An Interprofessional Approach to Pain Management in Persons with Moderate to Severe Dementia

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2 An Interprofessional Approach to Pain Management in Persons with Moderate to Severe Dementia Meghan Marcil, PT Joanne Pacione, RN Myla Santos, RN Carol Skanes, RN 2

3 Objectives To describe the importance of proper assessment of pain in persons with dementia Recognize the impact of under treating pain on quality of life, responsive behaviours, and health outcomes Understand the need to balance pain management and sedation in patients with dementia Gain knowledge of strategies for managing pain in persons with dementia Understand some of the challenges in assessing and managing pain in this population

4 Overview of Program Toronto Rehab - 20 bed in-patient behavioural assessment unit. Goal: Assessment and development of strategies to manage responsive behaviours of dementia so that patients can safely be cared for at their long term care facility. Referrals from LTC, Acute Care and community Interdisciplinary team assessment (Geriatric Psychiatrist, attending physician, OT, PT, SLP, SW, TR, PTA/OTA, CNS, primary RN, primary RPN, student nurses, pharmacy, chaplain, dietician, volunteers) Discharge: Patients generally return to the referring facility after a team conference to review strategies and medications Length of Stay--60 days

5 What is pain? "Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." (International Association for the Study of Pain, 2015) 5

6 True or False Patients with dementia experience less pain than patients without dementia 6

7 True or False People with dementia receive fewer analgesics than their counterparts without dementia 7

8 True or False Co-morbid depression reduces the pain threshold and increases the pain intensity 8

9 True or False One should only prescribe pain medications if you know for certain that the patient has pain 9

10 True or False Attitudes and beliefs among patients, families, and health providers can be substantial barriers to effective pain management 10

11 True or False Use of prn or as needed pain medication is more effective than having standing orders in frail elderly patients

12 True or False Family members have poor perceptions of their loved one s pain in patients with dementia 12

13 True or False There are pain assessment tools validated for patients with dementia 13

14 Case Study Mr. S Mr. S is a 94 year old man diagnosed with mixed dementia 7 years ago Living at home with his wife until November 2014 when he had a stroke and was admitted to an acute care hospital Severe cognitive and physical limitations following the stroke, requiring total assistance for ADLs Not eligible for LTC due to his responsive behaviours 14

15 Past Medical History Mixed Dementia (Alzheimer s & Vascular) Temporal/occipital CVA Atrial Fibrillation Hypertension Abdominal Aortic Aneurysm Benign Prostatic Hypertension Hx Delirium 15

16 Admitting Medications Atenolol Rivaroxaban Lax-a Day Vitamin D Tylenol prn *trial of antipsychotics in acute care caused drowsiness then discontinued 16

17 Assessment (Medical) Very drowsy Poor oral intake of fluids and solids Minimal verbal responses Spending all his time in bed Consistent leg pain and back pain Developed mid calf tenderness & swelling Significant physical aggression with care: Punching, hitting, scratching, kicking, spitting 17

18 Intervention Antibiotic treatment for abscess Started on gradually increasing dose of pain medications Tylenol, Hydromorphone and Pregabalin Senokot for constipation Proper seating assessment and gentle mobilization Pressure relief cushion and mattress Pre-care behavioural medication (Ativan & Trazadone) to decrease anxiety and aggression 18

19 Medications at discharge Atenolol, Rivaroxaban Lax-a-day, Senokot Vitamin D Hydromorphone 0.5 mg QID Pregabalin 50 mg QHS Tylenol 650 mg TID Ativan 0.5 mg 30 mins pre care Trazadone 25 mg 30 minutes before care 19

20 Delirium resolved Gains Improved cognition and communication Improved alertness Improved oral intake Reduced physical aggression during care; managed by 1 staff Improved mobility and toileting 20

21 Gains cont d Improved family satisfaction with patient s quality of life Improved social interactions with staff and family Patient eligible for LTC Limitations: Awaiting placement in acute care Transition/feasibility of care plan from rehab into acute care setting 21

22 Case Study: Mrs. M Mrs. M is a 73 year old woman admitted for her increasing responsive behaviours restlessness/agitation verbal aggression disrupted sleep pattern Lived in supportive housing prior to admission Admitted to TGH for rectal cancer surgery Behaviour worsened post operatively Delirium stabilized 22

23 Mrs. M. cont d Unable to return to previous apartment in supportive housing Not eligible for LTC due to her responsive behaviours Admitted to Geriatric Psychiatry for assessment, behavioural rehabilitation and management in order to be considered for LTC placement 23

24 Past Medical History Dementia (vascular) Hypertension Diabetes Type 2 Lumpectomy for Breast Ca Bowel Resection for cancer Colostomy 24

25 Assessment (Medical) Vitals and blood sugar within normal limits No obvious focal neurological findings Cardiovascular and respiratory exam within normal limits Laboratory work up normal Negative for UTI Positive for MRSA 25

26 Day Assessment (Behaviour) Pleasant and alert, cooperative with care, vital signs and medications Evening Constant calling out Pacing non-stop, unable to redirect Demands help quickly even with activities that she can perform on her own Irritable, impatient, calling staff names Pulling off colostomy bag Night Increased vocalization Agitated if does not receive request immediately Disrobing Poor sleep pattern 26

27 Medications on Admission Quetiapine 12.5 mg po q4h prn for agitation Lorazepam 0.5 me IM q2h prn if quetiapine is refused Metformin 1000 mg po bid Lantus insulin 10 units S/C qhs Ferrous Fumarate 300 mg po od Ramipril 10 mg po od Acetaminophen 1000 mg po q8h Hydromorphone 0.5 mg po q4h prn 27

28 Assessment and Interventions over 5 weeks Received Quetiapine/Lorazepam prn regularly for 1 week following admission, with no effect Quetiapine given regularly at 2 pm and 8 pm for few weeks but responsive behaviours unchanged Staff started to give hydromorphone prn consistently Pt calmer after hydromorphone given and behaviours improved 28

29 Recommendations Pain medications ordered on regular schedule Hydromorphone 0.5 mg po q12 h Acetaminophen 1000 mg po q8h Hydromorphone 0.5 mg po q4h prn for breakthrough pain Trazodone 75 mg at HS Quetiapine 12.5 mg po at 2pm and 8 pm All other medications from admission unchanged 29

30 Gains Outcomes No further continual calling out for help Requests for help that are reasonable and polite No irritability or name calling Not pulling off ostomy bag Participating in unit activities Sleeping well at night Eligible for LTC 30

31 Barriers/Learning Delay in receiving optimal pain control due to staff misinterpreting her behaviours and trying to manage with antipsychotics Staff Learning: better assessment of pain by Inter Professional Team (PAINAD, review of past medical hx) Trial of analgesics for calling out and agitation prior to antipsychotics to ensure pain is not masked or undetected 31

32 Case Study: Mrs. C Mrs. C is a 71 year old female patient admitted to Geriatric Psychiatry for responsive behaviours including: physical aggression during personal care anxiety/restlessness difficulty with meals disruptive sleep pattern Pt was living at home with her 84 year old husband as her primary caregiver Pt is full code

33 Past Medical History Mixed dementia (vascular and Alzheimer s) Longstanding History of Anxiety Osteoarthritis Severe Spinal Stenosis Depression Progressive aphasia

34 Assessment (Medical) Vital signs and neurological findings are within normal limits Abdomen slightly distended Positive for UTI Thoracolumbar kyphoscoliosis Delirium

35 Assessment (Behaviour) Vocalizations: growling, grunting and angry tones Irritable, restless and agitated Physically aggressive towards staff, copatients and objects (required up to 5 staff to provide care) Hallucinations (auditory and visual) Difficulty with feeding and spitting of food/medications

36 Assessment (Behaviour) Day - alert, angry facial expressions, difficultly with personal care, slow ambulation with stooped posture Evening continual physical aggression towards staff and copatients, punching husband and son Night not sleeping, agitated during personal care

37 Initial Medications (July 2015) Acetaminophen (PRN) Trazodone Lansoprazole Celecoxib Clonazepam Quinapril Hydrochlorothiazide Lorazepam ** Hydromorphone 2 mg PO BID (discontinued 1 week prior to admission to TRI as husband stopped medication) Started on Hydromorphone 0.5 mg TID on unit

38 Pain Assessment and Behaviour Interventions Strategies: Close observation Behavioural flow sheet Nursing care flowsheet Family Weekly rounds high emphasis on pain during rounds with healthcare team

39 Assessment and Interventions Receiving Hydromorphone 1 mg po TID with minimal breakthrough doses Pain still an issue therefore Hydromorphone increased to 2 mg TID 2 weeks later, patient drowsy, severe constipation and not eating, vomiting Hydromorphone was changed to 3 mg CR BID 3 weeks later, patient sleeping during day and impacting on family visits Hydromorphone reduced to 3 mg CR at HS Pain appears controlled

40 Challenges to Pain management Managing adverse effects Constipation Nausea and Vomiting Pruritus Somnolence during the day Poor oral intake Pressure ulcer Urinary retention

41 Current Medications (April 2016) Lansoprazole (no dosage change) Celecoxib (no dosage change) Clozapine Mirtazapine Bisoprolol Acetaminophen Hydromorphone 3 mg CR qhs

42 Interventions (Non-pharmalogical) Greek music Comfort --improved quality of life Dog therapy

43 Gains Outcomes Care is manageable by 1 staff Showers twice a week Sleeps all night Continues to recognize her family and shows affection towards them Improved family satisfaction Improved pain control Compliant with medications Improved nutrition Eligible and awaiting long term care bed

44 Outcomes Losses Decreased mobility Sitting for long periods Incontinent Isolates self in her room--decreased socialization

45 References Barry, H. E., Parson, C., Passmore, P. A., and Hughs, C. M. (2012). An exploration of nursing home managers knowledge of and attitudes towards the management of pain in residents with dementia. International Journal of Geriatric Psychiatry, 27, Bruneau, B. (2014). Barriers to the management of pain in dementia care. Nursing Times. 110 (28), 12. Cohen-Mansfield, J. (2014). Even with regular use of observation scale to assess pain among nursing home residents with dementia, pain relieving interventions are not frequently used. Evidence Based Nursing. 17(1), Collett, B. (2002). The use of chronic opioid therapy for patients with non-malignant pain. Annals of Long Term Care. 10(11) Cunningham, C., McClean, W., and Kelly, F. (2010). The assessment and management of pain in people with dementia in care homes. Nursing Older People. 22(7) Reuben, D. B., Herr, K.A., Pacala, J.T., Pollock, B.G., Potter, J.F. Semla, T.P. (2013) Geriatrics at your fingertips. American Geriatrics Society Herr, K., Coyne, P. J., McCaffery, M., Manworren, R., and Merkel, S. (2011). Pain assessment in the patient unable to self-report: Position statement with clinical practice recommendations. Pain Management Nursing. 12(4), Kovach, C. R., Noonan, P. E., Schlidt, A. M., Reynolds, S. and Wells, T. (2006) The serial trial intervention; an innovative approach to meeting needs of individuals with dementia. Journal of Gerontological Nursing, 32(4), McLachlan, A. (2011). Clinical Pharmacology of Analgesic Medicines in Older People; Impact of frailty and cognitive impairment. British Journal of Clinical Pharmacology. 71(3) Rabins, P. V. and Blass, D. V. (2014). Dementia. In the Clinic. Annals of Internal Medicine. 8 (5). Somes, J. and Stephens Donatelli, N. (2013). Pain assessment in the cognitively impaired or demented older adult. Journal of Emergency Nursing. 39(2),

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