As people grow old, they are highly likely to develop conditions which predispose them to intermittent acute pain or importunate pain states. In reference to Cunningham et al. (2010) the impact of dementia on processing of pain is different in different types of pain and the stage of dementia. Cunningham et al. (2010) conclude that there is a high possibility of under-detection of pain among individuals with dementia more so to those who have limited verbal communication. The assessment of cognitive status of individuals with dementia is critical in determining the pain assessment to use. The paper intends to illustrate the most effective pain management strategy for older adults with dementia. It re-examines how people suffering from dementia experience and communicates pain and also describes the principles of assessment and management of pain among individuals with dementia.
According to Cunningham et al. (2010) definition of pain is an unpleasant and subjective experience. In the common language pain is defined as an emotional reaction to stimuli causing distress to a person’s body or mind. In keeping with Anderson (2010) pain is a repulsive sensory and emotional experience that is associated with tissue damage. The experience of pain Anderson (2010) explains has three levels; Sensory- this is the discriminative component; Motivational – emotional responses - the affective component; Cognitive – meaning and implications - evaluative
Pain experience among people with dementia
There are several factors influencing the experience of pain and response to pain among people with dementia (Gary & Marwan, 2010). Importantly, knowing the cause of dementia is crucial. It is also critical to understand that changes in a person’s brain caused by Alzheimer’s ailment are dissimilar to those of vascular dementia, frontotemporal dementia or even Lewy body disease (Gary & Marwan, 2010). As dementia progress, Anderson (2010) indicates that the ability to respond to pain become increasingly impaired and most often in advanced dementia the level at which ones sensation is recognized with the increase of pain. Anderson (2010) notes that where language in impaired in dementia, it is extremely hard to know what an individual is experiencing and it becomes important to observe a person’s behavior o t body language.
There are several ways in which people communicate their pain. For instant they can give verbal information in regard to their pain experience or even communicate deliberately or inadvertently through body language. In keeping with Cunningham et al. (2010) the neuroendocrine system is associated with clearly acute pain and is usually observable in assessment of patient’s pain. Notably, the manner in which ant particular individual reports their pain is influenced by their personality and earlier experience as well as their culture. Cunningham et al. (2010) indicates that recognizing distress associated with pain is particularly hard in people who cannot communicate. Cunningham et al. (2010) further indicates that distress may be marked by silence, restlessness, reduction of activity, subtle cues or aggression which is idiosyncratic to an individual although potentially open to interpretation is a longstanding carer is conferred with. Cunningham et al. (2010) argues that if such behavior is attributed to dementia, then a person pain is at risk of being disregarded.
Assessment of pain among people with dementia involves collecting information through asking questions on the subject of symptoms (Shah, 2007). In cases where dementia is mild and moderate and where language is not hideously impaired a person can answer questions in regard to pain and discomfort. However it is critical to understand that just because a person can effectively use language it does no t mean that they have full comprehension on what is being said or that they c an convert their feeling into correct words or to communicate them effectively. In reference to Yap and Goh (2008) a clinician should attempt to verify verbal information from the patient observation and by recurring assessment. Verbal reports according to Cunningham et al. (2010) are valid as those in individuals in same age and with normal cognition. In such case, UCSF Medical Center (2009) indicates that it is possible to believe such information. Arguably, pain is a subjective experience and therefore clinicians must therefore depend on verbal and behavioral information as provident the patient regardless of whether the patient has normal cognition (UCSF Medical Center, 2009). It is essential that the carer assess pain to allow older persons who has cognitive impairment as the time to react to the question and ensure the questions are well understood.
Using Pain scales to Assess Pain
In accordance to Ory et al. (2005) the other way of assessing pain is through using pain scale. Ory et al. (2005) states that assorted visual analogue scales can be used for assessment of pain in people with dementia; as such, most of these people can complete one type of scale and the verbal descriptor scale falls in this category. In keeping with Cunningham et al. (2010), pain scale help in measuring the greatness of pain that is reliant of tangential pain system. Cunningham et al. (2010) further states that the scale can be administered either verbally or through patient and may be asked to place a mark on a calibrated scale. Nonetheless, elderly persons with dementia have difficulty in management of visual analogue scale due to visual impairment including manual dexterity. According to American Geriatrics Society (2002) observed indication of reliability of the observations that caregivers use to diagnose pain among the patient in advanced stages of dementia or poor language skills. AGS (2002) also states that there are six different areas that are observed and recorded while diagnosing pain in such circumstances. The observations of various scales are included in different tools that are available for assessing pain among patients with poor language. Some tools can be used in a busy setting while there are others that are very burdensome and that can be used for research purposes. Some of the observable areas include; facial expression, body language, changes identified in interpersonal interaction, negative vocalization, change in pattern of activities, and change in mental status i.e. increased depression or irritability.
Two tools used to address several areas that have been recommended by the AGS include assessment of discomfort in dementia and abbey pain scale (UCSF Medical Center, 2009). The Abbey pain scale according to UCSF Medical Center (2009) has a section that gives the nurses a particular pathway that should be followed while in the process of pain assessment. The pathway is based on the idea that the observable features in some types of distress and nurses are bound to detect causes of distress and make diagnosis of pain. Cunningham et al. (2010) indicates that as dementia advance, the ability of an individual to comprehend the concept involved while reporting pain intensity becomes impaired gradually and ultimately disappear. The ability to communicate pain verbally is impaired as language skills worsen. However, his does not marks the end of pain in a person suffering from dementia. In fact, articulation of pain calls for other ways of pain evaluation. Arguably, non-communicative patient’s pain assessment instrument (NOPPAIN) is introduced. This method has been introduced and uses six behaviors that are related to pain i.e. pain words, pain faces, pain noises, bracing, rubbing, and restlessness. NOPPAIN, according to Cunningham et al. (2010) is easy to administer by nursing staff to non-communicative persons who have mild or moderate dementia. Five steps of pain assessment in people with dementia include;
- Physical assessment- this is to establish physical causes of discomfort.
- Biographical history that help in identification of old injuries or throbbing conditions.
- If the above signs are negative and a person continues to express signs of pain it is advisable to use non-pharmacological interventions like massage, repositioning and cold/hot compresses.
- If the above is ineffective, then the nurse should try to recommend non-opioid analgesic and monitor for counteractive response.
- If even the above is unsuccessful, the nurse must seek an increase in the analgesic and administer a multidisciplinary review.
While assessing tools that are based on observation of behavioral indicators for use to non-verbal people with dementia Alagiakrishnan (2010) included all tools that are in the early stages of development. Alagiakrishnan (2010) have not come up with any standardized tool for non-verbal assessment and pain management among people with dementia who can not communicate. However, they have come up with a comprehensive approach to pain management and assessment.
- Anticipation and assumption of existence of pain from the pathology resulting from the damage, disease, procedure or surgery.
- Observation of a person’s behavior that set up a baseline for consequent behaviors. Regular monitoring for pain through a comprehensive list of pain-related behaviors like NOPPAIN. This should be done during activities since behaviors that occur at rest can be misleading.
- Observing for less noticeable indicators of pain, like agitation, increased pacing and aggression.
In case of uncertainty on the presence of pain, an analgesic can be administered and it should evaluate its presence. In case the intervention appears to relief the patient, pain can then be assumed o be a probable cause of the behavior. Use of transdermal patches may help to remove distress to persons with dementia.
Conclusively, Probability and predictability should assist in informing the assessing process and consequent treatment plan. In keeping with Alagiakrishnan (2010) there are specific times where care interventions can be used as an indicator of necessity to treat pain. It is important to address procedural pain that occur while dressing would or moving a painful limb in the cause of treatment.
Alagiakrishnan, K. 2010. Vascular Dementia. Viewed March 12, 2012 from
http://emedicine.medscape.com/article/292105-overviewAnderson, S.H. 2010. Mild Cognitive Impairment. Viewed March 13, 2012 from
Cunningham C, McClean W, Kelly F (2010). The assessment and management of pain in people with dementia in care homes. Nursing Older People. 22, 7, 29-35. Date of acceptance: June 30 2010.
Gary, A. & Marwan, N.S. 2010. Palliative Care for Advanced Alzheimer's and Dementia:
Guidelines. London: Springer Publishing Company.
National Institute on Aging. 2010. Viewed March 13, 2012 from
Ory, J. Yee, L., Tennstedt, R. & Schulz, K (2005) The Extent and Impact of Dementia care:
Unique Challenges Experienced by Family Caregivers. NJ: Sage Publishers.
Shah, A. 2007. Depression in cares of patients with dementia. Viewed March 12, 2012 from
http://www.priory.com/psych/carerdep.htm at 11 March 2012.UCSF Medical Center. 2009. Vascular Dementia. Viewed March 11, 2012 from
Yap. L, Goh, Y. 2008. Family Caregivers and Care giving in Dementia. Viewed March 13, 2012