Pain Assessment/Management in the Senior with Cognitive Impairment

1. Pain Assessment/Management in the Senior with Cognitive Impairment Darlene Grantham BN,MN, CHPCN (c) Clinical Nurse Specialist March 10, 2008

2. Manitoba’s Older Population • In 1991: • 146,605 Manitobans were > 65; • >65 represented 13.4% of total Manitoba population; • Manitoba ranked the second highest among the provinces in terms of the proportion of person aged 65 and over. • Statistics Canada (1992)

3. DementiaPrevalence Increases with Age 47% 50 40 30 20 10 0 Prevalence (%) 22% 10% 65  75  85 Age (year) Larson EB et al. Annu Rev Public Health 1992;13:431-449.

4. Dementia • Dementia (DSM-IV) • The development of multiple cognitive deficits: • Aphasia • Apraxia • Agnosia • Disturbance in executive functioning (social and/or occupational functioning) • Behavioral symptoms include: • Agitation/restlessness • Delusions/paranoia • Physical aggression • Verbalizations • Wandering

5. Alzheimers: Progression 25 ---------------------| Symptoms 20 |----------------------| Diagnosis 15 |-----------------------| Loss of functional independence MMSE score 10 |--------------------------------| Behavioural problems Nursing home placement 5 |-------------------------------------------| 0 Death |------------------------------------------ 1 2 3 4 5 6 7 8 9 Years Feidman and Gracon, 1996

6. Mild AD (MMSE 21­30) IMPAIRMENT • Cognition • Recall/learning • Word finding • Problem solving • Judgment • Calculation • Function • Work • Money/shopping • Cooking • Housekeeping • Reading • Writing • Hobbies • Behaviour • Apathy • Withdrawal • Depression • Irritability Adapted from Galasko, 1997

7. Moderate AD (MMSE 10­20) IMPAIRMENT • Cognition • Recent memory • Language (names, paraphasias) • Insight • Orientation • Visuospatial ability • Function • IADL loss • Misplacing objects • Getting lost • Difficulty dressing • (sequence and • selection) • Behaviour • Delusions • Depression • Wandering • Insomnia • Agitation • Social skills • unaffected Adapted from Galasko, 1997

8. Severe AD (MMSE <10) IMPAIRMENT • Function • Basic ADLs • Dressing • Grooming • Bathing • Eating • Continence • Walking • Cognition • Attention • Difficulty performing familiar activities (apraxia) • Language (phrases, mutism) • Behaviour • Agitation • Verbal • Physical • Insomnia Adapted from Galasko, 1997

9. Aging, Cognitively Impaired, Pain • Three distinct populations: • Frail, older persons recovering from an acute medical illness; • Persons with cognitive impairment who need long-term care; • Persons dying of chronic, progressive illness, such as cancer, end-stage renal, heart or lung • Teno, 2007

10. Use of pain medication in the Elder Population Achterberg et al. (2006) • Findings: • 62% received no pain medication at all • 34% used nonopioid pain medication • 6% received opioid medication • 3% received nonopioid and opoiod medication • 70% of residents with high cognitive performance received pain medication • 40% of residents with low cognitive performance received pain medication

11. Consequences of Untreated Pain • It is estimated that 80% of personal care home residents have substantial pain that is undertreated • Untreated pain results in: • depression • decreased socialization • sleep disturbance • impaired ambulation • behavioral problems • AGS Panel on Chronic Pain in Older Persons, 1998

12. Pain Assessment in the Senior with Cognitive Impairment • Gold standard patient’s self-report • Behavioral alterations have meaning and recognizing that nonverbal beings have conscious perceptions of pain • Behavioral or emotional reactions are just as important as verbal information • Anand & Craig 1996

13. Assessing Multiple Dimensions of Pain The ABCs of Pain Affective Dimension Behavioral Dimension Cognitive Dimension Physiological-Sensory Dimension

14. Affective Dimension of Pain Ferrell & Coyle (2001) • Is there a reason for the patient to be experiencing pain? • Was the patient being treated for pain? If so, what regimen was effective (include pharmacologic and non-pharmacologic interventions? • How does the patient usually act when he or she is in pain? (Note: the nurse may need to ask family)

15. Affective Dimension of Pain Ferrell & Coyle (2001) • What is the family’s interpretation of the patient’s behavior? Do they believe the patient is in pain? Why do they feel this way? • Try to obtain feedback from the patient e.g. ask patient to nod head, squeeze hand, move eyes up or down, raise leg, or hold up fingers to signal presence of pain.

16. Behavioral DimensionHorgas, et. al, (2007) • Non-verbal pain behaviors: • Facial expressions • Vocal behavior • Aggressive behavior • Increase in body movements • Changes in daily activities • Irritable, confused, withdrawn, agitated

17. Behavioral Dimension Objective Data (NANDA, 2001) • Guarding • Impaired thought process • Social withdrawal • Introspection • Altered time perception • Moaning • Crying PAIN

18. Restless Behavior: Not being able to sleep Behavioral Dimension • Pacing • Distracting self • Restless behavior • Hitting, pushing, swearing • Physical signs: diaphoresis • BP/Pulse/RR Change Objective Data (NANDA, 2001)

19. Memories: Connections to past pain shapes a patient’s response Cognitive Dimension • Beliefs • Attitudes • Meaning of the pain • Memory of past pain • Cognitive resources to cope • Locus of control

20. Harlos, 2002 Deafferentation Sympathetic Maintained Peripheral Physiological Dimension(Harlos, 2002) NEUROPATHIC NOCICEPTIVE Visceral Somatic • Organs – heart, liver, pancreas, gut, etc. • Superficial: skin • Deep: bones, joints, connective tissue, muscle

21. Nociceptive Somatic Pain (acute or chronic) • Common Locations of Pain: • Arms/Legs (14%) • Back (12%) • Joint (11%) • Hip (10%) • Soft Tissue (8%) • Pain-Related Disorders: • Arthritis/osteoarthritis • Osteoporosis • Hip fractures • Hip replacement • Contractures • Malignancies • Disc disease

22. Biliary colic Cholecystitis Diverticulitis Small bowel obstruction Large bowel obstruction Perforated viscus Appendicitis Incarcerated hernia Renal colic Pancreatitis Urinary Tract Infection Irritable bowel syndrome Sigmoid vovulus Intra-abdominal abscess Mesenteric ischemia Abdominal aortic aneurysm Acute myocardial infarction Pneumonia Pulmonary embolism Aortic dissection Diabetic ketoacidosis Nociceptive (Visceral) Acute Pain

23. Central Syndromes Central post-stroke pain Phantom limb pain Multiple sclerosis pain Parkinson disease pain Spinal cord injury pain (or compression) Cluster headaches Infection (bacterial/viral) Post-Polio Syndrome Vitamin B deficiency Peripheral Syndromes Chemotherapy induced neuropathy Regional pain syndrome HIV sensory neuropathy Neuropathy- tumor infiltration Painful diabetic neuropathy Post-herpetic neuralgia Post-mastectomy pain Trigeminal neuralgia Carpal tunnel or herniated disk Peripheral vascular disease Neuropathic Chronic Pain

24. Dry Mouth: A common side effect What Else to Assess? • Side-Effects of Therapy • Constipation • Gastric Fullness • Nausea • Sedation • Dry Mouth • Medications • Symptoms of Disease • Dyspnea • Fatigue

25. Two Times: A minimum of 2 times (24hrs)to assess a patient When to Assess? • Initial: • Assessment of the pain dimensions • Follow-up: • Routine reassessments are essential

26. Barriers to Pain Control in the Senior with Cognitive Impairment • Task focused care vs. patient centered care • Sensory and cognitive impairments may reduce the patient’s ability to communicate suffering • Goal of nursing homes is to maintain or improve physical functioning rather than palliate symptoms • The Minimum Data Set (MDS) • Unavailability of physicians in LTC

27. Barriers to Pain Control in the Senior with Cognitive Impairment • With hospital admission goal of care is discharge planning; • Cognition is not routinely assessed; • Health care providers are unaware of common cancer pain syndromes as well as pain in non-cancer illnesses; • Elderly persons with aggressive or agitated behaviors are usually sedated (which often increases the behaviors) • Pain assessment is rarely completed or even investigated in cognitively impaired

28. Barriers to Pain Control in the Senior with Cognitive Impairment • High staff turnover adversely affects pain care. • Nursing assistants provide a large proportion of direct patient care but are not trained in reporting cognitively impaired patient’s pain behaviors • Inadequate time between pain assessment and clinical intervention for pain contributes to increased pain • Physician training in geriatric and palliative care medicine • Reluctance to use opioids in the elderly for fear of causing confusion, delirium

29. Myths • Persons with Cognitive Impairment do not experience the same pain prevalence as cognitively intact individual. • Persons with Cognitive Impairment can not reliably use self-assessment pain scales.

30. Pain Prevalence and Cognitive ImpairmentMyth 1 Leong et. Al., (2007) • Objective: To determine prevalence of pain and its impact among cognitively impaired residents • Findings: • Pain prevalence did not differ between residents with normal cognition (48%), mildly impaired (46%)or severely impaired cognition (43%) • In fact those with impaired cognition (mild/severe) reported more acute pain.

31. Pain and Cognitive ImpairmentMyth 2 Pautex (2006) • Objective: performance of pain self-assessment scales in severely demented patients compared to observational data. • Findings: • 61% of 129 severely demented patients demonstrated comprehension of at least one scale. • Clinicians should not apply observational scales routinely in severely demented patients, because many are capable of reliably reporting their own pain.

32. Assessment Tools – NOPAINHorgas et. al., (2007) • The Non-communicative Patient’s Pain Assessment Instrument (NOPAIN) • Findings: • The NOPAIN is a reliable tool for evaluating pain in older adults with mild to moderate dementia • The NOPAIN tool is concise, easy to use, and requires minimal training

33. Pain relief Opioid for moderate to severe pain +/- Non-opioid +/- Adjuvant Step 3 Pain persisting Opioid for mild to moderate pain +/- Non-opioid +/- Adjuvant Step 2 Pain persisting Non-opioid for mild pain +/- Adjuvant Step 1 Analgesic Ladder PAIN Source: World Health Organization, 1992

34. Analgesics • BY MOUTH and AROUND THE CLOCK • “Start low and go slow” • Acetaminophen drug of choice for relieving mild to moderate nociceptive pain • Be extremely cautious using NSAIDS (especially in elderly) • Monitor side effects with opioids

35. May be appropriate for some residents with neuropathic pain Adjuvants

36. Nonpharmacologic Strategies • Used alone or in combination with pharmacologic strategies • Exercise • Physiotherapy, occupational therapy • Music • Therapeutic touch • Heat, cold therapy • Massage

37. Consult a Pain Specialist • Pain and Symptom Management Clinic (Health Science Center) • WRHA Palliative Care Program – • Physician to Physician (237-2053) • CNS consults to Acute and Community Hospitals, PCH, Outpatient Cancer Care Clinics, Outpatient Psychiatry, Homes (237-2400)

38. Summary Make Pain Visible as the 5th Vital Sign • Obtain patient’s self report of pain when possible otherwise become familiar with behavioral indicators of pain • review pain data often • display pain data in patient’s room & chart • share pain data during nursing report • Set red flag for unrelieved pain • Display usual pain experienced by patients on the unit - day by day

39. Questions