Journal of Pain & Palliative Care Pharmacotherapy. 2014;28:305–307. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2014.941136
EUROPEAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 08/29/14 For personal use only.
Pain Assessment in Cognitive Impairment Peter Passmore and Emma Cunningham A B STRA CT Pain may adversely affect cognition through its effects on mood and sleep, and chronic pain has been associated with brain atrophy. Studies suggest that chronic pain is undertreated in cognitively impaired people. Pain assessment should involve direct enquiry with the patient; where this is not possible, a proxy history from a caregiver or nurse should be obtained, and observational scales may also be useful. This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS assessment, cognitive impairment, dementia, geriatrics, pain
Pain, in particular chronic pain, is common in older people. Cognitive impairment in older people is also common and ranges from so-called mild cognitive impairment through to more severe cognitive impairment/dementia. (Common causes of cognitive impairment are listed in Box 1). Despite the high prevalence of both conditions in the elderly population, the recognition, detection, and management of pain in people with cognitive impairment is challenging.
on sleep, mood, and function in all patients. These are especially undesirable in those with cognitive impairment because disordered sleep and mood can adversely affect cognition. Pain is also linked to behavioral abnormalities in those with dementia. Furthermore, there is some evidence that chronic pain has a link to brain atrophy1 that may be relevant in terms of impaired cognition. It is therefore very important to recognize and assess the extent and impact of pain in this patient group.
RELATIONSHIP BETWEEN PAIN AND COGNITION BOX 1. Causes of cognitive impairment It is important to recognize the significance of pain in people with cognitive impairment. Pain has effects
• Dementia − Alzheimer’s disease − Frontotemporal dementia − Vascular dementia − Lewy body dementia − Parkinson’s disease dementia
Peter Passmore, MD, FRCP, FRCPI, is Professor of Ageing and Geriatric Medicine and Emma Cunningham, MB, MRCP, is a clinical research fellow in the School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast UK. This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. Address correspondence to: Peter Passmore (E-mail: [email protected]).
• Stroke • Learning disability • Multiple sclerosis • Motor neurone disease
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Journal of Pain & Palliative Care Pharmacotherapy
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 08/29/14 For personal use only.
UNDERTREATMENT OF PAIN IN DEMENTIA There is some evidence that clinicians manage acute pain equally well in patients with dementia as in those with no cognitive impairment, but there seems to be a significant problem with the recognition and management of chronic pain.2 Epidemiological studies suggest that significant numbers of older people with dementia are in pain, but around 40% of those in pain are not prescribed any form of analgesia.3,4 Major factors behind these findings could be the detection of pain and also attitudes or approaches to management of pain in people with dementia. Evidence from nursing homes suggests that the main barriers to pain management are obtaining an accurate report from the patient, lack of staff knowledge about pain management, and lack of a standardized approach to treatment of pain.5,6 It should be noted, however, that even where pain has been identified, patients may not necessarily receive appropriate treatment.6 There are very few studies of pain management in people with dementia. The use of a pain management protocol was examined in a controlled study in people with dementia living in nursing homes.7 In those patients randomized to receive the protocol, pain was reduced and there were significant benefits on agitation and overall behavioral problems compared with usual care. The authors suggested that a standardized approach to pain management in people with dementia could also result in reduced use of antipsychotic and other psychotropic medications in residents of nursing homes.
Pain assessment protocols begin with a direct enquiry with the patient. In milder stages of cognitive impairment, self-report is usually possible and use of a rating scale is suggested. A number of studies have identified that elderly patients and those with cognitive impairment have difficulty completing the visual analogue scale; numerical rating scales, verbal descriptor scales, or other visual scales such as the pain-faces scales originally developed for children may offer a better measurement.9 If the patient cannot usefully communicate, then a proxy history from caregiver or health care staff is needed. Use of a pain map can be useful. BOX 2. Behavioral pain indicators in cognitively impaired older persons12 Facial expressions:
• frowning, sad, frightened, grimacing Verbalizations:
• sighing, moaning, groaning, grunting, chanting, calling out, noisy breathing, asking for help, verbally abusive Body movements:
• rigid, tense body posture, guarding, fidgeting, pacing, rocking, restricted movement Changes in interpersonal interactions:
• aggressive, combative, resistive, less interactive, inappropriate, disruptive, withdrawn Changes in activity patterns:
• refusing food, appetite change, change in sleep, cessation of routines, wandering
PAIN ASSESSMENT IN COGNITIVE IMPAIRMENT Given that health care professionals are often aware of pain-causing conditions in their patients, pain should likewise be expected in the setting of cognitive impairment and conditions associated with pain should be noted. Pain assessment should also apply in all clinical settings: community, hospital ward, or institutional care. The establishment of protocols for pain assessment8 and pain management, allied to educational initiatives, are suggested. The approach to pain assessment is the same for people with cognitive impairment as for those without. In order, this is:
• Direct enquiry • History from a proxy such as a caregiver or nurse • Use of observational scales
Changes in mental status:
• crying, increased confusion, irritability, distress
Where self-report is not possible, observation and detection of pain-related behavior is a valuable approach to identification of pain in dementia. There are a number of scales that may be used for this purpose.10 Many of these are designed for, or have been used in, research studies, and many are not well validated. A scale for routine use in clinical practice should be effective and reproducible and relatively quick to perform. The scale suggested in the UK assessment guidelines is the Abbey Pain Scale.8,11 This is easy to use and suggests the presence of pain, although it is not as well validated as some of the more research-orientated scales. It is critical to ensure that pain is assessed both at rest and on movement. It Journal of Pain & Palliative Care Pharmacotherapy
European Perspectives On Pain and Palliative Care
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 08/29/14 For personal use only.
is widely acknowledged that pain in those suffering from dementia and cognitive impairment can be associated with behavioral disturbance (Box 2)12 and recent reports suggest that agitation and aggression rather than wandering are more prevalent.13 It is also important to be aware that a change in behavior can be an indicator of pain. Assessment of pain is necessary to ensure appropriate pain management. Similarly, an assessment after any intervention is needed to evaluate treatment response.
CONCLUSIONS There should be a routine direct enquiry about pain in the cognitively impaired population. A more widespread use of pain assessment protocols in people with cognitive impairment and dementia should mean increased levels of detection. Through improving pain detection, these measures should improve pain management in those with cognitive impairment and dementia. Improved pain management should in turn result in improvements in sleep, mood, and function, which would be a benefit in this population.
307
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES [1] Moayedi M, Weissman-Fogel I, et al. Brain Res. 2012; 1456:82–93. [2] Pickering G, Jourdan D, et al. Eur J Pain. 2006; 10:379–384. [3] Pautex S, Michon A, et al. J Am Geriatr Soc. 2006;54: 1040–1045. [4] Zwakhalen SM, Koopmans RT, et al. Eur J Pain. 2009;13: 89–93. [5] Barry HE, Parsons C, et al. Int J Geriatr Psychiatry. 2012;27: 1258–1266. [6] Achterberg WP, Pieper MJ, et al. Clin Interv Aging. 2013;8: 1471–1482. [7] Husebo BS, Ballard C, et al. BMJ. 2011;343:d4065. [8] Royal College of Physicians, British Geriatrics Society, British Pain Society. The Assessment of Pain in Older People: National Guidelines. Concise Guidance to Good Practice Series, No. 8. London, Royal College of Physicians; 2007. [9] Gagliese L. J Pain. 2009;10:343–353. [10] Zwakhalen SM, Hamers JP, et al. BMC Geriatr. 2006;6:3. [11] Abbey J, Piller N, et al. Int J Palliat Nurs. 2004;10:6–13. [12] AGS Panel on Persistent Pain in Older Persons. J Am Geriatr Soc. 2002;50(6 Suppl):S205–S224. [13] Ahn H, Horgas A. BMC Geriatr. 2013;13:14.
EUROPEAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 08/29/14 For personal use only.
Pain Assessment in Cognitive Impairment Peter Passmore and Emma Cunningham A B STRA CT Pain may adversely affect cognition through its effects on mood and sleep, and chronic pain has been associated with brain atrophy. Studies suggest that chronic pain is undertreated in cognitively impaired people. Pain assessment should involve direct enquiry with the patient; where this is not possible, a proxy history from a caregiver or nurse should be obtained, and observational scales may also be useful. This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS assessment, cognitive impairment, dementia, geriatrics, pain
Pain, in particular chronic pain, is common in older people. Cognitive impairment in older people is also common and ranges from so-called mild cognitive impairment through to more severe cognitive impairment/dementia. (Common causes of cognitive impairment are listed in Box 1). Despite the high prevalence of both conditions in the elderly population, the recognition, detection, and management of pain in people with cognitive impairment is challenging.
on sleep, mood, and function in all patients. These are especially undesirable in those with cognitive impairment because disordered sleep and mood can adversely affect cognition. Pain is also linked to behavioral abnormalities in those with dementia. Furthermore, there is some evidence that chronic pain has a link to brain atrophy1 that may be relevant in terms of impaired cognition. It is therefore very important to recognize and assess the extent and impact of pain in this patient group.
RELATIONSHIP BETWEEN PAIN AND COGNITION BOX 1. Causes of cognitive impairment It is important to recognize the significance of pain in people with cognitive impairment. Pain has effects
• Dementia − Alzheimer’s disease − Frontotemporal dementia − Vascular dementia − Lewy body dementia − Parkinson’s disease dementia
Peter Passmore, MD, FRCP, FRCPI, is Professor of Ageing and Geriatric Medicine and Emma Cunningham, MB, MRCP, is a clinical research fellow in the School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast UK. This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. Address correspondence to: Peter Passmore (E-mail: [email protected]).
• Stroke • Learning disability • Multiple sclerosis • Motor neurone disease
305
306
Journal of Pain & Palliative Care Pharmacotherapy
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 08/29/14 For personal use only.
UNDERTREATMENT OF PAIN IN DEMENTIA There is some evidence that clinicians manage acute pain equally well in patients with dementia as in those with no cognitive impairment, but there seems to be a significant problem with the recognition and management of chronic pain.2 Epidemiological studies suggest that significant numbers of older people with dementia are in pain, but around 40% of those in pain are not prescribed any form of analgesia.3,4 Major factors behind these findings could be the detection of pain and also attitudes or approaches to management of pain in people with dementia. Evidence from nursing homes suggests that the main barriers to pain management are obtaining an accurate report from the patient, lack of staff knowledge about pain management, and lack of a standardized approach to treatment of pain.5,6 It should be noted, however, that even where pain has been identified, patients may not necessarily receive appropriate treatment.6 There are very few studies of pain management in people with dementia. The use of a pain management protocol was examined in a controlled study in people with dementia living in nursing homes.7 In those patients randomized to receive the protocol, pain was reduced and there were significant benefits on agitation and overall behavioral problems compared with usual care. The authors suggested that a standardized approach to pain management in people with dementia could also result in reduced use of antipsychotic and other psychotropic medications in residents of nursing homes.
Pain assessment protocols begin with a direct enquiry with the patient. In milder stages of cognitive impairment, self-report is usually possible and use of a rating scale is suggested. A number of studies have identified that elderly patients and those with cognitive impairment have difficulty completing the visual analogue scale; numerical rating scales, verbal descriptor scales, or other visual scales such as the pain-faces scales originally developed for children may offer a better measurement.9 If the patient cannot usefully communicate, then a proxy history from caregiver or health care staff is needed. Use of a pain map can be useful. BOX 2. Behavioral pain indicators in cognitively impaired older persons12 Facial expressions:
• frowning, sad, frightened, grimacing Verbalizations:
• sighing, moaning, groaning, grunting, chanting, calling out, noisy breathing, asking for help, verbally abusive Body movements:
• rigid, tense body posture, guarding, fidgeting, pacing, rocking, restricted movement Changes in interpersonal interactions:
• aggressive, combative, resistive, less interactive, inappropriate, disruptive, withdrawn Changes in activity patterns:
• refusing food, appetite change, change in sleep, cessation of routines, wandering
PAIN ASSESSMENT IN COGNITIVE IMPAIRMENT Given that health care professionals are often aware of pain-causing conditions in their patients, pain should likewise be expected in the setting of cognitive impairment and conditions associated with pain should be noted. Pain assessment should also apply in all clinical settings: community, hospital ward, or institutional care. The establishment of protocols for pain assessment8 and pain management, allied to educational initiatives, are suggested. The approach to pain assessment is the same for people with cognitive impairment as for those without. In order, this is:
• Direct enquiry • History from a proxy such as a caregiver or nurse • Use of observational scales
Changes in mental status:
• crying, increased confusion, irritability, distress
Where self-report is not possible, observation and detection of pain-related behavior is a valuable approach to identification of pain in dementia. There are a number of scales that may be used for this purpose.10 Many of these are designed for, or have been used in, research studies, and many are not well validated. A scale for routine use in clinical practice should be effective and reproducible and relatively quick to perform. The scale suggested in the UK assessment guidelines is the Abbey Pain Scale.8,11 This is easy to use and suggests the presence of pain, although it is not as well validated as some of the more research-orientated scales. It is critical to ensure that pain is assessed both at rest and on movement. It Journal of Pain & Palliative Care Pharmacotherapy
European Perspectives On Pain and Palliative Care
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 08/29/14 For personal use only.
is widely acknowledged that pain in those suffering from dementia and cognitive impairment can be associated with behavioral disturbance (Box 2)12 and recent reports suggest that agitation and aggression rather than wandering are more prevalent.13 It is also important to be aware that a change in behavior can be an indicator of pain. Assessment of pain is necessary to ensure appropriate pain management. Similarly, an assessment after any intervention is needed to evaluate treatment response.
CONCLUSIONS There should be a routine direct enquiry about pain in the cognitively impaired population. A more widespread use of pain assessment protocols in people with cognitive impairment and dementia should mean increased levels of detection. Through improving pain detection, these measures should improve pain management in those with cognitive impairment and dementia. Improved pain management should in turn result in improvements in sleep, mood, and function, which would be a benefit in this population.
307
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES [1] Moayedi M, Weissman-Fogel I, et al. Brain Res. 2012; 1456:82–93. [2] Pickering G, Jourdan D, et al. Eur J Pain. 2006; 10:379–384. [3] Pautex S, Michon A, et al. J Am Geriatr Soc. 2006;54: 1040–1045. [4] Zwakhalen SM, Koopmans RT, et al. Eur J Pain. 2009;13: 89–93. [5] Barry HE, Parsons C, et al. Int J Geriatr Psychiatry. 2012;27: 1258–1266. [6] Achterberg WP, Pieper MJ, et al. Clin Interv Aging. 2013;8: 1471–1482. [7] Husebo BS, Ballard C, et al. BMJ. 2011;343:d4065. [8] Royal College of Physicians, British Geriatrics Society, British Pain Society. The Assessment of Pain in Older People: National Guidelines. Concise Guidance to Good Practice Series, No. 8. London, Royal College of Physicians; 2007. [9] Gagliese L. J Pain. 2009;10:343–353. [10] Zwakhalen SM, Hamers JP, et al. BMC Geriatr. 2006;6:3. [11] Abbey J, Piller N, et al. Int J Palliat Nurs. 2004;10:6–13. [12] AGS Panel on Persistent Pain in Older Persons. J Am Geriatr Soc. 2002;50(6 Suppl):S205–S224. [13] Ahn H, Horgas A. BMC Geriatr. 2013;13:14.
