Pain is a personal and
subjective experience, which could be disabling both physically and
psychologically. Untreated pain could have major implications on the health,
functioning and quality of life of an older adult. Most often the older adults
suffer from multiple medical conditions, consequently could have multiple types
and sources of pain. Although it is highly prevalent, evidence suggests that
pain is often poorly assessed and poorly managed, especially in older adults
and particularly in those with cognitive impairment due to dementia and/or delirium.
The assessment and treatment of pain in persons with cognitive
unique challenges, one of them being that they are unable
to communicate clearly about their level of pain and discomfort. Research has
shown that pain is often under recognized and under treated in people with
dementia mainly because they are less likely to ask for and receive analgesics.
Due to the complexity of the problem in elderly people
with cognitive impairment, it is very challenging to conduct randomized
controlled trials in these patients, leading to an overall lack of high quality
evidence base for this group of population. However, there is no dearth of
expert opinions in this matter, which in fact could be considered as a useful
database for clinical practice.
The aim of
the study recently published in BMC Geriatrics
was to collect
information and expert opinion on management of pain in hospitalized older
people who were cognitively impaired. Many Consultant Geriatricians/Dementia
Leads listed in the National Dementia
Audit were contacted electronically. They were provided with a questionnaire
with case scenarios to try and see the different pain management strategies
Of the 88
individuals who were successfully contacted, 37 responses were finally included
in the analysis. Nearly 85% of individuals rated themselves as 7 or above when
asked to rate their confidence level in managing each case on a scale of 1 to
10 where 1 = Not confident and 10 =
Use of analgesic
- There was a general consensus that paracetamol, whether used
orally or intravenously should be the first line of treatment since its
efficacy profile is well established, its side effects are minimal and it
has no effect on cognition.
- Respondents stressed the need for weighing the side effects of
opiates like delirium before prescribing them.
- It was also seen that weak opiates such as co-codamol, codeine
and dihydrocodeine were not a preferred choice mainly due to their
unwanted side effects on cognitive and bowel function; opioid drugs are
commonly associated with constipation.
- Tramadol was also not a drug of choice for the elderly due to
its potential to precipitate delirium.
- Nearly 91% of respondents suggested using morphine sulphate
after checking the patient's renal function.
- Nearly 77% used oxycodone due to a favorable side effect
profile when compared to morphine.
- 80% of respondents agreed that nefopam should be avoided mainly
due to its anticholinergic properties with significant risk of delirium.
- Most respondents advised against the use of oral NSAIDs in
patients with cognitive impairment. They could be used for short periods
along with anti-ulcer medications or for local use.
- Most respondents either avoided amitriptyline or advised use
with extreme caution. Amitriptyline is effective in neuropathic pain but
can worsen delirium. Pregabalin and gabapentin can also worsen sedation
There was a general awareness that since all pain
medications have potential side effects, it was important to review and monitor
patients and possibly co-prescribe medications to minimize these side effects
e.g., gastric protection during NSAID use.
Whereas most of the respondents agreed that assessment and re-assessment of pain was crucial, about one third of
respondents used clinical assessment alone. Others used established pain
assessment tools such as ABBEY, PAINAID etc.
Strengths of the
- Respondents participated willingly without any pressure being
put on them.
- The response rate to the questionnaire was 48% and most of
respondents were quite confident in the management of different pain
- Results were analyzed using mixed method approach.
Limitations of the
- Results are based on expert opinion and there is evidence gap
in the management of pain
- The total number of respondents is small even though the
response rate is good.
The study revealed lack of consensus regarding
management of pain in cognitively impaired hospitalized older
people, which just highlight the complexity of this clinical field. Patients should be comprehensively assessed
and analgesics should be selected with the aim of minimizing side effects.