Dementia Care Managing pain and symptom control

1. Dementia CareManaging pain and symptom control Gail Wilson

2. What is Pain ? • Pain is an unpleasant sensory and emotional experience that we associate with tissue damage • It involves 3 types of experience • The actual sensation • The knowledge about pain • The emotion aspect of pain • Pain can be • Acute- recent onset, often response to a tissue or organ damage. • Chronic • Non malignant-persists for more than one month, often associated with chronic disease • Malignant-linked to a cancerous process

3. To treat pain we need communication • Nobody else can feel your pain • We verbally communicate pain • Body language and behaviour can communicate pain • Chronic pain has many social and health consequences

4. Common causes of Pain in Dementia • osteoarthritis, • pressure sores • Infection • skin tears • leg ulcer dressings • stiffening of joints • muscle rigidity • constipation.

5. Earlier dementia – pain assessment • Verbal communication remains the main tool to assist diagnosis until it becomes very impaired • Time, simple clear questions, no complex language. • Pain intensity – the size of the problem • Careful carer observation and description

6. Advanced Dementia Pain Lack of meaningful verbalisation • 46% of dementia patients in the last year of life have pain. • Pain is underestimated and under documented by carers • The sensory pathways in the brain can be damaged in Alzheimers disease. These are the pathways that give meaning to pain. • The patient cannot tell of their experience of pain and agitation and behavioural problems are much more likely to occur • Alzheimers may allow an increased pain tolerance, due to damaged pathways but it does not decrease the pain

7. Advanced Dementia • Verbal expression is often lost • “ Pain is what the patient says it is” but what about the person who cannot say ? • * Those who cannot verbalise pain often don’t receive pain relief – nurses. carers don’t look for the cues (DCDC 2007)

8. Pain assessment for late dementia patients • Physiological changes • Pulse, temperature, sweating, blood pressure, respiratory rate, guarding • Observational changes • Agitation, aggression, reaction to touch, moaning, change in ability to move, hard to settle

9. Changes in body language • Facial Expression- frowning, fear, tearful • Knees drawn up, Foetal position, withdrawal • Carers intuition – Probability of Pain

10. Assessing Pain Probability of Pain • Mr Robinson is an elderly man with dementia who cannot respond verbally. • He has Rheumatoid Arthritis, in his hands, feet elbows and shoulders • What is the probability he is in chronic pain ? 0% 25% 50% 75% 80% 90% 100%

11. Advancing dementia • Mr Robinson , now has contracture of the knees, he cannot feed himself, cannot turn over in bed. However, you notice when the nurses turn him, his face grimaces and he withdraws his arms if touched • Has the pain probability score changed ? • You now give him pain killers 20 minutes before being turned, he does not grimace or pull his arms away • Has the pain probability score changed ?

12. Pain Assessment tools in Dementia • There are a number of tools that is recommended by the centre for Dementia care in Stirling University is • The Abbey Pain Scale (2004)

13. The Abbey pain scale for people with dementia who cannot verbalise

14. Comparing Probability and Abbey Pain Scale • Alex, 77 year old man with advanced dementia. He had been in a care home for 2 years. Over this time he was very active. From early morning until early evening he would be found walking around at home. He was thin, but are well and rarely presented ‘problem’ behaviours. He had only confused words that rarely made sense. One morning the nurse noted that Alex was still in bed. He was not interested in moving from a flat position to an upright position. If the nurse attempted to raise him to a sitting position he would pull away. His temperature was slightly elevated and his pulse was 110/min. • What observations would you make? • How probable is it that Alex has pain ? • How would you increase the probability that you diagnosis is correct? Use the Abbey Pain Scale

15. Other important symptoms which impact on pain • Urinary and faecal issues • Continence • Constipation • Anorexia • Breathlessness • Insomnia

16. Treatment and Analgesia • Comfort and environment • Distraction and social contact • The ANALGESIC ladder • Opioids in dementia • Consider alternatives to oral route

17. Conclusions • Pain and other symptoms are underestimated in Dementia • Frequent non verbal assessment and reassessment • Prescribe appropriate medications • Carer training