Pain Assessment/Management in the Senior with Cognitive
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Transcript Pain Assessment/Management in the Senior with Cognitive
Pain Assessment/Management in
the Senior with Cognitive
Impairment
Darlene Grantham BN,MN, CHPCN (c)
Clinical Nurse Specialist
March 10, 2008
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)
Dementia
Prevalence Increases with Age
47%
Prevalence (%)
50
40
30
22%
20
10%
10
0
65
75
Age (year)
85
Larson EB et al. Annu Rev Public Health 1992;13:431-449.
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
Alzheimers: Progression
MMSE score
25 ---------------------| Symptoms
20
|----------------------| Diagnosis
15
|-----------------------| Loss of functional independence
10
|--------------------------------| Behavioural problems
Nursing home placement
5
|-------------------------------------------|
0
Death |------------------------------------------
1
2
3
4
5
6
7
8
Years Feidman and Gracon, 1996
9
Mild AD (MMSE 2130)
IMPAIRMENT
Cognition
Function
Behaviour
Recall/learning
Word finding
Problem solving
Judgment
Calculation
Work
Money/shopping
Cooking
Housekeeping
Reading
Writing
Hobbies
Apathy
Withdrawal
Depression
Irritability
Adapted from Galasko, 1997
Moderate AD (MMSE 1020)
IMPAIRMENT
Cognition
Function
Behaviour
Recent memory
Language (names,
paraphasias)
Insight
Orientation
Visuospatial ability
IADL loss
Misplacing objects
Getting lost
Difficulty dressing
(sequence and
selection)
Delusions
Depression
Wandering
Insomnia
Agitation
Social skills
unaffected
Adapted from Galasko, 1997
Severe AD (MMSE <10)
IMPAIRMENT
Cognition
Function
Basic ADLs
Attention
Dressing
Difficulty performing
Grooming
familiar activities
(apraxia)
Bathing
Language (phrases,
Eating
mutism)
Continence
Walking
Behaviour
Agitation
Verbal
Physical
Insomnia
Adapted from Galasko, 1997
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
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
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
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
Assessing Multiple Dimensions of
Pain
The ABCs of Pain
Affective Dimension
Behavioral Dimension
Cognitive Dimension
Physiological-Sensory Dimension
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)
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.
Behavioral Dimension
Horgas, 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
Behavioral Dimension
Objective Data (NANDA, 2001)
Guarding
Impaired thought process
Social withdrawal
Introspection
Altered time perception
Moaning
Crying
PAIN
Behavioral Dimension
Objective Data (NANDA, 2001)
Pacing
Distracting self
Restless behavior
Hitting, pushing, swearing
Physical signs: diaphoresis
BP/Pulse/RR Change
Restless
Behavior: Not
being able to sleep
Cognitive Dimension
Beliefs
Memories:
Connections to past
Attitudes
pain shapes a patient’s
Meaning of the pain
response
Memory of past pain
Cognitive resources to cope
Locus of control
Harlos,
2002
Physiological
Dimension
(Harlos, 2002)
NEUROPATHIC
NOCICEPTIVE
Visceral
Somatic
-Superficial: skin
-Deep: bones, joints,
connective tissue,
muscle
• Organs –
heart, liver,
pancreas, gut,
etc.
Deafferentation
Sympathetic
Maintained
Peripheral
Nociceptive Somatic Pain (acute or
chronic)
Common Locations of
Pain:
Arms/Legs (14%)
Back (12%)
Joint (11%)
Hip (10%)
Soft Tissue (8%)
Arthritis/osteoarthritis
Osteoporosis
Hip fractures
Hip replacement
Contractures
Malignancies
Disc disease
Pain-Related Disorders:
Nociceptive (Visceral) Acute Pain
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
Neuropathic Chronic Pain
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
What Else to Assess?
Side-Effects of Therapy
Constipation
Gastric Fullness
Nausea
Sedation
Dry Mouth
Medications
Symptoms of Disease
Dyspnea
Fatigue
Dry Mouth: A
common side
effect
When to Assess?
Initial:
Assessment of the pain
dimensions
Follow-up:
Routine reassessments
are essential
Two Times: A
minimum of 2
times (24hrs)to
assess a patient
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
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
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
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.
Pain Prevalence and Cognitive
Impairment
Myth 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.
Pain and Cognitive Impairment
Myth 2
Pautex (2006)
Objective: performance of pain selfassessment 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.
Assessment Tools – NOPAIN
Horgas 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
Analgesic Ladder
Pain relief
Step 3
Opioid for moderate to severe pain
+/- Non-opioid
+/- Adjuvant
Pain persisting
Step 2
Opioid for mild to moderate pain
+/- Non-opioid
+/- Adjuvant
Pain persisting
Step 1
Non-opioid for mild pain
+/- Adjuvant
PAIN
Source: World Health Organization, 1992
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
Adjuvants
May be appropriate for some
residents with neuropathic pain
C o rtic o s te rio d s
In fla m m a to ry
D is e a s e
A n tid e p re s s a n ts
N e u ro p a th ic P a in
A n tic o n v u ls a n ts
N e u ro p a th ic P a in
Nonpharmacologic Strategies
Used alone or in combination with
pharmacologic strategies
Exercise
Physiotherapy, occupational therapy
Music
Therapeutic touch
Heat, cold therapy
Massage
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)
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
Questions