PAIN PAIN IN THE

COGNITIVELY IMPAIRED
SARAH BROWN
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

Ifbehaviorcontinues
1PHYSICAL Target
Proceedto2

2AFFECTIVE
 Serial Trial
Intervention

Ifbehaviorcontinues
2AFFECTIVE Target
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

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