Paediatric considerations
Elderly considerations
Neurocognitive (dementia) considerations
Epidemiology
60-80% of people with dementia regularly experience pain
1 in 3 have moderate to severe pain
Nociceptive is the most common type (70%)
Types of chronic pain are different in the elderly e.g orofacial pain due to poor oral health
Identifying/testing for pain
Pain is usually signaled by verbal communication - this is more difficult in dementia due to cognitive and communicative limitations
Tools:
Self-report
Asked in interviews or standardised forms in pain scales
Generally with MMSE <18 cannot reliably report pain
Visual analogue scale may be beyond the understanding of dementia patients
Numerical scales, or simply 'yes' or 'no' can be useful
Observer ratings
Necessary in moderate to severe dementia
Three behavioural demains to observe - Facial response, vocalisation, and body posture/movement
Interobserver rating scale variability leads to unproven reliability and low validity
However, simply TRYING to use a scale leads to improved recognition in nursing homes
Pain Assessment in Impaired Cognition (PAIC-15) - awaits testing
Assessing psychological comorbidities is even harder!
Automatic pain recognition
Often video based and target facial responses to pain
However machine learning is often on younger individuals which skews the results
Negative outcomes of pain
Chronic pain leads to increased levels of memory decline
Worse pain can lead to worse behavioral symptoms
Pain consequences are more severe in the elderly due to lower functional independence and increased social isolation
Implementation
Comprehensive treatment plan creation with a focus on interdisciplinary approaches and multimodal pain management plans
Non-pharmacological management options
Most research is in cognitively intact adults - as those with cognitive impairment are often excluded from trials
Exercise is 'assumed' to be beneficial for pain in individuals with dementia
This needs to be tailored to the individual of course
Psychological is likely to be difficult in moderate to severe dementia due to inability for cognitive processing required for therapies such as CBT, mindfulness etc.
Music therapy has evidence in the treatment of the behavioral and psychological symptoms of dementia (BPSD). It may assist with pain but there is a lack of evidence
Other considerations include: Massage, heat therapy, rocking chair therapy, rest, reiki
Pharmacological
Analgesic use in nursing homes is increasing world-wide
Paracetamol
For mild/moderate pain in advanced dementia
NSAIDs
SHOULD BE AVOIDED
Opioids
Buprenorphine is popular as can be given via patch. Side effects include the normal's but specifically in dementia - Personality change, confusion, sedation, somnolence
There are only studies on morphine and oxycodone - and these are limited
Adjuvants
No clinical trials on their safety. Likely to be risky due to significant psychotropic risk
Ref: Achterberg, Wilcoa,*; Lautenbacher, Stefanb; Husebo, Bettinac; Erdal, Anec; Herr, Keelad Pain in dementia, PAIN Reports: January/February 2020 - Volume 5 - Issue 1 - p e803
Males vs females
ATSIH patients
Important to ask about whether they identify as indigenous
Clear and respectful identification of roles
Confidentiality needs to be assured
Respectful discussion includes consideration of cultural values
Conversational or ‘yarning’ style of consult with open questions may be best
Recognise and use Aboriginal providers and supports
Person centred, or even family centred approaches are best
Registration forms and questionnaires may be viewed with mistrust given a general cultural divide of respect between government and ATSI peoples
understand impact of cultural days and events e.g. sorry periods
Flexible approach to appointment times is important
Consider both general and health literacy
Aim to have multiple contact numbers
Consider affordability and socio-economic disadvantage
Cultural, historical, and spiritual factors need to be considered
Gender comfort may impact consult and needs to be asked about
There may be reluctance to express pain due to shame concerns
Pregnancy
References:
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