1. ANA ASLAN INTERNATIONAL ACADEMY OF AGING ANA ASLAN INTERNATIONALFOUNDATION 1 PAIN QUANTIFICATION IN SEVERE ALZHEIMER’S DISEASE: ADVANTAGES AND DISADVANTAGES OF PAIN ASSESSMENT SCALES Ioana Ioancio, MD, PhD Ana Aslan International Academy of Aging, “Elias” University Emergency Hospital, Bucharest, Romania, Ileana Turcu, PhD Ana Aslan International Academy of Aging, Bucharest, Romania Luiza Spiru, MD, PhD Head of the Day Hospital of Memory Diseases, President of Ana Aslan International Foundation Vice-President of Ana Aslan International Academy of Aging, Professor of Geriatric Dept. ”Carol Davila” University of Medicine and Pharmacy, “Elias” University Emergency Hospital, Bucharest, Romania 26 th International Conference of Alzheimer Disease International ADI 2011 26-29 March 2011 Toronto, Canada 26 th International Conference of Alzheimer Disease International ADI 2011 26-29 March 2011 Toronto, Canada

2. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 2 Content Background  ‘Alzheimer’s Crisis’  Personality changes in dementias Our study  Aims  Subjects  Methods  Results  Discussions  Conclusions To do in the management of behavioral symptoms 2

3. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. Background 3  50-85% of the geriatric patients have pain  32-53% of the patients with dementia have pain daily  Dementia is associated with SNC changes that alter pain tolerance, but not pain thresholds. Horgas AL et al., 2009. Pain assessment in Persons with Dementia: Relationship Between Self Report and Behavioral Observation. J Am Geriatr Soc 57:126-132

4. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 4 Horgas AL et al., 2009. Pain assessment in Persons with Dementia: Relationship Between Self Report and Behavioral Observation. J Am Geriatr Soc 57:126-132 PAIN SELF REPORT  a standard criterion of pain assessment, but INSUFFICIENT !  often underestimates patient’s pain. Pain Self-Report contains:  pain presence  disclosed by Structured Pain Interview  pain intensity  pain duration  pain location

5. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 5 Catananti C, Gambassi G, 2010. Pain assessment in the elderly. Surgical Oncology, 9:140-148. Pain reporting depends of :  Biology  Age  older people experience less pain  the perception that pain is an inevitable part of aging  Culture  pain is something to be endured  pain means weakness  Religion  Ethnicity  Cognitive impairment

6. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 6 Linda Mc Auliffe et al., 2008. Pain assessment in older people with dementia: Literature review. Journal of Advanced Nursing. Barriers in pain recognition:  ’no - pain’ subset of people with dementia,  stoical attitudes.

7. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 7 Quantitative Assessment of Pain : 1. Visual Analogue Scale (VAS) 2. The faces pain scale 3. The verbal rating scale 4.The numerical rating scale. 1.Catananti C, Gambassi G, 2010. Pain assessment in the elderly. Surgical Oncology, 9:140-148. Pain measurement the most adequate assessment.

8. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 8 Quantitative Assessment of Pain : Involves:  Localisation and referral pattern of pain + complete functional physical examination  Characteristics of pain  McGill Pain Questionnaire (emotional, sensory and evaluative dimensions of pain)  Quantification of response to analgesic therapies.  Patient’s current level of functioning (ADL,IADL, Barthel Score)  Consideration of:  Affective disorders (anxiety, anger)  the Geriatric Depression Scale  Cognitive impairment, delirium and behaviour disturbances  Sleep disorders Frequent re-evaluation is an essential part of effective management 1.Catananti C, Gambassi G, 2010. Pain assessment in the elderly. Surgical Oncology, 9:140-148.

9. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 9 Dementia  a major impediment in the evaluation and management of pain. Cross-sectional studies  less analgesics were administrated in Alzheimer’s patients than in non-cognitively impaired old people. Cognitive impairment may be aggravated by uncontrolled pain. In clinical practice  the ability to remember, interpret and respond to pain can be altered in patients with dementia. 1.Catananti C, Gambassi G, 2010. Pain assessment in the elderly. Surgical Oncology, 9:140-148. Pain assessment in Dementia

10. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 10 The Pain Assessment in Advanced Dementia (PAINAD) includes:  assesses breathing,  negative vocalisation,  facial expression,  body language. The Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) -60 items organized in 4 groups:  facial expression,  activity/body movement,  social/personality/mood indicators  physiological needs Cf. Catananti C, Gambassi G, 2010. Pain assessment in the elderly. Surgical Oncology, 9:140-148.

11. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 11 Dolophus 2: 5 somatic items:  somatic complaints,  protective body posture adopted at rest,  protection of sore areas,  facial expression and gaze,  sleep pattern), 2 psychomotor items: based on observation of washing and/or dressing and mobility 3 psychosocial items:  communication,  social interaction,  behaviour) The Elderly Pain Caring Assessment -2(EPCA-2) 8 item behavioural scale to rate the intensity of pain in non-verbally communicating older patients. Cf. Catananti C, Gambassi G, 2010. Pain assessment in the elderly. Surgical Oncology, 9:140-148.

12. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 12 Our study The aim: Quantitative estimation of pain intensity using various pain scales, Detection of different scales power on patients referred to our Ana Aslan Memory Clinic from Bucharest, Romania. 12

13. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 13 Methods Patients: 510 patients diagnosed with severe Alzheimer dementia 398 females 112 males mean age 73.5 years Assessment tools:  Visual Analog Scale,  Graphic Scale,  Verbal Scale,  Word Descriptor Scale  Scales for Evaluation of Functional Performance (ADL, IADL). 13

14. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 14 For an accurate assessment of pain we had to identify the type of pain, the characteristics and severity of pain. The pain was quantified :  at the first visit  periodically afterwards. Only 10% (n=51) of all patients could be assessed using all 5 scales. 14

15. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 15 Results Scale Percent of compliant patients (assessment scale completion) Graphic Scale81% (n=413) Word Descriptor Scale52.9% (n=270) Evaluation of Functional Performance Scale 89.6% (n=457) Visual Analog Scale33% (n=168) Verbal Scale26.8% (n=137) 15% of patients’ assessments were deemed as ambiguous (contradictory results)

16. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 16

17. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 17 Conclusions  Because our patients have:  severe memory impairment  difficulty integrating pain experiences over time, A single pain quantification scale:  is far to reflect the involvement of pain in the patient’s situation  to offer sufficient information for his/her management  As much as possible scales must be applied  They must be correlated with:  the severity of cognitive impairments (psychometric scales scores)  the outcomes of analgesic medication  Information provided by the caregiver.

18. All rights reserved. No part of these slides can be reproduced, stocked or transmitted in no other form and through no other electronic, mechanic, or photocopy way, without the approval of “Ana Aslan” International Academy of Aging®© “Ana Aslan” International Foundation ®© Brain Aging International Journal ®©. 18 Only then we can adjust:  timing  dosage of different drugs administration (either for the disease per se or analgesics), or we can react by suggesting nondrug therapies for more physical, psychological, social and spiritual comfort.

19. ANA ASLAN INTERNATIONAL ACADEMY OF AGING ANA ASLAN INTERNATIONAL FOUNDATION Thank you for attention and feedback Healthy Brain Aging Healthy Aging Ioana Ioancio, MD, PhD ii@brainaging.ro Ileana Turcu, PhD it it@brainaging.ro Luiza Spiru, MD, PhD lsaslan@brainaging.ro