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Smerte og atferd hos pasienter med demens. Høyskolen i Buskerud Februar 2012  . Forskergruppe. Bettina Husebø , MD, PhD , UiB, SESAM, SUS Clive Ballard, MD, Prof. v/Kings College, London Reidun Sandvik, MSc , HiB Odd B. Nilsen, statistiker, SUS

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smerte og atferd hos pasienter med demens

Smerte og atferd hos pasienter med demens

Høyskolen i Buskerud Februar 2012  

forskergruppe
Forskergruppe
  • Bettina Husebø, MD, PhD, UiB, SESAM, SUS
  • Clive Ballard, MD, Prof. v/Kings College, London
  • Reidun Sandvik, MSc, HiB
  • Odd B. Nilsen, statistiker, SUS
  • Dag Aarsland, MD, Prof. v/SESAM, SUS og Karolinska, Stockholm

Finansiering og samarbeid

agitation and other bpsd are common
Agitation and other BPSD are common

>20: N=119

20-10: N=125

<10: N=162

Craig D, et al. Am J Geriatric Psychiatry 2005; 13: 460-468

slide4
Importantconsequences

Institutionalization

Cost

AGITATION

Restraints

Family burden

Harmful drugs

Reducedqualityoflife

Functional impairment

Patients

Carers

slide5
Behavioural disturbances: Multi-factorial

Structural brain changes

Neurochemical changes

Genes

AGITATION

Psychosocial factors

Unmet needs

Physical disease

Drugs

PAIN???

slide6
100

80

60

Placebo

Cumulative percentage of survival

40

Continue

20

Log-rank P=0.03

0

0

6

12

18

24

30

36

42

48

54

Time since randomisation (months)

83

(21)

62

(14)

23

(8)

At risk (No. of deaths) in subsequent 12 months:

82

(17)

65

(4)

32

(6)

Continue

10

(2)

4 (0)

Placebo

21

(2)

9 (2)

Antipsykotika reduserer livsforventning

The CALM-AD study

Log rank p=0.02

Ballard et al 2009 Lancet Neurology

The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. www.thelancet.com/neurology. 09 Jan 2009

pasienter p sykehjem kognitiv svikt smerte
Pasienter på sykehjem: kognitiv svikt/ smerte

Pasienter på sykehjem lider av vedvarende, underdiagnostisert og mangelfullt behandlet smerte (AGS-Panel 1998; Weiner 1999; Frampton 2003).

83% av sykehjemspasientene opplever regelmessig smerte som fører til inaktivitet, depresjon og redusert livskvalitet (Ferrell 1995).

Pasienter uten kognitiv svikt får 3 ganger mer analgetika enn pasienter med demens (Cohen-Mansfield 2002).

pain and dementia
Pain and dementia
  • Aging associated with pain (muscle skeletal diseases, neuropathic pain, cancer, vascular disease, fracture)
  • Unrecognized and untreatedpain due to reduced communicative skills, memory, and awareness
  • More pain and less pain-treatment in dementia (Husebø 2008)
  • Pain predicted agitation in dementia (Snow 2009)
  • Hypothesis: Pain treatment reduces agitation
slide12
Efficacy of treating pain to reduce agitation in residents of nursing homes with dementia: A cluster RCT
  • Setting: 18 NHs, 60 NH units (N=352), 5 municipalities in Norway
  • Design: Cluster-randomised, 8 week trial + 4-w wash-out period
  • Inclusion criteria: 65+ NH resident, dementia, clinically significant agitation for at least onse week (ie 39+ on CMAI)
  • Exclusion: advanced severe medicalillnesswithexpectedsurvival < 6 months, severe psychiatric/neurological disorder, severe aggression, severe renal/liver failure
slide15
Fixed dose regimen throughout the eight week treatment period. In those who were not able to tolerate this treatment, the dosage was either reduced or the participant was withdrawn from the study and treated as clinically appropriate.

*following the recommendations of the American Geriatrics Society(J Am Geriatr Soc 1998;46:635-51)

assessment of agitation dementia pain
Assessment of agitation, dementia, pain

Primary outcome measures

Cohen-Mansfield Agitation Inventory – long form (CMAI)

Secondary outcome measures

Mini-Mental State Examination (MMSE)

Functional Assessment Staging (FAST)

Activities of Daily Living (ADL)

Neuropsychiatric Inventory-Nursing Home Version (NPI-NH)

MOBID-2 Pain Scale (MOBID-2)

slide17
Results: Reduced agitation during pain-treatment

Treatment

Wash-out

Repeated measurement ANCOVA (LOCF):p<0.001

Average reduction 17%; Treatment effect 7.0 (95% CI 3.7-10.3)

summary
Summary
  • Systematic pain treatment was associated with a significant reduction in agitation and neuropsychiatric symptoms in addition to reduced pain
  • There were very few withdrawals due to sedation, and no reduction of cognition or ADL, suggesting that reduced agitation was not secondary to more sedation
conclusions
Conclusions
  • Assessment of pain is crucial in patients with dementia and agitation
  • Pain treatment should be considered for these patients, even if there is no clear evidence of manifest pain
publications
Publications
  • Aarsland D, Husebo B, Ballard C. Authors' reply to McShane and Regnard. BMJ 2011; 343:d5356.
  • Husebo BS, Ballard C, Nilsen OB, Sandvik R. Aarsland D. Effect of individual pain treatment on behavioural disturbances in nursing home patients with moderate and severe dementia: cluster randomised trial. BMJ 2011; 343:d4065 doi: 10.1136/bmj.d4065.
  • Husebo BS, Ballard C, Aarsland D. Efficacy of treating pain in patients with dementia. In: Pain in Older Persons. Newsletter. IntAssoc Stud Pain (IASP) 2011;4:2-3.
  • Sandvik K, Husebo BS. Smerte hos pasienter med demens. Demens&Alderspsykiatri 2012.
  • Sandvik K, Husebo BS. Vitenskap anvendt i praksis: Måler smerte hos personer med demens. Sykepleien 2011; 11:62-64.
  • Husebo BS, Ballard C, Aarsland D. Pain Treatment of Agitation in Patients with Dementia: A Systematic Review. Int J Geriatr Psychiatry 2011; DOI: 10.1002/gps.2649.

In preparation

  • Husebo BS, Ballard C, Aarsland. Pain and agitation in patients with dementia: Are we confident to identify and treat the right items of behavioural disturbances?
  • Husebo BS, Strand LI, Moe-Nilsen R, Ballard C, Aarsland. Internal and external responsiveness of the MOBID-2 Pain Scale used for nursing home patients with moderate to severe dementia.
  • Ballard C, Aarsland D, Husebo B, Corbett A, Malcangio M, Cohen-Mansfield J.Systematic review on analgesia treatment for people with dementia.
  • Fritze F, Ballard C, Aarsland, Husebo BS. Pain and depression in patients with dementia.
utfordringer og muligheter i
Utfordringer og muligheter I
  • Informert samtykke (2mnd)
  • NH ressurser
    • Motivasjon / Mangel av motivasjon
    • Kompensasjon for innsats
    • Undervisning (3 mnd), Veiledning
    • 3 undervisningsdager med diplomer, heder og ære ved avslutning
  • http://clinicaltrials.gov/ (registrering i internasjonal database)
  • http://www.legemiddelverket.no/ (6 mnd)
utfordringer og muligheter ii
Utfordringer og muligheter II
  • Review
  • Internasjonal prosjekt
  • Forskningsassistenter (masterstudenter R. Sandvik, S. Svendson)
  • 3x Bachelor (særoppgave for medisinstudenter)
  • PhD – data (F. Fritze, SESAM)
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