Pain management in patients with dementia

Abstract

There are an estimated 35 million people with dementia across the world, of whom 50% experience regular pain. Despite this, current assessment and treatment of pain in this patient group are inadequate. In addition to the discomfort and distress caused by pain, it is frequently the underlying cause of behavioral symptoms, which can lead to inappropriate treatment with antipsychotic medications. Pain also contributes to further complications in treatment and care. This review explores four key perspectives of pain management in dementia and makes recommendations for practice and research. The first perspective discussed is the considerable uncertainty within the literature on the impact of dementia neuropathology on pain perception and processing in Alzheimer’s disease and other dementias, where white matter lesions and brain atrophy appear to influence the neurobiology of pain. The second perspective considers the assessment of pain in dementia. This is challenging, particularly because of the limited capacity of self-report by these individuals, which means that assessment relies in large part on observational methods. A number of tools are available but the psychometric quality and clinical utility of these are uncertain. The evidence for efficient treatment (the third perspective) with analgesics is also limited, with few statistically well-powered trials. The most promising evidence supports the use of stepped treatment approaches, and indicates the benefit of pain and behavioral interventions on both these important symptoms. The fourth perspective debates further difficulties in pain management due to the lack of sufficient training and education for health care professionals at all levels, where evidence-based guidance is urgently needed. To address the current inadequate management of pain in dementia, a comprehensive approach is needed. This would include an accurate, validated assessment tool that is sensitive to different types of pain and therapeutic effects, supported by better training and support for care staff across all settings.

Pain Assessment in People With Dementia: Remaining Controversies

“…Some researchers have hypothesized that the physical component of pain experience may be compromised in PWD due to the disease process of dementia and its related neuropathological changes (Achterberg et al, 2013). Also, according to Hadjistavropoulos et al (2014), in addition to age-related cognitive impairments, dementia may cause an additional burden of cognitive impairment and associated neurodegenerative loss.…”

Tetrahydrocannabinol for neuropsychiatric symptoms in dementia

“…However, the number of eligible patients with both symptoms was much lower than predicted from the literature. 20 After inclusion of the first 8 patients, the criterion of pain was omitted. In the amended study, pain assessments were still included, allowing secondary evaluation of the efficacy of THC in reducing pain-related behavior and pain intensity in a subgroup of patients, of which the methods and results are described in appendix e-1 and table e-1 on the Neurology ® Web site at Neurology.org.…”

Is pain sensitivity altered in people with Alzheimer's disease? A systematic review and meta-analysis of experimental pain research

“…However, the impairment in cognitive and communication abilities associated with AD may provide a threat to the reliability of assessment measures that require significant input from the patient. Self-assessment measures, which require the patient to verbally report their pain, are more likely to be negatively impacted by restricted communication and cognitive abilities that might be evident at high levels of AD [41]. Empirical data seems to support this, with several studies [17,30] finding that patients with severe AD failed to pass reliability testing for the self-reported pain rating assessment and had to be excluded from analysis.…”