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 Delirium May Be Disguising Pain, A New Study Finds

The presence of delirium can complicate pain assessment and management, according to a recent study published in the American Journal of Hospice & Palliative Medicine.

In a retrospective study comparing health care workers’ pain judgment regarding older patients who had advanced cancer with and without a diagnosis of delirium, researchers found that determinations of pain control could be influenced or clouded by the presence of delirium. Additionally, the presence of delirium made it more challenging to judge if pain was being sufficiently managed.

Co-author Lucia Gagliese, PhD, associate professor at School of Kinesiology and Health Sciences at York University, and assistant professor in the departments of anaesthesia and psychiatry, University of Toronto, says, “Our results suggest the need for better pain assessment in older patients with advanced care and symptoms of delirium.” In these cases, she notes, “People often make judgments based on observations and best guesses. What is missing is the educational piece around pain and delirium.”
It is important, Gagliese says, for interdisciplinary team members to know the signs of delirium and separate these from pain symptomology. “Knowing a patient is key in looking for changes in usual behavior. A change might indicate onset of delirium or pain,” she observes.
However, if the team knows the patient, they are more likely to recognize when someone is in pain (for example, “Mrs. Jones always cries when she has pain”) and promptly identify behavior changes (for example, “Mr. Smith is always very alert, and he seems confused and unfocused tonight”). The team needs to be able to identify which condition that change is indicating.
Some symptoms of delirium are distinct—such as hallucinations, an inability to stay focused on a topic, difficulty speaking or recalling words, disorientation, and rambling or nonsense speech. It is important to note that these symptoms often fluctuate throughout the day and may disappear and then reappear. Symptoms usually are worse at night when it is dark and surroundings seem less clear or familiar. Caregivers and other team members need to understand that the presence of these signs points to delirium.
However, there are some symptoms that are common to delirium and pain. These include calling out or moaning, making unusual sounds, restlessness, agitation, and/or combative behavior. “Health care workers often see people with these signs as being in pain without considering the possibility of delirium,” says Gagliese. When these signs appear, it is essential to look for fever or signs of infection that may be triggering the delirium. “If you can identify the underlying mechanism and manage that, you can reduce or eliminate delirium, pain, and generally all suffering,” she says.
When staff are aware of the signs and symptoms of both delirium and pain and how to assess for both, they can identify the problem and address it appropriately. In general, says Gagliese, “If a patient exhibits signs of either condition, it should trigger a prompt assessment.” She adds, “For me, the priority is to try and reduce needless suffering and distress. The key to this is education, education, education.”
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