Event 4: Evaluating Treatment for Mildred

Follow-up Visit 1

Mildred and Tommy return to see Dr. Wright to discuss Mildred’s progress to date.

Follow-up Visit 2

Two weeks later Mildred and Tommy return for her second follow-up appointment with Dr. Wright.

Pain Signature on Follow-Up

It is important to evaluate the effectiveness of our treatments by comparing previous reports to current experiences.   The red X’s on this slide represent Mildred’s pain signature obtained at the time of a follow-up visit and the black X’s are her initial pain signature.   As you can see, she has improved in a number of areas.  So, if she continues to report the same level of pain, the pain signature tool can be used to highlight the very real improvements that she has experienced.

Pain Signature on Follow Up
Does pain affect your... Not at all A little Somewhat A lot As much as I can imagine
Energy   X X    
Mood   X   X  
Appetite   X      
Sleep   X   X  
Ability to do daily chores   X X    
Ability to enjoy yourself     X X  
Ability to think clearly   X      

Pain Perseveration and Dementia

  • Repeated pain reporting in the absence of distress
  • Analgesic trial of +/- benefit
  • Distract patient; don’t ask about pain unless there are non-verbal behavioral indicators
  • REAL-TIME OBSERVATION is key assessment tool

Persons with dementia may exhibit a phenomenon called “pain perseveration”, that is, the repeated reporting of pain that occurs without any sign of associated distress or suffering. Like other forms of perseveration, it occurs despite the absence or cessation of a stimulus and is a common characteristic of dementia.

Patients with pain perseveration will not exhibit nonverbal pain behaviors. Pain perseveration becomes the most likely explanation when the family or caregiver reports frequent pain report by a patient who does not appear to be in pain or when a patient who frequently talks about pain during the clinical encounter does not demonstrate objective signs of pain during the evaluation. An empiric analgesic trial may or may not be helpful in distinguishing physical pain from pain perseveration.  Patients with chronic non-cancer pain will not become pain-free with treatment, thus those perseverating will likely continue to do so. The persistence of pain reporting also may indicate lack of analgesic efficacy, thus an analgesic trial must be coupled with the other assessment approaches described earlier in this module.

When pain perseveration is suspected to be the driver of pain reporting, the best intervention may be distraction. Another strategy providers and caregivers can use to manage patients with pain perseveration is to avoid asking about pain unless nonverbal indicators or other signs of pain-related suffering emerge. The presence of pain perseveration can be easily missed if providers do not corroborate the patient’s experiences with family and directly observe patients completing relevant physical tasks, that is, real-time observation. In Mildred’s case, this involved observing while walking, an activity during which she reported pain. Providers should educate family about the possibility of pain perseveration and the importance of not over-treating pain reporting in isolation.

Wrap Up

University of Pittsburgh logo
University of Pittsburgh