Pain and Impaired cognition: Facts and fiction

Prof Dr Wilco Achterberg, MD, PhDLeiden University Medical Center,

The Netherlands

Disclosure Statement of Financial Interest

I, Wilco Achterberg, DO NOT have a financial interest/arrangement or

affiliation with one or more organizations that could be perceived

as a real or apparent conflict of interest in the context of the subject

of this presentation.

Pain in dementia: facts and fictions

Pain experience

Pain assessment

Pain treatment

FACTS: PAIN EXPERIENCE

Clinical pain report and intensity similar in mild to moderate cognitive impairment, but may be reduced in those with more advanced dementia.

Experimental studies: pain threshold unchanged, pain tolerance increased.

Autonomic reactivity to pain is altered in those with dementia

Unrelieved pain may be a contributing factor to the increased occurrence of BPSD (particularly resistance to care, repetitive vocalisation, agitation and aggression).

FICTIONS: PAIN EXPERIENCE

Pain is normal with aging

People with dementia do not feel pain

Emotional components of pain are reduced

FACTS: PAIN ASSESSMENT

Behavioural assessment scales (25+) available and promising.

Many tools have growing evidence of reliability and validity.

Self report remains a viable option for mild to moderate dementia.

Facial action coding system offers a viable pain assessment option

at least for research purposes?

Assessment of pain during a movement based protocol appears to be better

Behaviour Coding Tools• Facial action coding• Somatic interventions• Pain behaviours

Physiological Measures• Autonomic markers• Reflexes (RIII)• Neuroimaging (fMRI, PET)

Self Report Scaling– Verbal descriptor scales– Numeric scales– Graphic/picture scales

Proxy Ratings– Generalised (Minimum Data Set pain report)

TYPES OF PAIN ASSESSMENT

Eye brow lowersNose wrinkles

Eye lids tighten/close

Lips tighten/parted

Cheek area raised

Hadjistavropoulos, 2000,2002, 2007Kunz et al. 2007, 2008

Facial expressions of pain

Vocal expressions: (vocalise, moaning, noisy breathing, crying)Facial expressions: (grimace, clench teeth, frightened/tense face)Body language: (guarding/bracing, stiff body, rocking/withdrawn)General behaviour: (increased confusion, aggression, wandering)Physiologic signs: (tissue damage, vital signs change, previous Hx)

DS-DAT, PAINAD, Abbey, NOPAIN, DOLOPLUS-2, ALGOPLUS,CNPI, MOBID, RaPID, PACSLAC, ADD, FLACC, ECPA, PACI, PATCOA,

NVPS, FACS, Mahoney PS, CNAPAT, PADE...

Non-Verbal indicators of likely pain

Non verbal measures in persons with cognitive impairment

BEHAVIOURAL and PSYCHOLOGICAL DISTURBANCES

agitation in 11% of long term residents => 50% of those with advanced dementia

Cross-sectionnal study : SHELTER study. Tosato et al., 2011

Prevalence of behavioral and psychiatric symptoms according to presence of pain

Cluster randomised clinical trial Efficacy of treating pain to reduce behaviouraldisturbances in residents of nursing homes withdementia

Husebo et al., 2011

Cluster randomized controlled trialimplementation of the serial trial intervention for pain and challenging behaviour in advanced dementia patients (STA OP!): Pieper et al., 2011

Study ProtocolThe Behaviour and Pain in Dementia Study (BePAID) older people with dementia who have unplanned acute medical admissions

Scott et al., 2011

TREATING PAIN TO REDUCE AGITATION?

FACTS: PAIN TREATMENT

Pain is undertreated in persons with dementia.

• Across all health care settings:

acute hospital, sub acute and residential aged care

Across all studied disease entities (cancer, post operative, chronic pain).

Fewer PRN orders for analgesics are given to persons with dementia.

Dosage lower in persons with dementia regardless of class of analgesic (simple anti-inflammatory agents, narcotics).

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FICTIONS:PAIN TREATMENT

Response to pain treatments cannot be reliably monitored in dementia.

Lower dose analgesics are sufficient for people with dementia.

Greater adverse drug reactions occur in those with dementia.

Opioid medication given for strong acute pain worsens cognitive function in those with and without dementia

Specialist multidisciplinary treatment programs cannot be delivered to persons with dementia.

Objectives Cost-action: MAIN

Development of a- comprehensive and - internationally agreed-on - toolkit for - assessing pain in adults with cognitive impairment, especially with dementia.

Objectives Cost-action: SECONDARY

Preparing appropriate dissemination strategies for both toolkit and guidelines

Analyzing and, if possible, correcting scientific, social and political barriers against dissemination

Encouraging cross-national learning and consideration of cross-national differences in this process

Increasing the overall awareness for the deleterious situation of pain sufferers with cognitive impairment in the public and in bodies of experts

Questions?