Slides from the PANI Pain in Dementia Meeting held in The Long Gallery, Stormont on 26 March 2014.

1. Pain in Dementia
By kind invitation of
Jim Wells MLA
The Long Gallery, Parliament Buildings
26th March 2014

2. Pain in Dementia
Chaired by
Sarah Travers
The Long Gallery, Parliament Buildings
26th March 2014

3. Pain and Behaviour
Dr Pamela F Bell
Chair, The Pain Alliance of Northern Ireland
26th March 2014

4. An unpleasant sensory and emotional
experience caused by actual or potential
tissue damage or expressed in terms of
such damage
International Association for the Study of Pain
What is Pain?

5. Acute pain
A signal that something is wrong
It is protective
It prompts us to take action

6. Chronic pain
Does not signal new disease or injury
Serves no useful function
It has long-lasting effects

7. What are the effects of pain?
depression
changes in pulse
and blood pressure
fear
loss of
appetite
withdrawal
restlessness
increased
dependency
isolation
sleep disturbance

8. A little bit of neurobiology
injury
Dorsal
horn
lamina I Dorsal
horn
Lamina
V
Parabrachial
RVM
Limbic
system
Cingulate
dorsal columns
Peripheral nerve
Thalamus
Cerebral
cortex
PAG
+
-

9. A little bit of neurobiology
injury
Dorsal
horn
lamina I
Dorsal
horn
Lamina V
Parabrachial
RVM
dorsal columns
Peripheral nerve
PAG
+
-
Limbic System
Fear, anxiety, sleep, p
unishment
autonomic changes
Cingulate
Attention
Thalamus and
Cerebral Cortex
Location
& intensity
Change in muscle tone and
movement
Changes in sweating, heart
rate, blood pressure, breathing

10. How do we communicate our pain to others?
We describe it to them!
We also use body language!

11. How does our behaviour alter when we are in pain?
Different patterns of behaviour emerge
•Restlessness/withdrawal
•Vocalisations/silence
•Change in posture
•Weeping
•Refusing food
•Hitting our at others
•Disturbed sleep

12. Can we use these changes in behaviour
together with clinical signs to
determine if someone with dementia is
suffering pain?
One important question

13. The importance of pain in
people with dementia
Professor Peter Passmore
Professor of Ageing and Geriatric Medicine
Queen’s University, Belfast
26th March 2014

14. The impact of pain and dementia
on sufferers and carers
Dr Shaun Fleck
26th March 2014

15. Assessment and Management of Pain in Older
Adults
Professor Pat Schofield
Centre for Positive Ageing
University of Greenwich
26th March 2014

18. In the UK….
 10 million people in the UK are over 65 years old. The latest projections
are for 5½ million more older people in 20 years time and the number will
have nearly doubled to around 19 million by 2050.
 There are currently three million people aged more than 80 years and this
is projected to almost double by 2030 and reach eight million by 2050.
 The pensioner population is expected to rise despite the increase in the
women’s state pension age to 65 between 2010 and 2020 and the
increase for both men and women from 65 to 68 between 2024 and
2046. In 2008 there were 3.2 people of working age for every person of
pensionable age. This ratio is projected to fall to 2.8 by 2033.

19.  Around 700,000 people currently live with dementia and this is
expected to double to 1.4 million in the next 30 years.
• We anticipate 44m people world wide
 This trend is expected to have ramifications for the NHS in
the UK and in particular the training needs of the healthcare
workforce
Background

20. Disruptive or Challenging
Behaviours
 Severe pain is less likely to cause wandering.
 But, more likely to display aggressive and agitated
behaviours
 Hyochol & Horgas (2013)

23. Crude Prevalence
 0-93% !
 community ranged from 20-46%.
 residential care was higher and ranged from 28-73%.
 Highlights the variations between studies

24. Commonest sites of pain in older
persons
 Of the 22 studies that examined pain at different
sites, the three commonest sites of pain in older people
 Back (16 studies)
 leg, knee or hip (16 studies)
 Other joints (5 studies)

26. Pain in Residential
Aged Care Facilities
Management Strategies
August 2005
The Australian Pain
Society

27.  “Pain is exhausting… You have to walk slowly. You have to stop and make
an excuse or pretend to look in a shop window so that you can put your
hand on the window and rest a moment. It’s humiliating”.
 ‘Pain is frustrating because you can’t do things for yourself…Everything’s a
challenge.’
 ‘I get very depressed and anxious about it…it’s frightening, especially
when you live on your own.’
 ‘Pain can make you feel lonely because you feel that you’re the only one
that is suffering and can cope with it, and that is a lonely experience.’
Extracts taken from ‘listening events’ and interviews held with older people
who suffer pain (Help the Aged )
Perspectives from Older People

36. Guidelines: Summary
• Substantial differences in the population, methods, and definitions used in
published research makes it difficult to compare across studies and
impossible to determine a single definitive prevalence of pain in older
persons.
• The prevalence of pain in older persons living in residential care is
consistently higher than the prevalence of pain in older persons living in
the community, regardless of the definition of pain used.
• Older women have higher prevalence rates of pain than older men.
• The reported effect of age on pain prevalence in older persons is
inconsistent with some studies reporting an increase in prevalence with
age and others reporting a decrease in prevalence with age. The effect
also varies by gender and site of pain.
• The three commonest sites of pain in older persons are the back, leg/knee
or hip, and other joints.

37. Pharmacology
• Paracetamol should be considered as first-line treatment for the
management of both acute and persistent pain.It is important that
the maximum daily dose (4g/24 hours) is not exceeded.
• Non-selective non-steroidal anti-inflammatory drugs (NSAIDs)
should be used with caution in older people after other safer
treatments have not provided sufficient pain relief. The lowest dose
should be provided for shortest duration.
• All patients with moderate or severe pain should be considered for
opioid therapy
• Tricyclic antidepressants and anti-epileptic drugs have
demonstrated efficacy in several types of neuropathic pain

38. BBC News
 The NHS in England spent more than £440m last year
on painkillers. On average, health trusts in England
spent £8.80 per head of population on analgesics. But
in some northern towns and cities the figure was as
high as £15, while in parts of the south it was as low as
£3.26 per head.

39. Invasive
• Intra-articular corticosteroid injections in
osteoarthritis of the knee are effective in
relieving pain in the short term with little risk
of complications and/or joint damage. Intra-
articular hyaluronic acid is effective and free
of systemic adverse effects.
• The current evidence for the use of epidural
steroid injections in the management of
sciatica is conflicting

40. Non-Invasive
• Assistive devices are widely used and ownership of
devices increases with age.
• A number of complementary therapies have been found
to have some efficacy amongst the older population
including; acupuncture, TENS and massage.
• Guided imagery Biofeedback training and relaxation, CBT
in nursing home populations.
• Self management programmes may have benefit.

44. Ageing

45. The Unheard Voice of Pain

46. Why Pain Matters
 Many People with dementia have painful
conditions
 Pain is often unrecognised and untreated
 How individuals react to pain may depend on
attitudes, culture and age

47. Case Study

48. Year 1
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Anti Psychotic Anxiolytic Hypnotic Pain Relief Anti-Depressant Cog Enhancer
68.3%
24.4%
63.4%
12.2%
53.7%
9.8%
56.1%
24.4%
41.5%
24.4%
51.2%
4.9%
%ofResidents
Basline PostMedication Review from Baseline to Date

49. Year 2
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Anti Psychotic Anxiolytic Hypnotic Pain Relief Anti-Depressant Cog Enhancer
0.0% 0.0%
6.9%
0.0% 0.0% 0.0%
24.1%
20.7%
6.9%
96.6%
58.6%
10.3%
%ofResidents
Basline PostMedication Review from Baseline to Date

50. Intervention
Staff education
Assessment of pain
Review of medication
Dementia care mapping
Change in environment
Introduction of doll and animal therapy

51. Pro-active
Assessment and
Intervention (equals)
No/Reduced-Pain!

52. Questions and discussion
Led by
Sarah Travers