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Alzheimer's Disease & Dementia Message Board

Alzheimer's Disease & Dementia Board Index

[B]Definition of Pain[/B]
• Pain is whatever the experiencing person says it is, existing whenever he says it does” by: Margo McCaffery (Pain: Clinical Manual 2nd Edition, St Louis, Mosby 1999)
• This definition highlights the fact that pain is highly subjective and that the patient’s self report and description of pain are very important to understanding the pain experience.

[B]Prevalence of Pain in the Elderly[/B]
• The high prevalence of pain is primarily related to the increased rate of chronic health disorders of older persons; such as arthritis and peripheral vascular disease.
• There is also a greater prevalence of acute conditions, such as cancer and cardiovascular disease.

[B]Implications of Pain on the Elderly[/B]
Chronic pain can have deleterious effects on the physical functional and mental health of elderly adults. For example:
• Depression & withdrawal
• Sleep disturbances
• Impaired mobility
• Decreased activity engagement
• Gait disturbances & falls
• Deconditioning (lack of use of muscles etc)
• Malnutrition
• Increased health care use
• Delayed rehabilitation

[B]Characteristics of Dementia[/B]
• Dementia is a syndrome; there are many types
• Dementia atrophies cortical and sub-cortical areas of the brain
• Neurotransmitters depleted
• Progressive deterioration
• Dementia is characterised by memory loss, loss of judgement, language and communication deficits, confusion, withdrawal, and loss of ability for independent personal care.
[I]NOTE: Alz: Brain shrinkage in itself & special. Depression & confusion are tantamount in dementia patients.[/I]

[B]Effects of Dementia on Pain[/B]
• The destruction of cortical neuronal cells and depletion of neuronal neurotransmitters do not affect the transmission of pain sensations.
• Studies by Benedetti et al (1999) and Bachino & Snow et al (2001) indicate that cognitively impaired elders are no less sensitive to pain (pain threshold), but that they may fail to interpret the sensations as painful (pain tolerance)
[I]NOTE: Pain is still pain – outward expression is different, tolerance is higher. Watch for behaviour. Just because they can’t verbalise doesn’t mean it’s not real or there. Odd behaviour could be pain related, not disorder related.[/I]

[B]Signs of Pain in an Elder with Dementia[/B]
• Restlessness or agitation
• Aggression
• Resistance to care, combativeness
• Increased confusion
• Decreased mobility
• Crying
• Facial grimacing
• Moaning during care activities
• Altered respirations (rate & depth)
[I]NOTE: Odd behaviour could be pain. Don’t write them off just because they have dementia. Violence is higher in patients with pain # constipation # arthritis etc[/I]

[B]Assessment of Pain in Elders with Dementia[/B]
• Relies on communication between the Elder, multi-disciplinary health care providers and family members of the Elder.
• Inclusion of verbal self-reports of pain and non-verbal behaviours
• Comprehensive assessment
• Timing of assessment
• Reporting Assessment findings
• Documentation
• Evaluation
[I]NOTE: Check overall ’wellness’ during regular ob’s. Report discrepancies, confer with others. Believe the patient!! Check “wellness” during physical activity.[/I]

[B]Assessment Tools[/B]
• IN the early stages of dementia, an Elder may still be able to reliably report pain. As the dementia progresses, however, this ability to self-report pain will diminish.
• Pain assessment tools for Elders with Dementia need to be meaningful, effective, reliable, require minimal time for training and minimal time for completion
• Examples: Abbey Pain Scale and Pain-Aide Scale

[B]Pain Management Strategies[/B]
• The main goal is to maximise function & quality of life for the Elder.
• Pain treatment strategies that use a multi-dimensional approach
• Individualised to the Elder’s needs are the most effective
• A combination of pharmacological & non-pharmacological strategies should be used to relieve pain

[B]Pharmacological Strategies[/B]
• Pain treatment with medications is a complex decision-making process between the Elder, family & health care provider.
• Discussion, implementation, evaluation and documentation of medication usage.
• Balance of medication effectiveness and management of poly-pharmacy and side-effects.
• Frequency of use, type of pain, duration of treatment, and cost
• Start low .. GO SLOW !!
[I]NOTE: Too many med’s can cause adverse reactions and symptoms. CHECK![/I]

[B]Non-Pharmacological Strategies[/B]
• Physical relief strategies are interventions such as repositioning to promote comfort & skin breakdown, use of heat & cold, massage and mild exercise.
• Cognitive-behaviour approaches change the Elder’s perception of pain & improve coping strategies; such as relaxation, distraction, guided imagery, hypnosis, & prayer.

[I]NOTE: Classical music as background for listening/singing. Diversional therapy. Massage therapy , face, feet if tolerated. Aromatherapy.[/I]

[B]Barriers to Effective Pain Management[/B]
• Myths
• Labelling
• Fear
• Sensory deficits
• Family Judgements
• Perceived time restraints

[B]Future Considerations[/B]
• An important emerging concept is that Dementia is not a singular entity with regards to pain – different types of dementia are associated with distinct changes in pain perception, and therefore, may require differing pain management strategies.
• Further research into effective pain assessment and development of appropriate tools.

[I]NOTE: Frontal Temporal Lobe – No Awareness
.............Vascular – Pain perception[/I]

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