Deconstructing Chronic Low Back Pain in the Older Adult–Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part XI: Dementia

Abstract

Comprehensive pain evaluation for older adults in general and for those with CLBP in particular requires both a medical and a biopsychosocial approach that includes assessment of cognitive function. A positive screen for dementia may help explain why reported pain severity does not improve with usual or standard-of-care pain management interventions. Pain reporting in a person with dementia does not always necessitate pain treatment. Pain reporting in a person with dementia who also displays signs of pain-associated suffering requires concerted pain management efforts targeted to improving function while avoiding harm in these vulnerable patients.Key Words. Dementia; Chronic Pain; Low Back Pain; Lumbar; Primary Care.

Low back pain in older adults: risk factors, management options and future directions

“…It has been suggested that clinicians should consider assessing the cognitive function of older adults with LBP if patients have a known history of dementia, self or family report of memory loss, difficulty in providing details of LBP history that requires supplementary input from caregivers, age above 85 years, or inconsistency between observed pain behaviors and self-reported pain [ 212 , 213 , 218 ]. Some dementia screening tools (e.g., Montreal Cognitive Assessment [ 219 ], Mini-Cog [ 220 , 221 ], and Saint Louis University mental status examination [ 222 ]) have been recommended based on their psychometric properties, ease of use, and accuracy in identifying people with dementia [ 223 ]. Patients with positive screening results should be referred to subspecialty dementia experts (e.g., neurologists, geriatricians, or geriatric psychiatrists) for formal dementia evaluation in addition to LBP treatment.…”

“…Since people with moderate to severe dementia may display agitation, anxiety, or nonverbal pain behaviors (e.g., grimacing, yelling, hitting, or bracing), failure to detect pain as a potential cause of agitation may result in unnecessary prescription of anxiolytics or antipsychotics [ 224 ]. As such, proper procedures for evaluating nonverbal dementia patients should include: using a validated observational assessment tool to evaluate pain behaviors during rest and painful conditions/procedures, seeking surrogate report of pain behaviors, and monitoring responses following an analgesic trial [ 223 ]. Since the prevalence of dementia in people aged 85 or older can be as high as 50% [ 218 ], family members or informants are recommended to accompany these patients to meet health-care providers so as to provide detailed pain information [ 223 ].…”

“…As such, proper procedures for evaluating nonverbal dementia patients should include: using a validated observational assessment tool to evaluate pain behaviors during rest and painful conditions/procedures, seeking surrogate report of pain behaviors, and monitoring responses following an analgesic trial [ 223 ]. Since the prevalence of dementia in people aged 85 or older can be as high as 50% [ 218 ], family members or informants are recommended to accompany these patients to meet health-care providers so as to provide detailed pain information [ 223 ]. Several recent reviews have identified at least 24 observational pain assessment instruments for estimating pain in nonverbal patients [ 225 – 227 ].…”

“…While multiple observational pain assessment scales have been developed, there is no consensus on the use of a particular assessment tool. Different clinical guidelines have recommended different scales [ 223 , 225 ]. Given the rapid development and validation of different observational scales in the last decade, it is necessary to update existing guidelines on this issue.…”

Exclusion of Older Adults from Ongoing Clinical Trials on Low Back Pain: A Review of the WHO Trial Registry Database

“…A series of recently published review articles entitled “Deconstructing Chronic Low Back Pain in the Older Adult—Step‐by‐Step Evidence and Expert‐Based Recommendations for Evaluation and Treatment” offered strategies to provide rational care for older adults with chronic LBP. However, expert‐based recommendations presented in this series of articles need to be evaluated through CTs.…”