Pain and living with Dementia The Ultimate challenge?

Pain and living with Dementia The Ultimate challenge?
27/11/2018 Jane Buswell Nurse Consultant

Jane Buswell Nurse Consultant
A great deal is written about the effect of the mind on the body. Much of it is true. However, I do wish a little more attention was paid to the effect of the body on the mind (Florence Nightingale) Old age ain’t no place for sissies (Bette Davies) 27/11/2018 Jane Buswell Nurse Consultant

Dementia UK 2014 815,827 people living with dementia in UK 773,502 over 65 years of age Trend is an increase of 40% over next 12 years 27/11/2018 Jane Buswell Nurse Consultant

43,477 People living with dementia in Wales
Isle of Anglesey 1189 Gwynedd Conwy Denbighshire 1511 Flintshire Wrexham Powys Ceredigion Pembrokeshire 2062 Carmarthenshire 2939 Swansea Neath Port Talbot 2006 Bridgend The Vale of Glamorgan Cardiff Rhondda Cynon Taf 2987 Merthyr Tydfil Caerphilly Blaenau Gwent 900 Torfaen Monmouthshire 1525 Newport 27/11/2018 Jane Buswell Nurse Consultant

Distribution by Health Boards
Betsi Cadwaladr University Health Board 10,726 Powys Teaching Health Board ,376 Hywel Dda Health Board ,218 Abertawe Bro Morgannwg U. H Board 7,222 Cardiff and Vale University Health Board 5,553 Cwm Taf Health Board ,720 Aneurin Bevan Health Board 7,663 Total WALES ,477 27/11/2018 Jane Buswell Nurse Consultant

People with dementia may have difficulty understanding the meaning of the sensation of pain and placing it in context This could potentially explain atypical behavioural responses 27/11/2018 Jane Buswell Nurse Consultant

How do we know it’s distress?
Q: What does distress look like? Distressed vocals : verbal/nonverbal Irritability/agitation/aggression Social withdrawal/interference/sexualised Tearfulness Restlessness/repetition Eating more/less Sleep disturbance Sedation required Q: which symptoms are most likely to be treated? 27/11/2018 Jane Buswell Nurse Consultant

History.... 2004 Committee Safety Medicines Two antipsychotics Elderly people with dementia 3-fold increase in the risk of stroke compared with placebo magnitude of risk outweighed any likely benefit Commonly prescribed to manage challenging behaviour 2005 Europe-wide review Increased risk of stroke possible for all antipsychotics 27/11/2018 Jane Buswell Nurse Consultant

Banerjee: October 2009 180,000 with dementia treated with antipsychotics each year in England ONLY 20% may derive benefit two-thirds of prescribing could be unnecessary Additional 1,620 cerebrovascular events per year Studies indicate one additional CVE for every 55 people treated for 12 weeks Additional 1,800 deaths per year Studies indicate one additional death in every 100 people treated for 12 weeks Mortality risk increases the longer you take them 27/11/2018 Jane Buswell Nurse Consultant

Pain and distress The need to consider the possible relationships between pain, distress & behavioural symptoms is paramount 27/11/2018 Jane Buswell Nurse Consultant

Why do we need to worry Abundant research indicates that cognitively impaired older adults are prescribed significantly less pain medication and received significantly less pain medication compared to cognitively intact older adults A significant amount of research supports the belief that cognitively impaired people are still able to communicate the experience of pain Morrison and Siu (2000) examined pain management of patients with hip fractures and dementia. Most patient did not have a prescription for analgesia. Cognitively intact older adults received triple the amounts of analgesia in the first 48 hours of the post op period compared with those with advanced dementia. . The main difference between the two groups was an ability to report and and describe pain. If experiences of cognitively intact people are used as a comparison then the people with dementia received inadequate analgesia and experienced pain. 27/11/2018 Jane Buswell Nurse Consultant

Those at greatest risk of not receiving analgesia
Older than 85 years Cognitively impaired Male Members of ethnic minority Won et al 1999 Won A Lapane K et al (1999) Correlates and management of non-malignant pain in the nursing home Journal of American Geriatrics Society 47 (8) Some visual indicators of pain can be-aggressive behaviour, noisy breathing, tense fidgety, restlessness 27/11/2018 Jane Buswell Nurse Consultant

NCPOD 2010 Pain was poorly assessed and documented. Pre-operative pain management in some patients was absent or inadequate. Pain was not routinely assessed routinely post operatively in all the elderly surgical patients 27/11/2018 Jane Buswell Nurse Consultant

Dementia and End of Life
850,000 people in the UK have dementia One in three people over the age of 65 will end their lives with a form of dementia Pneumonia is listed as the ultimate cause of death in up to two-thirds of people with dementia Dementia is the third most common underlying cause of death for women in England behind heart disease and stroke 27/11/2018 Jane Buswell Nurse Consultant

Dying and dementia People may die from complications arising from end stage dementia People may being the early stages of dementia and die from another illness People may die from a mix of problems. Dementia may not be the main cause of death, but it interacts with other conditions and can complicated 27/11/2018 Jane Buswell Nurse Consultant

Additional complications
No diagnosis- no advance care planning! Diminishing mental capacity Difficulty with communication Uncertainty in prognosis 27/11/2018 Jane Buswell Nurse Consultant

People with dementia also experience…..
Immobility Neuropathic pain Post-stroke Arthritis Chronic back pain Constipation Urinary tract infection Pressure ulcers Vascular disease Heart disease Trauma Malignancy etc….. 27/11/2018 Jane Buswell Nurse Consultant

And their effects Depression Sleep disturbance Worsening cognition ‘delirious with pain’ Anxiety (fear)> Agitation/aggression (often attempting to avoid pain) >Poor interactions with carers >>Inappropriate prescription of sedatives> Reduced oral intake Increased risk of falls> further trauma 27/11/2018 Jane Buswell Nurse Consultant

MANAGING DISTRESS Starts with good assessment! CONSIDER THE 3 D’S: DEMENTIA DEPRESSION DELIRIUM And of course PAIN 27/11/2018 Jane Buswell Nurse Consultant

Does pain look any different ?
Note: cultural variations in expression of pain Facial expression (grimacing etc.) Verbal expression (moaning, calling out etc.) Physical body expression (body posture, pacing, rocking etc.) Changes in eating/sleeping habit Changes in routine Increase in confusion, irritability, distress NB. Pulse/BP may not be raised (different thresholds in dementia) 27/11/2018 Jane Buswell Nurse Consultant

How do we know it’s pain? A: we don’t always know, but we can make an educated guess 1. EXPECT PAIN: older people have more issues that can cause pain 2. LOOK FOR THE OBVIOUS: history of pain, trauma etc.; Already taking pain meds (but are they really???) Pain behaviour on personal care Reduced mobility/limb use 27/11/2018 Jane Buswell Nurse Consultant

Pain assessment 1. Can the person self-report? 2. If not: Do a pain screen as an observational assessment: note objective nature of questions 3. NB. Is the person actually taking their pain meds or are they missing doses? If pain screen score is more than 2/5, pain is likely >> 4. Complete Abbey scale to get more detailed picture 27/11/2018 Jane Buswell Nurse Consultant

Problems with assessment
Failure to understand questions Distracting/disturbing environment/hallucinations Sadness, anger or frustration Paranoia 27/11/2018 Jane Buswell Nurse Consultant

Pain assessment cont’d.
4. REVIEW, REVIEW, REVIEW!!! 5. Best to try similar times of day, avoid sundowning periods 6. Consider reporting & recording around lunchtime, include info. from previous night’s sleep, breakfast, behaviour around personal care etc. 7. Record details on distressed behaviour, NB. CONTEXT & TRIGGERS 8. Record medication, NB painkillers, sedatives + any adverse effects 27/11/2018 Jane Buswell Nurse Consultant

Observational scales for assessment of pain in non communicative patient Abbey pain scale Dementia Scale- (Alzheimer's type) Checklist of non verbal pain indicators Non-communicative patients with pain assessment instrument Pain Assessment in Advanced Dementia (PAINAD) DOLOPLUS2 27/11/2018 Jane Buswell Nurse Consultant

Managing distress Q: whose distress is being managed? Q: where do we start? A: KEEP IT SIMPLE! First: know the person really well If they were distressed earlier in their lives, how did that manifest itself? If they were in pain, how did they show it? 27/11/2018 Jane Buswell Nurse Consultant

Principles of distress management
What medication is the person already on? If ineffective, is it being taken properly as prescribed? Is it prescribed RTC/PRN? FIRST consider non-drug options Treat underlying conditions e.g. UTI Treat pain according to modified WHO ladder Use suspension/ topical treatments if issues of swallowing/compliance Only use covert meds where necessary & as per your policy If in doubt, always consider a trial of analgesics: but review regularly and discontinue if ineffective, before commencing alternative treatment 27/11/2018 Jane Buswell Nurse Consultant

Drug treatment Analgesics (even morphine related) treating pain effectively reduce the risk of delirium & falls Reducing distress from pain should allow reduced use of sedatives & antipsychotics Start low, go slow! Recent study in Norway* of NH residents showed that Rx with Paracetamol, XR morphine, Butrans patches +/- pregabalin reduced: Verbal agitation & restlessness * Husebo et al Am J Ger Psychiatry April 2013 Response of Agitated Behaviour to Pain Assessment in Persons with Dementia 27/11/2018 Jane Buswell Nurse Consultant

Pain – is what the patient says it is
But if they can’t tell you where or what it is? PRN prescribing = Patient Relief Nil 27/11/2018 Jane Buswell Nurse Consultant

Remember Pain in advanced dementia is a common symptom. People with dementia experience pain just as much as anyone else. Pain in people with dementia is often poorly recognised and under treated, and yet it is not difficult to treat. Caregivers need to work hard to understand a person's verbal and non-verbal signs that they are in pain. International Association of Hospice and Palliative Care 27/11/2018 Jane Buswell Nurse Consultant

Pain and living with Dementia The Ultimate challenge?

Similar presentations

Presentation on theme: "Pain and living with Dementia The Ultimate challenge?"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Pain and living with Dementia The Ultimate challenge?

Similar presentations

Presentation on theme: "Pain and living with Dementia The Ultimate challenge?"— Presentation transcript:

Similar presentations

About project

Feedback