2

An Interprofessional Approach

to Pain Management in

Persons with Moderate to

Severe Dementia

Meghan Marcil, PT

Joanne Pacione, RN

Myla Santos, RN

Carol Skanes, RN

Objectives

• To describe the importance of proper assessment of

pain in persons with dementia

• Recognize the impact of under treating pain on

quality of life, responsive behaviours, and health

outcomes

• Understand the need to balance pain management

and sedation in patients with dementia

• Gain knowledge of strategies for managing pain in

persons with dementia

• Understand some of the challenges in assessing and

managing pain in this population

Overview of Program • Toronto Rehab - 20 bed in-patient behavioural

assessment unit.

• Goal: Assessment and development of strategies to manage responsive behaviours of dementia so that patients can safely be cared for at their long term care facility.

• Referrals from LTC, Acute Care and community

• Interdisciplinary team assessment (Geriatric Psychiatrist, attending physician, OT, PT, SLP, SW, TR, PTA/OTA, CNS, primary RN, primary RPN, student nurses, pharmacy, chaplain, dietician, volunteers)

• Discharge: Patients generally return to the referring facility after a team conference to review strategies and medications

• Length of Stay--60 days

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What is pain?

"Pain is an unpleasant sensory and

emotional experience associated with

actual or potential tissue damage, or

described in terms of such damage."

(International Association for the Study of

Pain, 2015)

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6

True or False

Patients with dementia

experience less pain than

patients without dementia

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7

True or False

People with dementia receive

fewer analgesics than their

counterparts without dementia

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8

True or False

Co-morbid depression reduces the

pain threshold and increases the

pain intensity

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9

True or False

One should only prescribe pain

medications if you know for

certain that the patient has pain

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10

True or False

Attitudes and beliefs among

patients, families, and health

providers can be substantial

barriers to effective pain

management

10

True or False

Use of prn or as needed pain

medication is more effective than

having standing orders in frail

elderly patients

12

True or False

Family members have poor

perceptions of their loved one’s

pain in patients with dementia

12

13

True or False

There are pain assessment

tools validated for patients

with dementia

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Case Study – Mr. S

• Mr. S is a 94 year old man diagnosed with mixed dementia 7 years ago

• Living at home with his wife until November 2014 when he had a stroke and was admitted to an acute care hospital

• Severe cognitive and physical limitations following the stroke, requiring total assistance for ADLs

• Not eligible for LTC due to his responsive behaviours

15

Past Medical History

• Mixed Dementia (Alzheimer’s &

Vascular)

• Temporal/occipital CVA

• Atrial Fibrillation

• Hypertension

• Abdominal Aortic Aneurysm

• Benign Prostatic Hypertension

• Hx Delirium

16

Admitting Medications

• Atenolol

• Rivaroxaban

• Lax-a Day

• Vitamin D

• Tylenol prn

*trial of antipsychotics in acute care

caused drowsiness then discontinued

17

Assessment (Medical)

• Very drowsy

• Poor oral intake of fluids and solids

• Minimal verbal responses

• Spending all his time in bed

• Consistent leg pain and back pain

• Developed mid calf tenderness & swelling

• Significant physical aggression with care:

– Punching, hitting, scratching, kicking, spitting

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Intervention

• Antibiotic treatment for abscess

• Started on gradually increasing dose of pain medications

– Tylenol, Hydromorphone and Pregabalin

• Senokot for constipation

• Proper seating assessment and gentle mobilization

• Pressure relief cushion and mattress

• Pre-care behavioural medication (Ativan & Trazadone) to decrease anxiety and aggression

19

Medications at discharge

• Atenolol, Rivaroxaban

• Lax-a-day, Senokot

• Vitamin D

• Hydromorphone 0.5 mg QID

• Pregabalin 50 mg QHS

• Tylenol 650 mg TID

• Ativan 0.5 mg 30 mins pre care

• Trazadone 25 mg 30 minutes before care

20

Gains • Delirium resolved

– Improved cognition and communication

– Improved alertness

– Improved oral intake

• Reduced physical aggression during

care; managed by 1 staff

• Improved mobility and toileting

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Gains cont’d

• Improved family satisfaction with patient’s

quality of life

• Improved social interactions with staff and

family

• Patient eligible for LTC

• Limitations:

– Awaiting placement in acute care

– Transition/feasibility of care plan from

rehab into acute care setting

22

Case Study: Mrs. M

• Mrs. M is a 73 year old woman admitted for her

increasing responsive behaviours

– restlessness/agitation

– verbal aggression

– disrupted sleep pattern

• Lived in supportive housing prior to admission

• Admitted to TGH for rectal cancer surgery

• Behaviour worsened post operatively

• Delirium stabilized

22

23

Mrs. M. cont’d…

• Unable to return to previous apartment

in supportive housing

• Not eligible for LTC due to her

responsive behaviours

• Admitted to Geriatric Psychiatry for

assessment, behavioural rehabilitation

and management in order to be

considered for LTC placement

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24

Past Medical History

• Dementia (vascular)

• Hypertension

• Diabetes Type 2

• Lumpectomy for Breast Ca

• Bowel Resection for cancer

• Colostomy

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25

Assessment (Medical)

• Vitals and blood sugar within normal limits

• No obvious focal neurological findings

• Cardiovascular and respiratory exam within

normal limits

• Laboratory work up normal

• Negative for UTI

• Positive for MRSA

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Assessment (Behaviour) Day

– Pleasant and alert, cooperative with care, vital signs and medications

Evening – Constant calling out

– Pacing non-stop, unable to redirect

– Demands help quickly even with activities that she can perform on her own

– Irritable, impatient, calling staff names

– Pulling off colostomy bag

Night – Increased vocalization

– Agitated if does not receive request immediately

– Disrobing

– Poor sleep pattern

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Medications on Admission

• Quetiapine 12.5 mg po q4h prn for agitation

• Lorazepam 0.5 me IM q2h prn if quetiapine is

refused

• Metformin 1000 mg po bid

• Lantus insulin 10 units S/C qHS

• Ferrous Fumarate 300 mg po od

• Ramipril 10 mg po od

• Acetaminophen 1000 mg po q8h

• Hydromorphone 0.5 mg po q4h prn

27

28

Assessment and Interventions

over 5 weeks

• Received Quetiapine/Lorazepam prn regularly for 1

week following admission, with no effect

• Quetiapine given regularly at 2 pm and 8 pm for few

weeks but responsive behaviours unchanged

• Staff started to give hydromorphone prn consistently

• Pt calmer after hydromorphone given and behaviours

improved

28

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Recommendations

• Pain medications ordered on regular

schedule – Hydromorphone 0.5 mg po q12 h

– Acetaminophen 1000 mg po q8h

– Hydromorphone 0.5 mg po q4h prn for

breakthrough pain

– Trazodone 75 mg at HS

– Quetiapine 12.5 mg po at 2pm and 8 pm

– All other medications from admission unchanged

29

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Outcomes

Gains

• No further continual calling out for help

• Requests for help that are reasonable and

polite

• No irritability or name calling

• Not pulling off ostomy bag

• Participating in unit activities

• Sleeping well at night

• Eligible for LTC

30

Barriers/Learning

• Delay in receiving optimal pain control

due to staff misinterpreting her

behaviours and trying to manage with

antipsychotics

• Staff Learning: – better assessment of pain by Inter Professional

Team (PAINAD, review of past medical hx)

– Trial of analgesics for calling out and agitation prior

to antipsychotics to ensure pain is not masked or

undetected

31

Case Study: Mrs. C

• Mrs. C is a 71 year old female patient admitted to Geriatric Psychiatry for responsive behaviours including:

– physical aggression during personal care

– anxiety/restlessness

– difficulty with meals

– disruptive sleep pattern

• Pt was living at home with her 84 year old husband as her primary caregiver

• Pt is full code

Past Medical History

• Mixed dementia (vascular and

Alzheimer’s)

• Longstanding History of Anxiety

• Osteoarthritis

• Severe Spinal Stenosis

• Depression

• Progressive aphasia

Assessment (Medical)

• Vital signs and neurological findings

are within normal limits

• Abdomen slightly distended

• Positive for UTI

• Thoracolumbar kyphoscoliosis

• Delirium

Assessment (Behaviour)

• Vocalizations: growling, grunting and

angry tones

• Irritable, restless and agitated

• Physically aggressive towards staff, co-

patients and objects (required up to 5

staff to provide care)

• Hallucinations (auditory and visual)

• Difficulty with feeding and spitting of

food/medications

Assessment (Behaviour)

• Day - alert, angry facial expressions,

difficultly with personal care, slow

ambulation with stooped posture

• Evening – continual physical

aggression towards staff and co-

patients, punching husband and son

• Night – not sleeping, agitated during

personal care

Initial Medications (July 2015)

• Acetaminophen (PRN)

• Trazodone

• Lansoprazole

• Celecoxib

• Clonazepam

• Quinapril

• Hydrochlorothiazide

• Lorazepam

** Hydromorphone 2 mg PO BID (discontinued 1 week prior to

admission to TRI as husband stopped medication)

Started on Hydromorphone 0.5 mg TID on unit

Pain Assessment and

Behaviour Interventions

• Strategies:

– Close observation

– Behavioural flow sheet

– Nursing care flowsheet

– Family

– Weekly rounds – high emphasis on pain

during rounds with healthcare team

Assessment and Interventions

• Receiving Hydromorphone 1 mg po TID with minimal

breakthrough doses

• Pain still an issue therefore Hydromorphone

increased to 2 mg TID

• 2 weeks later, patient drowsy, severe constipation

and not eating, vomiting

– Hydromorphone was changed to 3 mg CR BID

• 3 weeks later, patient sleeping during day and

impacting on family visits

– Hydromorphone reduced to 3 mg CR at HS

• Pain appears controlled

Challenges to Pain management

• Managing adverse effects

– Constipation

– Nausea and Vomiting

– Pruritus

– Somnolence during the day

– Poor oral intake

– Pressure ulcer

– Urinary retention

Current Medications (April

2016)

• Lansoprazole (no dosage change)

• Celecoxib (no dosage change)

• Clozapine

• Mirtazapine

• Bisoprolol

• Acetaminophen

• Hydromorphone 3 mg CR qHS

Interventions

(Non-pharmalogical)

• Greek music

• Comfort --improved quality of life

• Dog therapy

Outcomes • Gains

• Care is manageable by 1 staff

• Showers twice a week

• Sleeps all night

• Continues to recognize her family and shows

affection towards them

• Improved family satisfaction

• Improved pain control

• Compliant with medications

• Improved nutrition

• Eligible and awaiting long term care bed

Outcomes

• Losses • Decreased mobility

• Sitting for long periods

• Incontinent

• Isolates self in her room--decreased

socialization

References • Barry, H. E., Parson, C., Passmore, P. A., and Hughs, C. M. (2012). An exploration of nursing home managers’

knowledge of and attitudes towards the management of pain in residents with dementia. International Journal of Geriatric

Psychiatry, 27, 1258-1266.

• Bruneau, B. (2014). Barriers to the management of pain in dementia care. Nursing Times. 110 (28), 12.

• Cohen-Mansfield, J. (2014). Even with regular use of observation scale to assess pain among nursing home residents

with dementia, pain relieving interventions are not frequently used. Evidence Based Nursing. 17(1), 24-25.

• Collett, B. (2002). The use of chronic opioid therapy for patients with non-malignant pain. Annals of Long Term Care.

10(11). 53-58.

• Cunningham, C., McClean, W., and Kelly, F. (2010). The assessment and management of pain in people with dementia

in care homes. Nursing Older People. 22(7). 29-35.

• Reuben, D. B., Herr, K.A., Pacala, J.T., Pollock, B.G., Potter, J.F. Semla, T.P. (2013) Geriatrics at your fingertips.

American Geriatrics Society. 210-222.

• Herr, K., Coyne, P. J., McCaffery, M., Manworren, R., and Merkel, S. (2011). Pain assessment in the patient unable to

self-report: Position statement with clinical practice recommendations. Pain Management Nursing. 12(4), 230-250.

• Kovach, C. R., Noonan, P. E., Schlidt, A. M., Reynolds, S. and Wells, T. (2006) The serial trial intervention; an innovative

approach to meeting needs of individuals with dementia. Journal of Gerontological Nursing, 32(4), 18-25

• McLachlan, A. (2011). Clinical Pharmacology of Analgesic Medicines in Older People; Impact of frailty and cognitive

impairment. British Journal of Clinical Pharmacology. 71(3). 351-364.

• Rabins, P. V. and Blass, D. V. (2014). Dementia. In the Clinic. Annals of Internal Medicine. 8 (5).

• Somes, J. and Stephens Donatelli, N. (2013). Pain assessment in the cognitively impaired or demented older adult.

Journal of Emergency Nursing. 39(2), 164-167.

Questions