Additional Material

Pre Test

Question 1

An 82 year old man reports pain in his knees for 10 years that is now preventing him from doing what he needs to do. He says that the main problem is that he is in too much pain to stand or walk for long enough to do his chores. He rates his pain as “12” on a 10-point scale. He says that he has tried acetaminophen, ibuprofen, and hydrocodone, but none of these have helped him. His past history is only notable for hyperlipidemia and well-controlled hypothyroidism. On exam, he appears anxious, but there are no demonstrable pain behaviors. He has a small effusion in both knees. He scores 16/30 on the Montreal Cognitive Assessment. The next most appropriate step is:

Incorrect

Correct. A comprehensive history and physical examination is the first step in pain management to direct the most appropriate treatment. The real-time evaluation provides information about verbal and non-verbal pain behaviors as well as pain perseveration. Answers a, c, and d represent treatments and should be considered only after a thorough assessment is complete.

Incorrect

Question 2

A 92 year old male with mild Alzheimer’s disease comes to the clinic complaining of severe pain in his knees from osteoarthritis. Steroid injections and acetaminophen are no longer effective. Additional comorbidities include hypertension, diabetes, coronary artery disease, constipation, and insomnia. The family is inquiring about the use of opioids. Which of the following statements is true regarding opioid use in persons with dementia?

Incorrect

Correct. Opioids represent an important and effective treatment for persistent pain refractory to first-line treatments in persons with and without dementia. Weaker opioids are used before stronger opioids to improve tolerability and reduce adverse effects such as sedation, confusion, and falls. Answer a is incorrect because tramadol has a side effect profile similar to other opioids and also lowers the seizure threshold. Answers b and d are incorrect as a diagnosis of dementia does not attenuate opioid side effects or alter pharmacokinetics and pharmocodynamics.

Incorrect

Question 3

The best way to get pain self-report information from an older adult with dementia is:

Incorrect

Correct. Self-report is the gold standard for pain report in persons with and without dementia. Verbal descriptor scales are preferred by persons with dementia, result in higher completion rates, and yield more reliable reports compared to other self-report pain measures. Answer a is incorrect as the verbal descriptor scale is superior to the numeric rating scale in persons with dementia. Answer c is incorrect because self-report represents the first step in a pain assessment that subsequently may need to be corroborated by an analgesic trial. Answer d is incorrect as persons with dementia can provide an accurate report of pain including well into the moderate stage.

Incorrect

Question 4

Each of the following should be considered a routine part of evaluating the older adult with chronic knee pain and dementia EXCEPT:

Incorrect

Correct. Examining the patient’s objective data such as a knee MRI and synovial fluid analysis to ascertain whether the knee is causing pain. A persistent pain evaluation should include a multifaceted assessment which includes asking the patient about their pain, observation of pain behaviors, and the caregiver’s perception of the patient’s pain. Objective tests are generally not part of a routine evaluation unless a concern arises. Answers a, b, and c are correct and incorporated as part of routine pain assessments.

Question 5

Which of the following is the LEAST likely to contribute to disability in the older adult with persistent pain and mild dementia?

Incorrect

Correct. Persons with dementia can learn to use assist devices which can be helpful to unload joint pressure and decrease pain. Answer a is incorrect as dementia may lead to a loss of insight and the meaning of pain resulting in increased pain-related disability. Answer b is incorrect as dementia is associated with depression which together can contribute to a greater likelihood of disability. Answer d is incorrect because dementia is associated with mobility impairment as is persistent pain which together increase disability.

Incorrect

Post Test

Question 1

Ms. A is a 78 y/o woman with h/o mild dementia brought to your office by her daughter because she has recently stopped going for walks. The patient denies pain but states that her knees ache all the time. She is not able to rate the pain on a scale of 1 to10 but agrees that she would call it moderate. Her daughter is concerned that she seems more withdrawn and finds her sleeping more during the day when she checks on her.

Based on the history gathered so far, what can you conclude regarding the severity of Ms. A’s pain?

Incorrect

Correct. Patients with dementia who can report pain provide reliable ratings and represent the gold standard in pain assessment. Answer a is incorrect as older adults with and without dementia often endorse different pain descriptors such as ache but such terms are not associated with pain severity. Answer b is incorrect as a noteworthy proportion of older adults have difficulty with the abstract rating of pain from the numeric rating scale, but that does not correlate with one’s pain intensity. Answer d is incorrect as persistent pain can interfere with a range of functions but such a relationship generally occurs with a higher severity level.

Incorrect

Question 2

Mr. B is an 88 y/o man with moderate dementia and known severe knee osteoarthritis. His caregiver brings him in because he has been uncooperative and combative after a recent hospitalization. He will not participate in physical therapy and fights with his caregivers during personal care. This is a significant change from his baseline. After examining him, his doctor believes that he is having pain and suggests a trial of scheduled acetaminophen.

Based on what you know about the impact of dementia on nociceptive pathways, which of the following may help explain his behavior change in response to pain?

Incorrect

Correct. Cognitive processing is altered in dementia and represents an integral component of modulation. Answers a, b, and c are incorrect as research has not demonstrated conduction, transmission, or transduction to be different in persons with dementia compared to other older adults.

Question 3

Which of the following walking assistive devices would likely be the easiest for a person with cognitive deficits to learn how to use?

Incorrect

Correct. Persons with dementia generally have an easier time learning to use a wheeled walker compared to other assist devices. However, as dementia progresses to the moderate and severe stages, patients may have difficulty learning to use an assistive device or forget to use it altogether. Answers a, b, and c are incorrect as a single-pronged cane, quad cane, and walker without wheels necessitate greater cognitive abilities to be used effectively to decrease persistent pain. That is, canes need to be held in the opposite hand to off-load a painful joint and a walker without wheels must be picked up with each step requiring a higher cognitive demand.

Question 4

When deciding on a treatment regimen for an older adult with mobility-limiting knee osteoarthritis, all of the following considerations are true EXCEPT:

Incorrect

Correct. Opioids represent an important therapeutic class for persons with moderate to severe pain with pain-related functional disability not adequately managed with topical treatments, non-opioid oral analgesics, or knee injections. Answers a, c, and d are correct statements.

Incorrect

Question 5

Mrs. C is an 82 y/o woman with moderate dementia brought in by her caregiver due to recent increased complaints of knee pain. She is having more difficulty ambulating in her home and has started sleeping on the couch because of difficulty climbing the stairs. Physical exam reveals tenderness to palpation along the medial and lateral joint lines and crepitus. There are no effusions. Standing x-ray shows severe joint space narrowing and osteophytes.

In a stepped approach to her care, what is the first referral you would make?

Correct. The first step in the management of knee pain in persons with osteoarthritis (supported by exam and x-ray) is non-pharmacologic approaches which includes an exercise program. Answers b and c are incorrect as joint replacement surgery and joint injections with corticosteroids represent steps in the approach to care but not the first step. Cognitive behavioral therapy can be helpful as a non-pharmacologic treatment but is not considered a first line therapy, has not been studied in dementia, and likely would confuse persons with dementia or be forgotten.

Incorrect

Supplemental Material

You have completed the essential content for this module. If you are interested in learning more about screening cognitive function, performing a knee exam in the patient with suspected knee osteoarthritis, or assessing physical performance in older adults, the following segments have been prepared for you.

Screening Cognitive Function

Mini Cog

Watch as Dr. Wright administers the Mini-Cog^TM to Mildred.

Addition References

Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021–1027. https://www.ncbi.nlm.nih.gov/pubmed/11113982
Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51(10):1451–1454. https://www.ncbi.nlm.nih.gov/pubmed/14511167
McCarten JR, Anderson P, Kuskowski MA, McPherson SE, Borson S, Dysken MW. Finding dementia in primary care: the results of a clinical demonstration project. J Am Geriatr Soc. 2012;60(2):210–217. https://www.ncbi.nlm.nih.gov/pubmed/22332672

Montreal Cognitive Assessment (MoCA)

Additional Reference

Nasreddine Z. Montreal Cognitive Assessment. Available at: http://www.mocatest.org

Performing a Physical Examination

Evaluation of the patient with suspected knee osteoarthritis.

Physical Performance Measure

Gait Observation
Timed Up and Go
Functional Reach