Assessing advanced cancer pain in older adults with dementia at the end‐of‐life

Abstract

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.

Pain Assessment in People With Dementia: Remaining Controversies

“…McDonagh et al (2016) suggested that age-related changes in the processing and interpretation of pain may imped the sensation of pain among older adults, thereby reducing their ability to self-report pain and putting them at greater risk for poor assessment and ineffective management of pain. However, the change in pain processing during later life is more complex (Monroe, Carter, Feldt, Tolley, & Cowan, 2012), as showed in another study (Horgas, Nichols, Schapson, & Vietes, 2007) that older adults become less able to endure strong pain sensations. Age-related physical/sensory changes in the CNS also explain reduced pain tolerance in the older adults (Hadjistavropoulos et al, 2014).…”

A Review of Pain Prevalence in Alzheimer's, Vascular, Frontotemporal and Lewy Body Dementias

“…Eight studies were conducted in Europe [17,18,19,20,21,22,23,24,25] and two studies in the USA [26,27]. Five studies examined outcomes in nursing homes [23,24,25,26,27], whereas five studies examined outcomes in community-dwelling people or patients recruited from outpatient clinics [17,18,20,21,22].…”

“…The mean subject age ranged from 70 to 86 years. Three studies focused solely on people with AD [17,21,22,27], five studies included people with AD, VaD, mixed pathologies and/or DLB [20,23,24,25,26], one study was a case-control study of AD and DLB [18] and one study included dementia subtypes based on motor neuron symptoms (i.e. parkinsonian syndromes) [19].…”

“…Different instruments for pain measurement were reported; four studies used the EQ-5D [17,18,20,21], two studies the Minimum Data Set (MDS) [25,27], one study the Mobilization-Observation-Behaviour-Intensity-Dementia-2 (MOBID-2) Pain Scale [24], one study the Discomfort Behavioural Scale (DBS) [26], one study a questionnaire that included pain domains [19], and in one study, the physician assessed if pain was present [23]. …”

“…Eight studies were conducted in Europe [17,18,19,20,21,22,23,24,25] and two studies in the USA [26,27]. Five studies examined outcomes in nursing homes [23,24,25,26,27], whereas five studies examined outcomes in community-dwelling people or patients recruited from outpatient clinics [17,18,20,21,22]. Five studies were cross-sectional [17,21,22,24,25,27], two longitudinal observational studies [19,23], one was a case-control study [18], one a retrospective cohort study [26] and one a randomized controlled trial [20].…”