Event 2: Pain Assessment and Treatment

Pain Measurement

Mrs. Rose will often grimace or groan during exam or activities of daily living (ADL). When shown a pain diagram, she points to her mouth only, but is often seen rubbing her mid- and low-back and occasionally her left lower extremity.  She demonstrates a range of pain behaviors: 1) frowning, moaning, and rubbing her lower back while sitting; 2) propping against a wall with movement; 3) wincing and resisting ADLs, sometimes combatively; 4) restlessness when seated after ADLs. She also demonstrates disrupted sleep.  Ms. Rose seems to calm down when she sees her niece.

Pain Behavior Assessment

As noted above, Mrs. Rose’s CNPI score of 7 suggests clinically significant pain.  She also demonstrates pain behaviors that include:

Facial expression

Frowning, wincing

Verbalizations

Moaning, saying “Stop” repeatedly

Body movement

Limited movement, rubbing, bracing, restless after ADLs

Interpersonal Interactions

Occasionally combative during ADLs

Activity patterns

Frequent awakenings, low levels of activity

Mental status

Irritability during ADLs

Review of Systems

Secondary to her moderate dementia, it is difficult to interview Mrs. Rose for other symptoms.  There is no fever or chills, neurologic symptoms aside from DAT, and no evident shortness of breath.

Checklist of Nonverbal Pain Indicators (CNPI) for Mrs. Rose

Vocal Complaints: Nonverbal

(sighs, gasps, moans, groans, cries)

With Movement

0

At Rest

1

Facial Grimaces/Winces

(Furrowed brow, narrowed eyes, clenched teeth, tightened lips, jaw drop, distorted expressions)

With Movement

1

At Rest

1

Bracing

(Clutching or holding on to furniture, equipment, or affected area during movement)

With Movement

1

At Rest

0

Restlessness

(Constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still)

With Movement

0

At Rest

1

Rubbing

(Massaging affected area)

With Movement

0

At Rest

1

Vocal Complaints: Verbal

(Words expressing discomfort or pain [e.g., "ouch," "that hurts"]; cursing during movement; exclamations of protest [e.g., "stop," "that's enough"])

With Movement

1

At Rest

0

Subtotal Scores

With Movement

3

At Rest

4

Total Score

7

Pain Assessment in Advanced Dementia (PAINAD)

Total Score

6

Treatment of Persistent Pain in Older Adults

Treatment Plan for Mrs. Rose

Action 1

Rule out common medical causes of behavioral changes in older adults (e.g. urinary tract infection)

A review of Ms. Rose’s recent labs, vitals, and today’s urinalysis are not strongly suggestive of an infectious process.  Its important to note that oftentimes the most notable symptom of urinary tract infections (UTI) in patients with dementia is behavioral changes and worsening confusion.  Fever and urinary symptoms may not accompany the UTI.

Action 2

Rule out common causes of behavioral changes in older adults (e.g. psychosis)

In older adults with dementia, depression can present with somatic symptoms, and psychosis can contribute to agitation.  In a patient with communication difficulties, the nursing staff most familiar with the patient's behavior should be involved.  Positive scores on a psychiatric screening tool should trigger a consultation.  If the consultation results in a trial of a neuroleptic, careful monitoring of ambulation may be necessary to prevent falls.

Action 3

Initiate scheduled comfort measures (e.g. positioning, massage, relaxation therapy)

Comfort measures could involve nursing and/or physical therapy.  Heat or massage could be tried prior to assisted ADLs, as well as on a routine basis during the week.  Soothing music or another distraction could be used after assisted ADLs.  In any case, the comfort measures could be given a time-limited trial and their effectiveness assessed through the use of a systematic observation tool such as the CNPI.

Action 4

Trial of scheduled analgesic – acetaminophen 1000 mg tid  (pop up narrative of importance of combining with routine assessment using validate tool)

If a trial of comfort measures fails, an analgesic trial is appropriate.  Preferably, the initial trial is with an analgesic with a reasonable safety profile.  A recent review identified acetaminophen as a moderately effective analgesic with a somewhat lower risk profile than NSAIDs.  (Although hepatic toxicity is a side effect that should be carefully monitored.)  As with the comfort measure trial, the analgesic trial should be time-limited and its effectiveness evaluated by a pre/post assessment of changes in pain behavior. If an acetaminophen trial fails, consideration should be given to either another analgesic or to neuropsychiatric consultation.

Action 5

Increase quetiapine XR to address increased non-cognitive behavioral symptoms of dementia Alzheimer’s type

Antipsychotic use for neuropsychiatric symptoms associated with Dementia Alzheimer’s Type is extremely controversial outside of the treatment of frank psychosis (e.g. hallucinations).  The use of these agents has additionally been linked to an increase in mortality in this patient population.  Increasing the dose of the quetiapine would not be recommended at this time.

Action 6

Discontinue quetiapine XR to address possible adverse effects

The use of antipsychotics in patients with dementia, aside from reported increased risk of mortality, may contribute to numerous treatment-related adverse effects including metabolic syndrome, insulin resistance, and oversedation.  Additionally, data to support their efficacy for this indication is modest, at best.  While frequently prescribed at lower doses (50-100mg at bedtime) for the treatment of insomnia, quetiapine prescribing in fashion should be discouraged.  Discontinuing the quetiapine at this time would be an appropriate course of action.

Action 7

Initiate scheduled opioid analgesic (e.g. hydrocodone / acetaminophen)

The initiation of a scheduled opioid for Ms. Rose (an opioid naïve patient) would be considered an aggressive treatment strategy at this point in time.  Even though she likely has untreated / undertreated pain symptoms, scheduled opioid therapy may result in over-sedation, and potentially, and increased risk of fall (this is controversial based on available data).  However, as needed dosing of analgesics is problematic for non-communicative patients unless close monitoring of nonverbal pain indicators is performed.  We would recommend scheduled dosing of either acetaminophen or the NSAID, salsalate, at this time.

Action 8

Initiate as-needed opioid analgesic (e.g. hydrocodone / acetaminophen)

The use of “as-needed” (PRN) dosing of analgesics for patient’s who are unable to accurately describe their pain quality or intensity is problematic.  With the proper training of long term care facility staff to monitor for pain symptoms using tools, such as the Checklist of Nonverbal Pain Indicators (CNPI) or the Pain Assessment in Advanced Dementia Scale (PAINAD), an “as-needed” order of a low potency opioid would be appropriate for Ms. Rose.  Her history of “codeine allergy” should be further reviewed as this drug is often cited as an allergy, when in fact the patient experienced nausea or itching with the medication (both of which are expected side effects).

Action 9

Initiate scheduled topical non-steroidal anti-inflammatory therapy (e.g. diclofenac gel)

Topically administered NSAIDs are an effective method for addressing pain symptoms when relatively localized in nature (i.e. individual large or small joints).  Studies indicate similar efficacy to orally administered NSAIDs with a fraction of the systemic exposure to active drug.  This may be attractive in an older patient, such as Ms. Rose, to avoid possible gastritis, NSAID-associated upper gastrointestinal bleed, and nephrotoxicity.  Caveats to the use of topically administered NSAIDs are their high cost and lack of third party insurance coverage in some cases.

Action 10

Request clinical lead, APN, PA, or MD / DO to coordinate inter-professional care planning meeting for Mrs. Rose, including niece

An interprofessional care planning meeting would be a viable strategy to address Ms. Rose’s new onset agitation.  While difficult to orchestrate in a real-world setting, this type of care is preferred and should be offered when possible.

Action 11

Initiate EMS services for evaluation at affiliated hospital

Ms. Rose does not have an acute medical issue necessitating transfer to a hospital and may worsen her agitation.  Unfortunately, long term care residents are frequently transferred when infectious processes are of high suspicion, even when outpatient therapy is reasonable.  We recommend against the use of EMS services and hospital transfer for Ms. Rose.

Action 12

Initiate levothyroxine at 100mcg PO daily as hypothyroidism likely explains agitation, dementia, and worsening pain

Ms. Rose has a mildly elevated thyroid stimulating hormone (TSH) and likely has subclinical hypothyroidism.  While long standing hypothyroidism may be associated with dementia, it is unlikely this is contributing significantly to Ms. Rose’s neuropsychiatric problems.  The initiation of levothyroxine in Ms. Rose may be deemed appropriate by some clinicians with her current TSH, however, older patients and those with histories of CAD should never be started with dosing at 100mcg daily.  We would not recommend the initiation of levothyroxine at this time and certainly not at this high of dose.

Action 13

Consultation with prosthodontist

Weight loss, decreased appetite, indicators of oral discomfort, and her swollen gums may suggest numerous etiologies of mouth pain including maladjusted prosthodontics (dentures).  A dental consult, if available, is a reasonable course of action.

Commentary on Different Assessment/Treatment Options

1. Increased agitation is common among long-term care residents, complicating differential assessment.
2. Increased agitation secondary to ADLs or other activity increases is a common indicator of pain at levels of severity that can occasion pain behaviors/agitation.
3. The Checklist of Nonverbal Pain Indicators is easy to use and provides targeted information relative to pain
4. Studies show scheduled analgesics (e.g. acetaminophen) can result in the reduction of agitation, non-cognitive behaviors, and increased activity in patients with dementia
5. Uncontrolled pain may contribute to behavioral changes in non-communicative patients with dementia and should be considered during assessment
6. Comfort measures and creating a relaxing environment may decrease pain-related agitation