Pain in Older Adults With Dementia: A Survey in Spain

Abstract

The risk of suffering pain increases significantly throughout life, reaching the highest levels in its latest years. Prevalence of pain in nursing homes is estimated to range from 40 to 80% of residents, most of them old adults affected with dementia. It is already known that pain is under-diagnosed and under-treated in patients with severe cognitive impairment and poor/absent verbal communication, resulting in a serious impact on their quality of life, psychosocial, and physical functioning. Under-treated pain is commonly the cause of behavioral symptoms, which can lead to misuse of antipsychotic treatments. Here, we present two Regional and National Surveys in Spain (2015-2017) on the current practices, use of observational tools for pain assessment, guidelines, and policies. Results, discussed as compared to the survey across central/north Europe, confirm the professional concerns on pain in severe dementia, due to poor standardization and lack of guidelines/recommendations. In Spain, observational tools are scarcely used because of their difficulty and low reliability in severe dementia, since the poor/absent verbal communication and comprehension are considered limiting factors. Behavioral observation tools should be used while attending the patients, in a situation including rest and movement, should be short (3-5 min) and scored using a numeric scale. Among the pain items to score, "Facial expression" and "Verbalization" were considered essential and very useful, respectively. This was in contrast to "Body movements" and "Vocalizations," respectively, according to the survey in central/north Europe. Scarce time availability for pain assessment and monitoring, together with low feasible and time-consuming tools, can make pain assessment a challenge. The presence of confounding factors, the low awareness and poor knowledge/education of specific tools for this population are worrisome. These complaints draw future directions to improve pain assessment. More time available, awareness, and involvement of the teams would also benefit pain assessment and management in cognitive impairment. The experiences and opinions recorded in these surveys in Spain and other E.U. countries were considered sources of knowledge for designing the "PAIC-15 scale," a new internationally agreed-on meta-tool for Pain Assessment in Impaired Cognition and the "Observational pain assessment" in older persons with dementia.

Keywords: International “IR” framework; dementia; elderly; guidelines; impaired cognition; pain; pain assessment; pain management.

Figure 1

Preliminary regional survey on the confidence on pain assessment for people without cognitive impairment (A), mild cognitive impairment/dementia (B), and moderate/severe cognitive impairment/dementia (C).

Figure 2

Participants (A), institutions (B), and dementia wards (C) profiles in the National Survey and geographical distribution of the answers received and panels of professionals.

Figure 3

On the use of rules and guidelines for pain assessment in people with mild cognitive impairment (MCI) or mild dementia (A), and cognitive impairment (CI), and severe dementia (B).

Figure 4

On the use of rules and audition of pain assessment (A), the use of observational instruments (B), and the different conditioning factors on the use of observational instruments for pain assessment in people with dementia (C).

Figure 5

Utility of pain items of observational scales for pain assessment in people with dementia (A, main items: facial expression, verbalization, vocalization, body movements; B, changes in interpersonal interactions, activity patterns/routine, mental status), and the professional preference about how to register pain (C).

Figure 6

Challenges (A) and Future directions (B) in the pain assessment and management in the cognitively impaired/dementia population.