Assessing and Treating Pain in
the Cognitively Impaired
R. Sean Morrison, MD
Hermann Merkin Professor of Palliative Care
Professor, Geriatrics and Medicine
Department of Geriatrics & Adult Development
Mount Sinai School of Medicine
New York, NY
Acknowledgements
Mary Ersek, PhD, RN
Swedish Medical Center, Seattle,
Washington.
mary.ersek@swedish.org
Acknowledgements
E L N E C
Geriatric Curriculum
End-of-Life Nursing Education Consortium
• “To provide nurses at all levels of preparation the
knowledge to provide competent, compassionate
palliative care to patients in a variety of clinical settings”
• ELNEC-Geriatrics: focused on licensed nursing staff & CNAs
working in long-term care settings
• Next ELNEC-Geriatric training: Pasadena, CA, September 12—
14, 2007
• For more information:
http://www.aacn.nche.edu/ELNEC/
Definitions of Pain
• “An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage”
IASP, 1979
• “Pain is whatever the person says it is…”
McCaffery & Pasero, 1999
Pain in Older Adults
• 25 – 56% community-dwelling elders
Helme & Gibson, 2001
• 45 – 85% nursing home residents
AGS, 2002
• 1/3 cancer pts receiving treatment and 2/3 with
advanced cancer
APS, 2003
• 50% of hospitalized pts in last 3 days of life
SUPPORT, 1995
Acute and Chronic Pain
ACUTE
• Sudden onset, in response
to illness or injury
• Usually decreases over
time as healing occurs;
self-limiting
• Goal: eliminate pain by
treating cause
• Physical signs: “fight or
flight”
• Behavioral signs
CHRONIC (PERSISTENT)
• Insidious onset, or follows
acute
• Lasts beyond expected
healing period or
associated with a chronic
condition
• Goal: maintain function &
quality of life
• Behavioral signs
Major Categories of Pain
Nociceptive
Sources: organs, bone, joint,
muscle, skin, connective tissue
Examples: arthritis, tumors,
gall stones
Character: dull, aching,
pressure, tender
Responds to traditional pain
medicines & therapies
Neuropathic
Source: peripheral nerve or
CNS pathology
Examples: postherpetic
neuralgia, diabetic
neuropathy
Character: shooting,
burning, stabbing
Requires different types of
medications than
nociceptive pain
Most Common Types of
Persistent Pain in Older Adults
• Musculoskeletal (e.g., low back pain,
osteoarthritis)
• Neuropathies (e.g., diabetic
neuropathy, post-herpetic neuralgia)
• Cancer
AGS, 2002
Nonverbal residents
• Advanced dementia
• Progressive neurological
disease
• Post CVA
• Imminently dying
• Developmentally
disabled
• Delirium
A b ility to se lf-re p o rt p a in
Pain Self-Report and Cognitive
Impairment in Dementia Patients
Nonverbal
C o g n itive im p a irm e n t
Is pain processed and perceived
differently by people with
dementia?
• Tolerance to acute pain possibly increases
but pain threshold does not appear to
change (Benedetti et al, 1999;2004)
• Dementia may blunt autonomic nervous
system’s response to acute pain (Rainero et
al, 2000)
• Cognitive impairment may ↓ perceived
analgesic effectiveness (Benedetti et al, 2006)
Can Residents with Cognitive
Impairment (CI) Give Reliable Pain
Reports?
• CI residents slightly underreport pain, but
their reports are valid (Parmelee et al., 1993)
• 83% of residents with mild to moderate
CI could reliably complete at least one
pain scale (Ferrell et al., 1995)
• 73% of post-op patients with moderate
CI were able to complete a 4-point verbal
descriptor scale (Feldt et al., 1998)
Cognitive Impairment & Pain
Management: Nursing Homes
• Pain is documented less frequently for CI
residents, even with similar numbers of painful
diagnoses as less impaired residents (Sengstaken &
King, 1993)
• Less analgesic is prescribed/administered for CI
residents, despite similar numbers of painful
diagnoses (Horgas & Tsai, 1998)
• Approximately ¼ of demented residents who
were identified as having pain were receiving
any analgesic therapy (Scherder et al, 1999; Bernabei et
al, 1998; Won et al, 1999)
Outcomes of Unrelieved
Pain
•
•
•
•
•
•
•
•
Unnecessary suffering
Depression and anxiety
Impaired ambulation, gait disturbance
Sleep disturbances
Decreased socialization
Increased healthcare utilization
Increased agitation and resistance to care
Impaired cognition
Pain and Delirium
• Risk factors for delirium among older
adults hospitalized with hip fracture
• Cognitive impairment (RR: 3.6; 95% CI 1.6—7.2)
• Received < 10 mg parenteral MS equivalents (RR:
5.4; 95% CI 2.4—12.3)
• In cognitively intact patients, severe pain
was associated with 9 times the risk of
delirium
—Morrison et al, 2003
Conceptual
Model for Pain
Assessment in
Noncommunicative
Persons with
Dementia
Snow et al, 2004
ASPMN Position
Statement/Guideline
• All persons deserve prompt recognition and
treatment of pain even when they cannot
express their pain verbally
• Establish a pain assessment procedure
• Use Hierarchy of Pain Assessment Techniques
• “Assume pain is present”
• Use empirical trials
• Re-assess and document
www.aspmn.org/Organization/position_papers.htm
Hierarchy of Data Sources
• Resident report (if
possible)
•
•
•
•
•
Prior pain history
Painful diagnoses
Behavioral indicators
Observer assessment
Response to
empirical therapy
Don’t make
assumptions
based on
medical
diagnoses or
scores on
dementia rating
scales
• Focus on present pain
• Find a scale that works
and use it consistently
• Use verbal reports and
observations
• Assess reliability by
asking about pain at
different time (when pain
is expected to be more
severe, e.g., during
movement)
Painful Diagnoses
•
•
•
•
•
•
•
•
Degenerative Joint Disease
Degenerative Disc Disease
Spinal Stenosis
Osteoporosis/Compression Fractures
Diabetes
Cancer
Herpes Zoster
Pressure Ulcers/wounds
Causes of Physical Pain in
Residents with Dementia
• Constipation or diarrhea
• Lodged food
particles
• Contractures
• Pressure ulcers
• UTI
Volicer & Hurley, 1999
Behavioral/Observational Cues
•
•
•
•
•
•
•
•
•
•
•
Grimacing or wincing
Bracing
Guarding
Rubbing
Changes in activity level
Sleeplessness, restlessness
Resistance to movement
Withdrawal/apathy
Increased agitation, anger, etc.
Decreased appetite
Vocalizations
Pain Behavior Assessment
Tools
• Checklist for Nonverbal Pain Indicators (CNPI)
(Feldt, 2000)
• NOPAIN (Snow et al, 2004)
• PAIN-AD (Warden et al, 2003)
• Pain Assessment Scale for Seniors with Severe
Dementia (PACSLAC) (Fuchs-Lacelle & Hadjistavropoulos,
2004)
• Also see: Herr, Decker, & Bjoro (2004). State of the Art
Review of Tools for Assessment of Pain in Nonverbal
Older Adults.
• Available at: http://www.cityofhope.org/prc/elderly.asp
Pain Behavior Assessment
Tools
• Checklist for Nonverbal Pain Indicators
(CNPI)…Feldt, 2000
• NOPAIN…Snow et al, 2003
• PAIN-AD… Warden et al, 2004
• Pain Assessment Scale for Seniors with Severe
Dementia (PACSLAC)…Fuchs-Lacelle & Hadjistavropoulos,
2004
• State of the Art Review of Tools for
Assessment of Pain in Nonverbal Older Adults
• Available at: http://www.cityofhope.org/prc/elderly.asp
Agitation
• Pittsburgh Agitation Scale – Resident
Case Manager Assessment
• Evaluates: aberrant vocalization,
motor agitation, aggressiveness,
resistance to care
• 0–16 with higher scores indicating
greater agitation
Minimize reliance on physical
signs
• ANS stimulation: ↑ BP, ↑ HR, ↑RR,
diaphoresis
• Blunted in elderly, esp. cognitively
impaired
• Only valid for acute pain
Caregiver Report
Pay particular
attention to
changes from
normal
behaviors
Empirical Trials in Nonverbal
residents
Try pain medicine
Behaviors suggest it
could be pain
Behaviors decrease
It’s probably pain!
A sse ss fo r
p o ssib le p a in
b e h a vio rs
D o cu m e n t
a sse ssm e n t a n d
R x re sp o n se
E n su re b a sic
co m fo rt n e e d s
a re m e t
R e -e va lu a te
p a in b e h a vio rs
E va lu a te a n d
tre a t n e w a cu te
p ro b le m s
(e .g ., U T I)
A d m in iste r
a n a lg e sic
Comfort Needs
Glasses? Dentures?
Hearing aid?
Environmental stressors?
Toileting?
Lonely? Fearful?
Over-stimulated?
Acute or New Pain
Fall?
Infection?
Impaction?
???
Evidence for attempting
empirical analgesic trial
• Regular analgesic therapy increased social
engagement in NH residents (Chibnall et al,
2005)
• Use of standardized assessment and
treatment protocol significantly decreased
discomfort among demented NH residents
(Kovach et al, 1999)
• Evaluation of 650 mg TID APAP: 63% decrease
in negative behaviors, 75% psychotropics
discontinued (Douzjian et al, 1998)
Administer Analgesic
• 650 – 1000 mg acetaminophen every 4
hours
• 2.5 hydrocodone/500 APAP or 2.5—5.0
oxycodone every 4 hours
• Include nondrug measures
Communication and
documentation is
critical in successful
assessment and
treatment of pain in
nonverbal residents