Pain Management in Dementia. Amy C. Denham, MD, MPH July 10, 2013
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1 Pain Management in Dementia Amy C. Denham, MD, MPH July 10, 2013
2 Objectives Describe the challenges of pain management in individuals with dementia Review the available tools for assessing pain in patients with dementia Evaluate the evidence for various pain management strategies for patients with pain and dementia Recommend an approach for assessing and treating pain in patients with dementia
3 Rationale Pain and dementia often co-occur Unclear how persons with dementia may experience pain differently Dementia impairs ability to describe symptoms Presentation of pain may be non-specific Change in behavior or emotional state Pain in persons with dementia is commonly undertreated or inappropriately treated
4 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 Many unmet needs may present similarly How to distinguish pain, hunger, over- or understimulation, anxiety, need to toilet, boredom, loneliness, etc.?
5 Assessment of Pain in Dementia: Assessment Tools Many assessment tools exist: ABBEY ADD CPAT CNPI DBS DOLOPLUS-2 PADE EPCA2 PAINAD MOBID PAINE NOPPAIN PACSLAC Administered by nurses or other caregivers Rely on behavioral observation Most have been validated in limited populations Examples and reviews of pain assessment tools at
6 Assessment of Pain in Dementia: Behavioral Cues Facial expressions Frown, grimace, wrinkled brow, rapid blinking Vocalizations Moaning, sighing, grunting, calling out, asking for help, verbal abuse Body movements Rigid posture, guarding, fidgeting, gait or mobility changes
7 Assessment of Pain in Dementia: Behavioral Cues Changes in interpersonal interactions Aggressive, combative, resisting care, socially inappropriate, withdrawn Changes in activity or routines Refusing food, sleep pattern changes, cessation of common routines Mental status changes Confusion, crying, irritability or distress
8 Assessment of Pain in Dementia: Suggested Approach For verbal patients, attempt self report Verbal descriptor scales better than numeric Limited validity/reliability if MMSE<15 Use behavioral observation Consider using a validated instrument (PAINAD, PACSLAC, DOLOPLUS-2, MOBID-2) If screen is positive, assess for other unmet needs Use physical exam to evaluate for source of pain
9 Treatment of Pain in Dementia Limited research available on treatment of pain in dementia Small trials of short duration Nursing home populations only Methodologic limitations in most of trials
10 Treatment of Pain in Dementia: Serial Trial Intervention Nursing-led intervention, RCT, 114 patients If a behavior change suggestive of pain occurs: 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
11 Treatment of Pain in Dementia: Husebo et al Cluster RCT of stepwise analgesic treatment 352 patients, 8 weeks Stepwise protocol initiated if pain identified 1. Acetaminophen 2. Oral morphine (up to 20mg/day) 3. Transdermal buprenorphine 4. Pregabalin Most patients stopped at step 1 Reduced agitation, aggression and pain No difference in ADLs Husebo et al, BMJ, 2011
12 Treatment of Pain in Dementia: Other Trials Manfredi et al, Int J Geriatr Psychiatry, week RCT, 47 patients with agitation Placebo v. oxycontin 20mg/day or morphine 20mg/day No significant differences between groups Chibnall et al, J Am Geriatr Soc, mo crossover RCT, 25 patients Placebo vs. acetaminophen (3g/day) Improved activities participation, agitation unchanged Buffum et al, J Am Geriatr Soc, week crossover RCT, 39 patients Placebo v. acetaminophen 650mg/day No difference between groups
13 Treatment of Pain in Dementia: Suggested Approach Limited data to inform our approach to pain management in dementia Assess for pain systematically If potential pain identified Attempt to find source of discomfort Start with nonpharmacologic measures Use scheduled acetaminophen for ongoing pain If no relief with acetaminophen, add opiate pain medication Reevaluate response after each intervention
14 Conclusions Assess for pain in patients with dementia Especially if change in behavior or mental status Use verbal self report if the patient is able Supplement with behavioral observation Use behavioral observation in non-verbal patients Assess for other unmet needs Use scheduled acetaminophen and nonpharmacologic measures Add opiates if not responsive to initial measures
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