A Pain in the --well, Somewhere!!
Why is pain underreported and undertreated in dementia clients? Do those with dementia feel pain differently and cannot express it? Is there a relationship between the prevalence of apathy and the verbal expression of pain? The inability (or lack of desire to) communicate pain in moderate-severe dementia is detrimental to treatment, and under-treatment of pain has been associated with increased disability, withdrawal, sleep disturbance, and depression in such clients (Ferrell, Ferrell & Rivera, 1995).
Since pain appears to be experienced differently and may not be reported verbally, The American Geriatric Society (latest update 2009) has published recommendations for assessing pain in dementia. The main categories for assessment of persistent pain in elderly patients with dementia are:
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Facial expressions – sad, grimacing, closed eyes, rapid blinking, slight frown or frightened face
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Verbalizations and vocalizations – sighing, moaning, asking for help, calling out, grunting, noisy breathing, verbally abusive
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Body movements – rigid or tense posture, fidgeting, gait or mobility changes, increased rocking or pacing
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Changes in interpersonal interactions – aggressive, combative, resisting care, decreased social interactions, withdrawn, socially inappropriate
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Changes in activity patterns or routines – refusing food or appetite changes, sleep or rest changes, increased wandering
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Mental status changes – crying or tears, increased confusion, irritability, or distress.
Pain has an autonomic component that can provide other clues to its presence. External signs can include pallor, perspiration, increased heart rate/blood pressure, vomiting, diarrhea, incontinence, urgency, and digestive reactions. Although these responses may be blunted in AD, they can still provide valuable information for determining that pain exists when a patient’s self-report is lacking (Gonzalez, 2015). Regardless of how pain is manifested in dementia, we cannot assume it does not exist. We owe it to our family members, clients, and friends with dementia to pursue the quest to discover if they are experiencing pain and to treat it to the best of our ability.
​Sources:
American Geriatric Society. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc, 2009;57:1331-46.
Ferrell BA, Ferrell B, & Rivera L. Pain in cognitively impaired nursing home patients, Journal of Pain and Symptom Management, 1995;10(8):591-598.
Gonzalez LCA. The neurologist facing pain in dementia. Neuralgia, 2015;30:574-585.