Managing chronic pain in patients with dementia

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By Micha Shalevshalev_hs

Chronic pain affects 1.5 billion people worldwide, an estimated 100 million of whom live in the United States. Yet we currently have no effective treatment options. Fortunately, research advances have determined some of the ways in which chronic pain changes the brain, and several promising research areas could lead to better treatment approaches.

Chronic pain is a frequent health problem in the elderly and is not part of the normal aging process. The prevalence levels range between 45 percent and 80 percent in line with an age-related increase in patient comorbidity (medical conditions that present simultaneously in a patient).  Chronic pain is usually defined as lasting at least three months or persists after an injury has fully healed. Research has highlighted the association of chronic pain in the elderly to loss of independence, poor diet and social isolation. Importantly as with many disease processes, chronic pain and the subsequent way it affects one’s life, is not evenly distributed throughout the population. Females and patients from a lower socioeconomic status have been shown to report more chronic pain.

Assessing pain accurately and communicating it to the healthcare team is clearly the keystone for effective management of pain. However, there are significant obstacles to doing this accurately in patients with cognitive impairment. These obstacles, particularly language deficits, make it difficult for the patient to convey the pain they are feeling. In addition, challenging patient behavior, which is often a result of pain, can make a physical assessment difficult. In line with the fact that many elderly patients suffer from persistent pain, a methodical approach must be taken with patients with underlying cognitive impairment to avoid under-treating a patient for pain syndromes.

Evaluating pain is best done in two distinct parts:

  1. Is the patient experiencing pain? There are a wide range of validated pain assessment tools that can aid healthcare professionals, caregivers and families in making decisions about a patient’s pain management. The selected assessment tool can vary between regions and certainly varies between countries. It is important for healthcare professionals to become familiar and competent with the locally-approved pain assessment tools.
  2. Evaluate the nature of pain syndrome. In simplistic terms there are four chronic pain syndromes that are important to differentiate due to variation in subsequent management. First, the most common syndrome in the general population is pain due to excess of nociceptive (painful or injurious) stimuli. Second, neuropathic pain is an intensively painful syndrome brought about by nerve injury or dysfunction of nerve pathways. Differentiating between neuropathic and nociceptive pain syndromes has important implications for diagnostic and treatment decisions. Third, chronic pain syndrome (or dysfunctional pain syndrome) is a constellation of syndromes that do not respond adequately to medical care. Finally, in a hospital setting it is common for patients to present with mixed pain syndrome. The classic example is a patient with cancer, who, due to the nature of the disease, can experience a number of different forms of pain

Approaching chronic pain as a national emergency would allow for a better future in terms of both treatments for chronic pain, costs to society, and individual well-being. It is time to take an honest look at where we are, get rid of unnecessary and unproven treatments, and advance neuroscience to the patient in the form of better treatments. Pain neuroscience has never been so exciting or well-positioned in terms of the potential it offers to change the current impasse. But it will take bold decisions to put into place a vision and plan of action.

Micha Shalev MHA CDP CDCM CADDCT is the owner of Dodge Park Rest Home and The Adult Day Club at Dodge Park, 101 Randolph Road, Worcester, as well as the new state-of-the-art Oasis at Dodge Park. He is a graduate of the National Council of Certified Dementia Practitioners program, and well-known speaker covering Alzheimer’s and Dementia training topics. The programs at Dodge Park Rest Home specialize in providing care for individuals with dementia and Alzheimer’s disease. The facility holds a FREE monthly support group meeting on the second Tuesday of each month for spouses and children of individuals with dementia and/or Alzheimer’s disease.

Shalev can be reached at 508-853-8180 or by e-mail at [email protected]. For more information, visit www.dodgepark.com. Archives of articles from previous issues can be read at www.fiftyplusadvocate.com.