PAIN PAIN IN THE

SARAH
BROWN
COGNITIVELY
IMPAIRED
Clinical Nurse Specialist
SESSMENT

DR. DAVID STRANG

Chief Medical Officer, Deer Lodge

Centre & PCH Program
April 12, 2010

The Issue of Pain in the

Cognitively Impaired

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

Ask Are you in pain?

Believe the persons 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

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)

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
Changes in interpersonal interactions
Changes in activity patterns or
routines
Mental status changes

Pain Assessment for

Cognitively Impaired
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 persons:
Current and past medical conditions and
surgeries
Current and previous medications
Physical examination
Relevant laboratory and diagnostic tests
*** Scope of assessment depends on
persons 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 Patients 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

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
Change
BehaviorChange
Identification
Identification
1PHYSICAL

2AFFECTIVE

Target

Ifbehaviorcontinues
Proceedto2

Serial Trial
Intervention
2AFFECTIVE

Target

Ifbehaviorcontinues
Proceedto3

3Trial:nonpharmacological
comfort
4Trial:analgesics
5Consultationortrialpsychotropic

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 selfreport 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, Odonnell 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.