NEWS & VIEWS DEMENTIA
Pain management in dementia —the value of proxy measures Bettina S. Husebo and Anne Corbett
The effective assessment and treatment of pain in individuals with dementia carries substantial challenges. A recent study evaluating the presence and treatment of pain in individuals with or without dementia reveals valuable insights into analgesic prescribing practices and highlights critical factors to be addressed in dementia treatment. Husebo, S. B. & Corbett, A. Nat. Rev. Neurol. 10, 313–314 (2014); published online 8 April 2014; doi:10.1038/nrneurol.2014.66
A recently published study compares the frequency of pain and treatment with analgesics in a large cohort of individuals with or without dementia.1 Pain is common in older adults, often from musculoskeletal conditions or caused by injury, comorbidities or infections. The prevalence of pain is high in individuals with dementia, and reports indicate that 50% of these patients regularly experience pain. 2 As the severity of cognitive impairment increases, this figure rises to 80% prevalence in patients with dementia who are living in care homes, primarily owing to the reduced self-report capacity in individuals in the late stages of dementia.2 Consequently, assessment and treatment of pain in these patients presents considerable challenges. Despite the high prevalence of pain in individuals with dementia, there is growing evidence of significant under-recognition and undertreatment.3,4 Analgesics are regularly prescribed to patients with dementia, but the suitability of the pain treatments currently given to these patients is unclear, and little attention has been paid to monitoring the long-term effects of these drugs, particularly among patients in care homes.5,6 The new study is important, as it contributes to the body of evidence highlighting the need for improved guidance on pain management in dementia and the urgent need for definitive research in this area. In the current study, Hoffmann et al. investigated health insurance claims data from 1,848 patients with a first diagnosis of dementia at 65 years of age or older, and 7,385 age-matched and sex-matched
controls without dementia.1 The aim was to investigate how the diagnosis of a pain ful condition correlated with pain treat ment between the two groups. Using logistic regression models and adjusting for covariates, the authors found a similar prevalence of pain-associated disorders in both groups. Initial analyses indicated that the proportion of individuals receiving analgesia was higher among patients with dementia than in the control group. After adjustment for patient sociodemographics, comorbidities and care needs, this finding was reversed— the proportion of individuals being prescribed analgesics was lower in the dementia group than in the non-dementia group. The conclusion drawn by the authors is that individuals with dementia do not receive adequate treatment for pain on the basis of their comorbidities and conditions that indicate pain.
‘‘
This study raises critical questions about the effectiveness of pain management in dementia
’’
Persistent, untreated pain causes substantial distress and discomfort in individuals with dementia, and might be a critical factor underlying symptoms such as agitation and aggression, which are common trigger symptoms for institutionalization and the use of potentially harmful medications such as antipsychotics.7 Pain also affects individuals’ quality of life in terms of sleep, mood, nutrition and social engagement.8,9
NATURE REVIEWS | NEUROLOGY
The effective identification and treatment of pain is, therefore, a critical aspect in the care of people with dementia, and the study by Hoffmann et al. addresses this important area of dementia practice and highlights key issues in research. This study raises critical questions about the effectiveness of pain management in dementia.1 Surprisingly, the sociodemographic, comorbidity and care factors caused a significant shift in the outcome of the study. Although individuals with and without dementia had equivalent diagnostic levels of pain, those with dementia received fewer prescriptions for analgesia— an unexpected finding given that the study participants were age-matched and sexmatched. This finding aligns with previous studies, which indicate a certain reluctance by physicians to prescribe analgesia to individuals with dementia. The authors also suggest that the use of analgesics in bedridden and immobilized patients in long-term care might be reduced because mobilization is no longer a primary goal in the care of these individuals. This proposal raises a serious issue around the expectation of treatment outcome in these patients, in whom dementia and comorbidities complicate the prognosis after a diagnosis of pain. These prescription data also revealed a higher than expected use of NSAIDs among individuals with dementia compared with controls. NSAIDs are not currently recommended for use in this patient group due to well-established adverse effects and a lack of supporting evidence for their efficacy. These findings highlight the urgent need for clear, evidence-based guidance for clinical staff on the most effective pain management approaches for people with dementia.10 Although Hoffmann et al. convey important messages,1 some key aspects of the study design should be considered. The cohort consisted of people with a new diagno sis of dementia, with mean age of 78 years, of whom the majority (80%) were residing in the community. Previous studies have focused on patients with mean age of 85 years who were living in care homes, making it difficult to draw comparisons with the current study. Importantly, the hetero geneity in the cohort, from individuals living independently to those in assisted care-home VOLUME 10 | JUNE 2014 | 1
© 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS
‘‘
…this study is a valuable indication of analgesic prescribing practices … for individuals with dementia…
’’
residences, means that the outcomes of the study may not be directly relevant to clinical practice. The needs of people living independently in the early stages of dementia are substantially different from those of patients with complex treatment requirements living in care homes, and treatment approaches vary in these different settings, with people living at home often taking medication as needed rather than with a regular prescription. When interpreting the findings of the study, therefore, one should bear in mind that a ‘one size fits all’ approach to pain treatm ent is not appropriate in patients with dementia. Another limitation of the study is that measures of both pain and analgesia prescription were made by proxy. For example, the prior diagnosis of a painful condition was used as an indicator of the presence of pain. The validity of this approach in place of a direct pain assessment is open to question, thereby casting doubt on the accuracy of the pain diagnosis and, thus, the reliability of the findings. The majority of individuals were living independently with minimal care and support, indicating a mild stage in dementia whereby selfreporting of pain would have been possible and probably more appropriate. The information on analgesic prescriptions provides
2 | JUNE 2014 | VOLUME 10
valuable data on prescribing practices but cannot be used to directly report on the effectiveness of treatments. In the absence of a specific pain measure, this information cannot be inferred, raising the issue of whether or not analgesic treatment is being effectively selected and is appropriate for an individual. Overall, this study is a valuable indication of analgesic prescribing practices among clinicians for individuals with dementia and a diagnosis of pain. The challenges in pain research in patients with dementia are highlighted, as is the need to assess the efficacy of certain analgesics and accurate pain assessment tools in individuals in the early and late stages of dementia. Future research will need to build on data of this kind in providing accurate guidance on the proper assessment and treatment of pain, so as to inform an effective treatment strategy for individuals with dementia. Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, Bergen 5020, Norway (B.S.H.). Wolfson Centre for Age-Related Diseases, King’s College London, Wolfson Wing, Hodgkin Building, London SE1 1UL, UK (A.C.). Correspondence to: B.H. [email protected] Acknowledgements B.S.H. would like to thank the University of Bergen and the G.C. Rieber Foundation for supporting her work. A.C. would like to thank the National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre and Dementia Unit at South London and Maudsley NHS Foundation Trust and King’s College London for supporting her time on this work.
Competing interests The authors declare no competing interests 1.
Hoffmann, F., van den Bussche, H., Wiese, B., Glaeske, G. & Kaduszkiewicz, H. Diagnoses indicating pain and analgesic drug prescription in patients with dementia: a comparison to ageand sex-matched controls. BMC Geriatr. 14, 20 (2014). 2. Corbett, A. et al. Assessment and treatment of pain in people with dementia. Nat. Rev. Neurol. 8, 264–274 (2012). 3. Achterberg, W. P. et al. Pain management in patients with dementia. Clin. Interv. Aging 8, 1471–1482 (2013). 4. Pieper, M. J. et al. Interventions targeting pain or behaviour in dementia: a systematic review. Ageing Res. Rev. 12, 1042–1055 (2013). 5. Haasum, Y., Fastbom, J., Fratiglioni, L., Kareholt, I. & Johnell, K. Pain treatment in elderly persons with and without dementia: a population-based study of institutionalized and home-dwelling elderly. Drugs Aging 28, 283–293 (2011). 6. Lovheim, H., Karlsson, S. & Gustafson, Y. The use of central nervous system drugs and analgesics among very old people with and without dementia. Pharmacoepidemiol. Drug Saf. 17, 912–918 (2008). 7. Corbett, A., Smith, J., Creese, B. & Ballard, C. Treatment of behavioral and psychological symptoms of Alzheimer’s disease. Curr. Treat Options Neurol. 14, 113–125 (2012). 8. Husebo, B. S., Ballard, C., Cohen-Mansfield, J., Seifert, R. & Aarsland, D. The response of agitated behavior to pain management in persons with dementia. Am. J. Geriatr. Psychiatry http://dx.doi.org/10.1016/ j.jagp.2012.12.006. 9. Husebo, B. S. et al. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ 343, d4065 (2011). 10. McLachlan, A. J. et al. Clinical pharmacology of analgesic medicines in older people: impact of frailty and cognitive impairment. Br. J. Clin. Pharmacol. 71, 351–364 (2011).
www.nature.com/nrneurol © 2014 Macmillan Publishers Limited. All rights reserved
Pain management in dementia —the value of proxy measures Bettina S. Husebo and Anne Corbett
The effective assessment and treatment of pain in individuals with dementia carries substantial challenges. A recent study evaluating the presence and treatment of pain in individuals with or without dementia reveals valuable insights into analgesic prescribing practices and highlights critical factors to be addressed in dementia treatment. Husebo, S. B. & Corbett, A. Nat. Rev. Neurol. 10, 313–314 (2014); published online 8 April 2014; doi:10.1038/nrneurol.2014.66
A recently published study compares the frequency of pain and treatment with analgesics in a large cohort of individuals with or without dementia.1 Pain is common in older adults, often from musculoskeletal conditions or caused by injury, comorbidities or infections. The prevalence of pain is high in individuals with dementia, and reports indicate that 50% of these patients regularly experience pain. 2 As the severity of cognitive impairment increases, this figure rises to 80% prevalence in patients with dementia who are living in care homes, primarily owing to the reduced self-report capacity in individuals in the late stages of dementia.2 Consequently, assessment and treatment of pain in these patients presents considerable challenges. Despite the high prevalence of pain in individuals with dementia, there is growing evidence of significant under-recognition and undertreatment.3,4 Analgesics are regularly prescribed to patients with dementia, but the suitability of the pain treatments currently given to these patients is unclear, and little attention has been paid to monitoring the long-term effects of these drugs, particularly among patients in care homes.5,6 The new study is important, as it contributes to the body of evidence highlighting the need for improved guidance on pain management in dementia and the urgent need for definitive research in this area. In the current study, Hoffmann et al. investigated health insurance claims data from 1,848 patients with a first diagnosis of dementia at 65 years of age or older, and 7,385 age-matched and sex-matched
controls without dementia.1 The aim was to investigate how the diagnosis of a pain ful condition correlated with pain treat ment between the two groups. Using logistic regression models and adjusting for covariates, the authors found a similar prevalence of pain-associated disorders in both groups. Initial analyses indicated that the proportion of individuals receiving analgesia was higher among patients with dementia than in the control group. After adjustment for patient sociodemographics, comorbidities and care needs, this finding was reversed— the proportion of individuals being prescribed analgesics was lower in the dementia group than in the non-dementia group. The conclusion drawn by the authors is that individuals with dementia do not receive adequate treatment for pain on the basis of their comorbidities and conditions that indicate pain.
‘‘
This study raises critical questions about the effectiveness of pain management in dementia
’’
Persistent, untreated pain causes substantial distress and discomfort in individuals with dementia, and might be a critical factor underlying symptoms such as agitation and aggression, which are common trigger symptoms for institutionalization and the use of potentially harmful medications such as antipsychotics.7 Pain also affects individuals’ quality of life in terms of sleep, mood, nutrition and social engagement.8,9
NATURE REVIEWS | NEUROLOGY
The effective identification and treatment of pain is, therefore, a critical aspect in the care of people with dementia, and the study by Hoffmann et al. addresses this important area of dementia practice and highlights key issues in research. This study raises critical questions about the effectiveness of pain management in dementia.1 Surprisingly, the sociodemographic, comorbidity and care factors caused a significant shift in the outcome of the study. Although individuals with and without dementia had equivalent diagnostic levels of pain, those with dementia received fewer prescriptions for analgesia— an unexpected finding given that the study participants were age-matched and sexmatched. This finding aligns with previous studies, which indicate a certain reluctance by physicians to prescribe analgesia to individuals with dementia. The authors also suggest that the use of analgesics in bedridden and immobilized patients in long-term care might be reduced because mobilization is no longer a primary goal in the care of these individuals. This proposal raises a serious issue around the expectation of treatment outcome in these patients, in whom dementia and comorbidities complicate the prognosis after a diagnosis of pain. These prescription data also revealed a higher than expected use of NSAIDs among individuals with dementia compared with controls. NSAIDs are not currently recommended for use in this patient group due to well-established adverse effects and a lack of supporting evidence for their efficacy. These findings highlight the urgent need for clear, evidence-based guidance for clinical staff on the most effective pain management approaches for people with dementia.10 Although Hoffmann et al. convey important messages,1 some key aspects of the study design should be considered. The cohort consisted of people with a new diagno sis of dementia, with mean age of 78 years, of whom the majority (80%) were residing in the community. Previous studies have focused on patients with mean age of 85 years who were living in care homes, making it difficult to draw comparisons with the current study. Importantly, the hetero geneity in the cohort, from individuals living independently to those in assisted care-home VOLUME 10 | JUNE 2014 | 1
© 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS
‘‘
…this study is a valuable indication of analgesic prescribing practices … for individuals with dementia…
’’
residences, means that the outcomes of the study may not be directly relevant to clinical practice. The needs of people living independently in the early stages of dementia are substantially different from those of patients with complex treatment requirements living in care homes, and treatment approaches vary in these different settings, with people living at home often taking medication as needed rather than with a regular prescription. When interpreting the findings of the study, therefore, one should bear in mind that a ‘one size fits all’ approach to pain treatm ent is not appropriate in patients with dementia. Another limitation of the study is that measures of both pain and analgesia prescription were made by proxy. For example, the prior diagnosis of a painful condition was used as an indicator of the presence of pain. The validity of this approach in place of a direct pain assessment is open to question, thereby casting doubt on the accuracy of the pain diagnosis and, thus, the reliability of the findings. The majority of individuals were living independently with minimal care and support, indicating a mild stage in dementia whereby selfreporting of pain would have been possible and probably more appropriate. The information on analgesic prescriptions provides
2 | JUNE 2014 | VOLUME 10
valuable data on prescribing practices but cannot be used to directly report on the effectiveness of treatments. In the absence of a specific pain measure, this information cannot be inferred, raising the issue of whether or not analgesic treatment is being effectively selected and is appropriate for an individual. Overall, this study is a valuable indication of analgesic prescribing practices among clinicians for individuals with dementia and a diagnosis of pain. The challenges in pain research in patients with dementia are highlighted, as is the need to assess the efficacy of certain analgesics and accurate pain assessment tools in individuals in the early and late stages of dementia. Future research will need to build on data of this kind in providing accurate guidance on the proper assessment and treatment of pain, so as to inform an effective treatment strategy for individuals with dementia. Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, Bergen 5020, Norway (B.S.H.). Wolfson Centre for Age-Related Diseases, King’s College London, Wolfson Wing, Hodgkin Building, London SE1 1UL, UK (A.C.). Correspondence to: B.H. [email protected] Acknowledgements B.S.H. would like to thank the University of Bergen and the G.C. Rieber Foundation for supporting her work. A.C. would like to thank the National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre and Dementia Unit at South London and Maudsley NHS Foundation Trust and King’s College London for supporting her time on this work.
Competing interests The authors declare no competing interests 1.
Hoffmann, F., van den Bussche, H., Wiese, B., Glaeske, G. & Kaduszkiewicz, H. Diagnoses indicating pain and analgesic drug prescription in patients with dementia: a comparison to ageand sex-matched controls. BMC Geriatr. 14, 20 (2014). 2. Corbett, A. et al. Assessment and treatment of pain in people with dementia. Nat. Rev. Neurol. 8, 264–274 (2012). 3. Achterberg, W. P. et al. Pain management in patients with dementia. Clin. Interv. Aging 8, 1471–1482 (2013). 4. Pieper, M. J. et al. Interventions targeting pain or behaviour in dementia: a systematic review. Ageing Res. Rev. 12, 1042–1055 (2013). 5. Haasum, Y., Fastbom, J., Fratiglioni, L., Kareholt, I. & Johnell, K. Pain treatment in elderly persons with and without dementia: a population-based study of institutionalized and home-dwelling elderly. Drugs Aging 28, 283–293 (2011). 6. Lovheim, H., Karlsson, S. & Gustafson, Y. The use of central nervous system drugs and analgesics among very old people with and without dementia. Pharmacoepidemiol. Drug Saf. 17, 912–918 (2008). 7. Corbett, A., Smith, J., Creese, B. & Ballard, C. Treatment of behavioral and psychological symptoms of Alzheimer’s disease. Curr. Treat Options Neurol. 14, 113–125 (2012). 8. Husebo, B. S., Ballard, C., Cohen-Mansfield, J., Seifert, R. & Aarsland, D. The response of agitated behavior to pain management in persons with dementia. Am. J. Geriatr. Psychiatry http://dx.doi.org/10.1016/ j.jagp.2012.12.006. 9. Husebo, B. S. et al. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ 343, d4065 (2011). 10. McLachlan, A. J. et al. Clinical pharmacology of analgesic medicines in older people: impact of frailty and cognitive impairment. Br. J. Clin. Pharmacol. 71, 351–364 (2011).
www.nature.com/nrneurol © 2014 Macmillan Publishers Limited. All rights reserved
