Pain Assessment and Management with Dementia Thomas Caprio, MD, MPH, MSHPE, CMD, HMDC, FACP, AGSF, FAAHPM Associate Professor of Medicine, Dentistry, Nursing, & Public Health Sciences Director, Finger Lakes Geriatric Education Center Chief Medical Officer, UR Medicine Home Care Medical Director, Visiting Nurse Hospice& Palliative Care October 2018 Dementia and Pain: Dilemmas Pain and dementia often co-occur Unclear how persons with dementia experience pain differently Cognitive issues impair the ability to describe/communicate symptoms Pain may be expressed in a non-specific manner such as a change in behavior or emotional state Pain in persons with dementia is commonly undertreated or inappropriately treated Pathway from Cognitive Dysfunction to Dementia Dementia Normal Aging Mild Cognitive Impairment Alzheimer s Disease NPA Conference 1
Prevalence of Alzheimer s Disease Future Projections by Age Group 14 12 10 Number of People (millions) 8 6 4 2 Age 65-74 Age 75-84 Age 85+ Total 0 2000 2010 2020 2030 2040 2050 Year Data Source: Evans, DA et al. Archives of Neurology August 2003 Do patients with dementia have pain? DEMENTIA Phenotype Cognition Behavior Function NPA Conference 2
Does dementia affect the perception of pain? Pain perception in Alzheimer s Disease Alzheimer s Disease (AD) is primarily a disorder of the neocortex with the somatosensory cortex relatively unaffected Thalamic nuclei (central pain syndrome) are not significantly affected by amyloid or tangles Hypothesis => Pain perception preserved Intralaminar nuclei of the thalamus with connections to the pre-frontal and frontal cortex may result in distortions of sensation Affective and emotional regulation from pain may be affected (manifest in behavior? coping?) Pain perception in Vascular Dementia In contrast to AD, vascular dementia is a heterogenous disorder Vascular lesions from small vessel disease or stroke could affect many different brain regions Central post-stroke pain syndrome can occur Impossible to predict how vascular dementia affects the perception of pain 9 NPA Conference 3
Pain perception in Fronto-Temporal Dementia Primary areas of degeneration in FTD occurs in the frontal and temporal lobes Frontal lobe has central role in pain elaboration, therefore pain experience can be altered Some studies described loss of pain consciousness as one of potential symptoms Clinically FTD manifests prominent behavioral symptoms, difficult to define the contributor of pain in theses behaviors Assessment of Pain in Dementia: Challenges Pain self-report scales are cognitively complex and require abstraction With advanced dementia, self-report may not be possible No direct measures => no gold standard to compare accuracy of pain assessment Agitation/behaviors (unmet needs) may present similarly to pain How to distinguish pain, hunger, over- or under-stimulation, anxiety, need to toilet, boredom, loneliness, etc.? 11 The gold standard of pain assessment is by self-report NPA Conference 4
Pain Assessment Numerical Rating Scale Do you have pain? How bad is your pain? Values: (0 none) 1 (mild) 10 (severe) Faces Pain Scale Advanced (End-Stage) Dementia: Losses in Function and Communication Pain Assessment: Cognitive Impairment Ask the patient first about pain Interview the caregivers and family - patterns of particular behaviors may have developed that indicate pain (e.g. placing a hand on the forehead for headache) Review the medical history (e.g. diabetic with painful neuropathy) Complete a physical examination and directed diagnostic studies to assess for common problems (e.g. fracture) NPA Conference 5
Case #1 Mr. C is 72yo man with dementia, residing in the nursing home he needs full assistance with personal care, walks with rolling walker, occasional periods of restlessness at baseline Evening and night staff note he has been agitated and calling out, hitting staff members when trying to get him out of chair to bed Case #1 (cont d) Some more information: Being treated for lower extremity cellulitis with one week course of antibiotics Has had repeated falls using his walker, last fall 2 days ago sustained some bruises Has diagnosis of osteoarthritis of both hips and knees Pain Assessment: Dementia Challenging in patients unable to communicate discomfort or pain Often rely on observation of behavior Some questions: Is patient s agitation due to untreated pain? Is patient s behavior different from baseline? Was there a recent fall, medical procedure, or change in condition that could be causing pain? 18 NPA Conference 6
Visual Signs of Pain Pain Assessment: Observation 1. Protection of sore areas 2. Facial expressions 3. Sleep pattern 4. During activity: washing, dressing 5. Mobility 6. Psychosocial: communication, social interaction, and behavior Pain Assessment in Advanced Dementia (PAINAD) Scale Modification on domains of the FLACC scale Five-item observational tool for nonverbal patients Total Score ranging from 0-10 Reference: Warden V, Hurley Ac, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc. 2003; 4:9-15. NPA Conference 7
Case #2 Mrs. J is 78yo woman with dementia and worsening agitation and restlessness. Constantly getting up from chair, needs walker and assist to ambulate; frequent falls During the day shift she is frequently yelling out obscenities and racial slurs or simply repeating help me Case #2 (cont d) PMH: Diabetes Mellitus, CAD, PAD, COPD, osteoarthritis, depression Staff notice she is redirectable with 1:1 activities, becomes fatigued when ambulating with one assist, no longer recognizes her daughter PAINAD: 8/10 Trial of scheduled acetaminophen 100mg TID associated with less verbal outbursts and no falls for a month (average PAINAD 0 in dayshift) NPA Conference 8
Case #2 (cont d) More restlessness and yelling at night and during personal care or toileting Staff approach patient with step-by-step descriptions of what is taking place with transfers or using bathroom PRN oxycodone 5mg added to regimen, used in morning before a.m. care or at bedtime Described now as a model resident of facility, good mood, no outbursts in many months Treatment of Pain in Dementia Pain frequently is the underlying cause of observed behavioral symptoms Can lead to inappropriate treatment with antipsychotic medications Evidence for efficient treatment with analgesics is limited Most promising evidence supports the use of stepped treatment approaches for pain combined with behavioral interventions Lack of sufficient training and education for health care professionals Need for further research to provide evidence-based guidance TREATMENT Guidelines Utilize least invasive route possible: Oral route preferable; concentrate sublingually Transcutaneous > subcutaneous > intravenous 1/2 usual starting doses for older patient and those with dementia Stabilize with short-acting before long-acting NPA Conference 9
Medications Acetaminophen considered first line therapy, can be used with opioids, be careful of total daily dosage (3000mg) NSAIDs high risk of GI and Renal toxicity in older adults (if used need low dose and shortest duration as possible) Tramadol many drug interactions, serotonin syndrome, risk of seizures. Confusion? Pain relief? Adjuvants: antidepressants, steroids, methadone Caution in patients with dementia: gabapentin, pregabalin, TCAs, etc. Opioids and Dementia Inherent fear by many that it will worsen somnolence, delirium, constipation, or is too strong for patients with dementia Stigma of opioid addiction, diversion, and abuse (Opioid Epidemic) But may be a very effective component of pain management strategy: Start low and go slow Reassess at regular intervals Provide a bowel regimen Untreated pain can precipitate delirium Treating Pain to Reduce Agitation BMJ reported RCT (2011): Showed efficacy of treating pain to reduce behavioral disturbances in residents of nursing homes with dementia Stepwise protocol for pain treatment 1. APAP 2. Morphine 3. Buprenorphine transdermal 4. Pregabalin Agitation was significantly reduced in the intervention group compared with control group after eight weeks Husebo et al, BMJ, 2011 Husebo BS, et al. BMJ 2011 NPA Conference 10
Treatment of Pain in Dementia: Serial Trial Intervention Nursing-led intervention, RCT, 114 patients Behavior change suggestive of pain: Attempt to identify source of discomfort or unmet need Institute non-pharmocologic comfort measures If behavior persists, administer analgesic (usually acetaminophen) If behavior persists, consult with NP, MD, hospice or geropsych Compared to usual care Less discomfort in treatment group (DS-DAT) Kovach et al. Am J Alzheimers Dis, 2006 32 Prevalence of Behavioral and Psychological Symptoms of Dementia (BPSD) 90% of patients with dementia will experience Source: Unmet need or source of distress Inability to communicate needs/emotions Also consider re-emergence of PTSD Most Common Agitation (75%) Wandering (60%) Depression (50%) Psychosis (30%) Screaming and violence (20%) NPA Conference 11
Modifiable Causes of Behavioral Symptoms Inadequate pain control Boredom/Isolation Acute Illness (but is not UTI w/o other symptoms) Adverse drug events Drug interactions Dehydration Hunger Incontinence Fluctuations in blood glucose Hypoxemia Hypothermia Pain Assessment: Core Areas Functional assessment (observations) Areas of concern (mobility impairment, weakness, ROM, falls, etc.) Medical Conditions (dementia, CHF, etc.) Psycho/Social Assessment (coping) Response to Medications (Rx, OTC, oral & topical) Response to Non-pharmacologic interventions: repositioning, heat/cold, massage, exercise, relaxation, distraction, acupuncture, chiropractic Team Communication is Key Clear goals needed and documentation of results (reported pain relief/reduction, activity level, non-medication modalities) High PRN use should be communicated by patient/caregiver and share with care team Report on: Lethargy, sleep patterns, daily activity changes, constipation, etc. Clinical staff often concerned about over medicating patients (worsening somnolence and confusion) NPA Conference 12
Pain Assessment Function Behavior Comfort Socialization Team Based Approach Pain Management Medications Non-pharmacologic Depression Sleep Physician Social Worker Nurses Patient/Family Pharmacist Physical Therapist NPA Conference 13