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.
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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
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0
Death |------------------------------------------
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Years Feidman and Gracon, 1996
9
Mild AD (MMSE 2130)
IMPAIRMENT
Cognition
Function
Behaviour
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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
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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
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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
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Consequences of Untreated Pain
 It is estimated that 80%
of personal care home
residents have
substantial pain that is
undertreated
 Untreated pain results
in:
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depression
decreased socialization
sleep disturbance
impaired ambulation
behavioral problems
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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
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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:
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Arms/Legs (14%)
Back (12%)
Joint (11%)
Hip (10%)
Soft Tissue (8%)
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Arthritis/osteoarthritis
Osteoporosis
Hip fractures
Hip replacement
Contractures
Malignancies
Disc disease
 Pain-Related Disorders:
Nociceptive (Visceral) Acute Pain
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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
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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