Pain assessment in cognitive impairment

With Emma Cunningham and Professor Peter Passmore  |  16 Apr 2015  |  Print

Pain assessment in cognitive impairment

Professor Peter Passmore is professor of ageing and geriatric medicine, Queens University Belfast, UK; Emma Cunningham is clinical research fellow, Queens University Belfast, UK.

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.

Box 1. Causes of cognitive impairment
  • Dementia

o   Alzheimer’s disease

o   Frontotemporal dementia

o   Vascular dementia

o   Lewy body dementia

o   Parkinson’s disease dementia

  • Stroke
  • Learning disability
  • Multiple sclerosis
  • Motor neurone disease

Relationship between pain and cognition

It is important to recognize the significance of pain in people with cognitive impairment. Pain has effects 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 atrophy[1] 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 group.

Under-treatment of pain in dementia

There is some evidence that clinicians manage acute pain equally well in those with dementia as 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 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 receipt of 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 in cognitive impairment

Given that healthcare 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 assessment[8] 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.

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 healthcare staff is needed. Use of a pain map can be useful

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 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

Box 2. Behavioral pain indicators in cognitively impaired older persons[12]

Facial expressions:

  • frown, 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

Changes in mental status:

  • crying, increased confusion, irritability, distress

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.

References:

  1. 1. Moayedi M, Weissman-Fogel I, et al. Abnormal gray matter aging in chronic pain patients. Brain Res 2012;1456:82-93.
  2. 2. Pickering G, Jourdan D, et al. Acute versus chronic pain treatment in Alzheimer’s disease. Euro J Pain 2006;10:379-384.
  3. 3. Pautex S, Michon A, et al. Pain in severe dementia: self-assessment or observational scales? J Am Geriatr Soc 2006;54:1040-1045.
  4. 4. Zwakhalen SM, Koopmans RT, et al. The prevalence of pain in nursing home residents with dementia measured using an observational pain scale. Euro J Pain2009;13:89-93.
  5. 5. Barry HE, Parsons C, et al. An exploration of nursing home managers’ knowledge of and attitudes towards the management of pain in residents with dementia. Int J Geriatr Psychiatry2012;27:1258-1266.
  6. 6. Achterberg WP, Pieper MJ, et al. Clinical Interventions in Aging2013;8:1471-1482.
  7. 7. Husebo BS, Ballard C, et al. British Medical Journal 2011;343:d4065.
  8. 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, RCP, 2007.
  9. 9. Gagliese L. Pain and aging: the emergence of a new subfield of pain research. J Pain 2009;10:343-353.
  10. 10. Zwakhalen SM, Hamers JP, et al. Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatr 2006;6:3.
  11. 11. Abbey J, Piller N, et al. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs 2004;10:6-13.
  12. 12. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002;50(6 Suppl):S205-S224.
  13. 13. Ahn H, Horgas A. The relationship between pain and disruptive behaviors in nursing home residents with dementia. BMC Geriatr 2013;13:14.

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