Steven M. Savvas

Pain and dementia

PurposeThe aim was to present current knowledge about pain assessment in people with dementia and to discuss special challenges and possible solutions.MethodsA literature search in MEDLINE® was performed.ResultsDue to the changing demographics of an aging population, an increasing number of people with dementia is expected. Many of these people will simultaneously suffer pain. Under-detection and under-treatment of pain in persons suffering from dementia is often described. As dementia progresses, the ability of the sufferer to verbally communicate his/her pain is often compromised, complicating the task of recognizing and treating pain. To improve pain recognition in dementia, many pain assessment tools have been developed. However, psychometric properties have to date been insufficiently examined.ImplicationsSelf-report ratings should be performed as long as justifiable. Behavioural pain assessment tools should be used in advanced dementia despite their current imperfections: in particular, the PAINAD for daily use and the PACSLAC at longer intervals. All available additional information about pain should be considered.ZusammenfassungZielZiel war es, den aktuellen Erkenntnisstand auf dem Gebiet der Schmerzerkennung bei Demenz darzustellen sowie die besonderen Herausforderungen und mögliche Lösungen zu diskutieren.MethodeEs wurde eine Literaturrecherche in MEDLINE® durchgeführt.ErgebnisseAufgrund der demographischen Entwicklung erwarten wir immer mehr Demenzkranke. Viele von ihnen leiden parallel unter Schmerzen. Probleme in der Schmerzerkennung sowie eine schmerztherapeutische Unterversorgung bei Demenzkranken werden häufig beschrieben. Mit Fortschreiten der Demenz schwindet die Fähigkeit, verbal Schmerzen auszudrücken, was die Schmerzerkennung wesentlich erschwert. So wurden in den letzten Jahren zahlreiche Instrumente zur Schmerzerkennung bei Demenzkranken entwickelt. Ihre Testgütekriterien sind aber häufig immer noch unzureichend untersucht.SchlussfolgerungSchmerzselbstbewertungsinstrumente sollten so lange wie möglich eingesetzt werden. Bei fortgeschrittener Demenz werden Fremdbewertungsinstrumente empfohlen: Trotz weiter bestehender Schwächen sind PAINAD für die tägliche Schmerzerfassung und PACSLAC für Kontrollen im Intervall zu empfehlen. Alle verfügbaren den Schmerz betreffenden zusätzlichen Informationen müssen berücksichtigt werden.

Pain and dementia: a diagnostic challenge.

PurposeThe aim was to present current knowledge about pain assessment in people with dementia and to discuss special challenges and possible solutions.MethodsA literature search in MEDLINE® was performed.ResultsDue to the changing demographics of an aging population, an increasing number of people with dementia is expected. Many of these people will simultaneously suffer pain. Under-detection and under-treatment of pain in persons suffering from dementia is often described. As dementia progresses, the ability of the sufferer to verbally communicate his/her pain is often compromised, complicating the task of recognizing and treating pain. To improve pain recognition in dementia, many pain assessment tools have been developed. However, psychometric properties have to date been insufficiently examined.ImplicationsSelf-report ratings should be performed as long as justifiable. Behavioural pain assessment tools should be used in advanced dementia despite their current imperfections: in particular, the PAINAD for daily use and the PACSLAC at longer intervals. All available additional information about pain should be considered.ZusammenfassungZielZiel war es, den aktuellen Erkenntnisstand auf dem Gebiet der Schmerzerkennung bei Demenz darzustellen sowie die besonderen Herausforderungen und mögliche Lösungen zu diskutieren.MethodeEs wurde eine Literaturrecherche in MEDLINE® durchgeführt.ErgebnisseAufgrund der demographischen Entwicklung erwarten wir immer mehr Demenzkranke. Viele von ihnen leiden parallel unter Schmerzen. Probleme in der Schmerzerkennung sowie eine schmerztherapeutische Unterversorgung bei Demenzkranken werden häufig beschrieben. Mit Fortschreiten der Demenz schwindet die Fähigkeit, verbal Schmerzen auszudrücken, was die Schmerzerkennung wesentlich erschwert. So wurden in den letzten Jahren zahlreiche Instrumente zur Schmerzerkennung bei Demenzkranken entwickelt. Ihre Testgütekriterien sind aber häufig immer noch unzureichend untersucht.SchlussfolgerungSchmerzselbstbewertungsinstrumente sollten so lange wie möglich eingesetzt werden. Bei fortgeschrittener Demenz werden Fremdbewertungsinstrumente empfohlen: Trotz weiter bestehender Schwächen sind PAINAD für die tägliche Schmerzerfassung und PACSLAC für Kontrollen im Intervall zu empfehlen. Alle verfügbaren den Schmerz betreffenden zusätzlichen Informationen müssen berücksichtigt werden.

Overview of Pain Management in Older Adults

Epidemiological data suggests that the prevalence of musculoskeletal and neuropathic pain increases with age until at least late mid-life, though the pattern is somewhat unclear beyond this point. And though the prevalence of some types of pain may peak in late midlife, pain is still a substantial and common complaint even in the oldest age groups. This article provides an overview of later-life pain and includes a brief review of its epidemiology, describes commonly encountered barriers to its management, and discusses guidelines and recommended approaches to its assessment and management.

Implementation of Sustainable Evidence-Based Practice for the Assessment and Management of Pain in Residential Aged Care Facilities

Pain is common in residential aged care facilities (RACFs). In 2005, the Australian Pain Society developed 27 recommendations for good practice in the identification, assessment, and management of pain in these settings. This study aimed to address implementation of the standards and evaluate outcomes. Five facilities in Australia participated in a comprehensive evaluation of RACF pain practice and outcomes. Pre-existing pain management practices were compared with the 27 recommendations, before an evidence-based pain management program was introduced that included training and education for staff and revised in-house pain-management procedures. Post-implementation audits evaluated the programs success. Aged care staff teams also were assessed on their reports of self-efficacy in pain management. The results show that before the implementation program, the RACFs demonstrated full compliance on 6 to 12 standards. By the projects completion, RACFs demonstrated full compliance with 10 to 23 standards and major improvements toward compliance in the remaining standards. After implementation, the staff also reported better understanding of the standards (p < .001) or of facility pain management guidelines (p < .001), increased confidence in therapies for pain management (p < .001), and increased confidence in their training to assess pain (p < .001) and recognize pain in residents with dementia who are nonverbal (p = .003). The results show that improved evidence-based practice in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce via this implementation program has shown improvements in staff self-efficacy and practice.

An Evidence‐Based Program to Improve Analgesic Practice and Pain Outcomes in Residential Aged Care Facilities

Pain is common in individuals living in residential aged care facilities (RACFs), and a number of obstacles have been identified as recurring barriers to adequate pain management. To address this, the Australian Pain Society developed 27 recommendations for comprehensive good practice in the identification, assessment, and management of pain. This study reviewed preexisting pain management practice at five Australian RACFs and identified changes needed to implement the recommendations and then implemented an evidence‐based program that aimed to facilitate better pain management. The program involved staff training and education and revised in‐house pain‐management procedures. Reviews occurred before and after the program and included the assessment of 282 residents for analgesic use and pain status. Analgesic use improved after the program (P < .001), with a decrease in residents receiving no analgesics (from 15% to 6%) and an increase in residents receiving around‐the‐clock plus as‐needed analgesics (from 24% to 43%). There were improvements in pain relief for residents with scores indicative of pain, with Abbey pain scale (P = .005), Pain Assessment in Advanced Dementia Scale (P = .001), and Non‐communicative Patients Pain Assessment Instrument scale (P < .001) scores all improving. Although physical function declined as expected, Medical Outcomes Study 36‐item Short‐Form Survey bodily pain scores also showed improvement (P = .001). Better evidence‐based practice and outcomes in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce using this program improved analgesic practice and pain relief in participating sites. Further attention to the continued targeted pain management training of aged care staff is likely to improve pain‐focused care for residents.

Should placebo be used routinely for chronic pain in older people

As research expands our understanding of underlying placebo mechanisms, interest turns to the clinical application of placebos. Whether placebos are appropriate and effective in the management of chronic pain in older people deserves considerable attention. The evidence suggests that adults of any age are responsive to placebos, and that placebo treatments can be effective for many conditions prevalent in older people. Though placebos in general already seem to be used with some regularity in medical practice, the use of placebos alone for chronic pain is probably unjustified unless other treatments are inadvisable or have been exhausted. However maximising the mechanisms that underpin placebo analgesia such as expectancy or the psychosocial context should be encouraged and would be considered a feature of good clinical practice. It would also be anticipated that older people may see an additional benefit with placebo treatments when such treatments reduce existing or planned medication regimes, as older people typically experience more comorbidities, increased susceptibility to adverse drug reactions, and altered pharmacological responses to drugs. Further research is still needed in placebo-related treatment paradigms for the management of chronic pain in older people.

Testing the reliability and validity of a Transition Map for older adults in long term care settings

ABSTRACT Mapping individual patterns of decline in older adults may aid coordinating long term aged care. This study developed a new scale (Transition Maps) to summarise the overall care pathway for long term aged care residents, in a simplified manner incorporating mapping concepts. Transition Maps were developed using mixed methods in two phases, and based on expert opinion, literature review, and input from aged care health professionals. Four professions (primary physician, nurse, allied health, lifestyle services) generated 147 Transition Maps for 38 residents living in a long term care. Preliminary construct validity and inter‐rated reliability were evaluated. Results showed that Inter‐rater reliability of agreement with the overall care pathway for each resident was kappa = 0.492. Consensus was lowest between nurse care managers and primary physicians (kappa = 0.384), and highest between nurse managers and Lifestyle Services (kappa = 0.77). Preliminary testing of the Transition Map scale provides initial support of construct validity and inter‐rater reliability and provides some evidence that Transition Maps can improve the coordination of long term aged care.

Treating pain in patients with impaired cognition

‘Impaired cognition’ can encapsulate many disorders, disabilities and diseases, affecting people of any age, but this article will focus on older adults in pain and with dementia. Key points discussed in this article may, however, be generalizable to other groups with impaired cognition. Note also that those with pain and dementia are not a homogenous group – etiology and severity of dementia will likely influence the person’s experience of pain, its clinical identification and assessment, as well as treatment modalities. Furthermore, the challenges associated with research on pain in severe dementia have resulted in considerable gaps in the evidence base. As such, the largest body of work in this area relates to persons with mild to moderate Alzheimer’s disease who have some capacity to self-report their pain.

Pain and dementia@@@Schmerz und Demenz: A diagnostic challenge@@@Eine diagnostische Herausforderung

PurposeThe aim was to present current knowledge about pain assessment in people with dementia and to discuss special challenges and possible solutions.MethodsA literature search in MEDLINE® was performed.ResultsDue to the changing demographics of an aging population, an increasing number of people with dementia is expected. Many of these people will simultaneously suffer pain. Under-detection and under-treatment of pain in persons suffering from dementia is often described. As dementia progresses, the ability of the sufferer to verbally communicate his/her pain is often compromised, complicating the task of recognizing and treating pain. To improve pain recognition in dementia, many pain assessment tools have been developed. However, psychometric properties have to date been insufficiently examined.ImplicationsSelf-report ratings should be performed as long as justifiable. Behavioural pain assessment tools should be used in advanced dementia despite their current imperfections: in particular, the PAINAD for daily use and the PACSLAC at longer intervals. All available additional information about pain should be considered.ZusammenfassungZielZiel war es, den aktuellen Erkenntnisstand auf dem Gebiet der Schmerzerkennung bei Demenz darzustellen sowie die besonderen Herausforderungen und mögliche Lösungen zu diskutieren.MethodeEs wurde eine Literaturrecherche in MEDLINE® durchgeführt.ErgebnisseAufgrund der demographischen Entwicklung erwarten wir immer mehr Demenzkranke. Viele von ihnen leiden parallel unter Schmerzen. Probleme in der Schmerzerkennung sowie eine schmerztherapeutische Unterversorgung bei Demenzkranken werden häufig beschrieben. Mit Fortschreiten der Demenz schwindet die Fähigkeit, verbal Schmerzen auszudrücken, was die Schmerzerkennung wesentlich erschwert. So wurden in den letzten Jahren zahlreiche Instrumente zur Schmerzerkennung bei Demenzkranken entwickelt. Ihre Testgütekriterien sind aber häufig immer noch unzureichend untersucht.SchlussfolgerungSchmerzselbstbewertungsinstrumente sollten so lange wie möglich eingesetzt werden. Bei fortgeschrittener Demenz werden Fremdbewertungsinstrumente empfohlen: Trotz weiter bestehender Schwächen sind PAINAD für die tägliche Schmerzerfassung und PACSLAC für Kontrollen im Intervall zu empfehlen. Alle verfügbaren den Schmerz betreffenden zusätzlichen Informationen müssen berücksichtigt werden.