Analgesic use among nursing homes residents, with and without dementia, in Poland

Increased pain unpleasantness and pain-related fMRI activation in the periaqueductal gray in Alzheimer's disease

Background

Pain continues to be underrecognized and undertreated in people with Alzheimer's disease (AD). The periaqueductal gray (PAG) is essential to pain processing and modulation yet is damaged by AD. While evidence exists of altered neural processing of pain in AD, there has not been a focused investigation of the PAG during pain in people with AD.

Purpose

To investigate the role of the PAG in sensory and affective pain processing for people living with AD.

Methods

Participants from a larger study completed pain psychophysics assessments and then a perceptually-matched heat pain task (warmth, mild, and moderate pain) during a functional MRI scan. In this cross-sectional study, we examined blood oxygenation level-dependent (BOLD) responses in the PAG and other pain-related regions in participants with AD (n = 18) and cognitively intact older adults (age- and sex-matched, n = 18). Associations of BOLD percent signal change and psychophysics were also examined.

Results

There were significant main effects of AD status on the temperature needed to reach each perception of warmth or pain, where people with AD reached higher temperatures. Furthermore, participants with AD rated mild and moderate pain as more unpleasant than controls. PAG BOLD activation was greater in AD relative to controls during warmth and mild pain percepts. No significant differences were found for moderate pain or in other regions of interest. Greater PAG activation during mild pain was associated with higher affective/unpleasantness ratings of mild pain in participants with AD but not in controls.

Conclusion

Results suggest a role for the PAG in altered pain responses in people with AD. The PAG is the primary source of endogenous opioid pain inhibition in the neuroaxis, thus, altered PAG function in AD suggests possible changes in descending pain inhibitory circuits. People with AD may have a greater risk of suffering from pain compared to cognitively intact older adults.

Large differences in the organization of palliative care in nursing homes in six European countries: findings from the PACE cross-sectional study

Background

To be able to provide high-quality palliative care, there need to be a number of organizational structures available in the nursing homes. It is unclear to what extent such structures are actually present in nursing homes in Europe. We aim to examine structural indicators for quality of palliative care in nursing homes in Europe and to evaluate the differences in terms of availability of and access to palliative care, infrastructure for residents and families, multidisciplinary meetings and quality improvement initiatives.

Methods

A PACE cross-sectional study (2015) of nursing homes in Belgium, England, Finland, Italy, the Netherlands and Poland. Nursing homes (N = 322) were selected in each country via proportional stratified random sampling. Nursing home administrators (N = 305) filled in structured questionnaires on nursing home characteristics. Organization of palliative care was measured using 13 of the previously defined IMPACT structural indicators for quality of palliative care covering four domains: availability of and access to palliative care, infrastructure for residents and families, multidisciplinary meetings and quality improvement initiatives. We calculated structural indicator scores for each country and computed differences in indicator scores between the six countries. Pearson’s Chi-square test was used to compute the p-value of each difference.

Results

The availability of specialist palliative care teams in nursing homes was limited (6.1–48.7%). In Finland, Poland and Italy, specialist advice was also less often available (35.6–46.9%). Up to 49% of the nursing homes did not provide a dedicated contact person who maintained regular contact with the resident and relatives. The 24/7 availability of opioids for all nursing home residents was low in Poland (37.5%).

Conclusions

This study found a large heterogeneity between countries in the organization of palliative care in nursing homes, although a common challenge is ensuring sufficient structural access to specialist palliative care services. Policymakers and health and palliative care organizations can use these structural indicators to identify areas for improvement in the organization of palliative care.

Spanish adaptation and validation of the Pain Assessment Scale in Advanced Dementia (PAINAD) in patients with dementia and impaired verbal communication: cross-sectional study

OBJECTIVES

The aim of this study was to adapt and validate the Pain Assessment in Advanced Dementia (PAINAD) scale in Spanish.

DESIGN

Cross-sectional observational study.

SETTING

Two health districts of Andalusian provinces, located in the south of Spain, through the Andalusian network of Primary Healthcare centres and four institutions dedicated to the care of patients with dementia.

PARTICIPANTS

A total of 100 older people, with a medical diagnosis of dementia and a score on the Global Deterioration Scale between 5 and 7 were assessed using the PAINAD scale.

PRIMARY AND SECONDARY OUTCOME MEASURES

Psychometric properties including content validity, construct validity and reliability of the scale have been tested.

RESULTS

The overall Item Content Validity Index was excellent (0.95). Regarding construct validity, it was confirmed that a lower use of analgesics implied a lower score on the PAINAD scale (p<0.05). The internal consistency of the scale was 0.76 and it increases to 0.81 if we remove the breathing item. Furthermore, the intraclass correlation coefficient (ICC) used to assess interobserver reliability was 0.94, whereas the ICC used to assess temporary stability was 0.55.

CONCLUSIONS

The Spanish version of the PAINAD scale is a valid tool to assess pain in patients with dementia and inability to communicate verbally.

Are Chronic Pain Patients with Dementia Being Undermedicated?

In dementia, neuropathological changes alter the perception and expression of pain. For clinicians and family members, this knowledge gap leads to difficulties in recognizing and assessing chronic pain, which may consequently result in persons with dementia receiving lower levels of pain medication compared to those without cognitive impairment. Although this situation seems to have improved in recent years, considerable geographical variation persists. Over the last decade, opioid use has received global attention as a result of overuse and the risk of addiction, while the literature on older persons with dementia actually suggests undertreatment. This review stresses the importance of reliable assessment and the regular evaluation and monitoring of symptoms in persons with dementia. Based on current evidence, we concluded that chronic pain is still undertreated in dementia.

Policy Implications for Pain in Advanced Alzheimer's Disease

Untreated pain in people with Alzheimer's disease continues to be a serious public health problem. Pain is a subjective and complex experience that becomes increasingly challenging to assess as cognition declines. Our understanding of pain processing is incomplete, particularly for special populations such as people living with Alzheimer's disease, and especially in the advanced stages of the disease. Pain-processing networks in the brain are altered in Alzheimer's disease, yet evidence suggests people living with Alzheimer's disease do not experience less pain. Rather, their pain is not adequately recognized or treated. Although scholarly publications provide important assistance, recent widespread reports and guidelines do not include sufficient guidance, especially as Alzheimer's disease progresses to the last stages. Additionally, current pain measurements may not accurately evaluate pain in this condition, and the existing definitions of pain are not adequate when considering the effects of Alzheimer's disease on pain-processing in the brain. There is a need for new, widespread policies, guidelines, and definitions to help clinicians adequately manage pain in people with Alzheimer's disease. These will need to hinge on continued research because it remains unclear how Alzheimer's disease impacts central pain processing, pain expression, and communication of pain. In the meantime, policies and guidelines need to highlight current best practices as well as the fact that pain continues in Alzheimer's disease.

Pain, Complex Chronic Conditions and Potential Inappropriate Medication in People with Dementia. Lessons Learnt for Pain Treatment Plans Utilizing Data from the Veteran Health Administration

Alzheimer's disease and related dementias (ADRD), pain and chronic complex conditions (CCC) often co-occur leading to polypharmacy and with potential inappropriate medications (PIMs) use, are important risk factors for adverse drug reactions and hospitalizations in older adults. Many US veterans are at high risk for persistent pain due to age, injury or medical illness. Concerns about inadequate treatment of pain-accompanied by evidence about the analgesic efficacy of opioids-has led to an increase in the use of opioid medications to treat chronic pain in the Veterans Health Administration (VHA) and other healthcare systems. This study aims to investigate the relationship between receipt of pain medications and centrally (CNS) acting PIMs among veterans diagnosed with dementia, pain intensity, and CCC 90-days prior to hospitalization. The final analytic sample included 96,224 (81.7%) eligible older veterans from outpatient visits between October 2012-30 September 2013. We hypothesized that veterans with ADRD, and severe pain intensity may receive inappropriate pain management and CNS-acting PIMs. Seventy percent of the veterans, and especially people with ADRD, reported severe pain intensity. One in three veterans with ADRD and severe pain intensity have an increased likelihood for CNS-acting PIMs, and/or opioids. Regular assessment and re-assessment of pain among older persons with CCC, patient-centered tapering or discontinuation of opioids, alternatives to CNS-acting PIMs, and use of non-pharmacological approaches should be considered.

Opioid, antipsychotic and hypnotic use in end of life in long-term care facilities in six European countries: results of PACE

Background

Opioids, antipsychotics and hypnotics are recommended for comfort care in dying. We studied their prescription during the last 3 days in residents deceased in the long-term care facility (LTCF).

Methods

In a retrospective, cross-sectional survey in Belgium, England, Finland, Italy, the Netherlands and Poland, LTCFs, selected by proportional stratified random sampling, reported all deaths over the previous 3 months. The nurse most involved in the residents’ care reviewed the chart for opioid, antipsychotic and hypnotic prescription, cause of death and comorbidities. Multivariable logistic regression was performed to adjust for resident characteristics.

Results

Response rate was 81.6%. We included 1079 deceased residents in 322 LCTFs. Opioid prescription ranged from 18.5% (95% CI: 13.0–25.8) of residents in Poland to 77.9% (95% CI: 69.5–84.5) in the Netherlands, antipsychotic prescription from 4.8% (95% CI: 2.4–9.1) in Finland to 22.4% (95% CI: 14.7–32.4) in Italy, hypnotic prescription from 7.8% (95% CI: 4.6–12.8) in Finland to 47.9% (95% CI: 38.5–57.3) in the Netherlands. Differences in opioid, antipsychotic and hypnotic prescription between countries remained significant (P < 0.001) when controlling for age, gender, length of stay, cognitive status, cause of death in multilevel, multivariable analyses. Dying from cancer showed higher odds for receiving opioids (OR 3.51; P < 0.001) and hypnotics (OR 2.10; P = 0.010).

Conclusions

Opioid, antipsychotic and hypnotic prescription in the dying phase differed significantly between six European countries. Further research should determine the appropriateness of their prescription and refine guidelines especially for LTCF residents dying of non-cancer diseases.

Non-Pharmacological Approaches to Pain Management in Residential Aged Care: a Pre-Post-Test Study

OBJECTIVES

The project aimed to evaluate a pain management program (PMP) using non-pharmacological approaches at five residential aged care facilities (RACFs) in Australia.

METHODS

The PMP involved a physiotherapist implementing four sessions per week of treatments (massage therapy, TENS, exercises and stretching, or combinations of these). Ninety-five participants were recruited (average age, 83 years; SD = 7.6; 38% men, 62% women; 56% with dementia). Sessions lasted approximately 10 minutes, and residents' levels of pain were recorded using a 5-point scale before and after each treatment. The intervention period for each participant was the first consecutive 8 weeks in which they received the intervention.

RESULTS

Data analyses showed: (1) a small but statistically significant decrease in the number of as required (PRN) medications; and (2) a decrease in average pain ratings from pre-session to post-session from 2.4 (some to moderate pain) to 1.1 (a little pain). Notably, residents with dementia received lower pain ratings than those without.

CONCLUSIONS

Non-pharmacological approaches to pain in residential care settings are effective, especially when two or more are combined. Staff working in residential care settings should rely on best practice to recognise pain in residents with dementia.

CLINICAL IMPLICATIONS

Non-pharmacological interventions may be effective in reducing pain and reliance on PRN medications in residential care settings, especially when two or more are used. Staff working in residential aged care settings should be provided with training in pain assessment and management, with particular attention to residents with dementia.

Prevalence of Chronic Pain, Particularly with Neuropathic Component, and Its Effect on Overall Functioning of Elderly Patients

Background

The prevalence of chronic pain among the elderly is high (estimated at 25–85%) and may adversely affect their everyday functioning, although it is often unrecognized.

Material/Methods

The aim of this study was to assess the prevalence of chronic pain, especially with the neuropathic component, and its effect on overall functioning of elderly patients. We enrolled 145 subjects older than 60 years (nursing home residents, or patients of outpatient geriatric clinic). Information on co-morbidities, functional and mental status, and medications was obtained using a questionnaire. Chronic pain was defined as lasting >3 months and the presence of neuropathic component was detected using the DN4 Questionnaire (Douleur Neuropathique en Questions).

Results

The mean age of patients was 76±9.68 years. Chronic pain was reported by 78% of participants and 32% reported neuropathic pain with neuropathic component (DN4 score ≥4 points). Patients complaining of chronic pain significantly more often presented mood disorders and lower satisfaction with life (particularly those with the highest pain intensity), with no difference in functional status according to the ADL (Activities of Daily Living) tool. Participants with chronic pain were treated with paracetamol (45%), non-steroidal anti-inflammatory drugs (25%), and opioids (24%).

Conclusions

The prevalence of chronic pain, particularly with neuropathic component, in the elderly population seems to be higher than expected based on previous reports, and its treatment appears to be ineffective. This problem requires further research and dissemination of knowledge on the diagnosis and treatment of chronic pain among health care workers caring for elderly patients on a daily basis.

Characteristics of pharmacological pain treatment in older nursing home residents

Background: Pain in older subjects with cognitive impairement is frequently undertreated. Purpose: The aim of the study was to characterize pain treatment among 199 elderly nursing home residents (NHR), aged 65 years and above. Patients and methods: In all studied subjects, cognitive functions were assessed. Based on the results, participants were divided into two groups: group 1 - cognitively intact subjects in whom the pain was evaluated based on Numerical Rating Scale (NRS), and group 2 - subjects with cognitive impairment, in whom Abbey Pain Scale (APS) was used to assess pain. Thereafter, subjects with inappropriately treated pain (ie, ineffectively treated or untreated) were analyzed in detail as group 1a (NRS >0) and group 2a (Abbey >2). Results: The prevalence of pain in group 1 and 2 did not differ (65% and 70% respectively). However, inappropriately treated pain occurred more frequently in group 2 (2a=85% vs 1a=64%; p<0.01). This was related to the more frequent occurrence of untreated pain (52% vs 22%; p<0.001), because the presence of ineffectively treated pain was comparable in both groups (34% vs 42%). Qualitative analysis of pharmacotherapy in subjects with inappropriately treated pain demonstrated that acetaminophen in low dosages was the most frequently consumed drug from the first step of the analgesic ladder (16 individuals), from the second step - a combination of tramadol and acetaminophen (8 individuals), and from the third step - buprenorphine was the only drug applied (6 individuals). Conclusion: Our study showed a high frequency of untreated or ineffectively treated pain in NHR, regardless of the cognitive status of studied subjects. However, these phenomena were particularly frequent in subjects with cognitive impairment. Thus, proper education of the staff is needed to increase their knowledge about both the pain assessment and its treatment.

Pain as a challenge in nursing home residents with behavioral and psychological symptoms of dementia

Introduction

In patients with dementia, observational scales are recommended for use in the assessment of pain. Unfortunately, their application is rare, and as a consequence pain is frequently underdiagnosed and undertreated in these types of subjects. Thus, the aim of the study was to assess analgesic treatment in nursing home residents with cognitive impairment and to delineate the relationship between pain and behavioral and psychological symptoms of dementia.

Patients and methods

The research was conducted in 2 nursing home facilities in Wielkopolska, Poland. The analyzed group consisted of 96 residents (78 female) with moderate and severe cognitive impairment in whom pain was assessed with the Abbey Pain Scale (APS) and agitation with the Cohen-Mansfield Agitation Inventory (CMAI). Thereafter, medical files related to drug prescriptions were analyzed.

Results

Analgesics were consumed by 33 individuals (34%); 24 (25%) received regular pain treatment and 7 individuals (7%) - as when needed pain treatment. A relationship was found between the APS and CMAI (r=0.45, p<0.0001). Subjects with a higher CMAI received sedative drugs more frequently (p<0.001), and despite having a higher APS (p=0.001), this did not correlate with higher analgesia.

Conclusion

Our study suggests that pain can be an important underlying cause of behavioral disturbances in older subjects with dementia. In order to reduce their frequency and to avoid excessive usage of sedatives, proper pain assessment and management are essential.

Temporal Trends in Analgesic Use in Long-Term Care Facilities: A Systematic Review of International Prescribing

OBJECTIVES

To explore global changes in the prescription of analgesic drugs over time in the international long-term care (LTC) population.

DESIGN

Systematic review.

SETTING

We included original research articles in English, published and unpublished, that included number of participants, country and year(s) of data collection, and prescription of analgesics (analgesics not otherwise specified, opioids, acetaminophen; scheduled only, or scheduled plus as needed (PRN)).

PARTICIPANTS

LTC residents.

MEASUREMENTS

We searched PubMed, EMBASE, CINAHL, International Pharmaceutical Abstracts, PsycINFO, Cochrane, Web of Science, Google Scholar, using keywords for LTC facilities and analgesic medication; hand-searched references of eligible papers; correspondence. Studies were quality rated using an adapted Newcastle-Ottawa scale. Pearson correlation coefficients were generated between percentage of residents prescribed an analgesic and year of data collection. If available, we investigated changes in acetaminophen and opioid prescriptions.

RESULTS

Forty studies met inclusion criteria. A moderate correlation (0.59) suggested that scheduled prescription rates for analgesics have increased over time. Similar findings were reflected in scheduled prescriptions for acetaminophen and opioids. No increase was seen when analyzing scheduled plus PRN analgesics. Use of opioids (scheduled plus PRN) appears to have increased over time.

CONCLUSION

Worldwide, use of opioids and acetaminophen has increased in LTC residents. Research is needed to explore whether this reflects appropriate pain management for LTC residents and if PRN medication is used effectively.