Pain in Dementia

By kind invitation of Jim Wells MLA The Long Gallery, Parliament Buildings26th March 2014

Pain in Dementia

Chaired by Sarah TraversThe Long Gallery, Parliament Buildings26th March 2014

Pain and Behaviour

Dr Pamela F BellChair, The Pain Alliance of Northern Ireland

26th March 2014

An unpleasant sensory and emotional experience caused by actual or potential tissue damage or expressed in terms of such damage

International Association for the Study of Pain

What is Pain?

Acute pain

A signal that something is wrong

It is protective

It prompts us to take action

Chronic pain

Does not signal new disease or injury

Serves no useful function

It has long-lasting effects

What are the effects of pain?

depression

changes in pulse and blood pressure

fearloss of appetite

withdrawal

restlessness

increased dependency

isolation

sleep disturbance

A little bit of neurobiology

injury

Dorsal horn

lamina I Dorsal horn

Lamina V

Parabrachial

RVM

Limbic system Cingulate

dorsal columns

Peripheral nerve

Thalamus

Cerebral cortex

PAG

+

-

A little bit of neurobiology

injury

Dorsal horn

lamina IDorsal horn

Lamina V

Parabrachial

RVM

dorsal columns

Peripheral nerve

PAG

+

-

Limbic SystemFear, anxiety, sleep, punishment autonomic changes

CingulateAttention

Thalamus and Cerebral Cortex Location& intensity

Change in muscle tone and movementChanges in sweating, heart rate, blood pressure, breathing

How do we communicate our pain to others?

We describe it to them!

We also use body language!

How does our behaviour alter when we are in pain?

Different patterns of behaviour emerge•Restlessness/withdrawal•Vocalisations/silence•Change in posture•Weeping•Refusing food•Hitting our at others•Disturbed sleep

Can we use these changes in behaviour together with clinical signs to determine if someone with dementia is suffering pain?

One important question

The importance of pain in people with dementia

Professor Peter PassmoreProfessor of Ageing and Geriatric MedicineQueen’s University, Belfast

26th March 2014

The impact of pain and dementia on sufferers and carers

Dr Shaun Fleck

26th March 2014

Assessment and Management of Pain in Older Adults

Professor Pat Schofield

Centre for Positive AgeingUniversity of Greenwich

26th March 2014

In the UK….

10 million people in the UK are over 65 years old.  The latest projections are for 5½ million more older people in 20 years time and the number will have nearly doubled to around 19 million by 2050.

There are currently three million people aged more than 80 years and this is projected to almost double by 2030 and reach eight million by 2050. 

The pensioner population is expected to rise despite the increase in the women’s state pension age to 65 between 2010 and 2020 and the increase for both men and women from 65 to 68 between 2024 and 2046.  In 2008 there were 3.2 people of working age for every person of pensionable age. This ratio is projected to fall to 2.8 by 2033.

Around 700,000 people currently live with dementia and this is expected to double to 1.4 million in the next 30 years.

• We anticipate 44m people world wide

This trend is expected to have ramifications for the NHS in the UK and in particular the training needs of the healthcare workforce

Background

Disruptive or Challenging Behaviours

Severe pain is less likely to cause wandering.

But, more likely to display aggressive and agitated behaviours

Hyochol & Horgas (2013)

Care homes in Kent (2012)

Crude Prevalence0-93% !

community ranged from 20-46%.residential care was higher and ranged from 28-

73%.

Highlights the variations between studies

Commonest sites of pain in older persons

Of the 22 studies that examined pain at different sites, the three commonest sites of pain in older people Back (16 studies) leg, knee or hip (16 studies)Other joints (5 studies)

Pain in Residential Aged Care Facilities

Management Strategies

August 2005

The Australian Pain Society

“Pain is exhausting… You have to walk slowly. You have to stop and make an excuse or pretend to look in a shop window so that you can put your hand on the window and rest a moment. It’s humiliating”.

‘Pain is frustrating because you can’t do things for yourself…Everything’s a challenge.’

‘I get very depressed and anxious about it…it’s frightening, especially when you live on your own.’

‘Pain can make you feel lonely because you feel that you’re the only one that is suffering and can cope with it, and that is a lonely experience.’

Extracts taken from ‘listening events’ and interviews held with older people who suffer pain (Help the Aged )

Perspectives from Older People

Care Homes Study

Behavioural Signs

Pain Assessment Application

Dementia Carers website

Methods

Guidelines on the Management of Pain in Older People (2013)

Guidelines: Summary• Substantial differences in the population, methods, and definitions used in

published research makes it difficult to compare across studies and impossible to determine a single definitive prevalence of pain in older persons.

• The prevalence of pain in older persons living in residential care is consistently higher than the prevalence of pain in older persons living in the community, regardless of the definition of pain used.

• Older women have higher prevalence rates of pain than older men.

• The reported effect of age on pain prevalence in older persons is inconsistent with some studies reporting an increase in prevalence with age and others reporting a decrease in prevalence with age. The effect also varies by gender and site of pain.

• The three commonest sites of pain in older persons are the back, leg/knee or hip, and other joints.

Pharmacology• Paracetamol should be considered as first-line treatment for the

management of both acute and persistent pain.It is important that the maximum daily dose (4g/24 hours) is not exceeded.

• Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in older people after other safer treatments have not provided sufficient pain relief. The lowest dose

should be provided for shortest duration.• All patients with moderate or severe pain should be considered for

opioid therapy

• Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain

BBC NewsThe NHS in England spent more than £440m last

year on painkillers. On average, health trusts in England spent £8.80 per head of population on analgesics. But in some northern towns and cities the figure was as high as £15, while in parts of the south it was as low as £3.26 per head.

Invasive• Intra-articular corticosteroid injections in

osteoarthritis of the knee are effective in relieving pain in the short term with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects.

• The current evidence for the use of epidural steroid injections in the management of sciatica is conflicting

Non-Invasive• Assistive devices are widely used and ownership of

devices increases with age.

• A number of complementary therapies have been found to have some efficacy amongst the older population including; acupuncture, TENS and massage.

• Guided imagery Biofeedback training and relaxation, CBT in nursing home populations.

• Self management programmes may have benefit.

Other Projects related to Ageing

Patient Leaflets

Ageing

The Unheard Voice of Pain

Why Pain Matters

Many People with dementia have painful conditions

Pain is often unrecognised and untreated How individuals react to pain may depend

on attitudes, culture and age

Case Study

Year 1

Anti Psychotic Anxiolytic Hypnotic Pain Relief Anti-Depressant Cog Enhancer0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

68.3%

24.4%

63.4%

12.2%

53.7%

9.8%

56.1%

24.4%

41.5%

24.4%

51.2%

4.9%

Basline Post

% o

f R

esid

ents

Medication Review from Baseline to Date

Year 2

Anti Psychotic Anxiolytic Hypnotic Pain Relief Anti-Depressant Cog Enhancer0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0.0% 0.0%

6.9%

0.0% 0.0% 0.0%

24.1%20.7%

6.9%

96.6%

58.6%

10.3%

Basline Post

% o

f R

esid

ents

Medication Review from Baseline to Date

Intervention

Staff educationAssessment of painReview of medicationDementia care mappingChange in environmentIntroduction of doll and animal

therapy

Pro-active

Assessment and

Intervention (equals)

No/Reduced-Pain!

Questions and discussion

Led by

Sarah Travers