communicative patients the multidimensional scales are the most suitable. By this means, the expressive, motor, emotional, functional and social interactions are evaluated. Pain may be responsible of progression and cognitive deterioration in dementia. This evolution could be reversible, and consequently it has to be foreseen in order to implement analgesic treatment. Trying to minimize adverse events, it has to be potent but closely monitored.

Impact of dementia on cancer discovery and pain

BACKGROUND

Dementia is clinically noted to influence both reporting and experience of cancer pains. However, no systemic evaluation of this aspect has been reported. The aim of the present study was to retrospectively evaluate how dementia modified the cancer discovery process, frequency of cancer pain reports and analgesic-narcotic use at a large psychiatric hospital.

METHODS

We reviewed all the records of cancer patients with and without dementia treated at the surgical ward of Matsuzawa Hospital from 1993 to 2004. Psychiatric diseases other than dementia, brain metastasis and alcoholism, as well as leukaemia and skin cancer, were excluded. Patients' communicativeness as to pain was ascertained from nursing records.

RESULTS

A total of 134 cancer patients with and without dementia (50 demented and 84 non-demented) were included. Demented patients were accidentally discovered to have cancer (48%) or by an unexpected unfolding of clinical signs (44%), whereas most non-demented patients (63%) voluntarily sought medical evaluation (P= 0.000). Overall, 76% of non-demented patients had cancer pains (stages I and II, 64%; stages III and IV, 84%), whereas just 22% of demented patients had cancer pains (stages I and II, 16%; stages III and IV, 26%; P= 0.000). Non-demented patients showed stage-dependent requirements for both non-narcotic analgesics (stages I and II, 64%; stages III and IV, 84%) and narcotics (stages I and II, 0%; stages III and IV, 41%). Demented patients required much less analgesics (stages I and II, 11%; stages III and IV, 13%), with only one stage IV patient requiring narcotics (P= 0.000).

CONCLUSION

Dementia greatly modifies the cancer discovery process, reduces prevalence of cancer pain and analgesic requirement.

Concept analysis of nurses' identification of pain in demented patients in a nursing home: development of a hybrid model

Pain is a subjective feeling, with no known biologic markers. Proof of its presence and measurement of intensity rely entirely on self-reporting by the patient. The hampered or abrogated ability of demented patients to report their pain is a major difficulty in pain assessment and management. The purpose of this study was to clarify and conceptualize pain identification in demented patients by nurses. The hybrid model of concept development was used in the development of a conceptual structure of pain in demented patients. Data were collected by literature review (theoretical phase) and among nurses caring for demented patients in three nursing homes in South Korea (fieldwork phase). The 13 nurses involved each reported >3 years' nursing home experience. In a hybrid model, pain identification in demented patients by nurses constituted an active daily process of integrating patient expressional cues during periods of pain and pain relief and involving three dimensions: identification schemes based on the stage and type of dementia, connecting assessments after each intervention, and cognitive efforts to establish the origin of pain. Identification of pain in demented patients by nurses is a complex process. More research is needed to formulate an assessment tool and pain management strategies for patients with dementia.

Pain management in older people

At times providing pain relief in elderly patients can prove troublesome. Their tolerance and perception of pain can differ from that of younger patients, while the incidence of pain is above that found in those of less advanced years.

Conventional approaches to providing pain relief can be successful, but the tolerance to the side-effects of those drugs used to provide pain relief can be less. Furthermore, polypharmacy can have implications for the range of analgesic drugs that can be considered. Fortunately there are an increasing range of medicinal products with reduced potential for side-effects that can be considered when treating older patients with pain.

Validité et utilité clinique d'une grille d'observation (PACSLAC-F) pour évaluer la douleur chez des aînés atteints de démence vivant en milieu de soins de longue durée

This study presents the validation of the French Canadian version (PACLSAC-F) of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). Unlike the published validation of the English version of the PACSLAC, which was validated retrospectively, the French version was validated prospectively. The PACSLAC-F was completed by nurses working in long-term care facilities after observing 86 seniors, with severe cognitive impairment, in calm, painful or distressing but non-painful situations. The test-retest and inter-observer reliability, the internal consistency, and the discriminent validity were found to be satisfactory. To evaluate the convergent validity with the DOLOPLUS-2 and the clinical relevance of the PACSLAC, it was also completed by nurses during their work shift, with 26 additional patients, for three days per week during a period of four weeks. These results encourage us to test the PACSLAC in a comprehensive program of pain management targeting this population.

[Pain and physical (in)activity in relation to cognition and behaviour in dementia]

Older persons with dementia may become confronted with a decline in the level of physical activity. Indeed, a positive relationship between physical activity and cognition has been demonstrated. Although the causality of this relationship needs to be confirmed in advanced dementia, particularly animal experimental studies show the possible negative influence of restrained physical activity on behavior of patients with dementia. Patients with dementia, who get immobilized because of agitation and restlessness, may show an increase in these two symptoms. Another cause for reduced physical activity or inactivity may be the experience of pain. Pain experience may even increase in dementia by neuropathological changes in the central nervous system. There is an increasing (inter)national interest for the development of a more reliable assessment and treatment of pain, for the causality of the relationship between pain and physical (in)activity, and for the causality of the relationship between physical (in)activity and cognition in dementia. In the present paper, the various topics will be addressed in this order.

Predictors of moderate or severe pain 6 months after orthopaedic injury: a prospective cohort study

OBJECTIVE

To determine predictors of moderate or severe pain 6 months after orthopaedic injury.

DESIGN

Prospective cohort study.

SETTING

Two adult level 1 trauma centers in Victoria, Australia.

PARTICIPANTS

A total of 1290 adults admitted with orthopaedic injuries and registered by the Victorian Orthopaedic Trauma Outcomes Registry.

MAIN OUTCOME MEASURES

Participant self-reported pain and health status using an 11-point numerical rating scale and the 12-item Short-Form health survey, respectively.

RESULTS

The prevalence of moderate or severe pain was 48% [95% confidence interval (CI), 45-51] at discharge and 30% (95% CI, 28-33) at 6 months postinjury. Failure to complete high school [adjusted odds ratio (AOR) 1.5 (95% CI, 1.1-1.9)], self-reported preinjury pain-related disability [AOR 1.8 (95% CI, 1.3-2.5)], eligibility for compensation [AOR 2.1 (95% CI, 1.6-2.8)], and moderate or severe pain at discharge from the acute hospital [AOR 2.4 (95% CI, 1.8-3.1)] were found to be independent predictors of moderate or severe pain at 6 months postinjury.

CONCLUSIONS

Moderate or severe pain is commonly reported 6 months after orthopaedic trauma. Pain intensity at discharge and the effects of a "no-fault" compensation system are potentially modifiable factors that might be addressed through intervention studies to reduce the burden of persistent pain after orthopaedic trauma.

Pain perception in the elderly patient

In the elderly patient, the barriers to effective treatment of pain are substantial. Even the perception of pain may differ from that in those of less advanced years. Of course, many other factors impinge on the presence of, and treatment of, pain in elderly patients. Issues of physical accessibility to treatment, cost of drugs, the presence of coexisting illness, the use of concomitant medication, and even the ability to understand the complaints of the patient who has cognitive impairment are only some of those factors that contribute to the complexity of the situation.

Disparities in pain management between cognitively intact and cognitively impaired nursing home residents

This study tests the association between residents' cognitive impairment and nursing homes' pain management practices. We used chart abstraction to collect data on 551 adults in six North Carolina nursing homes. From the standard data collected in the Minimum Data Set, 24% of residents experienced pain in the preceding week. Reports of pain decreased as cognitive abilities declined: nurses completing the Minimum Data Set reported pain prevalence of 34%, 31%, 24%, and 10%, respectively, for residents with no, mild, moderate, and severe cognitive impairment (P<0.001), demonstrating a "dose-response"-type result. Eighty percent of cognitively intact residents received pain medications, compared to 56% of residents with severe impairment (P<0.001). Cognitively impaired residents had fewer orders for scheduled pain medications than did their less cognitively impaired peers. Yet the presence of diagnoses likely to cause pain did not vary based on residents' cognitive status. We conclude that pain is underrecognized in nursing home residents with cognitive impairment and that cognitively impaired residents often have orders for "as needed" analgesics when scheduled medications would be more appropriate.

Pharmacological pain management in the elderly patient

With the increasing number of elderly patients the issue of pain management for older people is of increasing relevance. The alterations with aging of the neurobiology of pain have impacts of pain threshold, tolerance and treatment. In this review the available evidence from animal and human experimentation is discussed to highlight the differences between young and older subjects along with consideration of how these changes have practical effect on drug treatment of pain. Cognitive impairment, physical disability and social isolation can also impact on the accessibility of treatment and have to be considered along with the biological changes with ageing. Conventional pain therapies, while verified in younger adults cannot be automatically applied to the elderly without consideration of all these factors and in no other group of patients is a holistic approach to treatment more important.

Pain assessment in a geriatric psychiatry program

BACKGROUND

The assessment of pain in older persons with psychiatric illness is particularly challenging for health care professionals. There are few well-tested pain assessment tools for this population.

OBJECTIVES

A study was conducted to explore pain assessment and management issues in geriatric psychiatry.

METHODS

Seventy-four staff members of a geriatric psychiatry service at Regional Mental Health Care London, St Joseph's Health Care London, London, Ontario completed a survey to assess current pain assessment and management practice for geriatric psychiatry patients, and to identify indicators used to assess pain in this population. The results of the survey were later shared with members of the program's pain management team in a focus group discussion to explore opportunities on how to transfer these findings into clinical practice.

RESULTS

The majority of survey respondents (91.8%) agreed that pain assessment and management could be improved for patients; only 14.9% reported that there was a consistent approach to pain management. Misconceptions and attitudes about pain, lack of easily administered pain tools, inconsistent monitoring of pain, and lack of documentation of pain symptoms and indicators were identified as significant barriers to optimal pain management for their patients. A number of behaviours indicative of pain were identified but emphasis was placed on recognition of changes from usual behaviour.

CONCLUSIONS

The findings of the present study highlight the need for a comprehensive, practical and consistent approach to pain assessment and management, and provide insight into the critical components, including behavioural indicators, that could be incorporated into a pain protocol to be used with this population.

[The systematic evaluation of instruments designed to assess pain in persons with limited ability to communicate]

Chronic pain is often underdetected and undertreated in long-term care facilities. The use of self-report measures of pain (such as the visual analogue scale) is often problematic for older adults residing in long-term care because of the high prevalence of visual and auditory deficits and severe cognitive impairment. Observational measures of pain have been developed to address this concern. A systematic grid designed to assess the properties of existing observational measures of pain was used for seniors with dementia. The grid focused on the evaluation of content validity (12 items), construct validity (12 items), reliability (13 items) and clinical utility (10 items). Among the 24 instruments that were evaluated, several were deemed to be promising in the assessment of pain among older persons with severe dementia. Nonetheless, additional research is needed before their routine integration in the practices of long-term care settings.

Understanding distress in people with severe communication difficulties: developing and assessing the Disability Distress Assessment Tool (DisDAT)

BACKGROUND

Meaningful communication with people with profound communication difficulties depends on the ability of carers to recognize and translate many different verbal cues. Carers appear to be intuitively skilled at identifying distress cues, but have little confidence in their observations. To help in this process, a number of pain tools have been developed, but this sits uncomfortably with the lack of evidence that pain has any specific signs or behaviours. A palliative care team working with people with intellectual disabilities developed the Disability Distress Assessment Tool (DisDAT) to document a wide range of signs and behaviours of distress and when an individual is content.

METHOD

The tool was piloted with 16 carers and 8 patients. It was then assessed using quantitative and qualitative methods, employing 56 carers in routine clinical situations with 25 patients, most with severe communication difficulties. Carers of 10 patients participated in semi-structured interviews exploring the signs and behaviours demonstrated by patients when distressed and when content. These same 10 patients were observed for distress cues during different activities.

RESULTS

It became clear that distress did not have a common meaning among carers, but there was a clear understanding that distress did not just cover physical pain. The range of distress cues was wide, with no evidence that any cues were specific to particular causes. Although some distress cues were common between patients, each patient had a distinct pattern of distress cues. In addition, different carers identified a different range of distress cues, while the length of the relationship did not influence the number of cues identified. Most distress cues were a change from the norm, but some patients demonstrated distress as an absence of content cues. Carers found the DisDAT simple to use and useful, and several felt that DisDAT would have helped advocate for the patients in previous conflicts with clinical teams.

CONCLUSIONS

There was no evidence that pain has any specific signs or behaviours. The preliminary and assessment phases showed that distress was a useful clinical construct in providing care. The DisDAT reflected patients' distress communication identified by a range of carers, and provided carers with evidence for their intuitive observations of distress.

The Discomfort Behavior Scale: a measure of discomfort in the cognitively impaired based on the Minimum Data Set 2.0

Because persons with cognitive impairment often cannot self-report pain, it is imperative to develop instruments that use observable indicators. The purpose of this study was to develop and test the psychometric properties of the Discomfort Behavior Scale (DBS), which is comprised of 17 items from the Minimum Data Set (MDS). MDS data from 29,120 cognitively impaired nursing home residents were used for psychometric testing. Factor analyses of the DBS indicated that it reflects a single discomfort dimension. The items are tau equivalent, allowing unity weighting and simple summation to create scale scores, and the internal consistency was good. The DBS has potential to be useful in studies of efforts to improve pain management in cognitively impaired residents of nursing homes.

The psychometric quality and clinical usefulness of three pain assessment tools for elderly people with dementia

In view of the need for valid, reliable, and clinically useful scales to assess pain in elderly people with dementia, this study evaluated the psychometric properties of translated versions of the PAINAD, PACSLAC, and DOLOPLUS-2 scales. In an observational study design, two raters simultaneously assessed the nursing home residents (n=128) for pain during influenza vaccination and care situations. The PACSLAC was valued as the most useful scale by nurses. Cronbach's alpha was high (>.80) for the total scale at T2 and T3 and adequate for the 'Facial expression' and 'Social/personality/mood' subscales. IC scores for the 'Activity/body movement' and 'Physiological indicators/eating/sleeping changes/vocal behaviors' subscales were low. It demonstrated good validity and reliability, although the scale should be further refined. This refinement should increase homogeneity. The PAINAD showed good psychometric qualities in terms of reliability, validity, and homogeneity (alpha ranged .69-.74 at T2 and T3) (except for the 'Breathing' item). The PAINAD scale had lower scores for clinical usefulness in this sample. The Dutch version of the DOLOPLUS-2 was considered more difficult to use but showed acceptable psychometric qualities in terms of the issues assessed, except for the 'psychosocial reactions' subscale. IC of the DOLOPLUS were adequate for the total scale (alpha ranged .74-.75) and almost all subscales (alpha ranged .58-.80). Findings of this study provide evidence of validity and reliability of the three pain assessment scales. Now that a pain scale is available, future studies also need to focus on its implementation in nursing practice.

Pain intensity and pain affect in relation to white matter changes

Since aging is a risk factor for both dementia and the occurrence of painful conditions, with the number of aged people increasing in the next decades, an increase in the number of elderly people suffering from both conditions can be anticipated. Reliable pain assessment in this population is restricted by reduced communicative and cognitive capacity, with serious consequences for effective pain treatment. White matter changes are frequently observed in the various subtypes of dementia as well as in normal aging, and may play a crucial role in pain processing. In healthy elderly people, reliable pain assessment can be accomplished, which enables examining the relationship between pain experience and white matter changes. A normal structure and function of the white matter is extremely important for dorsolateral prefrontal cortex (DLPFC) functioning, which has recently been linked to pain inhibition. The present study focused on the relation between white matter changes and both pain intensity and pain affect in elderly people without dementia. The Coloured Analogue Scale (CAS) and the Number of Words Chosen-Affective (NWC-A) were applied to measure pain intensity and pain affect, respectively. The presence of white matter changes was significantly related to a higher score on the NWC-A but not the CAS score. These results suggest that pain experience may change as a result of aging and that white matter changes might be indicative for these alterations.

Pain in Alzheimer's disease: nursing assistants' and patients' evaluations

AIM

This paper reports on a study examining the level of agreement between the pain perceptions of nursing assistants, older people without dementia and patients with Alzheimer's dementia. It was hypothesized that nursing assistants would overestimate the pain experience of patients with Alzheimer's dementia.

BACKGROUND

There is now increasing evidence that, in contrast to other subtypes of dementia, patients with Alzheimer's disease might experience a decrease in pain. It is unfortunate that these latest insights into the complex relationship between subtypes of dementia and pain are not always included in education programmes for nursing assistants.

METHOD

Twenty patients with Alzheimer's disease and 17 older people with arthrosis and/or osteoporosis but no dementia and their personal nursing assistants participated in the study. Pain experience was assessed using the Coloured Analogue Scale for the assessment of Pain Intensity and Pain Affect, the Faces Pain Scale, and the Checklist of Non-verbal Pain Indicators. The data were collected in 2002-2003.

RESULTS

Before and after walking, the absolute difference in pain evaluation between nursing assistants and older people without dementia was statistically significantly less than the difference in pain evaluation between nursing assistants and patients with Alzheimer's disease on the Coloured Analogue Scale for Pain Intensity (P = 0.007 and P = 0.04, respectively) and on the Coloured Analogue Scale for Pain Affect (P = 0.009 and P = 0.01, respectively).

CONCLUSION

Nursing assistants may overestimate the extent of suffering from pain of patients with Alzheimer's disease. They might be very well able to estimate this pain, provided they were educated about new insights into the influence of the various subtypes of dementia on pain.

Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools

Background

Pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40–80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia.

Methods

This systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales.

Results

Twenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales (DOLOPLUS2; ECPA; ECS; Observational Pain Behavior Tool; CNPI; PACSLAC; PAINAD; PADE; RaPID; Abbey Pain Scale; NOPPAIN; Pain assessment scale for use with cognitively impaired adults) were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities.

Conclusion

Based on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility.

Anaesthesia in patients with dementia

PURPOSE OF REVIEW

The next couple of decades will be characterized by an increase in life expectancy, leading to an older population. As the incidence of Alzheimer's dementia and vascular dementia is rising with age, the future anaesthesiologist will be increasingly confronted with perioperative care of patients with impaired cognitive function. This paper tries to highlight some topics specifically related to demented patients.

RECENT FINDINGS

Psychometric testing and behaviour vary according to the type of dementia. Neuroanatomical and biochemical correlates for different types of dementia are more precise and better documented. Evidence exists that cognition may be impaired for weeks after anaesthesia, but the mental capacities of those who have undergone surgery are comparable to those of age controls in the long term. Most research efforts are focused on improving the daily functioning of people with cognitive impairment. Several new anticholinesterases are being evaluated. It is advantageous to keep cognition optimal throughout the perioperative period. Neuroleptics may be badly tolerated and, most importantly, pain pathways may be differentially affected in dementia.

SUMMARY

Anaesthesia in the demented patient may be complicated by a number of potential problems, including the comorbid pathology, the concomitant anticholinesterase activity, the need for normoventilation, monitoring of anaesthesia depth and the evaluation of postoperative pain. Anaesthesia in variant Creutzfeldt-Jakob disease is aimed at preventing the spread of the causing prion. There is a broad consensus that early return to the preoperative level of cognition is to be pursued, with the help of short-acting drugs and loco-regional anaesthesia.

Pain processing in dementia and its relation to neuropathology

Most clinical studies of pain in dementia have focused on assessment procedures that are sensitive to pain in "demented" or "cognitively impaired" elderly patients. The neuropathology of dementia has not played a major part in pain assessment. In this review, the neuropathological effects of dementia on the medial and the lateral pain systems are discussed. We focus on Alzheimer's disease (AD), vascular dementia, and frontotemporal dementia. Lewy-body disease and Creutzfeldt-Jakob disease are briefly reviewed. The results of the studies reviewed show that, although the subtypes of dementia show common neuropathological features (such as atrophy and white-matter lesions), the degree by which they occur and affect pain-related areas determine the pattern of changes in pain experience. More specifically, in AD and even more so in frontotemporal dementia, a decrease in the motivational and affective components of pain is generally present whereas vascular dementia might be characterised by an increase in affective pain experience. Future studies should combine data from experimental pain studies and neuropathological information for pain assessment in dementia.