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Pain Assessment/Management in the Senior with Cognitive Impairment. Darlene Grantham BN,MN, CHPCN (c) Clinical Nurse Specialist March 10, 2008. Manitoba’s Older Population. In 1991: 146,605 Manitobans were > 65; >65 represented 13.4% of total Manitoba population;

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Pain assessment management in the senior with cognitive impairment l.jpg

Pain Assessment/Management in the Senior with Cognitive Impairment

Darlene Grantham BN,MN, CHPCN (c)

Clinical Nurse Specialist

March 10, 2008

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Manitoba’s Older Population Impairment

  • In 1991:

    • 146,605 Manitobans were > 65;

    • >65 represented 13.4% of total Manitoba population;

    • Manitoba ranked the second highest among the provinces in terms of the proportion of person aged 65 and over.

      • Statistics Canada (1992)

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Dementia ImpairmentPrevalence Increases with Age








Prevalence (%)



65  75  85

Age (year)

Larson EB et al. Annu Rev Public Health 1992;13:431-449.

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Dementia Impairment

  • Dementia (DSM-IV)

    • The development of multiple cognitive deficits:

      • Aphasia

      • Apraxia

      • Agnosia

      • Disturbance in executive functioning (social and/or occupational functioning)

    • Behavioral symptoms include:

      • Agitation/restlessness

      • Delusions/paranoia

      • Physical aggression

      • Verbalizations

      • Wandering

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Alzheimers: Progression Impairment

25 ---------------------| Symptoms

20 |----------------------| Diagnosis

15 |-----------------------| Loss of functional independence

MMSE score

10 |--------------------------------| Behavioural problems

Nursing home placement

5 |-------------------------------------------|

0 Death |------------------------------------------

1 2 3 4 5 6 7 8 9


Feidman and Gracon, 1996

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Mild AD (MMSE 21­30) Impairment


  • Cognition

  • Recall/learning

  • Word finding

  • Problem solving

  • Judgment

  • Calculation

  • Function

  • Work

  • Money/shopping

  • Cooking

  • Housekeeping

  • Reading

  • Writing

  • Hobbies

  • Behaviour

  • Apathy

  • Withdrawal

  • Depression

  • Irritability

Adapted from Galasko, 1997

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Moderate AD (MMSE 10­20) Impairment


  • Cognition

  • Recent memory

  • Language (names,


  • Insight

  • Orientation

  • Visuospatial ability

  • Function

  • IADL loss

  • Misplacing objects

  • Getting lost

  • Difficulty dressing

  • (sequence and

  • selection)

  • Behaviour

  • Delusions

  • Depression

  • Wandering

  • Insomnia

  • Agitation

  • Social skills

  • unaffected

Adapted from Galasko, 1997

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Severe AD (MMSE <10) Impairment


  • Function

  • Basic ADLs

    • Dressing

    • Grooming

    • Bathing

    • Eating

    • Continence

    • Walking

  • Cognition

  • Attention

  • Difficulty performing familiar activities (apraxia)

  • Language (phrases, mutism)

  • Behaviour

  • Agitation

    • Verbal

    • Physical

  • Insomnia

Adapted from Galasko, 1997

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Aging, Cognitively Impaired, Pain Impairment

  • Three distinct populations:

    • Frail, older persons recovering from an acute medical illness;

    • Persons with cognitive impairment who need long-term care;

    • Persons dying of chronic, progressive illness, such as cancer, end-stage renal, heart or lung

      • Teno, 2007

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Use of pain medication in the Elder Population ImpairmentAchterberg et al. (2006)

  • Findings:

    • 62% received no pain medication at all

    • 34% used nonopioid pain medication

    • 6% received opioid medication

    • 3% received nonopioid and opoiod medication

    • 70% of residents with high cognitive performance received pain medication

    • 40% of residents with low cognitive performance received pain medication

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Consequences of Untreated Pain Impairment

  • It is estimated that 80% of personal care home residents have substantial pain that is undertreated

  • Untreated pain results in:

    • depression

    • decreased socialization

    • sleep disturbance

    • impaired ambulation

    • behavioral problems

      • AGS Panel on Chronic Pain in Older Persons, 1998

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Pain Assessment in the Senior with Cognitive Impairment Impairment

  • Gold standard patient’s self-report

  • Behavioral alterations have meaning and recognizing that nonverbal beings have conscious perceptions of pain

  • Behavioral or emotional reactions are just as important as verbal information

    • Anand & Craig 1996

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Assessing Multiple Dimensions of Pain Impairment

The ABCs of Pain

Affective Dimension

Behavioral Dimension

Cognitive Dimension

Physiological-Sensory Dimension

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A Impairmentffective Dimension of Pain Ferrell & Coyle (2001)

  • Is there a reason for the patient to be experiencing pain?

  • Was the patient being treated for pain? If so, what regimen was effective (include pharmacologic and non-pharmacologic interventions?

  • How does the patient usually act when he or she is in pain? (Note: the nurse may need to ask family)

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A Impairmentffective Dimension of Pain Ferrell & Coyle (2001)

  • What is the family’s interpretation of the patient’s behavior? Do they believe the patient is in pain? Why do they feel this way?

  • Try to obtain feedback from the patient e.g. ask patient to nod head, squeeze hand, move eyes up or down, raise leg, or hold up fingers to signal presence of pain.

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B Impairmentehavioral DimensionHorgas, et. al, (2007)

  • Non-verbal pain behaviors:

    • Facial expressions

    • Vocal behavior

    • Aggressive behavior

    • Increase in body movements

    • Changes in daily activities

    • Irritable, confused, withdrawn, agitated

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B Impairmentehavioral Dimension

Objective Data (NANDA, 2001)

  • Guarding

  • Impaired thought process

  • Social withdrawal

  • Introspection

  • Altered time perception

  • Moaning

  • Crying


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Restless Behavior: Impairment Not being able to sleep

Behavioral Dimension

  • Pacing

  • Distracting self

  • Restless behavior

  • Hitting, pushing, swearing

  • Physical signs: diaphoresis

  • BP/Pulse/RR Change

Objective Data (NANDA, 2001)

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Memories: Impairment Connections to past pain shapes a patient’s response

Cognitive Dimension

  • Beliefs

  • Attitudes

  • Meaning of the pain

  • Memory of past pain

  • Cognitive resources to cope

  • Locus of control

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Harlos, 2002 Impairment


Sympathetic Maintained


Physiological Dimension(Harlos, 2002)





  • Organs – heart, liver, pancreas, gut, etc.

  • Superficial: skin

  • Deep: bones, joints, connective tissue, muscle

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Nociceptive Somatic Pain (acute or chronic) Impairment

  • Common Locations of Pain:

    • Arms/Legs (14%)

    • Back (12%)

    • Joint (11%)

    • Hip (10%)

    • Soft Tissue (8%)

  • Pain-Related Disorders:

    • Arthritis/osteoarthritis

    • Osteoporosis

    • Hip fractures

    • Hip replacement

    • Contractures

    • Malignancies

    • Disc disease

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Biliary colic Impairment



Small bowel obstruction

Large bowel obstruction

Perforated viscus


Incarcerated hernia

Renal colic


Urinary Tract Infection

Irritable bowel syndrome

Sigmoid vovulus

Intra-abdominal abscess

Mesenteric ischemia

Abdominal aortic aneurysm

Acute myocardial infarction


Pulmonary embolism

Aortic dissection

Diabetic ketoacidosis

Nociceptive (Visceral) Acute Pain

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Central Syndromes Impairment

Central post-stroke pain

Phantom limb pain

Multiple sclerosis pain

Parkinson disease pain

Spinal cord injury pain (or compression)

Cluster headaches

Infection (bacterial/viral)

Post-Polio Syndrome

Vitamin B deficiency

Peripheral Syndromes

Chemotherapy induced neuropathy

Regional pain syndrome

HIV sensory neuropathy

Neuropathy- tumor infiltration

Painful diabetic neuropathy

Post-herpetic neuralgia

Post-mastectomy pain

Trigeminal neuralgia

Carpal tunnel or herniated disk

Peripheral vascular disease

Neuropathic Chronic Pain

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Dry Mouth: Impairment A common side effect

What Else to Assess?

  • Side-Effects of Therapy

    • Constipation

    • Gastric Fullness

    • Nausea

    • Sedation

    • Dry Mouth

    • Medications

  • Symptoms of Disease

    • Dyspnea

    • Fatigue

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Two Times: Impairment A minimum of 2 times (24hrs)to assess a patient

When to Assess?

  • Initial:

    • Assessment of the pain dimensions

  • Follow-up:

    • Routine reassessments are essential

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Barriers to Pain Control in the Senior with Cognitive Impairment

  • Task focused care vs. patient centered care

  • Sensory and cognitive impairments may reduce the patient’s ability to communicate suffering

  • Goal of nursing homes is to maintain or improve physical functioning rather than palliate symptoms

  • The Minimum Data Set (MDS)

  • Unavailability of physicians in LTC

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Barriers to Pain Control in the Senior with Cognitive Impairment

  • With hospital admission goal of care is discharge planning;

  • Cognition is not routinely assessed;

  • Health care providers are unaware of common cancer pain syndromes as well as pain in non-cancer illnesses;

  • Elderly persons with aggressive or agitated behaviors are usually sedated (which often increases the behaviors)

  • Pain assessment is rarely completed or even investigated in cognitively impaired

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Barriers to Pain Control in the Senior with Cognitive Impairment

  • High staff turnover adversely affects pain care.

  • Nursing assistants provide a large proportion of direct patient care but are not trained in reporting cognitively impaired patient’s pain behaviors

  • Inadequate time between pain assessment and clinical intervention for pain contributes to increased pain

  • Physician training in geriatric and palliative care medicine

  • Reluctance to use opioids in the elderly for fear of causing confusion, delirium

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Myths Impairment

  • Persons with Cognitive Impairment do not experience the same pain prevalence as cognitively intact individual.

  • Persons with Cognitive Impairment can not reliably use self-assessment pain scales.

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Pain Prevalence and Cognitive Impairment ImpairmentMyth 1 Leong et. Al., (2007)

  • Objective: To determine prevalence of pain and its impact among cognitively impaired residents

  • Findings:

    • Pain prevalence did not differ between residents with normal cognition (48%), mildly impaired (46%)or severely impaired cognition (43%)

    • In fact those with impaired cognition (mild/severe) reported more acute pain.

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Pain and Cognitive Impairment ImpairmentMyth 2 Pautex (2006)

  • Objective: performance of pain self-assessment scales in severely demented patients compared to observational data.

  • Findings:

    • 61% of 129 severely demented patients demonstrated comprehension of at least one scale.

    • Clinicians should not apply observational scales routinely in severely demented patients, because many are capable of reliably reporting their own pain.

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Assessment Tools – NOPAIN ImpairmentHorgas et. al., (2007)

  • The Non-communicative Patient’s Pain Assessment Instrument (NOPAIN)

  • Findings:

    • The NOPAIN is a reliable tool for evaluating pain in older adults with mild to moderate dementia

    • The NOPAIN tool is concise, easy to use, and requires minimal training

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Pain relief Impairment

Opioid for moderate to severe pain

+/- Non-opioid +/- Adjuvant

Step 3

Pain persisting

Opioid for mild to moderate pain

+/- Non-opioid +/- Adjuvant

Step 2

Pain persisting

Non-opioid for mild pain

+/- Adjuvant

Step 1

Analgesic Ladder


Source: World Health Organization, 1992

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Analgesics Impairment


  • “Start low and go slow”

  • Acetaminophen drug of choice for relieving mild to moderate nociceptive pain

  • Be extremely cautious using NSAIDS (especially in elderly)

  • Monitor side effects with opioids

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Nonpharmacologic Strategies Impairment

  • Used alone or in combination with pharmacologic strategies

    • Exercise

    • Physiotherapy, occupational therapy

    • Music

    • Therapeutic touch

    • Heat, cold therapy

    • Massage

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Consult a Pain Specialist Impairment

  • Pain and Symptom Management Clinic (Health Science Center)

  • WRHA Palliative Care Program –

    • Physician to Physician (237-2053)

    • CNS consults to Acute and Community Hospitals, PCH, Outpatient Cancer Care Clinics, Outpatient Psychiatry, Homes (237-2400)

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Summary Impairment

Make Pain Visible as the 5th Vital Sign

  • Obtain patient’s self report of pain when possible otherwise become familiar with behavioral indicators of pain

    • review pain data often

    • display pain data in patient’s room & chart

    • share pain data during nursing report

  • Set red flag for unrelieved pain

  • Display usual pain experienced by patients on the unit - day by day

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Questions Impairment