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Pain assessment & management in frail older people with/without dementia

Pain assessment & management in frail older people with/without dementia. Jo Hockley RN MSc PhD OBE Senior Research Fellow, Primary Palliative Care University of Edinburgh. Outline of my lecture. Background on pain and older people in nursing care homes

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Pain assessment & management in frail older people with/without dementia

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  1. Pain assessment & management in frail older people with/without dementia Jo Hockley RN MSc PhD OBE Senior Research Fellow, Primary Palliative Care University of Edinburgh

  2. Outline of my lecture • Background on pain and older people in nursing care homes • Remind us all of the BASICS of pain assessment • What influences the pain threshold in older people • Important aspects of pain assessment in older people • With/without cognitive impairment • Tools particularly used for people with advanced dementia • Management of pain

  3. PAIN - in nursing homes • Vast majority of older people who reside in nursing homes (NHs) suffer persistent pain (Takai et al 2010; Husebp 2008, 2011; Ferrell et al 1995) • 45-80% frail elderly NH experience pain • 23.7% & 26% NH residents experienced daily pain (Takai et al 2010; Bernabei et al 1998) • Most pain is related to musculoskeletal problems and neuropathies(Weiner & Hanlon 2001) • Elderly NH residents being sensitive to side effects associated with many analgesic drugs – does not justify the failure to treat pain(Ferrell et al 1995)

  4. Basics of pain assessment Different TYPES of pain Tissue pain Bone pain Capsular pain Muscular pain Nerve pain • Who has the pain? • “Pain is what the person says it is” • ACUTE versus CHRONIC pain

  5. Factors influencing the pain threshold (Twycross & Lack 1984) Threshold – LOWERED by: Threshold – RAISED by: • Discomfort • Insomnia • Fatigue • Fear & anxiety • Anger • Sadness & depression • Boredom & introversion • Mental isolation • Social abandonment & lonelines • Relief of symptoms • Sleep • Rest • Sympathy & understanding • Companionship • Elevation of mood • Diversional activity • Reduction in anxiety • Medication: analgesics; anti-depressants; anxiolytics

  6. Pain assessment tools most commonly used in specialist palliative care • SPC / cancer model – many different pain assessment tools: • ‘Faces’ • Words to describe pain [McGill Pain Questionnaire] • Visual analogue score (research) • Verbal Rating Scale (Closs 2004) • Body charts

  7. Most common symptoms identified during the last year of life among people with dementia. [McCarthy et al, 1997]

  8. Systematic review (Frampton, 2003) • Pain is under-reported and under-treated in cognitively impaired older people • Reporting habits of older people; the acceptance of reports by staff; the ability of carers to identify pain • Decline in verbal communication makes assessment very difficult • Lack of validated and reliable assessment tools for this population • Poorly treated pain is associated with increased risk of disability & depression

  9. PAIN – in dementia is different • Witnessed through residents’ behaviour: • Crying out; rubbing an arm or a leg; decreased function/withdrawal; change in sleep pattern; body bracing • Needs a DIFFERENT assessment tool:

  10. Common signs & symptoms of physical or affective discomfort in late-stage dementia • Increased agitation, fidgeting & repetitive movements • Tense muscles, body bracing • Increased calling out, repetitive verbalizations • Decreased functional ability, withdrawal • Change in sleep pattern • Increase in pulse, blood pressure & sweating

  11. BEHAVOURAL ASSESSMENT TOOLS • Verbal rating scale (Closs 2004) • PAINAD (Volicer & Hurley 2015) • DOLOPLUS 2 Scale (Lefebvre-Chapiro S. 2001) • Abbey Scale (Abbey 2002) • DisDAT - Disability Distress Assessment Tool (Regnard, 2003)

  12. Pain assessment tool for older people in care homes • Needs to know: • What type of pain? • Questions to residents who can tell you: • Where is the pain? • What makes your pain better? • What makes your pain worse? • How long have you had this pain? • Verbal rating scale: • “if 0/10 is no pain at all and 10/10 is the most excruciating pain you have ever had in all your life, what score would you give it?

  13. Doloplus-2 scale Observation of patient behaviour • 10 different situations that could potentially reveal pain • Somatic reactions x 5 • Psychomotor reactions x 2 • Psychosocial reactions x 3 • One of four different levels of pain intensity [0-3] for each behaviour • Potential total score of 30 – pain is confirmed by a score of 5 or more

  14. Doloplus 2 scale • Somatic reactions • Pain expressed through words, gestures, tears etc • Unusual protective body positions • Protection of sore area by defensive action/gesture • Facial expression • Sleep pattern • Psychomotor reactions • Pain while washing/dressing • Mobility • Psychosocial reactions • Communication • Social life • Behavoural problems

  15. Isobel’s on-going story: • Already taking tablets on Step 2 WHO ladder • Continued NSAIDs and commenced oral morphine 6hrly 5mgs • Increased to 30mgs / 6hrly – then to MST 30mgs bd • Difficulty swallowing tablets – Fentanyl patch 25mcg • Fentanyl increased to 50mcg – started walking around NCH

  16. Assessment andmanagement

  17. Assessment of pain for people with cognitive impairment • Behavioural observation scale – systematic review of behavioural observation scales (Zwakhalen et al, 2006) • DOLOPLUS2 • Pacslac • PAINAD • Abbey

  18. Abbey Pain Scale(Abbey et al, 2004)

  19. Management of chronic pain in older people with dementia • Start ‘low’ and ‘go slow’ • Use the WHO analgesic ladder – especially Step 2 but remember that codeine is more nauseating than an opiate • REGULAR analgesics + co-analgesics • PLUS APERIENTS • Softeners + pushers

  20. Management of chronic pain in older people with dementia… contd/ • Older people have a greater sensitivity to medication especially opiates/NSAIDs • Start oral morphine at 2.5-5mg/6hrly • Morphine is less nauseating than high dose codeine • Collaborate with geriatrician – helps their knowledge and empowerment • Use ‘long acting’ analgesics [ie MST or patchesButrans/Transdec/Fentanyl patch] once pain control is properly assessed/titrated on quick release morphine • NB Fentanyl patch 25mcg is equivalent to Morphine 20mgs/4hrly

  21. Very advanced dementia – used to like to have a doll to cuddle. I had known of her but never really chatted to her. Crying out – daughter arrived: • Arthritis since mid-20s • Long term codeine / paracetamol medication regularly x 4 daily • Prescribed Quotiepine for ‘behavour’ • Currently taking antibiotics for chest infection Rose’s story

  22. ‘We face a big challenge in end-of-life care of older people, not because of demographics, but due to ignorance and prejudice among practitioners and the general public, failing to apply evidence to develop best practice and failing to spread good practice.’(Philp, 2003: 153)

  23. Thank you!Any questions? jo.hockley@ed.ac.uk

  24. References Frampton M (2003) Experience assessment and management of pain in people with dementia. Age and Ageing; 32: 3, 248-251. Ferrell, B. A., Ferrell, B. R., & Rivera, L. (1995). Pain in cognitively impaired nursing home patients. Journal of Pain and Symptom Management, 10(8), 591–598. Weiner, D. K., & Hanlon, J. T. (2001). Pain in nursing home residents: Management strategies. Drugs and Aging, 18(1),13–29. Takai Y, Yamamoto-Mitani N, Okamoto Y, Koyama K, Honda A (2010) Literature Review of Pain Prevalence Among Older Residents of Nursing Homes. Pain Management Nursing, 11(4): 209-223 Bernabei R1, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop R et al (1998) Management of pain in elderly patients with cancer. JAMA. 1998 Jun 17;279(23):1877-82. McCarthy M, Addington-Hall J, Altman D (1997) The experience of dying with dementia: a retrospective study. Int. J. Geriatric Psychiatry, 12(3): 404–409 Closs et al (2004) A comparison of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment. Journal of Pain & Symptom Management 27(3): 196–205 Volicer L & Hurley A (2015) Assessment Scales for Advanced Dementia. Health Professions Press, Inc. Baltimore, Maryland. Lefebvre-Chapiro, S. & the Doloplus group. (2001). The Doloplus 2 scale – evaluating pain in the elderly. European Journal of Palliative Care, 8(5), 191-194.

  25. Abbey J, Piller N, De Bellis A, Esterman A, Parker D, Giles L, Lowcay B (2004) The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs. 2004 Jan;10(1):6-13. Regnard C, Reynolds J, Watson B, Matthews D, Gibson L, Clarke C. Understanding distress in people with severe communication difficulties: developing and assessing the Disability Distress Assessment Tool (DisDAT). J Intellect Disability Res. 2007; 51(4): 277-292. Zwakhalen SM, Hammers JP, Abu-saad HH, Berger MP (2006) BMC Geriatr. 27(6): 3

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