LUNCH WITH THE EXPERTS: Palliative Care for Advanced Dementia with Pain and Dementia

Transcription

1 LUNCH WITH THE EXPERTS: Palliative Care for Advanced Dementia with Pain and Dementia Carol Long, PhD, RN, FPCN Principal, Capstone Healthcare & Co-Director, Palliative Care for Advanced Dementia, Beatitudes Campus Learning Objectives: Describe processes for assessing pain in persons with advanced dementia. Present key clinical management strategies for managing pain in persons with advanced dementia. DISCLOSURE OF COMMERCIAL SUPPORT Carol Long, PhD, RN, FPCN does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. 1

2 Carol O. Long, PhD, RN, FPCN Principal, Capstone Healthcare & Co-Director, Palliative Care for Advanced Dementia, Beatitudes Campus Arizona Geriatrics Society 24 th Annual Fall Symposium October 25, Describe processes for assessing pain in persons with advanced dementia 2. Present key clinical management strategies for addressing pain in persons with advanced dementia Provide useful tools and strategies for use after this conference! Definition: Pain is whatever the person says it is, experienced whenever they say they are experiencing it (McCaffery & Pasero, 1999) Pain is reported in 25-50% of older persons living in the community (ELNEC Geriatric, 2012) Pain is reported in 45-80% of nursing home residents (ELNEC Geriatric, 2012) But what about persons with advanced dementia who cannot tell you about their pain? 2

3 Person with dementia concerns: o Do you have pain? o Older adults describe pain as discomfort, hurting or aching o Discomfort / pain from emotional distress, constipation, cold, hunger, and fatigue o Increased affective pain from difficulty managing everyday activities related to the disease state o Pre-existing conditions: arthritis, disc compression, neuropathies Staff & organizational concerns: o Concerns over use of opioid and potential delirium o Lack of consistent staff can be a problem or caregivers may not know the person o Reluctance to use opioids without a clear diagnosis o Psychotropics mask pain symptoms o Staff may forget what risk factors are present that may precipitate pain o Staff just don t know what they don t know Family concerns: o Fear of opioids o Do not understand or know pain behaviors We need to rethink how we come to know if a person with dementia has pain Don t use: No complaints of pain Adopt: Assume Pain is Present (APP) when behaviors emerge Pain is everyone s responsibility: Team effort is necessary If we don t assess, we can t address: o Guiding framework: Assess Address Evaluate - Document 3

4 Attempt to elicit self-report from person. If the person unable to self-report, document. Identify pathologic conditions or procedures that may cause pain. List the person s behaviors that may indicate pain. Identify behaviors that caregivers and others knowledgeable about the person think may indicate pain. Make a plan to address pain. Herr et al., 2011; Pasero & McCaffery, 2011 Investigate what may be causing the pain o Complete physical examination o Review medical history: Consider common pain etiologies in older adults (e.g. arthritis, UTI, fracture) o Check on basic needs: physical, social, psychological, environmental, spiritual o Ask: What are the behaviors that are new or escalating? Complete a comprehensive pain assessment & use evidence-based assessment tools o Secure as much information as possible: location, duration, frequency, modifying factors, and more o Self-report tools: ask if the person has pain! Then try to get intensity rating. o Behavioral assessment tools: List behaviors that suggest pain Used for individuals who are unable to self report Total score is derived cannot be used to calibrate intensity 1. NUMERIC RATING SCALE (NRS) No Pain Mild Moderate Worst Possible Pain Pain Pain Ask if the person has pain. Then ask On a scale of 0 to 10, with 0 meaning no pain and 10 meaning the worst pain you can imagine, how much pain are you having now? Ask them to point to the number on the scale. 4

5 2. FACES Pain Scale-Revised (FPS-R) The FPS-R is a self-report tool that a person may prefer over a NRS; often due to the pictures of 7 faces that range from happy to sad and distressed. Ask the person if they have pain. Then ask The faces show how much pain or discomfort someone is feeling. The face on the left shows no pain. Each face shows more and more pain and the last face shows the worst pain possible. Point to the face that shows how bad your pain is right NOW. Scoring: Score the chosen face as 0, 2, 4, 6, 8 or 10, counting left to right with 0 = no pain and 10 = worst pain possible IASP, Verbal Descriptor Scale (VDS) Pain Thermometer 1. Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) The PACSLAC is a comprehensive pain assessment tool containing 60 items scored as present or not (use of a checkmark) within the following categories: 1. Facial Expression (13 items) 2. Activity/Body Movement (20 items) 3. Social/Personality/Mood (12 items) 4. Other (Physiological changes/eating/sleeping changes/vocal Behaviors) (15 items) Useful for comprehensive pain assessment. Fuchs-Lacelle & Hadjistavropoulos,

6 2. Pain Assessment in Advanced Dementia (PAINAD) PAINAD can be used by nurse / CNA to screen for pain-related behaviors when observing an activity for 3 5 minutes. Score a 0, 1, or 2. Maximum score = Score Breathing Normal Occasional labored Noisy labored breathing, Independent of breathing, long period of Vocalization short period of hyperventilation, Cheynestokes respirations hyperventilation Negative None Occasional moan or Repeated troubled Vocalization groan, calling out, loud moaning low level of speech or groaning, crying with a negative or disapproving quality Facial Expression Smiling or Sad, frightened, Facial grimacing inexpressive frown Body Language Relaxed Tense, distressed Rigid, fists clenched, pacing, knees pulled up, pulling fidgeting or pushing away, striking out Consolability No need to Distracted or Unable to console, console reassured by voice or distract or reassure touch Total Warden, Hurley, & Volicer, Checklist of Nonverbal Pain Indicators (CNPI) Ask if the person has pain Then observe the person for the following behaviors at rest and during movement. Score a 0 if the behavior was not observed, 1 if occurred briefly during activity or at rest. Total number of indicators is summed with movement, at rest and overall. No cut-off score. Behavior With Movement At Rest 1. Vocal complaints: nonverbal (Sighs, gasps, moans, groans, cries) 2. Facial grimaces/winces (Furrowed brow, narrowed eyes, clenched teeth, tightened lips, jaw drop, distorted expressions) 3. Bracing (Clutching or holding onto furniture, equipment, or affected area during movement) 4. Restlessness (Constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still) 5. Rubbing (Massaging affected area) 6. Vocal complaints: verbal (Words expressing discomfort or pain [e.g. ouch, that hurts ];cursing during movement; exclamations of protest [e.g. stop, that s enough ]) Subtotal Scores Total Score Feldt, 2000 When addressing pain Connect the assessment with the intervention and goals of care 1. Address unmet needs 2. Use nonpharmacologic interventions 3. Add pharmacologic interventions start with serial trial intervention 6

7 Therapeutic communication Positioning and repositioning Toileting Hunger Ambulation Food and fluid Check if too cold or too warm Positioning and repositioning Comfort foods Massage Heat or cold applications Stimulating activity Quiet time / environment Music A hug! WHO 3-Step Analgesic Ladder is used based on verbal report and / or intensity of behavioral symptoms 3 categories: 1. Non-opioids (e.g. acetaminophen, NSAIDS) 2. Opioids 3. Adjuvants / Co-analgesics Start with serial trial intervention No Antipsychotics WHO Pain and Palliative Care Communications Program,

8 Initiate: Start low, go slow except with acute pain Titrate to effect Rotate to other medications as needed using equianalgesic tables Pain medication + non-pharm is always considered By mouth is best; consider liquid formulations If pain medications are found to be effective, they should be ordered routinely versus as needed --Schedule pain medications don t expect a person to ask! Consider Short-Acting (SA) Long-Acting (LA) for continuous pain Add SA (Immediate Release - IR) for Breakthrough Pain (BTP) Evaluate continuously as a team Document in the record: assessment, intervention, results Increase in o Nonpharmacologic interventions o Analgesic use o Improved comfort Decrease in o Antipsychotic use o Behaviors of discomfort Reviewed assessing and addressing pain & dementia o Various tools were discussed o Discussed pharmacologic and nonpharmacologic interventions Parting thoughts: o What does your facility do for persons with pain in general and for persons with dementia? o What are your policies and procedures? o What are your practices? o What could you do better? o What tools can you take back to use in your setting? 8