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PAIN PAIN IN THE

COGNITIVELY IMPAIRED
SESSMENT SARAH BROWN
Clinical Nurse Specialist
DR. DAVID STRANG
Chief Medical Officer, Deer Lodge
Centre & PCH Program

April 12, 2010


The Issue of Pain in the
Cognitively Impaired

 MDS data 2004-2007: 74% of PCH residents


have dementia
 Cognitively impaired are less likely to report
pain
 Cognitively impaired are no less likely to
experience pain
 Professional caregivers underestimate pain
severity
 Family members tend to overestimate pain
Case Study:
Cognitively Impaired
Mrs. Imen Pane

Medical Hx: Fractured right hip, right CVA, severe


dementia, OA, degenerative spine disease, aphasic.
Medications:Tylenol 650mg QID, Hydromorphone
Contin 3mg q12h, Dilaudid 1 mg PRN, Sennosides ii
tabs HS, Trazadone 100mg HS
Increasing agitated behavior and constantly rubbing
her right hip, moaning, sometime shouting, not able
to verbalize. Psychiatrist consulted for agitated
behavior.
Mrs. Imen Pane

On exam: vital signs normal, R hip-no


redness/warmth or tenderness on
palpation, recent XR indicate no problems,
bloodwork all normal. Grimaces when
transferred or turned in bed.
Family state that she used to have severe
arthritis in her hips and knees and was on
“high doses” of Dilaudid (but not sure how
much).
Pain Assessment Tool

Is completed:
 on admission
 a change in medical condition occurs that
may indicate the presence of new pain (eg.
hip fracture)
 verbal and/or behavioural observations of
pain are noted
 person/family states that they are having
pain
Pain Assessment for
Cognitively Impaired
 Self reports of pain are no less valid
 Ask ‘Are you in pain?’
 Believe the person’s report of pain
 May be able to use pain rating scales
or answer yes-no questions about pain
 Allow time to rate pain, ask more than
once and in more than one way
 Ask about present pain
Guidelines for Pain
Assessment for
Cognitively Impaired

 Assume the presence of pain with certain


disease, procedure or injury conditions
 Establish a baseline for behavior
 Monitor for presence of pain on a regular
basis using a comprehensive list of behaviors
 Indicators for pain may not be obvious
 If uncertain trial analgesics
Framework for
Behavioral Pain
Indicators
(American Geriatrics Society)

 Facial expressions: clenched teeth,


frowning, grimacing, sad
 Verbalizations/vocalizations: ‘ouch’,
cursing
 Non-verbal: moans, groans, shouting, crying
 Body movements: bracing, guarding,
massaging affected area
 Restlessness: agitation, rocking
Framework
continued

 Changes in interpersonal interactions


 Changes in activity patterns or
routines
 Mental status changes
Pain Assessment for
Cognitively Impaired

 Gather information from multiple


sources to determine history of pain
reaction and previous reactions to
pain
 Does the family believe the
patient has pain?
Pain Assessment for
Cognitively Impaired

 Assess for unmet needs:


eg. hunger, thirst, elimination
emotional needs

 Rule out other possible causes of pain:


eg. infection, constipation, wound,
undetected fractures, UTI
Identify Cause(s) of
Pain

Review person’s:
 Current and past medical conditions and
surgeries
 Current and previous medications
 Physical examination
 Relevant laboratory and diagnostic tests
*** Scope of assessment depends on
person’s care goals.
Physical Exam

• Overall impression/appearance
• Facial expression
• Body position and movement
• Areas of redness, swelling, warmth
• Palpation, tenderness
• Focused assessment:
eg. chest pain
Pain Assessment Tools
for the Cognitively
Impaired

• Includes only ‘specific’ behaviors, lacks


‘subtle’ behaviors, direct observation focused
• Completed by the nurse/team
• Scores correlate with 0-6 scale with 0: no pain
and 6: as bad as it can be
• Limited research
• Simple & Easy to use
Pain Assessment Tools

Non-Communicative Patient’s Pain


Assessment Instrument
• Includes ‘Specific’ behaviors only
• Designed for use by health care aids
• Reliable but should accompany more
comprehensive assessment
CCHSA Accreditation
standards

 A new Required Organizational


Practice for 2009 will be:
“Develop and implement an
organizational policy and protocol to
identify and treat cognitively impaired
residents requiring effective pain
management”
Management

• Non- Pharmacologic
• Pharmacologic
Non-Pharmacologic

• Wide range of potential


interventions
• Provision for other needs
• Reassurance, contact
• Massage, heat, ice
• Physiotherapy modalities
Pain Pills

• Pharmacologic management
includes four general drug groups:
• Acetaminophen
• NSAIDs
• Opioids
• Neuropathic pain meds
(antidepressants, anticonvulsants)
Pain Med-Cognition
Quandary

• All pain pills but acetaminophen


can adversely affect cognition,
especially in high-risk people such
as those with dementia, frailty
• Pain can impair cognition
• Chronic pain causes depression,
which impairs cognition
Pain Meds and
Cognition

• Opiates - sedation, delirium


• NSAIDs - delirium
• Anticonvulsants - sedation,
cognitive effects
• Tricyclics - anticholinergic effect
and sedation
So what to do?

• Difficult area to study, few studies


• Dementia further complicates
assessment of benefit
Pain Meds for
Agitation

• People with severe dementia may


not be able to report pain
• ‘Agitation’ (BPSD - Behavioral and
Psychiatric Symptoms of Dementia)
is common in dementia
• Some BPSD may be triggered by
unreported pain
Empiric Analgesia

• 2 small placebo-controlled cross-over


trials of pain meds for BPSD
• Opiates - 10 mg BID of oxycodone SR
or 20 mg daily of morphine SR vs
placebo in 25 patients
• Some reduction in BPSD among those
over age 85 with little observed
sedation
Empiric Analgesia

• Acetaminophen 1 g TID vs placebo


in 25 patients
• Small improvements in some
observed interactions on Dementia
Care Mapping
• No difference in BPSD
So Really, What To
Do?

• Assess for pain


• Suspect pain as a cause of BPSD
• Treat pain or suspected pain
• Start Low, Go Slow
What to do

• Try non-pharmacologic management


• But may be difficult to implement and
assess benefit due to dementia
• Try medication
• Start with scheduled acetaminophen,
about
1 g TID
What to do

• Consider topical non-steroidals for pain


localized to an exposed joint (e.g. knee)
• If ongoing pain, consider trial of opiates
• No evidence-base to favor one over another
• Use recognized pain management principles
i.e. basal analgesic with breakthrough prn
What to do

• Consider adjunctive analgesics


depending on diagnosis
• Consult a specialist
Serial Trial
Intervention
Dr. Christine Kovach

Behavior Change
Behavior Change 
Identification
Identification

If behavior continues
1  PHYSICAL Target
Proceed to 2

2  AFFECTIVE
Serial Trial
Intervention

If behavior continues
2 AFFECTIVE Target
Proceed to 3

3  Trial: non­pharmacological
 comfort

4    Trial: analgesics

5  Consultation or trial psychotropic
Study of STI

• 114 subjects in 14 nursing homes


• STI intervention by trained nurses
or control group with usual care
• STI nurses assessed more, gave
more interventions including meds
• STI subjects had less discomfort
Case Study:
Cognitively Impaired
Mrs. Imen Pane

Medical Hx: Fractured right hip, right CVA, severe


dementia, OA, degenerative spine disease, aphasic.
Medications:Tylenol 650mg QID, Hydromorphone
Contin 3mg q12h, Dilaudid 1 mg PRN, Sennosides ii
tabs HS, Trazadone 100mg HS
Increasing agitated behavior and constantly rubbing
her right hip, moaning, sometime shouting, not able
to verbalize. Psychiatrist consulted for agitated
behavior.
Mrs. Imen Pane

On exam: vital signs normal, R hip-no


redness/warmth or tenderness on
palpation, recent XR indicate no problems,
bloodwork all normal. Grimaces when
transferred or turned in bed.
Family state that she used to have severe
arthritis in her hips and knees and was on
“high doses” of Dilaudid (but not sure how
much).
Mrs. Imen Pane

The nurse gives Mrs. Pane a hot pack and puts


on some music in her room. She ensures that
Mrs. Pane has had something to eat and drink
and her incontinence product changed. Mrs.
Pane settles for a short while but then starts
to become agitated and moaning again.
The nurse then gives a breakthrough dose of
Dilaudid 1mg Prn and checks in on her one
hour later. Mrs. Pane is less agitated and
resting more comfortably.
Questions???
References

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