Transcript RECOGNITION & TREATMENT OF PAIN IN DEMENTIA

Cliff Singer, MD
Chief, Geriatric Mental Health and Neuropsychiatry
Acadia Hospital and Eastern Maine Medical Center
Bangor, Maine
Once Dementia is Diagnosed……
Know What You’re Treating:
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Primary Dementia: gradual, progressive
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Alzheimer’s disease
Multi-infarct vascular dementia
Dementia with Lewy Bodies
Parkinson’s Disease Dementia
Frontotemporal Dementia
Secondary dementia: acute or subacute:
 Traumatic Brain Injury
 CNS Infections
 Alcohol-related (Korsakoff’s)
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“Reversible” Causes
 Medical and psychiatric causes
Rule Out Depression and
Delirium*
Memory
Mood
Depression
Attention
Delirium
Dementia
Executive
Motor
*Fact is, this may not be so easy; they often co-exist.
Clinical Features At Diagnosis
AD
VaD
DLB
FTD
NPH
MDD
Delirium
age
older
older
older
younger
older
older
older
memory
poor
recent
recall
slow
retrieval
slow
retrieval
variable
slow
retrieval
slow
retrieval
poor
recent
recall
executive
less
severe
more
severe
more
severe
concrete,
dysfluent
speech
more
severe
more
severe
very
severe
attention
problems
normal
to mild
variable
waxing/w
aning
ADD
variable
variable
waxing/
waning
motor
findings
slowing
focal and
EPS
EPS
normal to
mild
gait
dyspraxia
slowing
ataxia
psychiatric
apathy,
anxiety
apathy,
anxiety
apathy,
VH
apathy,
disinhibit,
delusions
apathy
anxious,
sad,
irritable
VH,
delusion
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Tasks in Early Dementia
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Clarify diagnosis
Discuss prognosis
Discuss safety issues
Encourage quality of life activities
Basic geriatric care to minimize incontinence,
maximize mobility and stability, address
hearing and vision impairments
Planning for smooth transitions of care
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More Tasks in Early Dementia
Caregiver wellbeing addressed
 Consider cognitive enhancing meds
 Adapt daily activities to changing abilities
 Address pain to enhance comfort and
mobility
 Minimize iatrogenic problems
 Advanced directives established
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The Edinburgh Principles
Wilkinson H, Janicki M et al. J Intell Disabil Res 2002; 46:3:279-84
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1. Focus on QOL as that person would define it
2. Focus on a person’s capabilities
3. Involve the family
4. Ensure good diagnostic assessment and
treatment
5. Work to keep people with ID and dementia in their
chosen home
6. Ensure people with ID and dementia have access
to the broad range of dementia care in general
community
7. Advocate for research and public policy to meet
current and future needs
Goals in Severe Dementia
Maintain function and maximize comfort
 Explore options for change of residence
based on caregiver capabilities and needs
 Consider small details that may enhance
quality of life
 Minimize transitions between home and
ED and hospital
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Tasks for Severe Dementia
Assess cognition, behavior, function,
nutrition/hydration, pain/discomfort,
caregiver wellbeing at frequent intervals
 Make adjustments for decline in mobility
 Make adjustments for change in diet and
feeding strategies
 Review advanced directives
 Discuss transition to palliative care or
hospice
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Cognitive enhancing medicatinos:
Cholinesterase Inhibitors
Many neurodegenerative diseases
associated with reduced cholinergic
function (↓Ach)
 Inhibit acetylcholinesterase and ↑ Ach
 Acetylcholine: promotes alertness,
concentration, memory, visual perception
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Cholinesterase Inhibitors 2
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Donepezil (Aricept: AD, Mild-Mod-Sev AD)
 5 mg daily for one month, then 10 mg daily.
May go to 23 mg daily.
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Galantamine (Razadyne ER: Mild-Mod AD)
 8 mg daily for one month, then 16 mg. May go
to 24 mg daily.
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Rivastigmine (Exelon Patch: Mild-Mod AD, PDD)
 4.6 mg/24 hrs. daily for one month, then 9.5
mg/24 hrs. May go to 13.3 mg/24 hrs.
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Cholinesterase Inhibitors 3
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Alzheimer’s Disease
 Start and maintain for at least 1 yr.
 Expect improvement in some, slowed decline in
most, mild psychotropic effect
 Multiple small trials in DS w AD: generally positive
results but evidence of efficacy not yet convincing
(methodology?)
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PDD/LBD
 Expect better response and moderate
psychotropic effect (VH, delusions)
 No controlled data in DS or ID
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Other Clinical Issues
When to stop?
 Are they worth the money?
 Relative contraindications: PUD,
bradycardia, syncope, weight loss
 Off label
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 Vascular dementia: possible benefit?
 FTD, EtOH, TBI: No benefit
 No controlled data in ID
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Memantine (Namenda)
Effective in monotherapy but better as
adjunctive therapy with ChEI
 Improves neuronal function
 Well tolerated
 Approved for moderate to severe AD
 Started at 5 mg daily, with weekly
increases of 5 mg a day to 10 mg BID
 Not proven to be effective in DS w AD
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Case Example 1
Psychiatric consult requested for 62
year old man with Down’s Syndrome
 Admitted to med-surg unit
 Yelling for 6 weeks.
 Consult request: “Help with yelling.
Dementia getting worse.”
 Patient kept in room down hallway with
two doors to reduce disruptions from
loud patients.
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Case Example 2
82 year old woman in SNF with large right
frontal CVA three years ago
 Consult requested because of months of
intense crying episodes unresponsive to
multiple trials of antidepressants
 Cried with ADL care but also loud sobs and
long periods of wakefulness at night
 Exam: L hemiparesis w/contractures,
marked abulia and apathy, but could make
eye contact and show gentle smile
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Behavioral Symptoms AD
Lloyd et al. J. Geriatric Psychiatry Neuro 8:4:213-216, 1995
Symptom
Mild (%)
Mod (%)
Severe (%) Total (%)
Delusions
12
25
31
22
Hallucinations
12
15
8
10
Agitation
47
55
85
60
Dysphoria
12
45
62
38
Anxiety
24
65
54
48
Euphoria
18
0
8
8
Apathy
47
80
92
72
Disinhibition
35
40
31
36
Irritability
35
40
54
42
Restlessness
12
30
84
38
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Agitation
Can be due to anything causing distress
 R/O urinary retention, impaction, pain
 Consider the environment/interpesonal
 May be due to primary or secondary
psychiatric disorders
 But, dysphoric irritability is also a
primary symptom of neurodegeneration
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Other Sources of Agitation
Environmental
Interpersonal
Neurological
Psychological
Chaotic
Can’t hear
Overreact
Dysphoric
Complex
Can’t
understand
Underreact
Anxious
Noisy
Can’t see
Forget
Bored
Glare
Disrespected
Slow processing Feel useless &
out of place
Cold/hot
Rushed
Dyspraxia
Has agenda
Symptom Review
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MOMS
– mobility, output, memory, senses
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AND
– aches, neuro, delirium/delusions
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DADS
– depression, appetite, dermis, sleep
Analegesics:
Percentage of NH Residents With Dementia Receiving Analgesics
None
Mild
Moderate
Severe
68.2
75.0
35.5
28.6
Non-opioid
54.3
administered
50.0
22.6
11.6
Opioid
prescribed
40.9
4.2
6.5
7.1
Opioid
36.4
administered
4.2
3.2
7.1
Non-opioid
prescribed
Sources of Pain
Obvious: arthritis, spondylosis, GERD,
known injury or infection, headache,
neuropathy, pressure ulcers, skin tears,
joint deformities, compression fractures,
shingles, fibromyalgia
 Subtle: contractures, pressure points,
immobility, dental and periodontal,
constipation, urinary retention, unknown
injury, tight clothes, ear infection
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AGS Guidelines in Mild Dementia
Generally able to reliably report pain but
less reliable in people with low IQ
 Pose questions in present tense
 Use various terms for pain, discomfort,
hurt, uncomfortable, etc.
 Use frequent direct questioning
 Multidimensional pain instrument may
be helpful but not necessary
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APS and AGS in Severe Dementia
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Recommend using a validated pain scales for
cognitive impaired or nonverbal patients
 Scales are based on observation of behavior and
expression
 Scales have limitations (false + and -)
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 Verbal scales may be best in this group
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In DS w AD: Note recent changes in
vocalizations, facial expression, body posture
and movement patterns, agitation with ADL
care
Physiologic clues of distress may be only clue:
increased breathing or heart rate, increased
BP
Behavioral Clues
Facial expressions and affect
 Verbalizations/vocalizations
 Irritability and agitation
 Postural guarding
 Restlessness
 Withdrawn
 Anorexic
 Insomnia
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Suggested Scales
content
validity
constru
ct
validity
reliabilit
y
Practicality
Global
score
PACSLA
C
100
67
92
90
87
Abbey
Scale
81
61
56
93
73
DOLOPLUS
78
53
56
73
65
PADE
56
67
82
53
64
PAINAD
78
50
49
77
63
Numbers are percentages.
Discriminant validity
Zwakhalen, S., Hamers, J. & Berger, M. (2007). Journal of Advanced Nursing,
58(5), 493-502.
PADE
Villanueva M et al. JAMDA 2003; 4:1:9-15
24 items
 Facial expression
 ADLs
 Caregiver’s judgment of pain
 Good reliability and validity
 5-10 minutes to administer
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Agitated Behavior and Pain
Husebo BS et al. Am J Ger Psych 2013; in Press
Controlled trial of pain intervention
 352 patients in Norwegian NHs
 Dementia and moderate to severe pain
 All patients in intervention group
received scheduled analgesics in
stepwise approach
 CMAI factor analysis:
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 Verbal agitation showed greatest reduction
 Aggressive behaviors declined
CMAI Scores: Cohen-Mansfield Agitation Scale scores for verbal agitation
Most Common Behaviors in CohenMansfield Study:
General restlessness
 Constant requests for attention
 Pacing
 Complaining
 Repetitiveness
 Cursing
 Oppositional behavior
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Scheduled Analgesic Trial for
Agitation
Topical agents, lidocaine skin patch
Avoid NSAIDs, muscle relaxants
Acetaminophen 325-1000 mg TID or QID
(max. 3000 mg/day)
 Gabapentin 100-800 mg BID or TID
 Tramadol 25-50 mg BID or TID
 Opioid analgesics
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Hydrocodone 2.5-5 mg Q4-6 hrs.
Oxycodone 2.5-5 mg Q 6 hrs.
Hydromorphone 1-2 mg Q 4-6 hrs.
Methadone 2.5 mg Q 8-12 hrs.
Opioid Concerns
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Real
 Opioid naïve patients may have strong
reactions: over-sedation or delirium
 Constipation
 Tolerance
 Diversion
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Mythological
 Addiction
 Dementia: Opioids may increase confusion
initially, but cognitive tolerance develops quickly
and correlates with sedation
Case Example 1
Quick exam revealed tender, distended
abdomen
 Abdominal X-ray confirmed obstipation
 A wonderful nurse volunteered, did the
work and the yelling stopped
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Case Example 2
Crying not due to depression but strokerelated affect dysregulation
 But crying likely due to distress:
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 Pain from contractures and immobility
 Anxiety during the night
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Interventions:
 Scheduled analgesia
 Nighttime medication for anxiety and sleep
 Environmental and comfort measures
Aggression
If due to agitation or delusions, treat with
appropriate medications
 If episodic, requires root cause analysis
to identify triggers
 Stimulus and response need to be
modified
 Medications do not work well for
episodic aggression
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Pacing and Wandering
Consider trials of meds for anxiety,
akathisia, pain, RLS
 May be “agenda-driven”, such as
looking for something
 May be frontal hyperactivity (ADHD)
 May be tardive akathisia
 Need exercise and safe and secure
surroundings
 May be a terminal sign
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Sexual Disinhibition
Consider mania (especially in women)
 Consider legitimate need for intimacy
 If stimulus bound (eg breast grabbing),
isolate from stimulus
 If driven by libido, medroxyprgesterone
can be tried (case reports and small
case series)
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Apathy
Majority of patients with dementia
 Not depression
 Impoverished thinking
 Patients are quiet, placid, withdrawn
 No initiative, reluctant to shower
 “Ghosts”….spouses feel lonely
 Occasionally responds to stimulants, ChEI
and memantine
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Hallucinations
Visual: optimize vision, keep nightlights
on, cholinesterase inhibitors and low
dose quetiapine if Lewy Body or PDD
 Auditory: optimize hearing, mask with
“white noise”
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Sundowning
Circadian delirium with no effective
treatment
 Suggestions:
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Midday nap?
Music?
Structured activities?
Enhance exposure to bright light in AM?
Cholinesterase inhibitor?
Decrease stimulation?
Trials of low dose antipsychotic midday?
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Sleep Disorders
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Nighttime insomnia:
 Modest effect: daytime activity, enhanced light
exposure, melatonin augmentation
 More effective: trazodone, quetiapine, analgesia
Daytime sleepiness: R/O obstructive apnea,
reduce sedating meds, increase daytime
activity
 REM Behavior Disorder: clonazepam,
melatonin, cholinesterase inhibitor
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Psychotropics for Agitation
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Antipsychotics
 Use when delusions present
 Most evidence for efficacy in general dementia
population
 No data in ID dementia (fair quality data in
younger ID people with aggressive behaviors)
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Antidepressants (esp. SSRIs)
 Use for irritability, anxiety, dysphoria
Antiepileptics (caution)
 Benzodiazepines (caution)
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All psychotropics nearly double mortality risk.
Sedation and lethargy = falls, aspiration and death
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Targeting Psychotropics
Mood Stabilizer
Antidepressant
irritability
impulsivity
hyperactivity
Analgesic:
restless
calling out
grimacing
combative
agitation
physical
aggression
delusions
hallucinations
Stimulants:
apathy
sleepiness
Antipsychotic
anxiety
dysphoria
Trazodone,
Sed/Hyp:
insomnia
Clonazepam:
REM sleep
behavior
ChI:
apathy
hallucinations
misperceptions
confusion
inattention
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Comfort Measures
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Music
Snacks and drinks
Scheduled toileting
Low stimulation
1:1 activities: reading, singing, hand
massage, games, etc.
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Resources

National Task Group on Intellectual Disabilities and
Dementia Practices
 www.aadmd.org/ntg
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Alzheimer’s Disease Education and Referral Center
 www.nia.nih.gov/Alzheimer’s
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Family Caregiver Alliance
 www.caregiver.org
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Alzheimer’s Foundation of America
 http://www.alzfdn.org
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Nameste End of Life Dementia Care
 http://namastecare.com
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References
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Herrman N and Gauthier S. Diagnosis and
Management of Dementia: Management of Severe
Dementia. CMAJ 2008; 179:2:1279-87
Hogan DB et al. Diagnosis and Management of
Dementia: Nonpharmacologic and pharmacologic
therapy for mild to moderate dementia. CMAJ 2008;
179:10:1019-26
Hogan DB et al. Diagnosis and treatment of
dementia: Approach to management of mild to
moderate dementia. CMAJ 2008; 179:8: 787-93
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References
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Sadowsky CH and Galvin JE. Guidelines for the
management of cognitive and behavioral problems
in Dementia. JABFM 2012; 25:3:350-366
Stanton LR and Coetzee RH. Down’s Syndrome
and Dementia. Adv Psychiatric Treatment 2004;
10:50-8
Steinberg M and Lyketsos. Atypical antipsychotic
use in patients with dementia: Managing safety
concerns. Am J Psychiatry 2012; 169:9:900-906
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