Pain Assessment in Elderly with Behavioral and Psychological Symptoms of Dementia

Intersection of pain and behavioural and psychological symptoms of dementia in Alzheimer's disease

BACKGROUND

Pain is highly prevalent but challenging to assess in individuals with dementia. Non-cognitive symptoms, such as behavioural and psychological symptoms of dementia (BPSD) and undetected pain, can severely impair functionality and degrade the quality of life for Alzheimer's disease patients. This study aims to examine the relationship between pain and BPSD in patients with Alzheimer's disease.

METHODS

A hospital-based, cross-sectional study using a convenience sampling technique was conducted with Alzheimer's disease patients attending an outpatient clinic at a tertiary care geriatric centre. Participants' cognitive impairment was assessed using the Mini-Mental State Examination (MMSE), pain severity was evaluated with the Numeric Rating Scale (NRS) and Pain Assessment in Advanced Dementia (PAIN-AD) scale, and BPSD was measured using the Behavioural Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD). Over 6 months, 50 participants who met the inclusion and exclusion criteria were included.

RESULTS

The median age of the participants was 69 years, with a median MMSE score of 16. All participants experienced some level of pain and exhibited at least one BPSD. Statistical analysis revealed a significant association between both subjective and objective pain and behavioural and psychological symptoms. A strong correlation was also observed between NRS and PAIN-AD scores with affective disturbances and anxieties.

CONCLUSION

Common occurrence of pain and BPSD in Alzheimer's disease among the Indian population underscores the importance of pain assessment and management for enhancing patient well-being.

End-of-Life Care of Persons with Alzheimer's Disease and Other Dementias

End-of-life (EOL) care has been a common option for patients with terminal medical conditions such as cancers. However, the utilization of EOL care in Alzheimer disease and other dementing conditions have become available relatively recently. As the end-stage dementia approaches, the clinicians and caregivers become faced with numerous clinical challenges-delirium, neuropbehavioral symptoms, the patient's inability to communicate pain and associated discomfort, food refusal, and so on. In addition to providing quality clinical care to the EOL patients, clinicians should pay special attention to their families, assuring that their loved ones will receive supportive measures to improve quality of life (QOL).

Association between pain and behavioral and psychological symptoms of dementia (BPSD) in older adults with dementia: a systematic review and meta-analysis

BACKGROUND

Behavioral and Psychological Symptoms of Dementia (BPSD) are core and highly detrimental symptoms of dementia. Previous research has suggested a potential association between pain and BPSD, but pieces of evidence are lacking.

OBJECTIVE

This study aimed to investigate the association between pain and BPSD in patients with dementia.

METHODS

Seven databases were searched from inception to February 2024, including PubMed, Web of Science, Embase, CINAHL, Cochrane Library, China National Knowledge Infrastructure (CNKI), and WanFang Data. Cross-sectional and longitudinal studies were included. We included studies that involved older adults with dementia and assessed the pain and BPSD by using validated tools. The quality of cohort studies was assessed using the Newcastle-Ottawa Scale, and the quality of cross-sectional studies was evaluated using AHRQ criteria. Two researchers independently screened the articles, extracted the data, and assessed the quality of the studies. A meta-analysis was conducted using Stata 15.0. Data not suitable for meta-analysis was analyzed through a qualitative synthesis to provide a comprehensive overview of the findings.

RESULTS

A total of 12 studies were included, comprising nine cross-sectional studies and three longitudinal studies. All studies were of medium to high quality. Studies reported that pain was associated with 13 different types of BPSD, including agitation, aggression, abnormal thought process, anxiety, care refusal, delirium, depression, delusions, hallucinations, sexual disinhibition, sleep disturbances, socially inappropriate behavior, and wandering. A pooled odds ratio (OR) of 1.25 (95%CI [1.17,1.33], p < 0.001) indicated a significant positive association between pain and BPSD. Specifically, pain was positively associated with aggression (OR = 1.07, 95%CI [1.00,1.13], p = 0.035), agitation (OR = 1.17, 95%CI [1.14, 1.21], p < 0.001), and depression (OR = 2.11, 95%CI [1.76,2.52], p < 0.001). However, pain was significantly negatively associated with wandering (OR = 0.77, 95%CI [0.73, 0.81], p < 0.001).

CONCLUSIONS

Pain was significantly positively associated with BPSD in patients with dementia, specifically with aggression, depression, and agitation. However, pain was negatively associated with wandering. This emphasizes the importance of further research in this area and improved interventions for pain and BPSD management.

TRIAL REGISTRATION

www.crd.york.ac.uk CRD42023432320, registered 08/08/2024.

The process of pain assessment in people with dementia living in nursing homes: a scoping review

Background

Pain is a common symptom in people with dementia living in nursing homes, but cognitive impairment, including language and communication difficulties, challenges pain assessment and the ability to self-report pain.

Objectives

This study aimed to identify and summarize patterns, advances, and gaps in research literature describing pain assessment in people with dementia living in nursing homes.

Design

We conducted a scoping review following Arksey and O'Malley's methodological framework.

Methods

Systematic searches were conducted in CINAHL, Embase, MEDLINE, and PsycINFO. We included studies describing pain expressions in people with dementia and/or healthcare personnel assessment of pain in people with dementia, in a nursing home context. Charted data included demographics, methodological descriptions, ethical and quality assessment and relevant findings. Relevant findings were summarized using thematic analysis, and an overview of patterns, advances, and gaps in the research literature is presented.

Results

Thirty-nine studies were included. The results describe three patterns: (1) pain awareness; (2) suspected pain and (3) pain mapping. Collectively, these patterns constitute a process of pain assessment, integrating pain expressions of people with dementia. Important perspectives on self-reporting are touched upon in several of the included studies, though direct descriptions of attempts to capture the residents' own experience of pain are sparse.

Conclusion

This scoping review provides a comprehensive description of pain assessment in people with dementia living in nursing homes as a process in three steps. We identified several knowledge gaps in the understanding of this process and provide concrete recommendations for further research. The results underpin the importance of pain assessment approaches that incorporate the flexibility to meet residents' varying and potentially fluctuating ways of communicating pain.

Trial registration

This scoping review is registered in the Open Science Framework (https://osf.io/8kaf5/).

Real-time evaluation of an automated computer vision system to monitor pain behavior in older adults

Regular use of standardized observational tools to assess nonverbal pain behaviors results in improved pain care for older adults with severe dementia. While frequent monitoring of pain behaviors in long-term care (LTC) is constrained by resource limitations, computer vision technology has the potential to mitigate these challenges. A computerized algorithm designed to assess pain behavior in older adults with and without dementia was recently developed and validated using video recordings. This study was the first live, real-time evaluation of the algorithm incorporated in an automated system with community-dwelling older adults in a laboratory. Three safely-administered thermal pain tasks were completed while the system automatically processed facial activity. Receiver Operating Characteristic curves were used to determine the sensitivity and specificity of the system in identifying facial pain expressions using gold standard manual coding. The relationship between scoring methods was analyzed and gender differences were explored. Results supported the potential viability of the system for use with older adults. System performance improved when more intense facial pain expressiveness was considered. While average pain scores remained homogenous between genders, system performance was better for women. Findings will be used to further refine the system prior to future field testing in LTC.

Symptom severity reported by older adults with cancer and its impact on survival prognostication

INTRODUCTION

Symptom burden is a crucial factor for survival prognostication, but older adults may report fewer and less severe symptoms than younger patients. We investigated the impact of age on symptom severity and its prognostic implications in the prognostic model for advanced cancer (PRO-MAC).

MATERIALS AND METHODS

Eight hundred forty subjects with incurable cancer, who were reviewed by palliative medicine at a tertiary university hospital, were categorized into four groups based on age: < 65 (young), 65-74 (young-old), 75-84 (old-old), and ≥ 85 (oldest-old) for comparison. The study compared individual symptoms reported on the Edmonton Symptom Assessment System-revised (ESAS-r) and analyzed the significance of each prognostic variable in the PRO-MAC model using multivariate Cox proportional hazards regression analysis for all age categories. We generated the log-rank test for each age group to evaluate the effectiveness of PRO-MAC across age groups.

RSULTS

The older adults had significantly lower unadjusted mean scores in pain, tiredness, anxiety, wellbeing, and ESAS-r summative score compared to young adults. There was a higher proportion of older adults with no symptoms. The ESAS-r summative score remained a significant prognostic factor only in the young and young-old groups. More participants in the older age groups had dementia, which may impact reporting of symptom severity. Despite these findings, the PRO-MAC model remains applicable across all age groups as a multi-domain 90-day survival prognostication tool.

DISCUSSION

Symptom burden, including pain, tiredness, anxiety, wellbeing, as well as summative ESASr scores, are lower in older adults with cancer. This could affect the prognostication of survival using symptom burden. However, a multi-dimensional prognostic model like PRO-MAC remains effective for older adults with advanced cancer. Further research is needed to explore tools that can help older adults express the severity of their symptoms and incorporate this into survival prognostication.

Pressure injury pain over time among nursing home residents. Geriatr Nurs 2024;59:362-371. [PMID: 39127012 DOI: 10.1016/j.gerinurse.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

OBJECTIVE

Examine pressure injury (PrI) pain severity, stability, and current treatment of PrI pain among nursing home (NH) residents using two assessment tools and a descriptive cohort study design.

BACKGROUND

PrI pain affects quality of life of NH residents yet, best assessment methods, stability of PrI pain, and how to take care of the pain are not well known.

METHODS

Data collected from 33 residents with PrI (stages 1-4) from 4 NHs. All PrI were staged and assessed using the Bates-Jensen Wound Assessment Tool (BWAT) to determine severity. Verbal Response Scale (VRS) and Pain Assessment in Advanced Dementia (PAINAD) were used to assess general and PrI pain 3 times a day for two days within one week. Data classified as: no, mild, moderate, or severe pain. Proportions of participants with different levels of PrI pain were calculated. T tests were conducted to examine differences across time; VRS and PAINAD were examined for agreement.

RESULTS

Participants were 74 % female, 49 % white, 58 % cognitively intact, 58 % functionally dependent, and had mean age of 82 years old. The majority (52 %; n = 17) were full thickness PrI, stage 3 (n = 5), stage 4 (n = 7), unstageable (n = 5). The majority of participants (82 %; n = 27) reported PrI pain on at least one of six assessments over the two days; with 57 % mild, 26 % moderate and 16 % severe pain. More severe pain occurred in afternoon. No differences existed across days. Although there was a positive relationship between VRS and PAINAD in pain assessments (r = 0.38, P<.05), the agreement between the two scales, as indicated by Cohen's kappa (K = 0.19, p=.28), was found to be poor. Of those with PrI pain, 22 % had pain documented in the Minimum Data Set (MDS). Only 42 % of participants who reported PrI pain received pain medication within 12 h of initial pain assessment. Out of 28 participants who received routine pain medication for general pain, 18 of them reported experiencing no pain.

CONCLUSION

While VRS and PAINAD scores exhibited a relationship, their agreement was limited. Documentation of PrI pain on the Minimum Data Set (MDS) was found to be inadequate. Notably, 40 % of participants reported higher levels of PrI pain in the afternoon, suggesting this time may be opportune for PrI pain assessment and management. Interestingly, participants who received medication for general pain did not report PrI pain, suggesting that treatment of general pain may effectively alleviate PrI pain symptoms.

Predictive value of somatic and functional variables for cognitive deterioration for early-stage patients with Alzheimer's Disease: Evidence from a prospective registry on dementia

Alzheimer's disease (AD) imposes a major burden on affected individuals, their caregivers and health-care systems alike. Though quite many risk factors for disease progression have been identified, there is a lack of prospective studies investigating the interplay and predictive value of a wide variety of patient variables associated with cognitive deterioration (defined as key feature of AD progression). Study participants were patients with probable and possible AD, that were assessed at four time points over a period of two years (T1-T4). The main results were threefold: (i) over time, significant changes were observed regarding patients' cognitive functioning, activities of daily living and caregiver load (but not depression, pain, neuropsychiatric symptoms); (ii) intercorrelations between caregiver load and patients' cognitive and functional variables were high, correlation patterns remaining rather stable across time; (iii) cognitive functioning at T4 was best predicted by patients' age, sex, atrial fibrillation and activities of daily living at T1; and (iv) across all four assessment points, cognitive functioning was best predicted by time (i.e., disease duration), age, sex, activities of daily living and depression. Overall, even in early stages of AD and during a short two-year period, functional changes were significant and tightly intertwined with caregiver load, thus stressing the need to consider caregiver load when diagnosing and treating patients with AD. A novel and clinically relevant finding is that even in early stages of AD, cognitive deterioration was best predicted by a combination of patients' demographic, somatic and functional variables.

Pain prevalence, intensity, and association with neuropsychiatric symptoms of dementia in immigrant and non-immigrant aged care residents in Australia

Pain recognition for culturally diverse people is complex as pain experience is subjective and influenced by cultural background. We compared the prevalence, intensity, and association of pain with neuropsychiatric symptoms (NPS) between immigrants and non-immigrants living with dementia in residential aged care homes (RACHs) who were referred to two Dementia Support Australia programs. Immigrant status was defined by the documented country of birth. Pain and NPS were assessed using PainChek® and the Neuropsychiatric Inventory, respectively. Subgroup analyses were also completed for English-speaking and non-English-speaking immigrants. A total of 17,637 referrals [immigrants, n = 6340; non-immigrants, n = 11,297] from 2792 RACHs were included. There were no significant differences for the prevalence of pain across all groups. Immigrants were slightly more likely to have moderate pain or severe pain than non-immigrants. Non-English-speaking immigrants had 0.5 points higher total pain scores on average (Cohen's d = 0.10 [0.05, 0.15], p < 0.001) than non-immigrants. Total pain score had a significant effect on total NPS severity scores in all groups. While pain prevalence is similar across groups, higher pain intensities are more common among immigrants living with dementia. Increased care staff awareness, education, and training about the potential effect of culture on pain expression is needed.

Perception, behavior and experience of nursing assistants towards pain of older adults with dementia: A qualitative study

Nursing assistants are strategically positioned to detect and interpret behavioral alterations indicative of pain in residents suffering from dementia. Despite this, extant literature is scarce regarding their experiences in administering pain care to this demographic. Utilizing a phenomenological approach, this study engaged 17 nursing assistants selected via purposive sampling for semi-structured interviews. Data analysed by the Colaizzi 7-step method. Four emergent themes were discerned: perception of pain; strategies for coping with pain; emotional and psychological responses to pain-related caregiving; challenges and needs in pain-related caregiving. Nursing assistants play a unique and crucial role in the identification of pain, reporting and providing feedback to healthcare professionals, and implementing non-pharmacological interventions. However, these roles have not been fully utilized. Enhancements in pain management could be facilitated by decreasing staff turnover, augmenting educational and training programs, and incorporating empathy-focused situational training. The provision of mental health services is also recommended to ameliorate caregiving-induced stress.

The #SeePainMoreClearly Phase II Pain in Dementia Social Media Campaign: Implementation and Evaluation Study

BACKGROUND

Social media platforms have been effective in raising awareness of the underassessment and undertreatment of pain in dementia.

OBJECTIVE

After a successful pilot campaign, we aimed to scale our pain-in-dementia knowledge mobilization pilot initiative (ie, #SeePainMoreClearly) to several social media platforms with the aid of a digital media partner. The goal of the initiative was to increase awareness of the challenges in the assessment and management of pain among people with dementia. A variety of metrics were implemented to evaluate the effort. Through this work, we endeavored to highlight key differences between our pilot initiative (which was a grassroots initiative), focusing largely on Twitter and YouTube, and the current science-media partnership. We also aimed to generate recommendations suitable for other social media campaigns related to health or aging.

METHODS

Evidence-based information about pain in dementia was summarized into engaging content (eg, videos) tailored to the needs of various knowledge users (eg, health professionals, families, and policy makers). We disseminated information using Facebook (Meta Platforms), Twitter (X Corp), YouTube (Alphabet Inc), Instagram (Meta Platforms), and LinkedIn (LinkedIn Corp) and measured the success of the initiative over a 12-month period (2020 to 2021). The evaluation methods focused on web analytics and questionnaires related to social media content. Knowledge users' web responses about the initiative and semistructured interviews were analyzed using thematic analysis.

RESULTS

During the course of the campaign, >700 posts were shared across all platforms. Web analytics showed that we drew >60,000 users from 82 countries to our resource website. Of the social media platforms used, Facebook was the most effective in reaching knowledge users (ie, over 1,300,000 users). Questionnaire responses from users were favorable; interview responses indicated that the information shared throughout the initiative increased awareness of the problem of pain in dementia and influenced respondent behavior.

CONCLUSIONS

In this investigation, we demonstrated success in directing knowledge users to a resource website with practical information that health professionals could use in patient care along with pain assessment and management information for caregivers and people living with dementia. The evaluation metrics suggested no considerable differences between our pilot campaign and broader initiative when accounting for the length of time of each initiative. The limitations of large-scale health campaigns were noted, and recommendations were outlined for other researchers aiming to leverage social media as a knowledge mobilization tool.

Assessment of Preferences in Taking Painkillers among Students of Medicine, Dentistry, and Pharmacy: A Pilot Study

Students of pharmacy, medicine, and dentistry are important for shaping drug policy. The aim of this study is to assess and compare students preferences in taking painkillers. The study group consists of 382 students of pharmacy (28.8%), medicine (40.0%), and dentistry (30.1%). An anonymous questionnaire consisting of 17 questions was prepared using the Google Forms platform and distributed through social media. Ibuprofen was the most frequently preferred, regardless of the study major (57.8%). Pharmacy students expressed the least concern about the possible side effects of analgesics (17.5%). The fast onset of painkillers was more important for dental students (59.1%) and pharmacy students (44.7%), compared to medical students (39.22%). Medicine and pharmacy students indicated their studies to be their main source of information about painkillers compared to dentistry students (p = 0.001). There are no differences in pain severity regarding which analgesics are used among student groups (p = 0.547). Dental students experienced odontogenic pain less frequently (57.3%) than medical (79.7%) and pharmacy students (79.8%), (p = 0.000). Ketoprofen was the most frequently chosen prescription painkiller for odontogenic pain in all groups (49.4%). Gastrointestinal complaints were the most often reported side effects, regardless of the study major (87.1%). Choice of studies, gender, and year of study were the most important determinants of the choice of painkillers.

Pharmacological treatment of pain in Swedish nursing homes: Prevalence and associations with cognitive impairment and depressive mood

OBJECTIVES

Chronic pain is highly prevalent in nursing home residents and often occurs with depression as well as cognitive impairment, which can severely influence and limit the expression of pain.

METHODS

The present cross-sectional study aimed to estimate the prevalence of pain, depressive mood, and cognitive impairment in association with pharmacological treatment against pain and depressive symptoms among Swedish nursing home residents.

RESULTS

We found an overall pain prevalence of 52.8%, a prevalence of 63.1% for being in a depressive mood, and a prevalence of cognitive impairment of 68.3%. Among individuals assessed to have depressive mood, 60.5% were also assessed to have pain. The prevalence of pharmacological treatment for pain was 77.5 and 54.1% for antidepressants. Prescription of pharmacological treatment against pain was associated with reports of currently having pain, and paracetamol was the most prescribed drug. A higher cognitive function was associated with more filled prescriptions of drugs for neuropathic pain, paracetamol, and nonsteroidal anti-inflammatory drugs (NSAIDs), which could indicate an undertreatment of pain in those cognitively impaired.

CONCLUSION

It is important to further explore the relationship between pain, depressive mood, and cognitive impairment in regard to pain management in nursing home residents.

Prevalence of Chronic Pain Among People with Dementia: A Nationwide Study Using French Administrative Data

OBJECTIVE

Alzheimer's disease or Related Dementia (ADRD) is known to disturb pain perception and reduce the ability to report it, resulting in underestimation by practitioners and sub-optimal medical management. The aim of this study was to estimate the prevalence of all types of CP among people with ADRD.

DESIGN

Nationwide cross-sectional study.

SETTINGS

French community-dwelling and nursing home residents.

PARTICIPANTS

People with ADRD, >40 years old, treated with cholinesterase inhibitors or memantine, or with a diagnosis/long-term illness of ADRD and matched with a comparison sample.

SETTINGS

French community-dwelling and nursing home residents.

PARTICIPANTS

People with ADRD, >40 years old, treated with cognitive stimulants (cholinesterase inhibitors and memantine) or with a diagnosis/long-term illness of ADRD and matched with a comparison sample (non-ADRD).

MEASUREMENTS

The capture-recapture method was performed to provide estimates of the prevalence of CP. People treated with analgesic drugs for ≥6 months consecutively or with a medical diagnosis of CP (ICD-10 codes) or referred to a pain center were considered as having CP.

RESULTS

A total of 48,288 individuals were included, of which 16,096 had ADRD and 32,192 without ADRD. The estimated prevalence of CP in people with ADRD was from 57.7% [52.9;63.3] to 57.9%[53.0;63.9], and slightly higher than the non-ADRD sample (from 49.9%[47.0;53.2] to 50.4%[47.3;53.9], p <0.001).

CONCLUSIONS

The prevalence of CP among people living with ADRD was at least the same as or better than individuals without ADRD. This result should alert practitioners' attention to the need for effective pain assessment and management in this population who has difficulties to express and feel pain.

Perioperative Anxiety and Depression in Older Adults: Epidemiology and Treatment

The intervals before and after major surgery is a high-risk period for older adults; in this setting, anxiety and depression are common and serious problems. We comprehensively reviewed current evidence on perioperative anxiety and depression in older adults, focusing on epidemiology, impact, correlates, medication risks, and treatment. Principles of perioperative mental healthcare are proposed based on the findings. Prevalence estimates of clinically significant anxiety and depression range from 5% to 45% for anxiety and 6% to 52% for depression, depending on surgical populations and measurement tools. Anxiety and depression may increase risk for surgical complications and reduce patient participation during rehabilitation. Medical comorbidities, pain, insomnia, cognitive impairment, and delirium are common co-occurring problems. Concomitant uses of central nervous system acting medications (benzodiazepines, anticholinergics, and opioids) amplify the risks of delirium and falls. Based on these findings, we propose that anxiety and depression care should be part of perioperative management in older adults; components include education, psychological support, opioid-sparing pain management, sleep management, deprescribing central nervous system active medications, and continuation and optimization of existing antidepressants. More research is needed to test and improve these care strategies.

Emergency Department Pain Management in the Older Adult

Pain assessment and management in older adults is complex and requires evaluation and consideration of the type of pain, the acuity of the condition, comorbidities, and medications. Many older adults do not receive appropriate therapy for painful conditions in the emergency department (ED). This brief review article is focused on pharmacologic agents, drug-drug interactions, drug-disease interactions, and approaches in the management of painful conditions seen in older adults in the emergency department. Recommendations for specific painful conditions such as fragility fractures are discussed.

Pain Assessment in Oral Medicine through Its Different Dimensions: A Comprehensive Review

Orofacial pain is a complex experience made up of different features and involving various aspects of life. It has demonstrated a connection, especially when chronic, with conditions such as anxiety, depression, and sleep disorders, through paths that still have not been completely clarified. A deep understanding of orofacial pain and its impact on an individual's life is critical for planning accurate diagnostic and therapeutic approaches. This review seeks to provide a comprehensive overview of the components constituting the pain experience, its implications in an individual's life, the different tools for multidimensional pain assessment, and the specific applications for each tool. A comprehensive review was performed using the PubMed, Scopus, and Web of Science electronic databases. Ninety-five studies, including observational studies, clinical trials, case-control studies, and case reports, were included and analyzed in this review. Orofacial pain assessment exploits several methods, ranging from clinical evaluation to rating scales, questionnaires, and daily diaries. The choice of the correct instrument requires an evaluation of the type of pain experienced, of the patient's characteristics and abilities to complete particular tasks, and finally, of the assessment tool features.

Prospective study of pain and patient outcomes in the emergency department: a tale of two pain assessment methods

BACKGROUND

Accurate pain assessment is essential in the emergency department (ED) triage process. Overestimation of pain intensity, however, can lead to unnecessary overtriage. The study aimed to investigate the influence of pain on patient outcomes and how pain intensity modulates the triage's predictive capabilities on these outcomes.

METHODS

A prospective observational cohort study was conducted at a tertiary care hospital, enrolling adult patients in the triage station. The entire triage process was captured on video. Two pain assessment methods were employed: (1) Self-reported pain score in the Taiwan Triage and Acuity Scale, referred to as the system-based method; (2) Five physicians independently assigned triage levels and assessed pain scores from video footage, termed the physician-based method. The primary outcome was hospitalization, and secondary outcomes included ED length of stay (EDLOS) and ED charges.

RESULTS

Of the 656 patients evaluated, the median self-reported pain score was 4 (interquartile range, 0-7), while the median physician-rated pain score was 1.5 (interquartile range, 0-3). Increased self-reported pain severity was not associated with prolonged EDLOS and increased ED charges, but a positive association was identified with physician-rated pain scores. Using the system-based method, the predictive efficacy of triage scales was lower in the pain groups than in the pain-free group (area under the receiver operating curve, [AUROC]: 0.615 vs. 0.637). However, with the physician-based method, triage scales were more effective in predicting hospitalization among patients with pain than those without (AUROC: 0.650 vs. 0.636).

CONCLUSIONS

Self-reported pain seemed to diminish the predictive accuracy of triage for hospitalization. In contrast, physician-rated pain scores were positively associated with longer EDLOS, increased ED charges, and enhanced triage predictive capability for hospitalization. Pain, therefore, appears to modulate the relationship between triage and patient outcomes, highlighting the need for careful pain evaluation in the ED.

A systematic review of prevalence of pain in nursing home residents with dementia

BACKGROUND

The prevalence of dementia in nursing home (NH) residents is high, and pain is a troublesome symptom for them. Several studies since 2010 have focused on pain in NH residents with dementia, but there is a lack of systematic reviews on the prevalence of pain in NH residents with dementia.

AIM

To systematically review observational studies published from 2010 to 2023 on how pain is assessed and prevalence of pain found in NH residents with dementia.

METHODS

A systematic search was conducted in the MEDLINE, PubMed, PsycINFO, Embase, CINAHL, AgeLine, and Cochrane databases for studies published from January 2010 to August 2023. Studies were included if they were observational studies with a quantitative design where self-report, staff assessment, and/or chart review were used to define the prevalence of pain in samples or subsamples of NH residents with dementia.

RESULTS

Of 184 studies considered, 25 were included. The studies assessed pain as daily, present, clinically relevant, chronic, intermittent, persistent pain and/or if pain affected quality of life. The prevalence of pain was high in most studies of NH residents with dementia independent of whether pain was reported as presence of pain or clinically relevant pain, but the prevalence varied from 8.6% to 79.6%. This prevalence was quite stable across the NH stay, but higher towards the end of life (up to 80.4%). Study designs and methodologies differed considerably. About half relied on an observational assessment inventory.

CONCLUSION

The number of studies focusing on pain in NH residents with dementia was restricted and methodologies differed considerably. Relatively few studies used an observational assessment inventory. In view of the fact that residents with dementia may have difficulties communicating pain, clinicians should pay attention to pain in these residents, systematically and reliably uncover pain by use of observational inventories, and subsequently treat pain to secure high quality care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effects of ultrasound-guided QLB and TAPB combined with opioid-free anesthesia (OFA) on clinical efficacy of the patients undergoing abdominal surgery

Background

Although opioids provide effective analgesia for abdominal surgery, they also present serious unwanted side effects. Ultrasound-guild quadratus lumborum block (QLB) and transversus abdominis plane block (TAPB) have been proven to offer long-lasting and efficient analgesia during abdominal surgery. However, the clinical efficacy of ultrasound-guided QLB and TAPB combined with opioid-free anesthesia (OFA) in abdominal surgery remains unclear.

Objective

This study aimed to investigate the impact of ultrasound-guided QLB and TAPB combined with opioid-free anesthesia (OFA) on the clinical efficacy of abdominal surgery.

Methods

A total of 122 patients scheduled for abdominal surgery at People's Hospital of Wanning between March 2021 and April 2022 were enrolled in this study. Participants were randomly divided into two groups: the experimental group (QLB/TAPB + OFA, 62 patients) and the control group (opioid anesthesia, 60 patients). The clinical efficacy of the QLB/TAPB combined with OFA technique was evaluated by analyzing patients' vital signs, postoperative consciousness recovery time, numeric rating scale (NRS) score, and immune function in both groups.

Results

We observed that systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in experimental group were significantly higher than those in control group after induction (p < 0.05). Heart rate (HR) in experimental group was significantly lower than in the control group at intraoperative 1h (p < 0.05). Additionally, bispectral index (BIS), state entropy (SE), and response entropy (RE) levels in the experimental group were significantly higher than those in the control group (p < 0.05). Furthermore, extubation and awakening time were significantly shorter in the experimental group compared to the control group (p < 0.05). The NRS scores in the experimental group were markedly lower than those in the control group. Moreover, IL-6 and CRP levels in the experimental group were obviously lower than in the control group after postoperative 1d (p < 0.05). Interestingly, IL-6 (p < 0.001), CRP (p < 0.001), and PCT (p = 0.037) levels in female patients of the experimental group were all significantly lower than those in the control group after postoperative 1d.

Conclusions

Ultrasound-guided QLB and TAPB combined with OFA technique can reduce pain intensity and enhance the patients' immune function in abdominal surgery.

Pain and quality of life in nursing home residents with dementia after admission - a longitudinal study

BACKGROUND

Pain in nursing home (NH) residents with dementia is commonly reported and may affect Quality of Life (QoL) negatively. Few longitudinal studies have explored how pain and QoL develop in NH residents with dementia starting from their admission to the NH.

AIM

The aim was to explore pain, QoL, and the association between pain and QoL over time in persons with dementia admitted to a NH.

METHODS

A convenience sample, drawn from 68 non-profit NHs, included a total of 996 Norwegian NH residents with dementia (mean age 84.5 years, SD 7.6, 36.1% men) at NH admission (A1), with annual follow-ups for two years (A2 and A3). Pain and QoL were assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale and the Quality of Life in Late-Stage Dementia (QUALID) scale, respectively, at all assessments. Severity of dementia, personal level of activities of daily living, general medical health, neuropsychiatric symptoms, and the prescription of psychotropic drugs and analgesics (opioids and/or paracetamol) were also assessed at all assessments.

RESULTS

Mean (SD) MOBID-2 pain intensity scores were 2.1 (2.1), 2.2 (2.2), and 2.4 (2.1) at A1, A2, and A3, respectively. Participants who were prescribed analgesics had higher pain intensity scores at all assessments than participants not prescribed analgesics. The mean (SD) QUALID scores at each assessment were 19.8 (7.1), 20.8 (7.2), and 22.1 (7.5) at A1, A2, and A3, respectively. In the adjusted linear mixed model, higher pain intensity score, prescription of opioids, and prescription of paracetamol were associated with poorer QoL (higher QUALID total score and higher scores in the QoL dimensions of sadness and tension) when assessed simultaneously. No time trend in QoL was found in these adjusted analyses.

CONCLUSION

NH residents with dementia who have higher pain intensity scores or are prescribed analgesics are more likely to have poorer QoL. Clinicians, NH administrators, and national healthcare authorities need to look into strategies and actions for pharmacological and non-pharmacological pain treatment to reduce pain intensity while simultaneously avoiding negative side effects of pain treatment that hamper QoL.

Pain and Its Management in Patients Referred to a Geriatric Outpatient Clinic

(1) Background: A major problem affecting geriatric patients is pain. In addition to pain, a significant problem of old age is dementia and depression, which can hinder the diagnosis and treatment of pain. The aim of this study was to analyse the prevalence of pain in patients treated in a geriatric outpatient clinic and the treatment used. (2) Methods: The analysis was based on the records of 937 patients who visited the Geriatric Outpatient Clinic in Dobre Miasto between 2015 and 2020. Based on records containing data dating back to their first visit to the hospital, patients' experiences of pain, the presence of depressive symptoms and dementia, and the pharmacological treatment used for pain (analgesics and coanalgesics) were analysed. (3) Results: Pain complaints were reported by 311 patients (33.2% of the study group), 76% of the complaints were from females. The mean age of the patients was 78 years (SD = 8.45). At least one analgesic drug was taken by 107 patients (34.4%). The most commonly used analgesics were opioids (63 patients, 58.87%), especially tramadol. Of the potential coanalgesics, the largest number of patients used an antidepressant. (4) Conclusions: Despite the widespread prevalence of pain among the elderly, only about one-third of them were taking pain medication, mainly in the form of weak opioids. Patients with symptoms of dementia were found to report pain less frequently.

Assessing and managing pain in older people with dementia

There is little evidence to suggest that people with dementia experience less pain than those without dementia, however they are less likely to report their pain due to the cognitive impairments they experience as their dementia progresses. A comprehensive pain assessment that involves family members, carers and/or friends in the process is crucial to gain an understanding of a person's medical and pain history, and to ensure effective pain management in people with dementia. This article describes the identification, assessment and management of pain in older people with dementia. The author includes a fictional case study with the aim of supporting nurses to reflect on possible indicators of pain in a person with dementia and to consider the tools they may use when identifying and assessing this pain.

The Association of Cognitive Status and Post-Operative Opioid Prescribing in Older Adults

Objective

To examine the differences in opioid prescribing by cognitive status following common elective surgical procedures among Medicare beneficiaries.

Background

Older individuals commonly experience changes in cognition with age. Although opioid prescribing is common after surgery, differences in opioid prescribing after surgery by cognitive status are poorly understood.

Methods

We conducted a retrospective analysis of patients ≥65 years participating in the Health and Retirement Study (HRS) linked with Medicare claims data who underwent surgeries between January 2007 and November 2016 and had cognitive assessments before the index operation. Cognitive status was defined as normal cognition, mild cognitive impairment (MCI), or dementia. Outcomes assessed were initial perioperative opioid fill rates, refill rates, and high-risk prescriptions fill rates. The total amount of opioids filled during the 30-day postdischarge period was also assessed. Adjusted rates were estimated for patient factors using the Cochran-Armitage test for trend.

Results

Among the 1874 patients included in the analysis, 68% had normal cognition, 21.3% had MCI, and 10.7% had dementia. Patients with normal cognition (58.1%) and MCI (54.5%) had higher initial preoperative fill rates than patients with dementia (33.5%) (P < 0.001). Overall, patients with dementia had similar opioid refill rates (21%) to patients with normal cognition (24.1%) and MCI (26.5%) (P = 0.322). Although prior opioid exposure did not differ by cognitive status (P = 0.171), among patients with high chronic preoperative use, those with dementia had lower adjusted prescription sizes filled within 30 days following discharge (281 OME) than patients with normal cognition (2147 OME) and MCI (774 OME) (P < 0.001; P = 0.009 respectively). Among opioid-naive patients, patients with dementia also filled smaller prescription sizes (97 OME) compared to patients with normal cognition (205 OME) and patients with MCI (173 OME) (P < 0.001 and P = 0.019, respectively).

Conclusions

Patients with dementia are less likely to receive postoperative prescriptions, less likely to refill prescriptions, and receive prescriptions of smaller sizes compared to patients with normal cognition or MCI. A cognitive assessment is an additional tool surgeons can use to determine a patient's individualized postoperative pain control plan.

Establishing the Feasibility and Acceptability of a Caregiver Targeted Intervention to Improve Pain Assessment Among Persons With Dementia

Background and Objectives

Despite its prevalence and impact, pain is underdetected and undermanaged in persons with dementia. Family caregivers are well positioned to detect pain and facilitate its management in their care recipients, but they lack training in symptom recognition and communication. This study reports findings from a pilot trial evaluating the Pain Identification and Communication Toolkit (PICT), a multicomponent intervention that provides training in observational pain assessment and coaching in pain communication techniques.

Research Design and Methods

Family caregivers of persons with comorbid pain and moderate-to-advanced dementia were randomly assigned to PICT (n = 19) or a control condition (n = 15). Caregivers in the PICT group participated in four weekly sessions delivered by telephone with a trained interventionist; caregivers in the control group received an information pamphlet about pain and dementia. All participants completed surveys at baseline and 12 weeks. Caregivers in the intervention group also completed semistructured interviews at 12 weeks. Quantitative data were analyzed using descriptive statistics and t tests; qualitative data were analyzed using content analysis.

Results

All participants (100%) in the PICT group completed the intervention and most completed the 12-week assessment (94%). PICT randomized caregivers reported that the intervention helped them to feel more confident in their ability to recognize (67%) and communicate about pain symptoms (83%). At 12 weeks, caregivers in the PICT group showed a statistically significant improvement in self-efficacy in pain-related communication. In qualitative interviews, caregivers emphasized the utility of PICT's components, including pain assessment tools, and offered considerations for future enhancements, such as technology-based adaptations and integration within care delivery systems.

Discussion and Implications

This pilot trial demonstrates that PICT is feasible to implement, acceptable to caregivers, and has the potential to improve confidence in recognizing and communicating about pain. Results support conducting a fully powered efficacy trial, an important step toward future integration into real-world care delivery.

Clinical Trial Registration Number

NCT03853291.

Prevalence and persistent prescription of analgesic drugs in persons admitted with dementia to a nursing home - A longitudinal study

The overall aim was to explore the prevalence and persistent regular prescription of opioids and paracetamol among nursing home (NH) residents with dementia at admission and over time. A total of 996 residents with dementia, mean (SD) age 84.5 (7.6) years and (36.1% men), were included at admission (A1). Yearly assessments were performed for two years (A2 and A3) or until death. Pain was assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale. Information regarding prescription of analgesics, general physical health, personal activities of daily living, severity of dementia, neuropsychiatric symptoms, and prescription of psychotropic drugs was collected. A generalized linear mixed model was used to explore whether pain severity was associated with persistent and persistent prescription of opioids and/or paracetamol across timepoints. At A1, 495 of 996 (49.7%) NH residents were prescribed analgesics and prevalence increased at the follow-ups (A2: n = 630, 65.1%; A3: n = 382, 71.2%). Paracetamol was the most frequently prescribed analgesic at all assessments (A1: 45.5%; A2: 59.5%; A3: 67.1%). Opioid prescriptions were quite prevalent (A1: 18.1%; A2: 25.1%; A3: 28.3%), with odds approximately 13 times (OR = 13.3, 95% CI 6.8-26.0) and 9 times (OR = 8.6, 95% CI 3.7-20.3) higher for prescription at follow-up A2 and A3, respectively, relative to prescription at A1. In adjusted analyses, higher pain intensity and poor physical health were associated with prescription and persistent prescription of opioids and paracetamol. In conclusion, prevalence and persistent prescription of analgesics were high in NH residents with dementia. The odds for the prescription of opioids at follow-up were high if prescribed at baseline. Interdisciplinary collaboration, routine assessment of pain at admission and regularly thereafter, and systematic drug reviews are essential to adequately assess and treat pain in NH residents with dementia.

Pain in nursing home residents with dementia and its association to quality of life

OBJECTIVES

We aimed to describe pain, use of analgesics and quality of life (QoL) in people with dementia admitted to a Norwegian nursing home (NH), and to explore if and how pain was associated with their QoL when adjusting for sociodemographic characteristics, other health conditions and use of analgesics.

METHOD

A total of 953 Norwegian NH residents with dementia (mean age 84.0, SD 7.5 years, 35.8% men) were included at admission to the NH. Pain and QoL were assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale and the Quality of Life in Late-Stage Dementia (QUALID) scale, respectively. Severity of dementia, personal level of activities of daily living, general medical health, neuropsychiatric symptoms, and the use of psychotropic drugs and analgesics were assessed.

RESULTS

In total, 36% of the participants had clinically relevant pain intensity (MOBID-2 ≥ 3) and 52% received analgesics. Paracetamol was most frequently prescribed (45%). In an adjusted linear mixed model, more severe pain was associated with higher QUALID total scores, indicating poorer QoL (regression coefficient 0.52, 95% CI 0.36-0.69).

CONCLUSION

Pain prevalence at NH admission was high in residents with dementia; half used analgesics, particularly paracetamol. More severe pain was associated with poorer QoL when adjusting for sociodemographic characteristics, other health conditions, and use of analgesics. The routine assessment of pain at NH admission can uncover undiagnosed and untreated pain and allow for adequate non-pharmacological and pharmacological pain management and likely increased QoL.

Readiness for the aging population in private dental practices

BACKGROUND

As more adults reach advanced age with natural teeth, there is an increasing need for dental and dental hygiene practices to provide care for older adults and individuals living with dementia. Little is known about how well these populations are accommodated in private practice.

METHODS

Following approval from the Research Ethics Board at Mount Allison University, a survey was sent to the 517 practising dental hygienists in New Brunswick, Canada. They were asked to rate on 5-point scales their geriatric oral care knowledge, their willingness to receive more education on the topic, and how frequently they adjusted their care provision to meet the needs of older (age 70+) clients and those living with dementia.

RESULTS

A total of 121 dental hygienists responded (23.4% response rate). Overall, respondents were willing to learn more about geriatric care, but lacked knowledge about the oral health effects of certain medications frequently used by older adults, and about techniques for accessing the oral cavity of clients with dementia. Many accommodations recommended by geriatric specialists were not consistently carried out.

DISCUSSION

Given that older adults and adults with dementia make up an increasingly large part of the population in need of oral care, geriatric and dementia oral care needs should be emphasized in dental and dental hygiene practices and continuing education for dental hygienists.

CONCLUSION

More research is required on the impact of integrating accommodations for older clients and clients with dementia into clinical practice, as well as how oral care is experienced by these populations.

Psychometric properties of pain measurements for people living with dementia: a COSMIN systematic review

PURPOSE

Detecting pain in older people with dementia is challenging. Consequentially, pain is often under-reported and under-treated. There remains uncertainty over what measures should be promoted for use to assess pain in this population. The purpose of this paper is to answer this question.

METHODS

A search of clinical trials registered on the ClinicalTrial.gov and ISRCTN registries was performed to identify outcome measures used to assess pain in people with dementia. Following this, a systematic review of published and unpublished databases was performed to 01 November 2021 to identify papers assessing the psychometric properties of these identified measures. Each paper and measure was assessed against the COSMIN checklist. A best evidence synthesis analysis was performed to assess the level of evidence for each measure.

RESULTS

From 188 clinical trials, nine outcome measures were identified. These included: Abbey Pain Scale, ALGOPLUS, DOLOPLUS-2, Facial Action Coding System, MOBID-2, self-reported pain through the NRS or VAS/thermometer or Philadelphia Geriatric Pain Intensity Scale, PACSLAC/PACSLAC-2, Pain Assessment in Advanced Dementia (PAINAD), and Checklist for non-verbal pain behavior (CNPI). From these, 51 papers (5924 people with dementia) were identified assessing the psychometric properties of these measures. From these, there was strong- and moderate-level evidence to support the use of the facial action coding system, PACSLAC and PACSLAC-II, CNPI, DOLOPLUS-2, ALGOPLUS, MOBID, and MOBID-2 tools for the assessment of pain with people living with dementia.

CONCLUSION

Whilst these reflect measurement tools used in research, further consideration on how these reflect clinical practice should be considered.

PROSPERO REGISTRATION

CRD42021282032.

Assess of Combinations of Non-Pharmacological Interventions for the Reduction of Irritability in Patients with Dementia and their Caregivers: A Cross-Over RCT

Introduction: Dementia is a very common disorder that affects people over 65 years old all over the world. Apart from the cognitive decline, Behavioral and Psychological Symptoms of Dementia (BPSD) are a crucial matter in dementia, because they affect up to 90% of the patients during the course of their illness. Irritability has been found to be a common BPSD and one of the most distressing behaviors for the caregivers. The aim of the current study was to explore the efficacy of a combination of non-pharmacological interventions to treat irritability. Methods: Sixty patients with different types and stages of dementia with irritability were participated in a cross-over RCT. Three non-pharmacological interventions were used; (a) Validation Therapy (VT)/Psycho-educational program, (b) Aromatherapy/massage and (c) Music Therapy (MT). The study assessed the three non-pharmacological interventions in order to find the most effective combination of the interventions. This study did not compare pharmacological and non-pharmacological treatments. The interventions lasted for five days. There was no drop-out rate. All patients were assessed at baseline using Mini Mental State of Examination (MMSE), Addenbrooke’s Cognitive Examination Revised (ACE-R), Geriatric Depression Scale (GDS), Functional Rating Scale for symptoms in dementia (FRSSD), and Neuropsychiatric Inventory (NPI) (sub questions for irritability). Only NPI used for the assessment after each intervention. The analyses used categorical variables, Wilcoxon signed-rank test, Chi-square test and z value score. Results: The most effective combination of non-pharmacological interventions was Aromatherapy/massage (p = 0.003)-VT plus Psycho-educational program (p = 0.014) plus MT (p = 0.018). The same combination was the most effective for the caregivers’ burden, too (p = 0.026). Conclusions: The above combination of non-pharmacological interventions can reduce irritability in patients with dementia and caregivers’ burden.

Invariance of the PAINAD Scale Between the Black and White Residents Living With Dementia

The purpose of this study was to test the reliability and validity of the Pain Assessment in Advanced Dementia (PAINAD) and particularly consider whether or not this measure was invariant when used among the Black and White residents. Baseline data from an implementation study testing that included a sample of 553 residents, 30% of who were Black, from 55 nursing were included in this study. The Winsteps statistical program was used to perform the Rasch analysis and evaluate the reliability and validity of the measure based on internal consistency, infit and outfit statistics, mapping, and a differential item functioning (DIF) analysis. The AMOS statistical program was used for confirmatory factor analysis. The findings supported the reliability and validity of the PAINAD when used with these individuals and demonstrated that there was no evidence of invariance between the Black and White residents. All the items fit the model, but there was not a good spread of the items across the pain level of the participants. The majority of the participants (75%) were so low in pain signs or symptoms that they could not be differentiated. Based on the clinical practice and observations, it is recommended that additional items can be added to the measure such as observing the individual for evidence of resisting care, retropulsion when trying to stand, hitting or kicking when turning in bed, hitting or kicking when transferring from bed to chair, hitting or kicking when ambulating, or hitting or kicking when raising arms, less engagement with others, and decreased participation in the activities previously enjoyed.

Chronic Pain in the Elderly: Mechanisms and Perspectives

Chronic pain affects a large part of the population causing functional disability, being often associated with coexisting psychological disorders, such as depression and anxiety, besides cognitive deficits, and sleep disturbance. The world elderly population has been growing over the last decades and the negative consequences of chronic pain for these individuals represent a current clinical challenge. The main painful complaints in the elderly are related to neurodegenerative and musculoskeletal conditions, peripheral vascular diseases, arthritis, and osteoarthritis, contributing toward poorly life quality, social isolation, impaired physical activity, and dependence to carry out daily activities. Organ dysfunction and other existing diseases can significantly affect the perception and responses to chronic pain in this group. It has been proposed that elderly people have an altered pain experience, with changes in pain processing mechanisms, which might be associated with the degeneration of circuits that modulate the descending inhibitory pathways of pain. Aging has also been linked to an increase in the pain threshold, a decline of painful sensations, and a decrease in pain tolerance. Still, elderly patients with chronic pain show an increased risk for dementia and cognitive impairment. The present review article is aimed to provide the state-of-art of pre-clinical and clinical research about chronic pain in elderly, emphasizing the altered mechanisms, comorbidities, challenges, and potential therapeutic alternatives.

Association of Variation in Behavioral Symptoms With Initial Cognitive Phenotype in Adults With Dementia Confirmed by Neuropathology

IMPORTANCE

Behavioral and psychological symptoms of dementia (BPSDs) in association with amnestic and nonamnestic cognitive phenotypes have not been evaluated across diagnoses of Alzheimer disease pathology (ADP), Lewy body-related pathology (LRP), and mixed pathology (ADP-LRP).

OBJECTIVES

To determine the clinical phenotypes at the initial visit that are associated with the nature and severity of BPSDs in patients with ADP, LRP, and ADP-LRP.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective longitudinal cohort study included 2422 participants with neuropathologically confirmed ADP, LRP, or mixed ADP-LRP in the National Alzheimer Coordinating Center database from June 20, 2005, to September 4, 2019. Participants had a mean (SD) interval of 5.5 (2.8) years from initial visit to autopsy.

MAIN OUTCOMES AND MEASURES

Clinician-determined diagnosis of change across 10 BPSDs (agitation, apathy, depression, delusions, disinhibition, auditory hallucinations, visual hallucinations, irritability, personality change, and rapid eye movement [REM] sleep behavior) and the highest severity score for behavioral change on the Neuropsychiatric Inventory Questionnaire (NPI-Q).

RESULTS

A total of 2422 participants (1187 with ADP, 904 with ADP-LRP, and 331 with LRP) were included in the analysis (1446 men [59.7%]; mean [SD] age, 74.4 [10.1] years). Compared with initial amnestic symptoms, executive symptoms were associated with a higher risk for 7 of the 10 BPSDs (hazard ratio [HR] range, 1.28-2.45), and visuospatial symptoms were associated with a higher risk for 2 of the 10 BPSDs (HR range, 1.91-2.51), but neither were associated with a low risk for any BPSD. Language symptoms were associated with a low risk of onset for 3 of 10 BPSDs (HR range, 0.43-0.79) and a high risk for 1 BPSD (personality change) (HR, 1.42 [95% CI, 1.10-1.83]). Participants with LRP had a lower risk for agitation (HR, 0.74 [95% CI, 0.60-0.92]), disinhibition (HR, 0.78 [95% CI, 0.62-0.99]), and irritability (HR, 0.81 [95% CI, 0.68-0.96]) and a higher risk for apathy (HR, 1.19 [95% CI, 1.02-1.38]), depression (HR, 1.32 [95% CI, 1.12-1.55]), auditory (HR, 2.00 [95% CI, 1.37-2.93]) and visual (HR, 2.78 [95% CI, 2.21-3.49]) hallucinations, and REM sleep behavior changes (HR, 4.77 [95% CI, 3.61-6.31]) compared with the ADP group. The ADP-LRP group had a higher risk for delusions (HR, 1.27 [95% CI, 1.08-1.48]), auditory (HR, 1.62 [95% CI, 1.21-2.15]) and visual (HR, 1.57 [95% CI, 1.30-1.89]) hallucinations, and REM sleep behavior changes (HR, 2.10 [95% CI, 1.63-2.70]) than the ADP group and a lower risk for visual hallucinations (HR, 0.56 [95% CI, 0.45-0.71]) and REM sleep behavior changes (HR, 0.44 [95% CI, 0.34-0.57) than the LRP group. Overall, women showed a lower risk of agitation (HR, 0.86 [95% CI, 0.75-0.98]), apathy (HR, 0.79 [95% CI, 0.71-0.87]), visual hallucinations (HR, 0.76 [95% CI, 0.64-0.90]), irritability (HR, 0.77 [95% CI, 0.69-0.86]), and REM sleep behavior change (HR, 0.45 [95% CI, 0.35-0.58]) and a higher risk of depression (HR, 1.26 [95% CI, 1.13-1.41]). Older age was associated with a lower risk of most BPSDs (HR range, 0.98-0.99) except delusions (HR, 1.00 [95% CI, 1.00-1.01]) and auditory hallucinations (HR, 0.99 [95% CI, 0.97-1.00]) and a low NPI-Q composite score (β = -0.07 [95% CI, -0.08 to -0.05]; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that the risks of BPSDs differ with respect to the initial cognitive phenotype, underlying neuropathology, age, and sex. Awareness of these associations could be helpful in dementia management.

Non-pharmacological interventions to reduce pain in dementia: A quasi-experimental study

This study evaluated a non-pharmacological intervention nursing protocol for pain control and assessment of its evolution in a cohort of patients with moderate-to-severe dementia residing in three long-term care facilities in a metropolitan area in Spain. The study was a quasi-experimental pre- and post-exploratory intervention. The presence of pain was evaluated before and after the interventions of nursing protocol for 7 days, carried out by nurses. 157 residents of three centers participated (mean age 81.8 years, 58.1% were women, 83.2% had severe or moderately severe dementia and 65.2%) had regularly scheduled analgesic treatment. At baseline evaluation, the prevalence of pain, assessed with the PAINAD scale was 43.9% and this increased to 73.5% when pain was measured during bathing. The implementation of the nursing protocol of non-pharmacological interventions produced a decrease in pain of 11% (p = 0.0001). Multivariate Ancova analysis demonstrated that non-pharmacological interventions were effective independently of other factors as pressure sores or gender. The implementation of non-pharmacological interventions in social health care centers can produce a decrease in pain for those with dementia.

Current management of cancer pain in Italy: Expert opinion paper

Introduction

Chronic pain and breakthrough cancer pain (BTcP) have a high prevalence in all cancer types and cancer stages, combined with a significant physical, psychological, and economic burden. Despite efforts to improve appropriate management of cancer pain, a poor assessment and guilty undertreatment are still reported in many countries. The purpose of this expert opinion paper is to contribute to reduce and clarify these issues with a multidisciplinary perspective in order to share virtuous paths of care.

Methods

Common questions about cancer pain assessment and treatment were submitted to a multidisciplinary pool of Italian clinicians and the results were subsequently discussed and compared with the findings of the published literature.

Conclusion

Despite a dedicated law in Italy and effective treatments available, a low percentage of specialists assess pain and BTcP, defining the intensity with validated tools. Moreover, in accordance with the findings of the literature in many countries, the undertreatment of cancer pain is still prevalent. A multidisciplinary approach, more training programs for clinicians, personalised therapy drug formulations, and virtuous care pathways will be essential to improve cancer pain management.

Feasibility study protocol of the PainChek app to assess the efficacy of a social robot intervention for people with dementia

AIM

This study aims to test the feasibility of the PainChek app to assess pain for people with dementia living in residential aged care facilities (RACFs). It will also identify the optimal dosage and efficacy of a social robot (personal assistant robot [PARO]) intervention on chronic pain for people with dementia.

DESIGN

This is a feasibility randomized controlled trial with three groups.

METHODS

Forty-five residents living with dementia and chronic pain will be recruited from one RACF. The intervention consists of an individual 15-min non-facilitated session with a PARO robot twice a day (Group 1), a PARO robot once a day (Group 2), or a Plush-Toy (non-robotic PARO) once a day (Group 3) from Monday to Friday for 4 weeks. Participants will be followed at 4 and 8 weeks after baseline assessments. The primary outcome will be the feasibility of using the PainChek app to measure changes in pain levels before and after each session. Secondary outcomes include staff-rated pain levels, neuropsychiatric symptoms, quality of life and changes in psychotropic and analgesic medication use. Participants, staff and family perceptions of using PARO and the PainChek app will be collected after the 4-week intervention.

DISCUSSION

This study will test the use of the PainChek app and PARO to improve pain management for people with dementia. Results from this study will help determine its usefulness, feasibility and acceptability for pain management in people with dementia living in RACFs.

IMPACT

As pain is a significant problem for people with dementia, this project will generate evidence on the use of the PainChek to measure the efficacy of a social robot intervention that has the potential to improve the quality of pain care in people with dementia.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry number (ACTRN12621000837820) date registered 30/06/2021.

Insufficient pain control for patients with cancer and dementia during terminal cancer stages

PURPOSE

To estimate differences in pain control between patients with cancer and with or without dementia during terminal cancer stages 3 months or 1 month before cancer death.

PATIENTS AND METHODS

We conducted frequency matching cohort for age, sex, and year of death for both groups at a 1:4 ratio. The prescription prevalence, total cumulative dose, and average daily dose of opioids during the terminal cancer stages 3 months and 1 month before cancer death were estimated.

RESULTS

Patients with cancer and dementia were prescribed lower amounts of opioids 3 months before death (57.5% vs. 73.9%, respectively; adjusted odds ratio [OR] 0.46; 95% confidence interval [CI] 0.44-0.49) and 1 month before death (54.4% vs. 70.3%, respectively; adjusted OR 0.50; 95% CI 0.47-0.53). The total cumulative dose of opioids (mg) was lower in patients with cancer and dementia 3 and 1 month(s) before death (3 months: 1,578 mg vs. 2,666 mg, respectively; β=-1,125.9, P<0.001; 1 month: 921 mg vs. 1,533 mg, respectively; β=-622.1, P<0.001). The average daily opioid dose (mg/day), patients with cancer and dementia received a lower dose 3 months before death (31 mg vs. 48 mg; β=-22.6, P<0.001) and 1 month before death (38 mg vs. 60 mg; β=-17.1, P<0.001).

CONCLUSION

The prevalence of opioid prescription was significantly lower in patients with both cancer and dementia during their terminal cancer stages 3 months and 1 month before death.

Pain Assessment for Individuals with Advanced Dementia in Care Homes: A Systematic Review

Pain is prevalent in older people, especially in those with advanced dementia who have communication impairments. Although pain is recognised to be present in this population, it is often under-assessed and ineffectively managed. The assessment of pain in advanced dementia is extremely challenging and complex, particularly in institutional settings such as care homes. This study systematically reviews the literature to examine and characterise the evidence for the use of pain assessment tools in care homes with individuals living with advanced dementia. Relevant publications were sourced from electronic bibliometric medical databases including AMED, CINAHL Plus, Medline, PsycINFO, EMBASE, TRIP Pro, Google Scholar, and HINARI. The database search was supplemented by screening citations and reference lists, in addition to a grey literature searches. The search identified 2221 studies, among which 26 were included in the review. The majority of the studies were observational, which created a rich source of data to create four major themes. The findings were informed and shaped by working with key stakeholders to develop a conceptual model that can contribute to developing evidence-based practice. This highlights the importance of a comprehensive, multi-disciplinary approach to pain assessment in this population, which is beyond the use of tools.

Pain and Associated Neuropsychiatric Symptoms in Patients Suffering from Dementia: Challenges at Different Levels and Proposal of a Conceptual Framework

Old age is critically associated with multi-morbidity, chronic pain, and high risk for dementia. Recognizing and treating pain is very much dependent on language comprehension and production. Both may be impaired in dementia. Moreover, neuropsychiatric symptoms may interact with pain perception. The main aims of the present article were 1) to identify key areas for future research to elucidate the relation between pain and associated neuropsychiatric symptoms in dementia, and 2) to provide a conceptual framework for ameliorating the clinical process of recognizing, assessing, and managing pain in non-communicating patients with advanced dementia.

Uncontrolled Pain and Risk for Depression and Behavioral Symptoms in Residents With Dementia

OBJECTIVES

Limited cohort studies have assessed the association between uncontrolled pain and risk for behavioral and psychological symptoms of dementia (BPSDs). We conducted a longitudinal cohort study to examine whether associations exist between uncontrolled pain and risk for 2 common BPSDs-depression and behavioral symptoms-among long-term care (LTC) residents with Alzheimer disease and related dementia (ADRD).

DESIGN

This retrospective cohort study analyzed quarterly data from the 5% Medicare sample linked to Minimum Data Set (MDS) 3.0 between January 1, 2011, and December 31, 2015.

SETTING AND PARTICIPANTS

LTC residents aged 50 years or older with ADRD who had chronic pain and at least 2 quarterly MDS 3.0 assessments.

METHODS

LTC residents were followed up quarterly from first observed quarterly MDS 3.0 until first outcome event or last observed quarterly MDS 3.0. Uncontrolled pain was defined as numerical rating scale >4, verbal descriptor scale of moderate or severe pain, or ≥1 pain indicators on the Checklist of Nonverbal Pain Indicators. Depression was defined as ≥10 on the Patient Health Questionnaire 9; behavioral symptoms were defined as the presence of psychotic (delusions or hallucinations) or disruptive behaviors (rejection of care, or physical, verbal, or other aggressive behaviors). Generalized linear models (GLMs) with marginal structural modeling (MSM) stabilized weights were used to examine uncontrolled pain and outcome risk.

RESULTS

The incidence rate of depression and behavioral symptoms during follow-up was 9.4 and 23.1 per 100 resident-years, respectively. Results from the MSM-GLMs showed that LTC residents with uncontrolled pain had a higher risk than those with controlled pain for developing depression [hazard ratio 1.67, 95% confidence interval (CI) 1.54-1.81] and behavioral symptoms (hazard ratio 1.28, 95% CI 1.19-1.37).

CONCLUSIONS AND IMPLICATIONS

Uncontrolled pain was associated with elevated risk for depressive and behavioral symptoms in dementia, underscoring the importance of pain assessment and control among LTC residents with ADRD.

Pain in Dementia: Prevalence and Association With Neuropsychiatric Behaviors

CONTEXT

Pain is linked to behaviors and psychological symptoms of dementia (BPSD); however, it often remains underrecognized in this population.

OBJECTIVES

We aimed to investigate the prevalence and intensity of pain in people living in aged care homes with BPSD and by dementia subtypes and the association between pain intensity and BPSD.

METHODS

A 1-year retrospective cross-sectional analysis was conducted on BPSD and the presence of pain in referrals to a national BPSD support service using the Neuropsychiatric Inventory and PainChek®, respectively. Referrals were categorized into two groups: pain group and no pain group.

RESULTS

Of the 479 referrals (81.9 ± 8.3 years old) included in the analysis, two-thirds (65.6%) had pain identified, with almost half (48.4%) of these categorized as experiencing moderate-severe pain. Pain was highly prevalent (range: 54.6-78.6%) in all subtypes of dementia, particularly in mixed dementia and dementia with Lewy bodies. Compared with the no pain group, the pain group had 25.3% more neuropsychiatric behaviors, 33.6% higher total severity of these behaviors, and 31.4% higher total distress caused to caregivers. For all results, effect sizes were small to medium (η²p = 0.04-0.06). Despite a high prevalence of aggressive or agitated behaviors across the entire group, the pain group was 3.8 times more likely to experience these behaviors than referrals not in pain.

CONCLUSION

There is a strong need to consider the possibility of pain as a contributor to behavioral changes in aged care residents living with dementia.

Measuring the prevalence of sleep disturbances in people with dementia living in care homes: a systematic review and meta-analysis

Study Objectives

Sleep disturbances are a feature in people living with dementia, including getting up during the night, difficulty falling asleep, and excessive daytime sleepiness and may precipitate a person with dementia moving into residential care. There are varying estimates of the frequency of sleep disturbances, and it is unknown whether they are a problem for the individual. We conducted the first systematic review and meta-analysis on the prevalence and associated factors of sleep disturbances in the care home population with dementia.

Methods

We searched Embase, MEDLINE, and PsycINFO (29/04/2019) for studies of the prevalence or associated factors of sleep disturbances in people with dementia living in care homes. We computed meta-analytical estimates of the prevalence of sleep disturbances and used meta-regression to investigate the effects of measurement methods, demographics, and study characteristics.

Results

We included 55 studies of 22,780 participants. The pooled prevalence on validated questionnaires of clinically significant sleep disturbances was 20% (95% confidence interval, CI 16% to 24%) and of any symptom of sleep disturbance was 38% (95% CI 33% to 44%). On actigraphy using a cutoff sleep efficiency of <85% prevalence was 70% (95% CI 55% to 85%). Staff distress, resident agitation, and prescription of psychotropic medications were associated with sleep disturbances. Studies with a higher percentage of males had a higher prevalence of sleep disturbance.

Conclusions

Clinically significant sleep disturbances are less common than those measured on actigraphy and are associated with residents and staff distress and the increased prescription of psychotropics. Actigraphy appears to offer no benefit over proxy reports in this population.

An Objective Pain Score for Chronic Pain Clinic Patients

Objectives

Although numerous studies have looked at the numeric rating scale (NRS) in chronic pain patients and several studies have evaluated objective pain scales, no known studies have assessed an objective pain scale for use in the evaluation of adult chronic pain patients in the outpatient setting. Subjective scales require patients to convert a subjective feeling into a quantitative number. Meanwhile, objective pain scales utilize, for the most part, the patient's behavioral component as observed by the provider in addition to the patient's subjective perception of pain. This study aims to examine the reliability and validity of an objective Chronic Pain Behavioral Pain Scale for Adults (CBPS) as compared to the traditional NRS.

Methods

In this cross-sectional study, patients were assessed before and after an interventional pain procedure by a researcher and a nurse using the CBPS and the NRS. Interrater reliability, concurrent validity, and construct validity were analyzed.

Results

Interrater reliability revealed a fair-good agreement between the nurse's and researcher's CBPS scores, weighted kappa values of 0.59 and 0.65, preprocedure and postprocedure, respectively. Concurrent validity showed low positive correlation for the preprocedure measurements, 0.34 (95% CI 0.16-0.50) and 0.47 (95% CI 0.31-0.61), and moderate positive correlation for the postprocedure measurements, 0.68 (95% CI 0.56-0.77) and 0.67 (95% CI 0.55-0.77), for the nurses and researchers, respectively. Construct validity demonstrated an equally average significant reduction in pain from preprocedure to postprocedure, CBPS and NRS median (IQR) scores preprocedure (4 (2-6) and 6 (4-8)) and postprocedure (1 (0-2) and 3 (0-5)), p < 0.001. Discussion. The CBPS has been shown to have interrater reliability, concurrent validity, and construct validity. However, further testing is needed to show its potential benefits over other pain scales and its effectiveness in treating patients with chronic pain over a long-term. This study was registered with ClinicalTrial.gov with National Clinical Trial Number NCT02882971.

Pain prevalence among residents living in nursing homes and its association with quality of life and well-being

BACKGROUND

Pain is common and often more complex to assess among nursing homes residents with cognitive impairments. Thus, more research is needed of different pain assessment methods in elderly care and how these assessments outcomes are related to quality of life, as there mostly should be a negative relationship. There is a risk that pain are under diagnosed among persons with cognitive impairment.

AIM

The aim was to describe and compare pain prevalence among nursing home residents (1) using different pain assessment methods (2) in relation to cognitive status and to (3) examine associations between pain and quality of life or well-being.

METHODS

A cross-sectional correlational design was used, participants were 213 nursing home residents and data were collected through interviews using standardised protocols. Instrument used were Katz index of ADL, Mini-Mental-State-Examination, Quality of Life in Late-Stage Dementia scale, WHO-5 well-being index, Numeric Rating Scale and Doloplus-2 scale.

RESULTS

The results showed high pain prevalence, but no significant difference based on cognitive level. Pain classification at the individual level varied somewhat when different instruments are used. The results indicated that use of a single-item proxy-measure for pain tends to show higher pain prevalence and was not statistically significant related to quality of life. The relationship with quality of life was statistically significant when self-rated pain instruments or multi-component observation were used.

CONCLUSIONS

The study shows that it is difficult to estimate pain in residents living at nursing homes and that it continues to be a challenge to solve. Self-rated pain should be used primarily to assess pain, and a multi-component observation scale for pain should be used when residents are cognitively impaired. Both self-rated pain and multi-component observation also support the well-known link between pain and quality of life. Single-item proxy assessments should only be used in exceptional cases.

Pain management and cognitive function among older adults: an exploratory study of the China Health and Retirement Longitudinal Study

BACKGROUND

Chronic pain and cognitive decline are common age-related conditions affecting a large segment of older populations. Little is known about the pathway of cognitive functioning during the course of pain management in older adults.

AIMS

The study aimed to examine the association between chronic body pain management and cognitive function over time among Chinese older adults.

METHODS

A total of 792 respondents aged 60 and above from urban and rural households in 28 provinces, 150 counties/districts, and 450 communities were selected from the China Health and Retirement Longitudinal Study (2013-2015). Cognitive function was measured in three domains: episodic memory, mental status, and global cognitive function. Difference-in-differences approach and mixed-effects linear regression models were employed to assess the association between chronic body pain management and cognitive function over time.

RESULTS

Scores of mental status were found to decline slower by 0.49 unit (SE = 0.22, p < 0.05) in respondents who received pain management using analgesics, complementary and alternative medicine, or both from 2013 to 2015 after controlling for basic demographic and health confounders.

CONCLUSION

Chronic pain management was associated with slower decline in domain-specific cognitive function, mental status over time. Findings of the study may contribute to understanding the mechanism of change in diverse cognitive abilities attributable to pain symptoms. More research is needed to elucidate the mediating effect of pain on cognitive decline, which could lead to testing of the impact of pain management on cognitive function among older population in both clinical and community settings.

How to Teach Medical Students About Pain and Dementia: E-Learning, Experiential Learning, or Both?

OBJECTIVE

Pain management in persons with mild to moderate dementia poses unique challenges because of altered pain modulation and the tendency of some individuals to perseverate. We aimed to test the impact of an e-learning module about pain in communicative people with dementia on third-year medical students who had or had not completed an experiential geriatrics course.

DESIGN

Analysis of pre- to postlearning changes and comparison of the same across the student group.

SETTING

University of Pittsburgh School of Medicine and Saint Louis University School of Medicine.

SUBJECTS

One hundred four University of Pittsburgh and 57 Saint Louis University medical students.

METHODS

University of Pittsburgh students were randomized to view either the pain and dementia module or a control module on pain during a five-day geriatrics course. Saint Louis University students were asked to complete either of the two modules without the context of a geriatrics course. A 10-item multiple choice knowledge test and three-item attitudes and confidence questionnaires were administered before viewing the module and up to seven days later.

RESULTS

Knowledge increase was significantly greater among students who viewed the dementia module while participating in the geriatrics course than among students who viewed the module without engaging in the course (P < 0.001). The modules did not improve attitudes in any group, while student confidence improved in all groups.

CONCLUSIONS

Medical students exposed to e-learning or experiential learning demonstrated improved confidence in evaluating and managing pain in patients with dementia. Those exposed to both educational methods also significantly improved their knowledge.

Impact of the Fascia Iliaca Block on Pain, Opioid Consumption, and Ambulation for Patients With Hip Fractures: A Prospective, Randomized Study

OBJECTIVES

To determine the effect of the fascia iliaca block (FIB) on patients undergoing surgery for hip fractures.

DESIGN

Prospective, randomized controlled trial.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Patients (N = 97) undergoing surgery for hip fractures were prospectively randomized to receive either a perioperative FIB (FIB group) or no block (control group) from February 2018 to April 2019.

MAIN OUTCOME MEASURES

Visual analog scale (VAS) score, morphine milligram equivalents, and postoperative ambulatory distance.

RESULTS

Fifty-seven patients were randomized to the FIB group, and 40 patients were randomized to the control group. Eighteen patients crossed over from the FIB to the control group, and 12 patients crossed over from the control to the FIB group. In the intent-to-treat analysis, demographic data, mechanism of injury, radiographic fracture classification, and surgical procedure were similar between the 2 groups. The FIB group consumed fewer morphine milligram equivalents before surgery (13 vs. 17, P = 0.04), had a trend toward an improved visual analog scale score on postoperative day 2 (0 vs. 2 P = 0.06), and walked a farther distance on postoperative day 2 (25' vs. 2', P = 0.09). A greater proportion of the FIB group were discharged home (50.9% vs. 32.5%, P = 0.05). There were no differences in opioid-related, block-related, or medical complications between groups. In the as-treated and per-protocol analyses, there were no significant differences.

CONCLUSIONS

A single perioperative FIB for patients with hip fractures undergoing surgery may decrease opioid consumption and increase the likelihood that a patient is discharged home.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.