How can clinicians determine the presence of pain in cognitively impaired patients? And how do you know the medication is working if your patient can’t tell you?
Pain is a subjective complaint for which health care professionals largely depend upon self-report by patients. However, how do you determine the presence of pain in cognitively impaired patients? How do you determine its severity? And how do you know that the medication is working if your patient can’t tell you?
A recent review of the problem of pain among patients who suffer with dementia identifies many of the associated issues associated and provides recommendations for addressing them.1
Dementia largely occurs among older patients who are more likely than younger patients to suffer from many disorders that can cause pain, such as arthritis, cancer, diabetic neuropathy, and shingles. Furthermore, some disorders such as Parkinson disease and stroke can cause both severe pain and dementia. Studies show that as many as 60% to 80% of residents of nursing homes with dementia and over 50% of those in the community with it experience pain.2
The greatest challenge to health care providers is determining whether patients with dementia are experiencing pain. Although patients with mild to moderate dementia may still be able to respond appropriately when asked if they are experiencing pain, those with more severe dementia are probably unable to gauge how much pain they feel, so asking them this question is unlikely to provide much information nor will the commonly used instruments to measure pain such as numerical rating scales. Thus, it falls on health care providers to find alternative methods for identifying pain in those who can’t respond. The best to way determe whether pain is present is to observe patients.
There are multiple challenges with regard to treatment of elderly patients with dementia. Although analgesic medications may be beneficial, as with all geriatric patients, cormorbid conditions and reduced renal and hepatic function can make it difficult to find the optimal balance between pain relief while avoiding adverse events. Furthermore, because patients with dementia may be limited in their ability to self report, they may be unable to report adverse effects of medications.
Recommendations with regard to pharmacologic management of pain among those with dementia are based primarily on those for geriatric patients in general as there is little research on their efficacy specifically for patients with dementia.
Acetaminophen is considered the first-line medication although there is limited research beyond 3 months of use, which would be considered that it is being used for chronic pain. Opioids may be effective in managing pain although it is still an open question whether their benefits outweigh their potential adverse events. Other medications commonly used for the management of chronic pain are the serotonin-norepinephrine reuptake inhibitors (SNRIs) and the gabapentinoids. Avoid NSAIDs because of their potential adverse effects.
Opioids are known for their sedating effects, thus benefits ascribed to opioids for patients with dementia may be due to their sedating effects. Measurement of efficacy would be primarily based on observation of the patients, thus, sedation might be confused with reduction of pain in patients. Another issue is prn prescribing. In nursing homes, analgesic medications are often prescribed on a prn basis, wich means that patients with dementia who are unable to report that they are having pain are unlikely to receive pain medication.
As with the treatment of chronic pain for patients of any age, nonpharmacologic treatments should be considered and may be effective. They have the added benefits of essentially being free of adverse events so therefore are unlikely to exacerbate other medical problems. However, as with pharmacologic therapies, there is limited research on these treatments for this patient cohort and the recommendations are primarily based on those for geriatric patients without dementia. Many of the treatments for chronic pain provided by physical and occupational therapists are focused on educating patients by teaching them alternative methods to manage their pain and how to perform tasks using different body mechanics. Obviously, learning new material would be difficult for many patients with dementia.
Rely on observation of patients with dementia to determine if they are experiencing pain, agitation may be a reflection of pain. Be especially observant for indications of pain among patients who are suffering from disorders that frequently cause pain such as rheumatologic disorders, Parkinson disease, and diabetes. Do a benefit-to-harm analysis before starting any interventions for pain.
1. Achterberg W, Lautenbacher S, Husebo B, et al. Pain in dementia. Pain Clin Updates. 2020;5:1-8.
2. Sengstaken EA, King SA. The problems of pain and its detection among nursing home residents. JAm Geriatric Soc. 1993;41:541-544.