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“The Pain of Dementia”
Dr Paula Moffat
Geriatrician and Palliative Care Physician
Outline
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What is pain?
Pain in RCF and in those with dementia
Consequences / Barriers
Aims of assessment
– Recent publications
• Management
• Case studies
How big is the problem
• Aging population with increasing numbers of people with
dementia
• 154,872 people using residential aged care services at 30
June 2006 [1].
• Aged population are more susceptible to multiple comorbidities / chronic disease
• Pain increases in prevalence with age, but it is not inherent
part of the aging process
• Australian study of NH residents: range of 27.8% - 86%
experienced chronic pain [2,3]
• Prevalence of pain >60yo = 250 per 1000 [4]
• Prevalence of pain <60 = 125 per 1000 [4]
Pain in those with dementia
• Often under recognised and under treated in those with
cognitive impairment, communication problems and
residents of RCF
– Cognitive impairment is the strongest predictor not to self report
pain [5]
– >40% of NH residents are unable to report pain due to poor
cognition [2]
• Pain [6] : cross sectional study of 2779 >65yo community
patients in Canada
– >75yo, chronic health conditions, cognitive impairment and req
interpreter received less opioid alone or in combination
Additional facts
• Older people receive less analgesia than younger
individuals with similar conditions
• Those with cognitive impairment receive less
analgesics than those that are cognitively intact
– Horgas and Tsai – cognitively impaired NH residents are
administered less analgesic medication than those
without cognitive impairment [7]
What don’t we know
• Extent of the problem: lack of research
especially of pain in those with dementia in
RCF
– Amount of research is increasing
• We don’t know what the best way to detect
pain is in those who have dementia
Research of pain in people with dementia [8]
ISSUES INVOLVED IN THE MANAGEMENT
OF PAIN IN THE ELDERLY [9]
DIAGNOSIS: altered presentation,
dementia, coexisting problems
DRUG THERAPY: PK, polypharmacy,
attitudes to meds, medical issues
RESPONSE TO DRUGS: pharmacodynamics
PHYSICAL THERAPY - restrictions
PSYCHOLOGICAL THERAPY:
previous experiences, behavioural patterns
Barriers to pain management in the elderly [10]
• Attitudes of patients
– Fear of diagnosis, disease progression, investigations, medications (s/e,
addiction, loss of control)
– Misconception that pain is part of the aging process
• Attitudes of carers: family and nursing staff
– Lack of education
– Fears of medications
• Attitudes of medical staff
- Underestimation of pain by clinicians
– Fear of medications and side effects
• Problems with assessment
- Inadequate assessments
- Cognition (dementia) :BPSD
- Non verbal
Dementia as a barrier to pain assessment
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Memory loss
Personality changes
Judgement
Abstract thinking
Language skills
• Symptoms attributed to
dementia may be an
indication of pain
– Aggressive behaviour
– Resistant behaviour
What are the common causes of pain in the elderly?
• What is the aetiology of the pain: OA (foot,
leg and joint)
• Females: OA, RA, headache, FMR
• Males: Gout, CHD, AS
What is pain??
Pain pathophysiology
Factors influencing pain and pain perception of pain
Mechanistic classification of pain
pain
Nociceptive
-Somatic
-visceral
Neuropathic
-Central
-peripheral
Mixed /
undetermined
WHO Analgesic Ladder
Is there changes in PERCEPTION of
pain in the elderly
• No strong evidence that their perception is any different
• Small psychological studies: pain related changes in
increase pain threshold (may be assoc with under reporting
of pain and increased risk of undiagnosed or ongoing
injury) [11]
• Reduced efficacy of the endogenous analgesic system and
greater senitisability of pain processing pathways – may
contribute to greater persistence and anatomical spread of
pain [12]
Future study ….[13]
• Placebo effect is lacking in those with
cognitive impairment
• Prof McLachlan heading a 3 yr study into
determining blood levels and pain responses
to work out better dosing guidelines
Consequences of pain in people with
dementia
• Impaired mobility & ability to self
care
• Decreased socialisation
• Anxiety
• Sleep disturbances
• Impaired appetite and memory
• Depression
• Weight loss
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Agitation
Resistant behaviour
Aggression
Calling out
Delirium
Recent developments in pain in dementia : BMJ
2005 [8]
• Self report vs. observational studies
• Sensory – discriminative vs. motivational –
affective
– Sensory – discriminative aspect of pain is assoc with the
self reporting scales
• motivational – affective should be applied to all
irrespective of communication –
– Observational scales focus on the motivational affective
aspects of pain
– Particularly likely to reflect the need for treatment
Recent developments in pain in dementia : BMJ
2005 [8]
• Observational scales are not truly specific to the
behavioural they detect are due to pain
• Observational scales miss subtle signs as well
• Changes in autonomic function are not reliable
• Sensory discriminative aspects are processed in the lateral
pain system
• Motivational affective responses are processed in the
medial pain system
Benedetti et al [14]
• – observed that pain thresholds (sensory discriminative aspect) of AD
patients did not differ from those with out AD; whereas pain tolerance
(motivational affective aspect) was increased in AD patients
– Anatomically- the lateral pain pathways (primary sensory area) is preserved
– Medical pain pathway (ant cingulate gyrus) is impaired
– Therefore AD patients may have difficulty understanding the meaning of
the sensation and placing it in context- may explain the adverse behaviours
observed
– Different types of dementia may have different relationships to sensory and
motivational aspects
Recent developments in pain in dementia : BMJ
2005 [8]
Assessment of pain
“the 5th vital sign’
Aim of assessment of pain
• Underlying pathology as the cause
– What can be done about the direct cause / causes
– Goal: treat underlying cause or symptom control
• Associated consequences of the pain
– Depression, anxiety
– Behavioural changes
• Assessment of functional state
• Management plan
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Non pharmacological
Pharmacological
Setting goals
Frequent review
What is the best way to assess pain in the
elderly?
• APS also
Recommends
the
use of
observational
pain tools, in
particular the
Abbey &
PAINAD [15]
……early stage of dementia
• Self report
• 83% of residents with an average MMSE of
12 were able to complete at least one self
report measure- word descriptor having the
highest completion rate [16]
Modified Version of the Brief Pain Inventory for
use in RACF. K. Auret et al 2008, JAGS [17]
• Phase I & II: modified BPI change numerical to word
descriptors – feasibility, stability, internal consistency
reliability
• 33 (phase I) & 149 (phase II) RACF in Perth
• 3 items each for pain intensity & pain interference
• Item for pain location and movement protocol
• Adequate internal consistency reliability with likely stable
results over time
• ?screening tool, assess effectiveness of pain relief
interventions
….severe dementia
• APS recommends ABBEY or PAINAD
Observational pain tools
• Systemic review - 2006
(BMC Geriatrics) [18]
• 12 observational tools
• psychometric qualities &
criteria - concluded that
PACSLAC & DOLOPLUS2
most approp scales
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DOLOPLUS2
ECPA
ECS
Observational pain tool
CNPI
PACSLAC
PAINAD
PADE
RaPID
Abbey
NOPPAIN
Pain assess scale for use in CI
older adults
Pain in severe dementia: self assessment or
observational scales. 2006 JAGS [19]
-prospective clinical study of 129 geriatric inpatients and
geriatric psychiatric service
-MMSE<11
- 3 assessment tools: verbal, horizontal visual and faces pain
scale
- Nursing team independently completed and observational
pain rating scale (DOLPLUS-2)
- Outcomes: comprehension, inter and intra rater reliability
and comparison of pain intensities on different scales
Faces
Pain
Scale
Horizontal
visual
analogue
scale
Pain in severe dementia: self assessment or
observational scales. 2006 JAGS [19]
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Outcomes: 61% were able to demonstrate comprehension of at least one scale
(49% with MMSE ≤6 had comprehension of at least one scale)
Comprehension was better for the verbal and face pain scales
For those that had good comprehension the inter and intrarater reliability of the
3 self assess scales was high ICC 0.88-0.98
Correlation between the 3 assessments: Spearman's correlation co-efficient
0.45-0.94 (P<0.001)
Observation rating correlated at least moderately with self assessment (r=
0.25-0.63)
For those reporting pain, the observational rating scale underestimated severity
compared to all 3 self assessment scales
Pain in severe dementia: self assessment or
observational scales? [19]
Pain in severe dementia: self assessment or
observational scales? [19]
EVALUATING PAIN in those
with DEMENTIA:
Comparison of a PHYSICIANS EXAMINATION
with OBSERVATIONAL PAIN TOOLS (ABBEY
& PAINAD)
Authors: P. Moffat, K. Auret, C. Toye
AIM
• To describe any correlations in detecting
pain by means of a physical examination
(Physicians Pain Examination Tool: PPET) and
[recommended] observational pain tools:
Abbey and PAINAD in nursing home
residents with dementia
RESULTS: Methods of assessing pain
No pain
Mild pain
PPET cat
score
7 (31.8%)
8 (36.4%)
ABBEY
19 (86.4%)
3 (13.6%)
PAINAD
16 (72.7%)
6 (27.3%)
scored 1-3
Mod pain
6 (27.3%)
Severe pain
1
(4.5%)
Self report vs MMSE
Self report of
pain
MMSE =0
MMSE = 1-10
MMSE >10
Total number
Yes
0
2
2
4
No
5
6
2
13
Unable to
answer
5
0
0
5
SELF REPORT
MEDICAL NOTES
FREQENCY
PERCENT (%)
YES
Participant report
1
25
Staff report
2
50
Unknown report
1
25
TOTAL
4
100
No report
5
38.5
Staff report
5
38.5
Unknown report
3
23.1
TOTAL
13
100
No report
1
20
Staff report
2
40
Relative report
1
20
Unknown report
1
20
TOTAL
5
100
NO
NO ANSWER
SUMMARY
• Pain assessment:
– Observational pain tools underestimate the
number and intensity of pain compared to a
physicians examination
– Good statistical correlation between Abbey &
PAINAD and only moderate correlation between
the PPET and the observational pain tools
SUMMARY
• Pain assessment
– PPET had good agreement with the ‘Physicians Global
impression of pain’
– However, the Physicians impression tends to
underestimate pain compared to PPET: supported by
other studies in dementia patients
– Self reporting of pain still achievable in demented
patients: self reporting of pain is supported by pain
detected by the PPET despite the degree dementia
Assessment & Management of pain
• Combination of self report, examination,
observation, multidisciplinary input
• Goal: eliminate pain may not be the realistic goal
– Average response to non malignant pain is 30% and
neuropathic pain 50% and improve function
– Cancer pain: alleviation of symptoms is the main goal
– Overall goal: improve QUALITY OF LIFE
Medications
• paracetamol: metabolized by glucuronidation (not
altered by age)
– First line: good safety profile, hepatotoxicity is rare –
more common in malnourished & alcoholics
– Buffum et al 2004 JAGS: prn vs. reg paracetamol in
severe dementia
• Nil significant difference in discomfort scores in the 2 groups
• Regular paracetamol may be inadequate relief for the treatment
of pain
• NSAIDS: increased elimination secondary to decrease in
GFR
– Superior to paracetamol in OA
– Renal impairment & other medications affecting renal impairment
– GIT S/E (2/3 of elderly will not have symptoms of bleeding/
perforation)
– Cardiovascular events esp. COX2 but also non COX specific
agents
– Confusion, tinnitus, agitation, fluid retention
Tramadol
• Dual modes of action: mu receptor and inhibits the
reuptake of serotonin and nor adr
• Partially antagonised by naloxone
• Tolerance and dependence
• Useful for nociceptive and neuropathic pain
• High adverse effects: n, v, dizziness, constipation, delirium
• Serotonin syndrome by itself and other serotonergic drugs
SSRI or MAO Inh
Opioids
• sedative & nausea dissipates within days usually
• Constipation, hallucinations and gastric stasis are not self limiting
– Importance of prescribing an antiemetic and laxative
– Elderly sensitive to effects of sedation, confusion, falls, poor balance,
constipation, nausea
– Which opioid? – renal function, others
– Codeine: 10% of Caucasians don’t convert to morphine
– Route of administration: orally mostly, topically
• In setting of chronic pain : iv contraindicated
• Small proportion of patients with opioid sensitive pain that have significant s/e:
spinal administration may be effective
Morphine
• Absorbed in the SI (oral bioavail 30%)
• Metabolised in the liver to M3G & M6G
• In plasma: [M3G] < [M6G] < morphine
• Concept of
– break through pain
– incident pain
• Calculation of total daily dose and break through dose (1/6- 1/12 of the
TDD)
• No comparative data at equi-analgesic doses to allow
recommendations of a particular opioid [#]
• Choice between morphine and oxycodone is one of personal choice
(oral oxycodone has higher oral bioavailability – which may result in
less interindividual variation in the bioavailability)
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Buprenorphine: marked for chronic pain
Transdermal patch (precautions)
Dose equivalence not fully est.
But roughly 5mg patch = 5mg MS Contin bd
Ceiling effect
Not fully antagonised by naloxone
Dose conversion tables
• Auret K. AFP 2006: 35 (10); pp 762-5.
Neuropathic pain
• Common in the elderly: PHN, diabetic neuropathy,
central post stroke, radicular spinal pain, trigeminal
neuralgia
• Diagnosis is usually clinical
• Examination:
– hyperalgesia,
– allodynia (pain in response to a non painful stimuli),
– hyperpathia (increased pain threshold with summation
of pain on repetitive stimulation)
Neuropathic pain: Antidepressant drugs [20]
• TCA’s: Amitriptyline, nortriptyline
– NNT (50% pain relief in diabetic neuropathy) =
3.5,
– NNT 2.1 in PHN
• SSRI - not enough evidence yet
Neuropathic pain: antiepileptic drugs [20]
• Only carbamazepine, phenytoin, gabapentin &
lamotrigine evaluated in double blind clinical trails
• Carbamazepine:
– (anecdotally) better against paroxysmal shooting,
lancinating pains vs constant burning pain
– Dose 400-1000mg
– NNT 3.3 for painful diabetic neuropathy
– Not enough evidence for PHN
– Drug of choice for trigeminal neuralgia NNT 2.6, NNH
3.4 for minor adverse effects
– Need to monitor: s/e, FBP, LFT’s, ECG
Neuropathic agents: gabapentin [20]
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Effective for diabetic neuropathy & PHN
NNT 3.7 - diabetic neuropathy
NNT PHN 3.2
Start dose of 100mg tds, increase to around 9001200mg / day
• Dose reduction if renal impairment
• Sodium valproate
– Very little evidence!!
– Other agents
• Mexilitine (oral analogue of lignocaine), clonidine –
side effects limit use in the elderly
• Ketamine
• Capsaicin
• Lignocaine patches
Local therapies
• PERIPHERAL NV
BLOCKS
• Nerve blocks
– May precede neurolysis
– Somatic nvs, plexuses,
sensory, sympathetic,
visceral nvs or ganglia
• chemical or physical
neurolysis
• joint injections
• CENTRAL NEUROAXIAL
PHARMACOTHERAPY
• Opioids
• Local anaesthetics
• Clonidine
• baclofen
Local therapies cont
• Spinal surgical techniques
• Degenerative conditions precipitating spinal
stenosis, herniated discs, foraminal stenosis
• sugery
• Epidural steriods
• Physical therapy: heat & cold, TENS,
massage
• Physiotherapy
• Occupational therapy
Practical tips
Practical tips
• On admission: proforma?
– PMHx,
– current examination
– Self report
• Encourage family and staff to have input with regards to
pain assessment
• Observational screening tool?
• Medications: start low, go slow, monitor for s/e
• Examination 3 months in those who don’t have pain
• Pain clinics / geriatric clinics or referral
Take home messages
• Pain in the elderly with dementia is common
• Use multidisciplinary input for the assessment and
management
• May use screening tools – but no substitute for self
report and examination with repeated reviews
• Trail of interventions / medications with regular
review
Case study 1
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Mr RB is 75yo is a resident in HLC
He has been ‘acting up’
Additionally the staff have noted he is groaning when he walks to the dining
room
PMHx:
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PD with cognitive impairment (MMSE 9),
OA,
Diabetes type 2
HTN,
IHD with previous CABG,
osteoporosis (vertebral fractures)
BPH with urinary incontinence
• Medications:
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Aspirin 100mg
Madopar 200
Coloxyl and senna 2 tabs bd
Paracetamol soluble 1gm qid
Caltrate
Vitamin D
Gliclazide
Tramadol 100mg bd
Venlafaxine
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On examination:
Sweaty, hypertensive, agitated, confused, tachycardic
CVS, Resp, NAD
Neuro: not compliant with full examination but features of
Parkinson's
• Abdo: ? Constipation
• LL: signs of OA, signs of PVD, no pain elicited when being
examined
Case study 2
• Betty is an 88yo lady with dementia (MMSE 12)
• Normally very mobile, in last 2 weeks has been more withdrawn and
has increasing resistant behaviour (refusing personal care)
• Noted also decrease in appetite and wt loss
• PMHx: breast cancer (mastectomy) on tamoxifen, melanoma
(incomplete excision 2 months earlier), GORD, dementia, unrinary
incontinence
• Medicaitons: tamoxifen 20mg od, esomeprazole 20mg od, paracetamol
1gm qid
• Family also been saying that they feel she is in
pain: back /abdominal pain,
• O/E: cachetic BMI 19 (on admission 23 1 yr
previous) , oral thrush, epigastic tenderness,
tender hepatomegaly and distended abdomen
• vertebral tenderness at T9
• What would be your management plan
– Additional information
– Investigations – appropriateness
– Non pharmacological
– Pharmacological management
REFERENCES
• 1. Australian Bureau of Statistics www.abs.gov.au
• 2. Majar I, Higgins IJ. Unrecognized pain in nursing home residents.
Veterans Health 1997;60:13-15
• 3. Fox PL et al. Prevalence and treatment of pain in older adults in
nursing homes and other long term care institutions. A systematic
review. Can Med Assoc J 1999; 160:329-333
• 4. Crook et al. The prevalence of pain complaints in the general
population. Pain 1984; 18(3):299-314
• 5. Weiner DK et al. Predictors of pain self report in nursing home
residents. Aging Clinical and Experimental Research 1998; 10(5):411420
• 6. Maxwell CJ et al. The prevalence and management of current daily
pain among older home care clients. Pain 2008
References cont
• 9. Horgas AL et al. Analgesic drug prescription and use in cognitively
impaired nursing home residents. Nurs Res 1998;47:235-242
• 8. Scherder E et al. Recent developments in pain in dementia. BMJ
2005;330:461-464
• 9. Workman BS. Management of chronic pain in older people. Aust J of
Hospital Pharm. 1998;28(5): 361-367
• 10. Peterson G et al. Analgesia in the elderly: should not be a painful
experience. Aust Pharm 2006;25(1):52-60
• 11. Edwards RE. Age assoc differences in pain perception and pain
processing. Pain in older persons, progress in pain research and
management. Seattle: IASP Press; 2005 p 45-65
• 12. Gibson SP. Pain and aging: the experience over the adult life span.
Proceedings of the 10th World Congress on Pain, Progress in pain
research & Management. Seattle: IASP Press; 2003 p 767-90
References cont...
• 13. Martin K. The painful side of dementia. Aust J of Pharm. 2007;
88:32-34
• 14. Benedetti F et al. Pain threshold and tolarance in Alzheimers
Disease. Pain 1999;80:377-82.
• 15. The Australian Pain Society. Pain in Residential Aged Care
Facilities: Management Strategies 2005. www.apsoc.org.au
• 16. Ferrell BA et al. Pain in cognitively impaired nursing home
residents. J Pain Symptom Manage 1995;10:591-8
• 17. Auret K et al. Development and Testing of a Modified Version of the
Brief Pain Inventory for Use in Residential Aged Care Facilities. JAGS.
2008;56:301-306
References cont…
• 18. Zwakjalen SMG, et al. Pain in elderly people with
severe dementia: A systemic review of behavioural pain
assessment tools. BMC Geriatrics. 2006; 6:3
• 19. S Plaxiu
• 20. Ahmad M, Goucke CR. Management Strategies for the
treatment of neuropathic pain in the elderly. Drugs Aging
2002;19(12):929-945