Pain Management for Patients With Late-Stage Dementia

People with dementia have often been excluded from medical studies focused on pain and pain management, but there is evidence that they experience frequent pain, which is often poorly assessed and under-treated. A new treatment plan (called a protocol) has been developed for assessing and appropriately treating pain in patients with late-stage dementia, who typically have difficulty communicating verbally.

Medical College of Wisconsin researcher David E. Weissman, MD, Professor of Medicine, and his colleagues, Julie Griffie, RN, MSN, CS, AOC, Nurse Specialist, and Sandy Muchka, RN, MS, OCN, Nurse Specialist, helped develop and test the Assessment of Discomfort in Dementia (ADD) Protocol at Wisconsin nursing homes. The research was part of a larger education project to improve pain management practices. The research was led by Christine R. Kovach, PhD, RN, of Marquette University in Milwaukee, and also included Sandy Matson, RN, C, MA, of the Lakeland Nursing Home in Elkhorn, Wisconsin.

The ADD program is designed to help physicians and caregivers:

• More accurately assess discomfort in people with dementia who can no longer verbally describe physical pain or emotional discomfort
• More accurately and thoroughly treat physical pain or emotional discomfort
• Decrease the inappropriate use of psychotropic medication, such as tranquilizers

Common signs displayed by people with late-stage dementia who experience physical or emotional discomfort include: increased agitation, fidgeting, or repetitive movements; tense muscles, body bracing; increased calling out or repetitive verbalizations; decreased cognition, decreased functional ability or withdrawal; changes in sleep pattern; falling; increase in pulse, blood pressure, and sweating. A good deal of emotional discomfort in dementia patients comes from difficulty sorting out and negotiating everyday life activities.

The ADD Protocol

1. Physical causes for discomfort such as inflammation, infection, acute illness, chronic conditions, etc. were assessed first.
2. As part of the physical assessment, the patient's history was explored, including consultation with the patient's family regarding potential causes of pain.
3. If the physical assessment was negative and there was no apparent reason for discomfort, then nonpharmacological (non-drug) comfort interventions were used. These included soothing and supportive verbal communication, soothing and supportive touch, physical exercise and movement, and sensory stimulation including music therapy and therapeutic massage.
4. If the nonpharmacological interventions were unsuccessful in relieving the patient's discomfort, then the staff administered a non-narcotic analgesic, such as 500 milligrams of acetaminophen (e.g. Tylenol).
5. If there was not a response to trying an "as needed" analgesic, then a stronger analgesic or, sometimes, a psychotropic drug was prescribed.

Nurses at 32 facilities underwent training and implemented the ADD Protocol in their treatment of a total of 104 patients, whose ages ranged from 46 to 100 years. The protocol was followed when a patient displayed signs of possible discomfort.

Results
Results of the study indicate that the stages of assessment and treatment set forth in the ADD protocol did help to reduce the frequency of discomfort symptoms expressed by the patients. In the 7 days before the study, the patients displayed an average of 32.85 behavioral symptoms associated with discomfort. In the period following use of the ADD protocol, this was reduced to 23.47 behaviors -- a statistically significant improvement.

The protocol was associated with an increase in the use of scheduled analgesics and in the use of nonpharmacological comfort interventions, especially music therapy and therapeutic massage. However, use of the protocol was not associated with changes in use of "as needed" analgesics or in the administration of "as needed" or scheduled psychotropics. Psychotropic drugs can mask signs of physical pain and thus may contribute to undertreatment of pain.

The nurses who participated in the program were surveyed, and according to questionnaires 44% of them felt that the protocol was somewhat helpful in aiding patients, and 44% felt that it was very helpful.

The results of this pilot project demonstrate that the needs of this group can be recognized and treated. But the authors of the study stress that further improvement in palliative care services are needed for the silent but growing population of people with late stage dementia.

The report of the research was published in the December 1999 issue of the Journal of Pain and Symptom Management.

For more information on this topic, see the HealthLink article End-Stage Alzheimer’s - the Long Goodbye.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.