Scenario 1
Margaret is an 85-year-old female recently admitted to a longterm nursing care facility. She has a diagnosis of dementia and has limited communication. She is oriented to herself and follows one and two step directions. You will be completing an initial assessment for pain and cognition.
Question 1
What is the initial approach in gathering information about the presence of pain an older adult with limited communication?
Discussion Question 1
For older adults who have limited communication, a clinical recommendation for pain assessment is to utilize the hierarchy of pain.6, 7 The hierarchy begins with eliciting a self-report of pain. The hierarchy of pain is a general recommendation for clinical practice in adults who unable to self-report. It is important to begin with the attempt at self-report and progress through the hierarchy as appropriate. Additional steps include searching for potential causes of pain, observe patient behaviors, proxy reporting, and attempt a trial of an analgesic.
Question 2
In an older adult with moderate to severe dementia and receptive aphasia, what valid and reliable tool would you recommend using in this case to obtain information about the presence of pain?
Discussion Question 2
In older adults with limited communication, there is no standardized pain assessment tool. Ther are several pain assessment tools that include observation of behavior as recommended in the hierarchy of pain. We chose the Pain Assessment in advanced dementia (PAINAD)12 based on Margaret’s diagnosis of dementia and her limited communication. Older adults with limited communication are typically unable to use the faces scale, pain visual analog scale or complete the body diagram.
Question 3
In pain assessment in an older adult with limited communication, what pain assessment observations might best assist you in your assessment?
Discussion Question 3
In pain assessment, timing can be very important. For example, pain at rest may be different compared to pain with movement or activity. Posture sitting in a chair may not be representative of pain as it is a resting position. Interaction with staff and others is also not a reliable measure of pain assessment. Facial expression with movement is the best selection as it is an assessment of pain with movement. The American Geriatrics Society has guidelines for behavioral pain indicators. Behavioral pain indicators include facial expressions, verbalizations, body movements, changes in interpersonal reactions, changes in activities and mental status changes.
Scenario 2
Gerald is a 78-year-old male with dementia and limited communication. He has been in the long-term nursing facility for two years and is demonstrating decreased participation in self-care, especially oral care. You are concerned about his oral and dental health.
Question 4
Poor oral health can contribute to oral pain. What is the most common symptom of poor oral care in older adults?
Discussion Question 4
In poor oral health, increased dental caries including decayed teeth, periodontal disease, ill-fitting dentures, neglect of oral hygiene and inflammation or infection.10, 3, 4 Drooling, bruxism, and tongue mobility are not typically symptoms of poor oral care but may contribute to changes in oral health.
Question 5
What signs are most indicative of dental or oral pain in an older adult with limited communication?
Discussion Question 5
For dental or oral pain in an older adult with limited communication, they may frequently be seen pulling at the cheek or lip. Often, these adults may decrease food and fluid intake. Confusion and social activity changes may be more related to change in mental status.
Question 6
What is the most common factor contributing to a decline in oral health in an older adult with dementia and limited communication?
Discussion Question 6
In an older adult with dementia and limited communication, oral health may be significantly impacted by medication. Side effects of medications such as diuretic, antipsychotics and antidepressants can lead to decreased saliva and dry mouth.11 Dry mouth can cause difficulty with chewing, speaking and swallowing.11 Co-morbidities may be increased in older adults, but the changes in oral health are more directly seen due to medication side effects. The answers for nutrition and toothbrush are less likely to be the most common factor contributing to a decline in oral health.
Question 7
Dental examination and treatment for oral health and oral pain in older adults who are in long term care are most limited by which of the following?
Discussion Question 7
For older adults in long term nursing care facilities, many have limited access to a dentist.
Scenario 3
Since being admitted to a Long Term Care facility two weeks ago, Margaret shows increasing combativeness, weight loss, decreased eating, and decreased self-care. Following a care conference, Margaret’s nurse and grandson review the results of the nursing assessment and treatment recommendations for Margaret.
Question 8
Select the most likely diagnosis you suspect in a case like Margaret’s.
Discussion Question 8
UTI: A Urinary Tract Infection (UTI) in older adults with dementia, the primary sign of a UTI may be a change in cognitive status as the patient is not able to tell you about the typical signs of a UTI such as those seen in younger adults. The typical signs of a UTI are (1) pain or a burning sensation upon urinating; (2) the urge to urinate more frequently; (3) lower abdominal pain, and (4) fever. In addition, there may be no fever in an older adult. In Margaret’s case, her changes in behavior may have some signs of a UTI however; she also had a change in functional activity and weight loss, not typical of a UTI.
Advancing Dementia: Dementia is a progressive condition with expect changes in memory and communication, physical activity and functional abilities that occur over time. Each person progresses at a different rate, depending on the source of the dementia: vascular, dementia with Lewy bodies, frontotemporal dementia, or Alzheimer’s. In addition, other factors such as age, comorbidities such as stroke, diabetes, side effects of medication and repeated infections may influence the progression of dementia. In Margaret’s case the changes we are seeing have occurred more quickly than expected due only to change in dementia.
Knee osteoarthritis is an unlikely diagnosis. Mouth pain is the best fit for the likely diagnosis for Margaret than UTI, advancing dementia or knee osteoarthritis. The other diagnoses listed above fit part of the changes we have seen in Margaret’s case, but don’t fit all her symptoms exactly. As an additional consideration, Margaret is having pain based on her PAINAD score that is in an unknown location. Further investigation and examination is warranted for a more likely diagnosis for Margaret.
Question 9
What is the most difficult component when using an interdisciplinary treatment plan for pain management for Margaret?
Discussion Question 9
In this case of interdisciplinary care, the caregivers and the patient and family are in multiple physical locations. Coordinating communication is the most difficult component. In this case communication is completed via fax, face to face, during examination by the nurse practitioner and dentist. and during care conferences. Sharing information is more challenging than comorbidities, pain reduction strategies and quality of life.
Question 10
When considering treatment options for oral pain in an older adult with limited communication, which treatment strategy would be the best recommendation?
Discussion Question 10
Based on Margaret’s diagnosis of oral pain and changes in oral health, the best answer is improved oral care. As part of good oral health, every attempt is made to retain teeth, thus eliminating transition to dentures as an answer. The non-pharmacological option of an NSAID or use of hot/cold pack may be viable options for pain reduction, but the greatest relief of pain most typically occurs with dental repair or extraction.
