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
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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
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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
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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)
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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
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Changes in interpersonal interactions
Changes in activity patterns or routines
Mental status changes
Pain Assessment for
Cognitively Impaired

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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
•
•
•
•
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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
Behavior Change
Change
Identification
Identification
1 PHYSICAL
2 AFFECTIVE
Target
If behavior continues
Proceed to 2
Serial Trial Intervention
2 AFFECTIVE
Target
If behavior continues
Proceed to 3
3 Trial: non-pharmacological
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
Bjoro K, Herr K. Assessment of pain in the nonverbal or cognitively impaired older adult. Clin Geriatr Med. 2008;
24((2):237-262.
Chibnall JT, et al. Effect of acetaminophen on behavior, well-being, and psychotropic medication use in nursing home
residents with moderate-to-severe dementia. J Am Geriatr Soc. 2005;53(11):1921-29.
Horgas AL, Elliott AF, Marsiske M. Pain assessment in persons with dementia: Relationship between self-report and
behavioral observation. J Am Geriatr Soc. 2009; 57(1): 126-132.
Kovach C, et al. The serial trial intervention: An innovative approach to meeting needs of individuals with dementia. J of
Geront Nurs 2006; 18-27.
Kovach C, et al. Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.
Am J of Alzheimers Dis Other Demen 2006; 21:147-155.
Manfredi PL, et al. Opioid treatment for agitation in patients with advanced dementia. Int J Geriatr Psychiatry. 2003;
18:700-705.
McAuliffe L, Nay R, O’donnell M, fetherstonhaugh D. Pain assessment in older people with dementia: Literature review. J
Adv Nurs. 2009; 65(1):2-10.
Pesonen A et al. Evaluation of easily applicable pain measurement tools for the assessment of pain in demented patients.
Acta Anaesthesiol Scand. 2009; 53(5):657-664.
Reynolds KS et al. Disparities in pain management between cognitively intact and cognitively impaired nursing home
residents. J Pain Symptom Manage. 2008; 35(4):388-396.
Scherder E, et al. Pain in dementia. Pain. 2009; 1-3.
Schofield P. Assessment and management of pain in older adults with dementia: A review of current practive and future
directions. Current Opinion in Supportive and Palliative Care. 2008; 2(2):128-132.
WRHA Pain Assessment and Management Clinical Practice Guidelines. June 2008.