1. Dementia Care Managing pain and symptom control
Gail Wilson

2. Pain is an unpleasant sensory and emotional experience that we associate with tissue damage
It involves 3 types of experience
The actual sensation
The knowledge about pain
The emotion aspect of pain
Pain can be
Acute- recent onset, often response to a tissue or organ damage.
Chronic
Non malignant-persists for more than one month, often associated with chronic disease
Malignant-linked to a cancerous process
What is Pain ?

3. To treat pain we need communication
Nobody else can feel your pain
We verbally communicate pain
Body language and behaviour can communicate pain
Chronic pain has many social and health consequences

4. Common causes of Pain in Dementia
osteoarthritis,
pressure sores
Infection
skin tears
leg ulcer dressings
stiffening of joints
muscle rigidity
constipation.

5. Earlier dementia – pain assessment
Verbal communication remains the main tool to assist diagnosis until it becomes very impaired
Time, simple clear questions, no complex language.
Pain intensity – the size of the problem
Careful carer observation and description
Is pain small, meduim large.

6. Advanced Dementia Pain Lack of meaningful verbalisation
46% of dementia patients in the last year of life have pain.
Pain is underestimated and under documented by carers
The sensory pathways in the brain can be damaged in Alzheimers disease. These are the pathways that give meaning to pain.
The patient cannot tell of their experience of pain and agitation and behavioural problems are much more likely to occur
Alzheimers may allow an increased pain tolerance, due to damaged pathways but it does not decrease the pain

7. Verbal expression is often lost
Advanced Dementia
Verbal expression is often lost
“ Pain is what the patient says it is” but what about the person who cannot say ?
* Those who cannot verbalise pain often don’t receive pain relief – nurses. carers don’t look for the cues (DCDC 2007)

8. Pain assessment for late dementia patients
Physiological changes
Pulse, temperature, sweating, blood pressure, respiratory rate, guarding
Observational changes
Agitation, aggression, reaction to touch, moaning, change in ability to move, hard to settle
Lion

9. Changes in body language
Facial Expression- frowning, fear, tearful
Knees drawn up, Foetal position, withdrawal
Carers intuition – Probability of Pain

10. Assessing Pain Probability of Pain
Mr Robinson is an elderly man with dementia who cannot respond verbally.
He has Rheumatoid Arthritis, in his hands, feet elbows and shoulders
What is the probability he is in chronic pain ?
0% 25% 50% 75% 80% 90% 100%

11. Advancing dementia
Mr Robinson , now has contracture of the knees, he cannot feed himself, cannot turn over in bed. However, you notice when the nurses turn him, his face grimaces and he withdraws his arms if touched
Has the pain probability score changed ?
You now give him pain killers 20 minutes before being turned, he does not grimace or pull his arms away

12. Pain Assessment tools in Dementia
There are a number of tools that is recommended by the centre for Dementia care in Stirling University is
The Abbey Pain Scale (2004)

13. The Abbey pain scale for people with dementia who cannot verbalise
Give out hand out

14. Comparing Probability and Abbey Pain Scale
Alex, 77 year old man with advanced dementia. He had been in a care home for 2 years. Over this time he was very active. From early morning until early evening he would be found walking around at home. He was thin, but are well and rarely presented ‘problem’ behaviours. He had only confused words that rarely made sense. One morning the nurse noted that Alex was still in bed. He was not interested in moving from a flat position to an upright position. If the nurse attempted to raise him to a sitting position he would pull away. His temperature was slightly elevated and his pulse was 110/min.
What observations would you make?
How probable is it that Alex has pain ?
How would you increase the probability that you diagnosis is correct? Use the Abbey Pain Scale
More professional discussion with GP = Help prescribing the right analgesia.

15. Other important symptoms which impact on pain
Urinary and faecal issues
Continence
Constipation
Anorexia
Breathlessness
Insomnia

16. Treatment and Analgesia
Comfort and environment
Distraction and social contact
The ANALGESIC ladder
Opioids in dementia
Consider alternatives to oral route
Pyschotropic drugs – review for pain.

17. Conclusions Pain and other symptoms are underestimated in Dementia
Frequent non verbal assessment and reassessment
Prescribe appropriate medications
Carer training