1. Pain Management for People with Dementia
Emma Hall

2. Acknowledgments
Thank you to Dr Pace for use of his slides

3. Guidance 1.Assessment of pain in older people RCP/BGS/BPS 2007
2. Guidance on recognition, assessment, management of pain in people who have dementia 2014 Rasmussen et al

4. What is pain? “Pain is what a patient says hurts”
Usually a sign of tissue damage – but chronic pain is not.
What about patients who cannot say what their pain is?

5. The pain experience What you know, believe, remember
or think about
the pain:
cognition
Your emotional state:
happy, depressed, secure,
exhausted…
The pain sensation
itself

6. These are things we can work on – it’s not just down to medication!
Reduces pain
Information
Being rested
Good mood
Company
Distraction
These are things
we can work on
– it’s not
just down to
medication!
Depression
Isolation
Boredom
Increases pain
Fear
Lack of sleep

7. Why do frail elderly people get pain? Write down some causes?

8. Why do frail elderly people get pain?
Arthritis
Post herpetic neuralgia
Trigeminal neuralgia
Post stroke – central or spasticity
Degenerative spinal disease
Pressure ulcers
Diabetes complications
Constipation
Urine symptoms
Peripheral vascular disease
Muscle aches and
pains
Falls
Fractures
Cancer

9. Pain in people with dementia
Most people with dementia probably can tolerate more pain than people with no dementia.
But they get so little treatment for it that they end up suffering more pain than other patients.
WHY?

10. Pain in people with dementia
Difficult to identify
They cannot tell us
when they are in pain
We have to go to them
if they are not mobile
They cannot describe the
pain to us.
Their faces may become
less expressive
Is it pain or something else ?

11. Do people with dementia experience less pain
Probably not- although dementia may damage some of pain perception pathways

12. Is it a common problem?
Australian study of NH residents: range of 28% - 86% experienced chronic pain
Prevalence of pain >60yo = 250 per 1000
Prevalence of pain <60 = 125 per 1000

13. Type of pain
More likely to have incident pain- pain on turning, wound dressings etc
What are the implications of this?

14. How do I know someone is in pain?
Facial gestures
Behaviour
KNOW YOUR PATIENT!

15. Behaviours suggestive of distress
Agitation, fidgeting
Repetitive movements
Tense muscles
Body bracing
Increased calling out
Not eating
Repetitive verbalisations
Decreased cognition
Decreased function
Withdrawal
Changes in sleep pattern
If you see these behaviours, can you tell
that someone is in pain?

16. Assessment Point to painful area Use of body maps
Mild impairment- use same intensity scales

17. Assessment-examples of tools
Doloplus
PAINAD
Abbey

18. What can you do without using medication?
Reposition
Exercise
Massage
Local warmth (NOT heat!)
Comfortable dressings
TENS machines
If you can find out why someone is in pain, you will be able to figure out ways to reduce pain.

19. The secrets of pain control with medication
Give early on
Give regularly if pain frequent
Give by mouth
Check soon after: was it enough?

20. Drugs-challenges Consent , best interests, covert administration etc
Differences in metabolism
Low body weight
Kidney and cardiac function commonly poor and affects which drugs/doses can be used
Multiple other drugs (are they all needed)-interactions
Difficulty swallowing
Patches ( good if pain always there-not so good if incident)
Start lowest possible dose and monitor
Match type and duration pain with painkiller eg short acting opioids

21. Medication Match the pain( type and how often) with painkillers eg:
If pain only on movt./dressing changes then prn eg paracetamol or short acting opioid
Consider topical agents eg wounds diamorphine in intrasite gel, local anesthetic preparations etc

22. Drugs for pain Paracetamol (Panadol) Good for many mild pains
2 tablets every 4-6 hours
Maximum (usually) 8 a day
CAUTION: extreme low body weight,severe liver disease
Tablets, capsule, soluble, suppository ( IV- not sc)
DO NOT EXCEED MAXIMUM DOSE!
If not strong enough at full dose, step to a stronger pain killer eg codeine, tramadol.

23. Weak opioids Codeine, tramadol, cocodamol etc
If paracetamol has failed, give
Dihydrocodeine 30mg 4 hourly (max 8/day)
Tramadol mg 4 hourly – up to 400mg/day
Co-codamol 30/500 (8/500 tablets are too weak) 2 tablets 4-hourly (max 8 a day)
All are constipating – often need to give laxative
eg Docusate + Senna, ensure prn anti-emetic

24. Opioids
Patches- buprenorphine:advantage re adherence unreliable swallow etc
Morphine, oxycodone, fentanyl, tramadol etc
Morphine still 1st choice in most patients
Starting dose 5-10mg 4-hourly (unless opioid naïve)
Constipates: give laxatives eg Docusate + Senna.
Nausea- usual is haloperidol 0.5mg od (note this is “off-label”- avoid in Parkinsons)

25. Myths about morphine Worries about opioids
Kidney or liver function deteriorates
May cause drowsiness, delirium
Long term side effects

26. Special kinds of pain Neuropathic pain: nerve damage Muscular pain
Skin pain
Colic
These pains may not respond to usual painkillers. May need specialist advice.

27. When should I call for help?
If pain severe and cannot be controlled.
If normal painkillers are giving major side effects
If unusual pain
If very drowsy or keeps being sick with morphine
If becomes very jerky after painkillers are started

29. Case What did we do? Regular paracetamol was not enough
Regular morphine 10mg every four hours
Change to syringe driver when dying.
Started to eat and interact again, did not behave as
if in pain any more.

30. Summary
Assessment is key – Doloplus/ behaviour chart pre and post pain intervention
Therapeutic trial-tailored to type of pain
Feel able to call for advice

31. Thank you. Questions? Q Any questions?