1. End-of-Life Care and Dementia
Assessing and
Managing Symptoms

2. Symptom Management Challenges Multifactorial causes Communication
Impact of dementia
Impact of pain & other symptoms causing further decline
Impact – chronic pain can cause cognitive decline (McCracken, Iverson 2001), forgetfulness, Falls,
Dementia impact – decline creates symptoms but also adds to struggle to manage symptoms

3. Common Symptoms in Dementia
Pain
Breathlessness
Fever
Appetite/Feeding Problems
Delirium
Constipation
Loss of peripheral Vision
Depression
Anxiety
Incontinence
Pressure Ulcers
Nausea/vomiting
Thrush
Sialorrhoea

4. Lack of Education and Assessment
Recognition of Pain
It has been well documented that patients with dementia experience pain but this is poorly managed
One study revealed in the last 6 months of life 75% of people with dementia were found to have unrelieved pain
(Mitchell et al, 2004) (Kunz et al 2007) (Thune-Boyle 2010) (Husebo et al 2011)
Inadequate symptom management of pain could be due to a number of factors
Lack of Education and Assessment
Fear of adverse effects resulting in under-dosing
Shipman Effect

5. Causes of Pain
Co morbidities
Cancer
Osteoarthritis
Cardiac/Angina
Chronic pain conditions
Falls/Fractures
Pressure sores
Constipation

6. Issues for Dementia & Elderly
Pain Management:
Issues for Dementia & Elderly
Refusal of medications (paranoia)
Route – swallowing, refusal, confusion
Myths
Elderly dose considerations: metabolism, weight,
kidney / liver function, hydration
Polypharmacy & number of pills
Patches / Syringe Drivers
Myths: dementia pt’s don’t experience pain, opioids will aggravate behaviour, side effects unmanageable, family barriers, sedating will aggravate decline

7. Pain Assessment Tools
Verbal
NRS, VAS, FACES
Non Verbal
Abbey Pain Scale
NOPPAIN
DisDAT
PAINAD

15. Management of Pain
Criticism of Tools
(Herr et al 2010) (Zyczkowska et al 2007)
Person Centred Approach
Identify patients relationship with Distress

27. Relating to the case study
Assess the patient using the PAINAD tool
Liaise with Family and Carers
Discuss Joan’s normal response to distress
Using the WHO analgesic pain ladder recommend appropriate course of action to relieve distressing symptoms.
Consider other measures

28. References
Herr, K.A. and Mobily, P.R. (1996). Pain management for the elderly in alternate care. In: Ferrell, B.R. and Ferrell, B.A. eds. Pain in the Elderly. Seattle: IASP Press 101–9
Kerr, D., Cunningham, C. and Wilkinson, H. (2006) Responding to the Pain of People with a Learning
Disability and Dementia. Joseph Rowntree Foundation, York Publishing
Kerr, D., Cunningham, C. and Wilkinson, H. (2006). Learning disability and dementia: are we prepared? Journal of Dementia Care 14 (3): 17–19
Kunz, M., Scharmann, S., Hemmeter, U.,Schepelmann, K. and Lautenbacher, S. (2007).
The facial expression of pain in patients with dementia. Pain 133: 221–8
Zwakhalen, S.M.G., Hamers, J.P.H., Abu-Saad,H.H. and Berger, M.P.F. (2006) Pain in elderly
people with severe dementia: A systematic review of behavioural pain assessment tools.
BioMed Central Geriatrics 6: 3
Zyczkowska, J., Szczerbin´ska, K., Jantzi, M.R. and Hirdes, J.P. (2007). Pain among the oldest old in community and institutional settings, Pain 129:167–76