Poorly managed pain has been identified as a significant public health concern in people with Alzheimer’s disease (AD) in previous studies.
For a study published in BMC Medicine, Todd B. Monroe, PhD, RN-BC, FAAN, and colleagues studied pain responses in two groups of adults age 65 and older, one consisting of cognitively healthy people and the other involving people diagnosed with AD. Everyone in the AD group was physically healthy and able to communicate and rate pain verbally. The 3-year study used a psychophysical thermal stimulation to test for and examine self-reports of pain in each group. The authors compared the perception threshold for three experimental heat pain intensities and reports of unpleasantness associated with each.
Connecting the Dots
“We found that patients with AD required higher temperatures to report sensing warmth, mild pain, and moderate pain than the cognitively-intact participants,” says Dr. Monroe. “This may lead to delays and underreporting of pain. However, we didn’t observe a difference between groups in reporting how unpleasant the sensations were at any level. Our results suggest that all clinicians caring for people with AD should look closely for subtle signs of pain. What may seem minor on the surface might actually be a sign of a more serious problem. It’s possible that patients are not ‘connecting the dots’ on what’s happening to them as quickly as cognitively-intact people.”
When patients with AD have pain, studies show that it may be challenging for them to express pain, a problem that may be exacerbated for those with worsening cognitive impairment. “Clinicians should remind caregivers to watch for non-verbal clues that may indicate pain,” Dr. Monroe says. “Such clues include frowning, grimacing, rapid blinking, crying, hand-wringing, and rubbing or holding limbs or other parts of the body. Other clues may include resisting care and/or lashing out, rocking, or pacing. Additional indicators of pain include diminished appetite, sleeplessness or restlessness, or changes in personality.”
More Attention Needed
Dr. Monroe advises clinicians to document any conditions that might cause or exacerbate pain in patient records and note if there are any effective treatments. “This data is essential to ensure that healthcare providers know which patients with AD might have painful conditions or who may be at high risk for pain,” he says. “Even when patients with AD can communicate verbally, we shouldn’t wait for them to report pain or assume that they’ll tell us spontaneously.”
Regardless of mental status, any pain that is verbally reported should be treated, according to Dr. Monroe. “Pain assessment should not be a one-time activity,” he says. “Overall, pain in patients with AD requires more attention. We need to take a comprehensive approach that includes questioning and observations as well as information from caregivers and family members about the patient’s behaviors, personality, and patterns.” He adds that assessing the patient’s response to treatment is essential after initiating any pain therapy.
Greater efforts are needed to train clinicians on pain assessment and treatment in patients with AD in nursing and medical schools, says Dr. Monroe. “While further study is needed, it’s becoming increasingly clear that healthcare providers should make pain evaluation for AD patients a priority.” He notes that he and his colleagues are in the process of analyzing the neuroimaging data from the current study in hopes of further elucidating changes in the neurobiology of pain in AD and gaining a better understanding of pain processing in dementia.
Todd B. Monroe, PhD, RN-BC, FAAN, has indicated to Physician’s Weekly that he has worked as a consultant for Affinity Online Solutions in Canada. He has also received grants/research aid from the NIH, National Institute of Aging, the John A. Hartford Foundation, Atlantic Philanthropies, Mayday Fund, the Vanderbilt Office of Clinical and Translational Scientist Development and the Vanderbilt Clinical and Translational Research Scholars Program.
Readings & Resources (click to view)
Monroe TB, Gibson SJ, Bruehl SP, et al. Contact heat sensitivity and reports of unpleasantness in communicative people with mild to moderate cognitive impairment in Alzheimer’s disease: a cross-sectional study. BMC Med. 2016;14:74. Available at: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0619-1.
Monroe TB, Misra SK, Habermann RC, Dietrich MS, Cowan RL, Simmons SF. Pain reports and pain medication treatment in nursing home residents with and without dementia. Geriatr Gerontol Int. 2013;14:541-548.
Scherder E, Bouma A, Borkent M, Rahman O. Alzheimer patients report less pain intensity and pain affect than non-demented elderly. Psychiatry. 1999;62:265-272.
Benedetti F, Vighetti S, Ricco C, et al. Pain threshold and tolerance in Alzheimer’s disease. Pain. 1999;80:377-382.