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The Assessment and Management of Pain in the Demented and Non-Demented Elderly Patient

Andrade, D. C. , Faria, J. W. , Caramelli, P. , Alvarenga, L. , Galhardoni, R. , & Siqueira, S. R…Teixeira, M. L. (2010): Pain: elderly patients. Arq Neuropsiquiatr 2011; 69(2-B): 387-394. The authors reviewed various double blind, randomized, controlled trials along with their systematic reviews to evaluate different methods of assessing and managing pain in demented and non-demented elderly people. They utilized articles published in Scopus, Pubmed and Web of Science from the years 1966 to 2010.

In this literature they reviewed the physiology of pain in the elderly and the different available ways of assessment and management of their pain. World’s elderly population is on the rise because of the wider age span. At the same time, chronic degenerative diseases, for example cardiovascular disease, osteoporosis, depression and cancer, prevail in them, thus increasing the chances of chronic pain. Persistent pain has been reported to be in 45-80% of the population. It causes dependency, decrease mobility and higher financial stress.

Proper assessment helps in treating pain in the general population. But when we deal with demented people like Alzheimer’s patients, pain goes unreported or under assessed. Alzheimer’s disease (AD) is affecting almost 5% of people, aged 65 years. It makes almost one third of people above the age of 85 years. Several studies in the past have shown that demented patients have high pain prevalence and under-treated pain creates further dependency, cognitive deficiency, insomnia and depression. Physiology of Pain in the Elderly

The authors state that many studies have been conducted to find the clues regarding how differently the elderly folks, specially demented, perceive pain as compared to the younger, non-demented people. These studies were heterogeneous and involved small group of people. Experimental pain, for example by using electrical stimulation and a tourniquet, was inflicted in different body parts and participants were asked to press a button to indicate the detection, level of pain and tolerance threshold.

The authors noted conflicting results in different studies but they inferred that most studies reported that increasing age causes decrease pain tolerance but increase pain threshold. This flattening interval between pain onset and the limit of tolerance is called “Limen” in psychophysics. This shows the significance of decreased nociceptive functions of brain and lower production of endogenous opioids in elderly folks. Studies further reported that threshold level was very high in the demented patients as compared to the non-demented people.

Alzheimer’s patients can sense and discriminate pain because their cortical primary and secondary sensory areas and lateral thalamus are intact but the degenerative pathology of their disease affects the limbic system and prefrontal cortex, affecting their emotional response to pain. Evaluation of the Elderly Patient with Pain Scales and Questionnaires This scholarly article focuses on the importance of systematic evaluation of pain in demented elderly as most of them can’t describe or report pain; as a result their pain goes untreated.

The authors described four important ways to evaluate pain, reviewing from different studies. Self-report tools. This is a direct and validated tool used while taking the history of pain from the patient. It comprises of several different scales. But the visual analogical scale (VAS) is used most commonly. If this is difficult to use, different scale should be used. Direct observation tools. This takes in account the body language, behavior and inter-personal relationship changes, verbalization, non-verbal sounds and emotional states, as direct measures to assess pain.

Care giver reports. This uses the method of pain assessment through the reports by the care givers, especially in the case of non-verbal institutionalized advance demented clients. Combined scale. This scale was used in a recent study involving 2779 elderly clients. It reported that half of the patients had persistent pain and one out of five was not treated. The authors noted that there is no way to assess neuropathic pain. This type of pain can make it more challenging to overall assess and treat pain in advanced demented people.

Basis of the pharmacological management of pain in the elderly The article reports the significance of pharmacological interventions in this population. More adverse effects are noticed in them as their metabolic and drug elimination rates get lower with age and being on multiple medicines for co-existing diseases further complicates the situation. World Health Organization (WHO) recommends non-steroidal anti-inflammatory for the mild pain. Whereas, mild opioid can be added for the moderate pain. Strong opioids can only be added for the severe pain.

Anti-epileptics and anti-depressants can be given for neuropathic pain. Non-pharmacological interventions Furthermore, psychological/behavioral therapy, local heat/cold applications, massage, even transcutaneous electrical nerve stimulation showed good results as non-pharmacological interventions for pain. The authors reported that regular systematic pain assessment during and after treatment and keeping a close look at any adverse effects, to treat them, is the key for adequate pain control in any patient, specially the demented elderly patients.

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