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 Patients With AD Don’t Perceive Or Report Pain As Readily As Others: Study

A new study published in BMC Medicine from Vanderbilt University is a reminder about the challenges of assessing and managing pain in people with Alzheimer’s disease (AD). Todd Monroe, PhD, RN-BC, FAAN, and colleagues reported that individuals with AD don’t perceive pain as readily as healthy older adults, and this may lead to delays and underreporting of pain. As a result, he suggested, this alteration in pain detection may be one reason that people with AD tend to be undertreated for pain.
Monroe and his team studied pain responses in two groups of adults age 65 and older, one composed of cognitively healthy people and the other made up of people diagnosed with Alzheimer’s disease. Everyone in the AD group was physically healthy and able to communicate and rate pain verbally. The three-year study used a psychophysical thermal stimulation to test for and examine self-reports of pain in each group.
“We compared the perception threshold for three experimental heat pain intensities and the reports of unpleasantness associated with each,” Monroe said. “We found that participants with Alzheimer’s disease required higher temperatures to report sensing warmth, mild pain, and moderate pain than the cognitively intact participants. What we didn’t find was a difference between the two groups in reporting how unpleasant the sensations were at any level.”
Monroe said the researchers assumed that as AD advanced and cognition worsened, pain would be more distressing for these patients. However, “we found no evidence that people with Alzheimer’s disease are any more—or any less—distressed by pain or that pain becomes less unpleasant as their disease advances.”
Even when patients with AD have pain, studies show that it may be challenging for them to let others know that they are in pain. One’s ability to effectively respond to a verbal pain assessment or questioning about pain is widely considered to diminish with worsening cognitive impairment.
While pain assessment should be individualized, it is generally agreed that patients with Mini Mental Status Exam scores below 15 are too impaired to fully complete or understand self-reporting pain scales. However, regardless of mental status, if someone verbally reports they are in pain, it should be considered true.
Because it may be difficult for patients with AD to verbally express pain, it is important to remind caregivers to watch for nonverbal clues that may indicate pain, such as frowning, grimacing, rapid blinking, crying, hand-wringing, rubbing or holding limbs or other parts of the body, resisting care and/or lashing out at caregivers, rocking, or pacing. Additional indicators of pain include diminished appetite, sleeplessness or restlessness, or changes in personality (for example, a normally docile person becoming agitated or disruptive).
At the same time, patient records should document any conditions that might cause or exacerbate pain, as well as previous painful conditions and effective treatments. This is essential to ensure that physicians, nurses, and other caregivers know which patients with AD might have painful conditions or who may be at high risk for pain, Monroe said.
However, even when patients with AD are capable of communicating verbally, caregivers shouldn’t wait for them to report pain. “We can’t assume that patients will spontaneously report pain. In a previous study published in Geriatrics and Gerontology International we found that even people with mild AD are more likely to report pain if simply asked,” said Monroe. When patients are nonverbal, he said, it still is important to ask them.
“Don’t assume they can’t communicate if asked questions about pain,” he said. Whether the person is verbal or nonverbal, Monroe recommends asking questions that deal with “comfort” rather than “pain.” For example, ask the patient if walking or eating has become uncomfortable.
Monroe and his team also recently completed a study published in the Archives of Psychiatric Nursing in which they asked nurses working in skilled nursing centers how they assess and make decisions to administer pain meds in people with advanced dementia. Nurses consistently reported that they focus on the patient’s appearance of comfort.
“In that study we were surprised to learn how important the appearance of comfort was to nurses,” Monroe said. Nurses also reported that they sometimes had to help family members feel comfortable with the administration of pain medications to people with dementia.
Pain assessment, in general, should not be a one-time activity and should involve a comprehensive approach that includes questioning and observations, as well as caregivers’ and family members’ knowledge about the patient and his or her behaviors, personality, and patterns.
Assessments should not only be designed to determine the presence of pain, but also location, intensity/severity, frequency, aggravating/relieving factors, impact of the pain on the person’s life, and any pain treatments the person is currently receiving. Following the initiation of treatment, it is essential to assess the patient’s response to treatment and then reassess over time to identify opportunities to reduce or eliminate drug therapy.
Overall, pain in patients with AD requires more attention, said Monroe. He would like to see more pain assessment and treatment in AD addressed in nursing and medical schools, as well as studied on a broader scale. He said that while further study is needed, it is becoming increasingly clear that health care providers should make pain evaluation for people with AD a priority.
“We are in the process of analyzing the neuroimaging data from the current study, which we hope will further elucidate changes in the neurobiology of pain in Alzheimer’s disease.”
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