Pain Alleviation – Important Factor for Quality of Life in Seniors with Dementia

Nevenka Krčevski ŠkvarčFaculty of Medicine University of Maribor

Institute for Palliative Medicine and care

Slovenia

These individuals have complex care needs, multi-year periods of disability, and heavy reliance on the support of their

families and other caregivers

Irreversible dementia

Dementia – the most frequent neurodegenerative disease

Dementia

Associated with ageing:

5% > 65 years30% - 40% > 80 years

Risk factors:

Genetics 10% - 30%FemaleLower educationBrain traumaThyroid diseasesB vitamin insuficienceHigh blood fat

2010:35,6 mil

2030Twice more

Progressive irreversible impairment :

• loss of cognitive abilities• loss of language• loss of the ability to carry out

everyday activities

Could you recognize pain in these patients?

These patients suffer pain

• Pain behaviors may be complex and individualized and can be associated with depression, functional impairment and agitated behavior

• Pain can be a significant, under-reported and under-treated problem

If the person with dementia has the loss of pain memory, pain is new frightened experience which produce behavioral disturbances

Common causes of pain in dementia

• Neuropathic pain

• Incident pain

• Chronic pain

• Acute pain

Toothache

Celulitis

DVT

Arthritis

Pressure ulcers

Spasticity

Contractures

DPN

PZN

Dressing

Movements in bedbound patients

Pain in Dementia

• > 50% regularly experience pain

• Associated with:

Occurrence of neuropsychiatric functioning

Decline in cognitive functioning

Decline in performance of activities of daily life

Decrease in quality of life

• Differences in pain prevalence between dementia subtypes

FearDepression

Loss of appetiteLoss of body weight

Loss of memorySleep disturbancesImpaired mobility

Aggression, restlessnessDelirium

AD45,8%

VaD56,2%

LBD50-70%

Mixed53,9%

Cravelo L et al. Chronic pain in elderly with cognitive decline: a narrative review. Pain Ther. https:/doi.org/10.1007/s40122-019-0111-7.published online: 21 January 2019

Chronic pain conditions in Alzheimer‘s diseasein comparison with elderly without dementia

No dementia AD

MMSE 23±5 6±7

Arthritis/arthrosis/osteoporosis

65% 70%

Neuropathic pain 16% 15%

Cancer 27% 4%

Post surgical/fractures 6% 5%

Miscellaneous 20% 25%

Passmore et al. Https://www.gmjournal.co.uk/mediaI21697/sept2010p499.pdf

The problem of pain in patients with dementia lies significantly in the ability to recognize and assess their pain

Components of pain experience

affectivestate

cognitivestate

nociceptivesensoryinput

Typical degeneration of AD involves the affective-motivational component of pain (medial pathway) more than the sensory-discriminative dimension (lateral pathway)

Biopsychosocial model of pain and dementia3 heterogeneous phenomena: pain, aging and dementia

Decoding

PAIN

Pain report or expression

Pain judgment

Patient factorsPhysical

Impairment/ataxiaVerbal/numeric

DysfluenciesDysautonomia

Healthcare Worker/Caregiver Factors

AgeEmpathy

PerceptionPain beliefsExperience

Distress/burden

Biologic/Sensory

Age/agingSexComorbidityHealth statusPain experienceNeuropathologyDementia subtype

Social

Socioeconomic statusLiving situation

Affective

DepressionFear and pain

Pain unpleasantnessAnxiety

Autonomic responses

Cognitive

EducationSematic memoryEpisodic memory

Executive functionCognitive status

Abstract reasoningVigilance/AttentionAnticipation of pain

Gagliese l et all. Pain, aging and dementia: towards a biopsychosocial model. Progress in neuropharmacology 2018;87:207-15.

The process of pain management

Pain assessment

Differential assessment:

neuropsychiatric symptoms

Interdisciplinary treatment plan

Pharmacological treatment

Social psychological

spiritual

Psychological interventions

Review of response to treatment

Pain assessment

Self-report

Observation

Therapeutic trial

Examination

Pain assessment = guidance for effective treatment

The challenges of pain assessment in dementia

• Self-report of pain

• Regular pain assessment tools

• Education in communication

• Assessment tools

• Validation and implementation

of observational tools

• Expression of pain

• Difficult differentiation between causes of neuropsychiatric symptoms

Use few toolsConsider visual and hearing

impairmentUse the help of speech therapist

Most GPs were unfamiliar with dementia-specific pain assessment tools with only 10% reporting any knowledge of their existence

Jennings AA, Linehan M, Foley T. The knowledge and attitudes of general practitioners to the assessment and management of pain in people with dementia. BMC Fam Practice (2018)19:166. https://doi.org/10.1186/s12875-018-0853-z

Functional Assessment Staging Test (FAST)

Stage Patient condition Level of functional decline Expected duration of stage

Stage 1 Normal adult No functional decline N/A

Stage 2 Normal older adult Personal awareness of some functional decline Unknown

Stage 3 Early Alzheimer‘s disease Noticeable deficits in demanding job situations Average duration 7 years

Stage 4 Mild Alzheimer‘s disease Requires assistance in complicated tasks such as handling finances, traveling, planning parties

Average duration 2 years

Stage 5 Moderate Alzheimer‘s disease Requires assistance in choosing proper clothing Average duration 1.5years

Stage 6 Moderately severe Alzheimer‘s disease

Requires assistance with dressing, bathing, toileting. Experiences urinary and fecal incontinence

Average duration 3,5 -9,5 months

Stage 7 Severe Alzheimer‘s disease Speech ability declines to about a half-dozen intelligible words. Progressive loss of ability to walk, to sit up, to smile, to hold head up

Average duration 1 – 1,5 years

Self repo

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Self repo

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The challenges of pain assessment in advanced dementia

• The presence of physical pain or acute problems associated with pain could be overlooked by observers (toothache, ear problems, ungues incarnates)

• Pain could be overlooked due to mental problems

• No past/no future

• The present is everything

• Unable to split attention

In advanced dementia pain occupies the whole of

consciousness –

it becomes their whole world

Pain Assessment in Dementia

• Ability to recognize

• Ability to evaluate

• Ability to verbally communicate their pain

Self-reportAutomatic pain

assessment with video systems

Observational pain scales

Self-reportCommon etiological factors

Observation of patient‘s behaviorInformation from caregiver

Analgesic trialFACS:

Facial acting coding system

Tools mentioned for pain assessment in people with dementia

English language Dutch language German language

Pain Assessment in AdvancedDementia Scale (PAINAD)

Pain Assessment in AdvancedDementia Scale (PAINAD)

Beutreilung von Schmerzen beiDemenz (BESD)

Faces Pain Scale Faces Pain Scale Faces Pain Scale

Numeric rating scale Numeric rating scale Numeric rating scale

Visual analogue scale Visual analogue scale Visual analogue scale

Checklist Nonverbal Pain Indicators DOLOPLUS DOLOPLUS

Abbey pain scale Pain assessment checklist for seniors with limited ability to communicate (PACSLAC)

Beobachtunginstrument fur das schmerzassessmnet bei altenmenschen mit demenz (BISAD)

The Rotterdam Elderly Pain Observation Scale (Repos)

ECPA Scale

Scale not specified

Delirium Observation Screening Scale (DOS)

Zurich Observation Pain Assessment (ZOPA)

Scale not specified

Behavior pain scale (BPS)Braden scale

Zwakhalen S et all. Pain in older adults with dementia. Schmerz 2018;32:364-73.

Observational clinical approach was found to be valid and accounted for

more variance in differentiating pain-related and non-pain- related

states than did a detailed time-consuming fine grained approach

(FACS)

Hadjistavropoulos T et al. Pain in severe dementia: a comparison of a fine-grained assessment approach to an observational checklist designed for clinical settings. Eur J Pain 2018;22(5):915-25

PACSLAC: 31 pain behaviors

Observe for 5 min

Interpretation:

Moderate pain = 4 – 6Severe pain = 7 - 10

10 different situations that could potentially

reveal pain

5 Somatic reactions2 Psychomotor reactions3 Psychosocial reactions

One of ten different levels of pain intensity (0-3) for

each behavior

Potential total score of 30

The challenges of pain treatment in dementia

• Medical, social and psychological needs

• Higher risk of adverse reactions of drugs

• Altered evaluation of pain

• Altered complain on pain

Pharmacological treatment Non - pharmacological treatment

Physiological changesHigh comorbidityDrug interactions

Interventions on biopsychosocial factorsMultimodal cognitive behavioral therapyPhysical therapyComplementary therapies

The challenges of pharmacological pain treatment in dementia

Opioids

• Reduced access: impaired cognition and communication ability, neuropathological changes

• Higher risk: delirium, constipation, fractures

NSAIDs

• Can have significant cardiac, gastrointestinal, and renal risks

Pharmacological treatment

Approach Considerations

Simple analgesics and anti-inflammatory agents

Paracetamol Recommended first-line therapy. Well tolerated and side effects are rare. Do not exceed recommended maximum daily dose

NSAIDs High risk of serious side effects in elderly. Use for shortest time possible. Increased risk of gastrointestinal side effects when combined with low dose aspirin. Topical NSAIDs effective for localized non-neuropathic pain and generally well tolerated

Opioids

Weak opioids For moderate pain. Consider combination with paracetamol. Anticipate constipation

Strong opioids Indicated for severe pain not responding to non-opioid treatment. Side effects such as sedation, nausea and vomiting may worsen at opioid initiation/dose escalation. Anticipate constipation. Increase fall risk. Opioids for pain management rarely leads to addiction

Tramadol Limited analgesic effect, but lower sedative and respiratory effects. Lower risk of constipation. Contraindicated in patients with a history of seizures or prescribed other serotonergic drugs

Adjuvants

Tricyclic antidepressants Good efficacy for neuropathic pain but anticholinergic side effects limit use in older patients. Nortriptyline may produce less anticholinergic side effects

Serotonin-noradrenaline reuptake inhibitors

Duloxetine. Recommended for use in older patients with neuropathic pain. De effects: hyponatremia, dizziness, abdominal pain, nausea

Anticonvulsants Side effects: sedation, dizziness, peripheral edema. Elimination of gabapentin/pregabalin depend on renal function. Dose reduction for patients with renal impairment

Non –pharmacological treatment

• Interventions on biopsychosocial factors

• Cognitive behavioral therapy

• Physical therapy

• Complementary therapies

Affective – depressionSocial dimension

MassageTENS

ExercisesStretching

OsteopathyAcupuncture

Herbal medicineHomeopathy

AromatherapyArjuvedic medicine

Conclusion

The physical needs of people with dementia often get missed, not noticed or even mistaken for behaviors that are inappropriate behavior that often will be classed as challenging

Explore the changes in the person and their behavior to determine if pain is their concern.

Use appropriate tool for pain assessment

Do the most appropriate pain management in order to improve their quality of life