Learning Objectives

  1. Recognize pain in persons with dementia incorporating several assessment techniques
  2. Appreciate changes in nociceptive pathways that may accompany dementia
  3. Describe a rational stepped care treatment approach for older patients with persistent knee pain and concomitant dementia

Target  Audiences

  • Medical Students: Years 1-3
  • Nursing Students: Advanced undergraduates; 1st and 2nd year master’s degree candidates
  • Dental Students: Year 3-4
  • Physical Therapy Students (DPT): Year 2
  • Pharmacy Students: Year 3

Case Description

Arthritis is the second most common chronic medical condition in the US and approximately 50% of sufferers report meaningful pain on a regular basis. Knee osteoarthritis is one of the most common conditions. Likewise, dementia increases in frequency with age, so that by age 85, 30-50% of older adults experience cognitive impairment. Pain is underdiagnosed and undertreated in persons with dementia.  Dementia-related brain changes may distort pain behaviors, complicating the assessment process. Also, the therapeutic index of analgesics is narrowed in dementia. This case focuses on pain assessment and management in an older adult with dementia highlighting nuances in approach and common pitfalls. 

Potential Impact of An Older Adult with Persistent Knee Pain and Dementia Education

  1. Improve knowledge: Integrate multifaceted pain assessment; identify pain-related disability; incorporate cognition as part of a comprehensive pain assessment; increase caregiver input in pain assessment and management; avoid over- and under-prescribing of analgesics. 
  2. Change attitudes: Engender provider confidence in their ability to help patients with dementia in pain. Dispel myths about pain and dementia.
  3. Gain skills: Improve patient-provider therapeutic relationship; improve treatment outcomes.

Acknowledgements

University of Pittsburgh

Joseph Shega, MD†: Case Leader
Debra K. Weiner, MD ‡,1,2,3,4: Case Content Expert, CoEPE Co-Director
Rollin Wright, MD, MA 2,§: Case Content Expert
Monica Malec, MD*: Case Content Expert
Kelley Fitzgerald, PhD, PT5: Case Content Expert
Zsuzsa Horvath, PhD6,7: CoEPE Director
Heiko Spallek, DMD, PhD, MSBAƐ: CoEPE Co-Director

1School of Medicine, Department of Anesthesiology; 2School of Medicine, Division of Geriatric Medicine; 3School of Medicine, Department of Psychiatry; 4Clinical and Translational Science Institute; 5School of Health and Rehabilitation Sciences, Department of Physical Therapy; 6School of Dental Medicine, Office of Faculty Affairs; 7School of Dental Medicine, Department of Dental Public Health

Non-University of Pittsburgh Related Appointments

† Vitas Innovative Hospice Care, Southeast Region; ‡ VA Pittsburgh Healthcare System, Geriatric Research Education and Clinical Center; §UPMC Presbyterian Hospital Internal Medicine Residency Program; *University of Chicago School of Medicine, Section of Geriatrics and Palliative Medicine; ƐFaculty of Dentistry, The University of Sydney

Funding

  • National Institute on Drug Abuse for funding the Center of Excellence in Pain Education

Administration and Planning

  • Center of Excellence in Pain Education Faculty Team
  • Denise Deverts, Translational Research Facilitator, University of Pittsburgh School of Dental Medicine, for her administrative support

Support

  • Thomas W. Braun, Dean, University of Pittsburgh School of Dental Medicine, for his support of the project 
  • Mark S. Redfern, Vice Provost for Research, University of Pittsburgh, for his support of the project
  • Deans of the Health Sciences School, University of Pittsburgh, for their support of the project
  • Support Staff, VA Pittsburgh Healthcare System
  • Support Staff, University of Pittsburgh School of Dental Medicine, for administrative and technical support and for providing recording locations for the project
  • University of Pittsburgh School of Medicine, Standardized Patient Program  

Internal Review

  • Ajay Wasan, MD, Department Chair, Pain Medicine, University of Pittsburgh School of Medicine

Production

  • Michael Dziabiak, Media Specialist, University of Pittsburgh School of Dental Medicine, for direction, camera, and editing
  • Heiko Spallek, Pro-Dean, Faculty of Dentistry, University of Sydney, for camera
  • Jesse Vitela, Technical Support Specialist, SciQuest, for lighting, camera, sound recording
  • Jordan Hammill, Instructional Technologist, University of Pittsburgh School of Dental Medicine, for direction, lighting, camera and sound recording
  • Robert C.T. Steele in the role of “Tommy”

Disclaimer

This curriculum resource was supported with funding from the NIH Pain Consortium, which approves the educational value of the information provided. The authors listed on this resource are responsible for its content, and questions may be directed to their Center of Excellence in Pain Education. The NIH Pain Consortium provides these evidence-based curriculum resources on pain management as a service to academic medical, dental, nursing, pharmacy and other health professional schools.

This resource is for educational purposes and is not intended as medical practice guidelines. Evidence-based practices may have changed since the publication of the resource.

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