Pain Management

Pain in dementia

It is important to know that people with dementia can and do experience pain from the same ailments as people without dementia. 1  Nevertheless, it has been reported that almost half of Australian nursing home residents are completely incapable of reporting pain due to cognitive disability or communicative impairment.2  Pain can be very difficult to assess in people with dementia which leads to unnoticed and untreated pain. 1  It is very important that people with dementia have pain regularly assessed and properly managed.  Some people with dementia will be able to communicate both presence and level of pain and when this occurs it is important that these reports are accepted as they would be from people with no cognitive impairment. 2

Scale assessment of pain in dementia

Although the first step in pain assessment is to ask the patient if they have pain it has been found to be more effective to use an established scale to determine whether a patient is experiencing pain or not. 2  The Verbal Rating Scale (VRS) is recommended for use for several reasons.  It has good scale properties, is well understood by people that have mild to moderate dementia, takes less demonstrations to be understood and is quick and easy for the clinician or carer to use. 3  To administer the VRS, the carer or clinician simply asks the patient to rate their pain as none, mild, moderate or severe.

Severe dementia

The VRS (see above) may also be used in people with severe dementia though not with the same success, with only about one third responding effectively to the scale. 3  Although some have advocated the use of non-verbal scales, such as the 'Faces Pain Scale', these have low success in people with severe dementia.  As such, clinicians and carers should also look for behavioural signs of pain, as described by Alzheimer’s Australia and shown below: 1

  • Changes in behaviour
  • Sleeping more than usual
  • Crying
  • Facial or verbal expressions
  • Reluctance to move

The most effective person to report on these changes in behaviour are the people close to the person with dementia, such as family and regular carers.  For this reason it is important that these people are regularly consulted in relation to pain management.

Pharmaceutical recommendations for pain in dementia

It is very important that once pain is established it is dealt with quickly.  The Australian Pain Society, along with Alzheimer’s Australia, recommend that analgesics should be used regularly in people with dementia that experience pain and not just when required. 2 To achieve this, the lowest dose possible that provides pain free comfort should be prescribed and administered regularly.  In addition, it is important to be aware that people who refuse food and become malnourished are likely to require lower doses of opiates and that the balance between effective pain relief medication and side effects caused by these medications should be periodically assessed. 4

Non-pharmaceutical pain relief for people with dementia

Although pharmaceutical pain relief is the most commonly used method to treat pain in dementia there are several non-pharmaceutical techniques that could be provided by both family and carers that may also assist to relieve or reduce pain. Some of these techniques are listed below: 1

  • Repositioning
  • Verbal reassurance and support
  • Soothing touch
  • Physical exercise or movement
  • Cold or heat therapy
  • Massage
  • Music
  • Hand activity (stress balls, worry beads, play dough)

References and recommended reading

  1. Alzheimer’s Australia. (2005) Information Sheet 2.11 – Pain. Available online at www.alzheimers.org.au/upload/HS2.11.pdf
  2. The Australian Pain Society. (2005). Pain in Residential Aged Care Facilities: Management Strategies. Available online at www.apsoc.org.au/owner/files/9e2c2n.pdf
  3. Jose Closs, S., Barr, B., Briggs, M., Cash, K., & Seers, K. (2004). A comparison of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment. Journal of Pain and Symptom Management, 27, 196-205.
  4. Abbey, J. (2006). Palliative Care and Dementia.  Alzheimer’s Australia.  Available online at www.alzheimers.org.au/upload/palliativecare.pdf