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Smerte og atferd hos pasienter med demens

Smerte og atferd hos pasienter med demens. Høyskolen i Buskerud Februar 2012  . Forskergruppe. Bettina Husebø , MD, PhD , UiB, SESAM, SUS Clive Ballard, MD, Prof. v/Kings College, London Reidun Sandvik, MSc , HiB Odd B. Nilsen, statistiker, SUS

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Smerte og atferd hos pasienter med demens

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  1. Smerte og atferd hos pasienter med demens Høyskolen i Buskerud Februar 2012  

  2. Forskergruppe • Bettina Husebø, MD, PhD, UiB, SESAM, SUS • Clive Ballard, MD, Prof. v/Kings College, London • Reidun Sandvik, MSc, HiB • Odd B. Nilsen, statistiker, SUS • Dag Aarsland, MD, Prof. v/SESAM, SUS og Karolinska, Stockholm Finansiering og samarbeid

  3. Agitation and other BPSD are common >20: N=119 20-10: N=125 <10: N=162 Craig D, et al. Am J Geriatric Psychiatry 2005; 13: 460-468

  4. Importantconsequences Institutionalization Cost AGITATION Restraints Family burden Harmful drugs Reducedqualityoflife Functional impairment Patients Carers

  5. Behavioural disturbances: Multi-factorial Structural brain changes Neurochemical changes Genes AGITATION Psychosocial factors Unmet needs Physical disease Drugs PAIN???

  6. 100 80 60 Placebo Cumulative percentage of survival 40 Continue 20 Log-rank P=0.03 0 0 6 12 18 24 30 36 42 48 54 Time since randomisation (months) 83 (21) 62 (14) 23 (8) At risk (No. of deaths) in subsequent 12 months: 82 (17) 65 (4) 32 (6) Continue 10 (2) 4 (0) Placebo 21 (2) 9 (2) Antipsykotika reduserer livsforventning The CALM-AD study Log rank p=0.02 Ballard et al 2009 Lancet Neurology The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. www.thelancet.com/neurology. 09 Jan 2009

  7. Pasienter på sykehjem: kognitiv svikt/ smerte Pasienter på sykehjem lider av vedvarende, underdiagnostisert og mangelfullt behandlet smerte (AGS-Panel 1998; Weiner 1999; Frampton 2003). 83% av sykehjemspasientene opplever regelmessig smerte som fører til inaktivitet, depresjon og redusert livskvalitet (Ferrell 1995). Pasienter uten kognitiv svikt får 3 ganger mer analgetika enn pasienter med demens (Cohen-Mansfield 2002).

  8. bettina.husebo@isf.uib.no

  9. Pain and dementia • Aging associated with pain (muscle skeletal diseases, neuropathic pain, cancer, vascular disease, fracture) • Unrecognized and untreatedpain due to reduced communicative skills, memory, and awareness • More pain and less pain-treatment in dementia (Husebø 2008) • Pain predicted agitation in dementia (Snow 2009) • Hypothesis: Pain treatment reduces agitation

  10. Efficacy of treating pain to reduce agitation in residents of nursing homes with dementia: A cluster RCT • Setting: 18 NHs, 60 NH units (N=352), 5 municipalities in Norway • Design: Cluster-randomised, 8 week trial + 4-w wash-out period • Inclusion criteria: 65+ NH resident, dementia, clinically significant agitation for at least onse week (ie 39+ on CMAI) • Exclusion: advanced severe medicalillnesswithexpectedsurvival < 6 months, severe psychiatric/neurological disorder, severe aggression, severe renal/liver failure

  11. bettina.husebo@isf.uib.no

  12. Groups were similar at baseline

  13. Fixed dose regimen throughout the eight week treatment period. In those who were not able to tolerate this treatment, the dosage was either reduced or the participant was withdrawn from the study and treated as clinically appropriate. *following the recommendations of the American Geriatrics Society(J Am Geriatr Soc 1998;46:635-51)

  14. Assessment of agitation, dementia, pain Primary outcome measures Cohen-Mansfield Agitation Inventory – long form (CMAI) Secondary outcome measures Mini-Mental State Examination (MMSE) Functional Assessment Staging (FAST) Activities of Daily Living (ADL) Neuropsychiatric Inventory-Nursing Home Version (NPI-NH) MOBID-2 Pain Scale (MOBID-2)

  15. Results: Reduced agitation during pain-treatment Treatment Wash-out Repeated measurement ANCOVA (LOCF):p<0.001 Average reduction 17%; Treatment effect 7.0 (95% CI 3.7-10.3)

  16. bettina.husebo@isf.uib.no

  17. bettina.husebo@isf.uib.no

  18. Summary • Systematic pain treatment was associated with a significant reduction in agitation and neuropsychiatric symptoms in addition to reduced pain • There were very few withdrawals due to sedation, and no reduction of cognition or ADL, suggesting that reduced agitation was not secondary to more sedation

  19. Conclusions • Assessment of pain is crucial in patients with dementia and agitation • Pain treatment should be considered for these patients, even if there is no clear evidence of manifest pain

  20. Publications • Aarsland D, Husebo B, Ballard C. Authors' reply to McShane and Regnard. BMJ 2011; 343:d5356. • Husebo BS, Ballard C, Nilsen OB, Sandvik R. Aarsland D. Effect of individual pain treatment on behavioural disturbances in nursing home patients with moderate and severe dementia: cluster randomised trial. BMJ 2011; 343:d4065 doi: 10.1136/bmj.d4065. • Husebo BS, Ballard C, Aarsland D. Efficacy of treating pain in patients with dementia. In: Pain in Older Persons. Newsletter. IntAssoc Stud Pain (IASP) 2011;4:2-3. • Sandvik K, Husebo BS. Smerte hos pasienter med demens. Demens&Alderspsykiatri 2012. • Sandvik K, Husebo BS. Vitenskap anvendt i praksis: Måler smerte hos personer med demens. Sykepleien 2011; 11:62-64. • Husebo BS, Ballard C, Aarsland D. Pain Treatment of Agitation in Patients with Dementia: A Systematic Review. Int J Geriatr Psychiatry 2011; DOI: 10.1002/gps.2649. In preparation • Husebo BS, Ballard C, Aarsland. Pain and agitation in patients with dementia: Are we confident to identify and treat the right items of behavioural disturbances? • Husebo BS, Strand LI, Moe-Nilsen R, Ballard C, Aarsland. Internal and external responsiveness of the MOBID-2 Pain Scale used for nursing home patients with moderate to severe dementia. • Ballard C, Aarsland D, Husebo B, Corbett A, Malcangio M, Cohen-Mansfield J.Systematic review on analgesia treatment for people with dementia. • Fritze F, Ballard C, Aarsland, Husebo BS. Pain and depression in patients with dementia.

  21. Utfordringer og muligheter I • Informert samtykke (2mnd) • NH ressurser • Motivasjon / Mangel av motivasjon • Kompensasjon for innsats • Undervisning (3 mnd), Veiledning • 3 undervisningsdager med diplomer, heder og ære ved avslutning • http://clinicaltrials.gov/ (registrering i internasjonal database) • http://www.legemiddelverket.no/ (6 mnd)

  22. Utfordringer og muligheter II • Review • Internasjonal prosjekt • Forskningsassistenter (masterstudenter R. Sandvik, S. Svendson) • 3x Bachelor (særoppgave for medisinstudenter) • PhD – data (F. Fritze, SESAM)

  23. http://www.bbc.co.uk/news/uk-14182472http://www.bbc.co.uk/news/health-14138884http://www.bbc.co.uk/news/uk-14182472http://www.bbc.co.uk/news/health-14138884 bettina.husebo@isf.uib.no

  24. bettina.husebo@isf.uib.no

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