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Pain is treated poorly in older postoperative patients. Cognitive impairment and age strongly influence the amount of analgesic nurses administer to older patients after surgical repair of hip fracture. Provision for patient comfort is a fundamental ethical obligation of healthcare providers. Clinicians need to pursue this goal more aggressively, especially for cognitively impaired, postoperative older adults.

These findings provide support for the conclusion that a Web-based intervention is effective in improving the psychosocial well-being of participants at a 6-month follow-up. Future research needs to investigate the long-term effectiveness of Web-based interventions for sustaining psychosocial well-being, including factors that may affect quality of life, such as diabetes-specific beliefs, attitudes, social support, and disease-specific coping skills.

Aim To assess advanced cancer pain in older adults with dementia at the end-of-life. Background Self-report is the gold standard for pain assessment; however, people with Alzheimer’s disease may lose the ability to report pain. Biochemical and neuropathological changes occur in Alzheimer’s disease that impairs the affective, sensory, and motor pain processing regions of the brain. Because people with severe Alzheimer’s disease may lose the ability to report their sensory and emotional response to pain verbally, external motor displays of pain, such as grimacing, have been suggested for use in people with Alzheimer’s Disease. Design Between groups cross sectional study. Method Retrospective chart audits of people with Alzheimer’s disease in nine nursing homes in the US in 2009. Participants were nursing home residents (n = 48) with mild to very severe dementia, pain and cognitive measures were collected during the final 3 months of life. The primary outcome variable was the Discomfort Behaviour Scale score (a measure of observed pain behaviour) and the main predictor variable was the Cognitive Performance Scale score (a measure of Alzheimer’s disease severity). Medication administration (opioid, non-narcotic, and psychotropic medications) recorded over the final 2 weeks of life was collected as a covariate of interest. Results Alzheimer’s disease severity was negatively associated with pain behaviours. Post hoc procedures showed that this difference was due to the difference in pain behaviours between individuals with moderate and very severe Alzheimer’s disease. Total amount of opioid analgesic, total number of doses of non-narcotic medications, and psychotropic medications administered over the last 2 weeks of life were not statistically significantly correlated with pain behaviour. An inverse correlation was found between cognitive ability (Cognitive Performance Scale score) and total amount of opioid medication indicating that individuals with severe Alzheimer’s disease received less opioid. Conclusion Because people with worsening Alzheimer’s disease have fewer pain behaviours, assessing pain using behavioural indicators can be a challenge. Improving methods to assess for pain in people with Alzheimer’s disease is of critical public health importance. Moreover, future studies are urgently needed to further examine the sensory, emotional, and behavioural responses to pain in people with Alzheimer’s disease.

Aim One condition associated with severe end-of-life pain that can lead to a poor quality of death is cancer. Cancer pain in people with dementia is of particular concern because of communication problems that occur with worsening disease. The aim of the current pilot study was to examine the association between hospice enrolment, dementia severity and pain among nursing home residents who died from advanced cancer. Methods Between-groups cross-sectional chart audits of 55 nursing home residents with dementia who died from cancer were carried out. Results A total of 45% of residents were in hospice at the end-of-life. Residents in hospice were more likely to receive an opioid (80% vs 43%, P = 0.005); but less likely to show severe cognitive impairment (20% vs 50%, P = 0.050). Enrolment in hospice was associated with an increased likelihood of receiving an opioid after controlling for level of cognitive impairment (OR = 3.9, 95% CI = 1.1–14.0, P = 0.037). Lower levels of cognitive functioning were associated with a decreased likelihood of receiving an opioid after controlling for enrolment in hospice (OR = 0.3, 95% CI = 0.1–0.8, P = 0.030). Notably, 40% of nursing home residents with dementia who died from cancer did not receive any opioid during this time. Conclusions Preliminary results suggest that hospice enrolment might be influenced by the facility or region of this particular country. Hospice enrolment predicts more opioid pain treatment in residents with dementia and terminal cancer; however, no resident with very severe dementia and terminal cancer was placed in hospice care. Severely cognitively impaired nursing home residents requiring opioids are at great risk of suffering from untreated advanced cancer pain. New methods are urgently required to improve end-of-life palliative care for nursing home residents with terminal cancer and severe dementia.

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Few studies have explored the phenomenon of pain in people with severe cognitive impairment. Pain assessment, which depends primarily on people's ability to describe dimensions of pain, becomes problematic when clients' cognitive impairment is so severe they cannot respond to pain assessment tools. The purpose of this study was to describe the phenomenon of pain for a subgroup of aggressive cognitively impaired nursing home residents who were enrolled in a larger study of aggressive behavior. To determine if pain was a possible factor influencing aggression, information was sought from five sources: family members, nursing assistant (NA) caregivers, medical record listings of pain-related diagnoses, use of analgesics, and observations of aggressive behaviors. Families reported pain in 44% of subjects, while NAs reported pain in 66% of subjects. Seventy-six percent of subjects had one or more pain-causing diagnoses. Sixty-four percent of subjects whose family members thought they may have pain were being treated with analgesics, compared to 44% of subjects whose NA reported they may be experiencing pain. Aggression scores were significantly higher in subjects who had two or more pain-related diagnoses and in subjects with arthritis. Nurses who are aware of a history of pain, reports of pain by families and caregivers, presence of pain-related medical diagnoses, and who realize pain may be a trigger for aggressive behavior may be more likely to recognize pain in cognitively impaired older adults. Better pain assessment should lead to improved treatment of pain in this population.