REVIEW ASK THE EXPERTS
Treating pain in patients with impaired cognition Steven M Savvas*,1 Dr Savvas is an early career researcher in psycho pharmacology with a PhD in Medicine (Pharmacology) from the University of Adelaide. He has extensive experience in clinical trials, having worked in a number of roles since 2006, and has a track record for conducting research in challenging areas such as drug dependence and dementia. Since 2011, he has worked at the National Ageing Research Institute and published in the geriatric field in dementia, pain and aged care. He is currently the coordinator for a large multi-site clinical trial involving people with pain and dementia in residential aged care.
Stephen J Gibson1 Professor Gibson is the chair of the International Association for the Study of Pain special interest group for pain in older persons and a past President of the Australian Pain Society. He has been involved in pain research for over 25 years and is currently the Deputy Director of the National Ageing Research Institute and Director of Research at the Caulfield Pain Management and Research Centre, Australia. Professor Gibson is a registered psychologist and holds the position of Professor within the Department of Medicine, University of Melbourne. He was awarded the 2006 Pfizer international visiting professorship in pain medicine and remains active in clinical practice via his involvement with multidisciplinary pain management centers. Professor Gibson has contributed to more than 150 peer-reviewed publications and is a sought after speaker at international meetings. His current research interests include studies on pain assessment and treatment in persons with dementia, age differences in pain and its impacts as well as the implementation of pain management guidelines into the residential aged-care sector.
‘Impaired cognition’ can encapsulate many disorders, disabilities and diseases, affecting people of any age, but this article will focus on older adults in pain and with dementia. Key points discussed in this article may, however, be generalizable to other groups with impaired cognition. Note also that those with pain and dementia are not a homogenous group – etiology and severity of dementia will likely influence the person’s experience of pain, its clinical identification and assessment, as well as treatment modalities. Furthermore, the challenges associated with research on pain in severe dementia have resulted in considerable gaps in the evidence base. As such, the largest body of work in this area relates to persons with mild to moderate Alzheimer’s disease who have some capacity to self-report their pain. National Ageing Research Institute, Melbourne, Australia *Author for correspondence: Tel.: +61 383 872 465; Fax: +61 39 3874 030; [email protected]. 1
10.2217/PMT.14.27 © 2014 Future Medicine Ltd
Pain Manag. (2014) 4(5), 335–338
part of
ISSN 1758-1869
335
ASK THE EXPERTS Savvas & Gibson What are the main challenges associated with treating pain in people with impaired cognition? QQ
Dementia may affect the experience of pain itself though research in this area is equivocal. Studies relying on proxy pain report (e.g., the patient has limited capacity to self-report their own pain) provide some evidence that the prevalence of pain diminishes as dementia severity increases [1–3] . However when self-report is possible the research is less consistent. Some studies suggest pain prevalence does not differ in persons with dementia (or that pain may even increase), albeit the requirement for self-report necessarily precludes those with more severe dementia and in which greatest degree of change might be expected [4,5] . Research using experimental pain techniques in conjunction with neuroimaging demonstrate that dementia related brain changes may alter lateral (sensory) and medial (affective) pain-related brain pathways (for a review see Monroe et al. [6]). Some acute pain studies of when pain is just noticeable suggest pain threshold in persons with Alzheimer’s disease is not significantly different [7,8] , and conclude that the sensory processing of pain remains relatively intact in persons with dementia (at least in the early progression of Alzheimer’s disease). However, pain tolerance studies on the limits of pain endurance are still inconclusive. They demonstrate an increase, no difference or even a decrease in pain tolerance, which may be specific to the modality of the pain administered [9] . The clinician likewise faces challenges in investigating pain in people with dementia. Patients with cognitive impairment can often still selfreport pain [10] in a reliable and valid way, though there may be increasing reliance on proxy report as dementia severity worsens. Observer-rated pain assessment scales that measure behavioral indicators of pain have merit, but even behavioral signs (principally the facial, body and verbal cues) might eventually be lost in very advanced dementia. Other indirect measures that may be attributable to pain, such as general agitation, depression and hostility, or other measures such as function and quality of life, could also have utility. As pharmacological treatment approaches have a primary role in pain management in persons with dementia, due consideration is needed regarding the pharmacokinetics, pharmacodynamics and side effects profile of pain management drugs. Studies of placebo responses in persons with Alzheimer’s disease suggest an attenuated effectiveness and therefore an
336
Pain Manag. (2014) 4(5)
increased dose of analgesic to achieve the same level of pain relief [11] . Risks and benefits of drug administration may need careful balancing, particularly when managing pain with opioids. Finally, patient engagement with treatment may also be a limiting factor, for instance refusing medication and other forms of non-compliance such as forgetting appropriate drug dosage and timing. How has the pain management of this population changed over the last 10 years? QQ
Earlier research in this field suggested an insufficient use of analgesics in the treatment of patients with dementia (for review see Husebo et al. [12]), though more recent studies indicate this has possibly been reversed (with even potential overtreatment) [13,14] . The proliferation of observational pain assessment tools in the last decade has complemented greater scrutiny of pain management in those with dementia and highlighted greater awareness of behaviors that may be indicative of potential pain. With an arsenal of appropriate scales, focus has started to shift to treatment methodologies. A stepwise pain management approach using escalating dose, stronger analgesics or adjuncts is gaining recognition as an appropriate pain management method in persons with dementia. For example, a recent study demonstrated the efficacy of an 8 week stepwise protocol (with paracetamol, oral morphine, buprenorphine patch, or oral pregabaline) in reducing agitation and pain in people with moderate to severe dementia [15] . What do you view as the key concepts the physician must keep in mind when treating this population? QQ
There are four key concepts: 1) A greater awareness of pain as an issue in patients with dementia, as well as mindfulness that dementia severity and type may substantively impact the pain management approach; 2) Self-report of pain is often possible. When not possible (often with more severe dementia), observational pain scales are recommended. Movement often exacerbates pain so a thorough mobilization should be conducted during pain assessment, particularly when using observational scales; 3) Due to differences in pharmacokinetic and pharmacodynamics drug profiles when administered to older patients and/ or persons with dementia, individual titration of analgesics that considers the individual risks and benefits of treatment is important. Dosage deemed
future science group
Treating pain in patients with impaired cognition appropriate in cognitively intact patients may be inadequate in older persons with dementia; 4) Pain relief may not be the sole end point. Improving function or protecting existing body systems, minimizing harm or side effects, improving quality of life, mental health or even maintenance of existing cognitive function, may have equal or greater merit in evaluating treatment success.
ASK THE EXPERTS
and anxiety [18] . Treating negative affect globally in the patient in pain with dementia may secondarily improve pain catastrophizing. Cognitivebehavior treatment approaches that modify pain beliefs and coping skills may also have some use [19] , though the evidence base is limited and dementia severity would be a limiting factor. Looking forward, what needs to be implemented in the clinic in order to ensure the best possible care? QQ
Observer-rated pain assessment instruments for people with dementia have proliferated in recent years. What are, currently, the best options? QQ
There is no consensus on which tool is best, and tool selection may vary according to setting and need. For example, the NOPPAIN is easy to use for carers and nursing assistants, whilst the PAINAD may be more appropriate for more highly trained staff in aged care. The ABBEY is quick to administer and the CNPI requires little training. The ALGOPLUS is designed for monitoring acute pain and the DOLOPLUS has been widely translated into other languages and is suitable in a number of settings. The PACSLAC is a comprehensive assessment scale, though somewhat lengthy to administer. How much of a problem is pain catastrophizing in this population and how can a clinician measure and treat it? QQ
The relationship between catastrophizing and pain in persons with dementia is largely unknown. In the cognitively intact, pain catastrophizing contributes to the pain experience [16] , and typically manifests as increased fear in anticipation of pain (magnification), perceived lack of control to avoid that pain (helplessness), and an inability to stop thinking about the pain (rumination). Appropriate measurement tools include the catastrophizing section in the Pain-Related Self-Statements Scale or the Pain Catastrophizing Scale, but their use in those with dementia has never been reported. There is a gap in the knowledge base as we are unaware of a scale that can measure pain catastrophizing by observation (such as using behavior as a proxy). Conceptually, pain catastrophizing also has a strong negative affective component with one study reporting that negative mood accounts for most of pain catastrophizing’s psychological impact on pain [17] . However contesting research suggests that pain catastrophizing is distinct from negative affect and has its own unique contribution on pain disability, independent of depression
future science group
Pain is a complex perceptual phenomenon made evermore complex with comorbid impaired cognition. Multidisciplinary approaches to pain management will need greater integration with existing systems to ensure best care. Both pharmacological and non-pharmacological approaches to pain management may be useful for persons with dementia, with limited evidence for the efficacy of non-pharmacological approaches [20,21] . The contributing role of depression in those with pain and dementia may also need greater scrutiny. Benchmarks for a successful treatment may also need adjustment. Complete pain relief is not always the most appropriate goal. Improved function may be an entirely reasonable marker of success. Another appropriate outcome is improved mental health. For patients with severe impairment, lengthy direct observation may be the most viable assessment tool to gauge treatment outcome. What exciting developments do you foresee in the pain management of people with impaired cognition? QQ
There is increasing recognition that pain may be a cause of problematic behaviors in persons with dementia [22] . With a foundation of appropriate assessment tools, a greater emphasis on pain management approaches would be of benefit. Neuroimaging that identifies objective markers of pain will further advance the field, as may future technologies (such as identifying behavioral indicators of pain using facial recognition software). However, current and future studies on improving the evidence base that guides routine clinical practice may be the most exciting development of all in the field of pain management of persons with dementia. Disclaimer The opinions expressed in this interview are those of the interviewees and do not necessarily reflect the views of Future Medicine Ltd.
www.futuremedicine.com
337
ASK THE EXPERTS Savvas & Gibson Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes
References 1
2
3
4
5
6
7
338
Proctor WR, Hirdes JP. Pain and cognitive status among nursing home residents in Canada. Pain Res. Manag. 6(3), 119–125 (2001). Wu N, Miller SC, Lapane K, Roy J, Mor V. Impact of cognitive function on assessments of nursing home residents’ pain. Med. Care 43(9), 934–939 (2005).
employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
8
Kunz M, Mylius V, Scharmann S, Schepelman K, Lautenbacher S. Influence of dementia on multiple components of pain. Eur. J. Pain 13(3), 317–325 (2009).
9
Jensen-Dahm C, Werner MU, Dahl JB et al. Quantitative sensory testing and pain tolerance in patients with mild to moderate Alzheimer disease compared with healthy control subjects. Pain 155(8), 1439–1445 (2014).
Walid MS, Zaytseva N. Pain in nursing home residents and correlation with neuropsychiatric disorders. Pain Physician 12(5), 877–880 (2009).
10 Ferrell BA, Ferrell BR, Rivera L. Pain in
Leong IY-O, Nuo TH. Prevalence of pain in nursing home residents with different cognitive and communicative abilities. Clin. J. Pain 23(2), 119–127 (2007).
11 Benedetti F, Arduino C, Costa S et al. Loss of
Patel KV, Guralnik JM, Dansie EJ, Turk DC. Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study. Pain 154(12), 2649–2657 (2013).
12 Husebo BS, Achterberg WP, Lobbezoo F
Monroe TB, Gore JC, Chen LM, Mion LC, Cowan RL. Pain in people with Alzheimer disease: potential applications for psychophysical and neurophysiological research. J. Geriatr. Psychiatry Neurol. 25(4), 240–255 (2012). Benedetti F, Arduino C, Vighetti S, Asteggiano G, Tarenzi L, Rainero I. Pain reactivity in Alzheimer patients with different degrees of cognitive impairment and brain electrical activity deterioration. Pain 111(1–2), 22–29 (2004).
cognitively impaired nursing home patients. J. Pain Symptom Manage. 10(8), 591–598 (1995). expectation-related mechanisms in Alzheimer’s disease makes analgesic therapies less effective. Pain 121(1–2), 133–144 (2006). et al. Pain in patients with dementia: a review of pain assessment and treatment challenges. Nor. Epidemiol. 22(2), 243–251 (2012). 13 Haasum Y, Fastbom J, Fratiglioni L, Kåreholt
I, Johnell K. Pain treatment in elderly persons with and without dementia: a populationbased study of institutionalized and home-dwelling elderly. Drugs Aging 28(4), 283–293 (2011). 14 Lövheim 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(9), 912–918 (2008). 15 Husebo BS, Ballard C, Sandvik R, Nilsen
OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents
Pain Manag. (2014) 4(5)
of nursing homes with dementia: cluster randomised clinical trial. Br. Med. J. 343, d4065 (2011). 16 Wood BM, Nicholas MK, Blyth F, Asghari A,
Gibson S. Catastrophizing mediates the relationship between pain intensity and depressed mood in older adults with persistent pain. J. Am. Pain Soc. 14(2), 149–157 (2013). 17 Hirsh AT, George SZ, Riley JL 3rd, Robinson
ME. An evaluation of the measurement of pain catastrophizing by the coping strategies questionnaire. Eur. J. Pain 1(1), 75–81 (2007). 18 Sullivan MJ, Stanish W, Waite H, Sullivan
M, Tripp DA. Catastrophizing, pain, and disability in patients with soft-tissue injuries. Pain 77(3), 253–260 (1998). 19 Smeets RJEM, Vlaeyen JWS, Kester ADM,
Knottnerus JA. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J. Pain 7(4), 261–271 (2006). 20 Bradford A, Shrestha S, Snow ALet al.
Managing Pain to Prevent Aggression in People With Dementia A Nonpharmacologic Intervention. Am. J. Alzheimers Dis. Other Demen. 27(1) 41–47 (2012). 21 Pieper MJC, van Dalen-Kok AH, Francke AL
et al. Interventions targeting pain or behaviour in dementia: A systematic review. Ageing Res. Rev. 12(4), 1042–1055 (2013). 22 Gibson SJ. What does an increased prevalence
of behavioral and psychological symptoms of dementia in individuals with pain mean? Pain 153(2), 261–262 (2012).
future science group
Treating pain in patients with impaired cognition Steven M Savvas*,1 Dr Savvas is an early career researcher in psycho pharmacology with a PhD in Medicine (Pharmacology) from the University of Adelaide. He has extensive experience in clinical trials, having worked in a number of roles since 2006, and has a track record for conducting research in challenging areas such as drug dependence and dementia. Since 2011, he has worked at the National Ageing Research Institute and published in the geriatric field in dementia, pain and aged care. He is currently the coordinator for a large multi-site clinical trial involving people with pain and dementia in residential aged care.
Stephen J Gibson1 Professor Gibson is the chair of the International Association for the Study of Pain special interest group for pain in older persons and a past President of the Australian Pain Society. He has been involved in pain research for over 25 years and is currently the Deputy Director of the National Ageing Research Institute and Director of Research at the Caulfield Pain Management and Research Centre, Australia. Professor Gibson is a registered psychologist and holds the position of Professor within the Department of Medicine, University of Melbourne. He was awarded the 2006 Pfizer international visiting professorship in pain medicine and remains active in clinical practice via his involvement with multidisciplinary pain management centers. Professor Gibson has contributed to more than 150 peer-reviewed publications and is a sought after speaker at international meetings. His current research interests include studies on pain assessment and treatment in persons with dementia, age differences in pain and its impacts as well as the implementation of pain management guidelines into the residential aged-care sector.
‘Impaired cognition’ can encapsulate many disorders, disabilities and diseases, affecting people of any age, but this article will focus on older adults in pain and with dementia. Key points discussed in this article may, however, be generalizable to other groups with impaired cognition. Note also that those with pain and dementia are not a homogenous group – etiology and severity of dementia will likely influence the person’s experience of pain, its clinical identification and assessment, as well as treatment modalities. Furthermore, the challenges associated with research on pain in severe dementia have resulted in considerable gaps in the evidence base. As such, the largest body of work in this area relates to persons with mild to moderate Alzheimer’s disease who have some capacity to self-report their pain. National Ageing Research Institute, Melbourne, Australia *Author for correspondence: Tel.: +61 383 872 465; Fax: +61 39 3874 030; [email protected]. 1
10.2217/PMT.14.27 © 2014 Future Medicine Ltd
Pain Manag. (2014) 4(5), 335–338
part of
ISSN 1758-1869
335
ASK THE EXPERTS Savvas & Gibson What are the main challenges associated with treating pain in people with impaired cognition? QQ
Dementia may affect the experience of pain itself though research in this area is equivocal. Studies relying on proxy pain report (e.g., the patient has limited capacity to self-report their own pain) provide some evidence that the prevalence of pain diminishes as dementia severity increases [1–3] . However when self-report is possible the research is less consistent. Some studies suggest pain prevalence does not differ in persons with dementia (or that pain may even increase), albeit the requirement for self-report necessarily precludes those with more severe dementia and in which greatest degree of change might be expected [4,5] . Research using experimental pain techniques in conjunction with neuroimaging demonstrate that dementia related brain changes may alter lateral (sensory) and medial (affective) pain-related brain pathways (for a review see Monroe et al. [6]). Some acute pain studies of when pain is just noticeable suggest pain threshold in persons with Alzheimer’s disease is not significantly different [7,8] , and conclude that the sensory processing of pain remains relatively intact in persons with dementia (at least in the early progression of Alzheimer’s disease). However, pain tolerance studies on the limits of pain endurance are still inconclusive. They demonstrate an increase, no difference or even a decrease in pain tolerance, which may be specific to the modality of the pain administered [9] . The clinician likewise faces challenges in investigating pain in people with dementia. Patients with cognitive impairment can often still selfreport pain [10] in a reliable and valid way, though there may be increasing reliance on proxy report as dementia severity worsens. Observer-rated pain assessment scales that measure behavioral indicators of pain have merit, but even behavioral signs (principally the facial, body and verbal cues) might eventually be lost in very advanced dementia. Other indirect measures that may be attributable to pain, such as general agitation, depression and hostility, or other measures such as function and quality of life, could also have utility. As pharmacological treatment approaches have a primary role in pain management in persons with dementia, due consideration is needed regarding the pharmacokinetics, pharmacodynamics and side effects profile of pain management drugs. Studies of placebo responses in persons with Alzheimer’s disease suggest an attenuated effectiveness and therefore an
336
Pain Manag. (2014) 4(5)
increased dose of analgesic to achieve the same level of pain relief [11] . Risks and benefits of drug administration may need careful balancing, particularly when managing pain with opioids. Finally, patient engagement with treatment may also be a limiting factor, for instance refusing medication and other forms of non-compliance such as forgetting appropriate drug dosage and timing. How has the pain management of this population changed over the last 10 years? QQ
Earlier research in this field suggested an insufficient use of analgesics in the treatment of patients with dementia (for review see Husebo et al. [12]), though more recent studies indicate this has possibly been reversed (with even potential overtreatment) [13,14] . The proliferation of observational pain assessment tools in the last decade has complemented greater scrutiny of pain management in those with dementia and highlighted greater awareness of behaviors that may be indicative of potential pain. With an arsenal of appropriate scales, focus has started to shift to treatment methodologies. A stepwise pain management approach using escalating dose, stronger analgesics or adjuncts is gaining recognition as an appropriate pain management method in persons with dementia. For example, a recent study demonstrated the efficacy of an 8 week stepwise protocol (with paracetamol, oral morphine, buprenorphine patch, or oral pregabaline) in reducing agitation and pain in people with moderate to severe dementia [15] . What do you view as the key concepts the physician must keep in mind when treating this population? QQ
There are four key concepts: 1) A greater awareness of pain as an issue in patients with dementia, as well as mindfulness that dementia severity and type may substantively impact the pain management approach; 2) Self-report of pain is often possible. When not possible (often with more severe dementia), observational pain scales are recommended. Movement often exacerbates pain so a thorough mobilization should be conducted during pain assessment, particularly when using observational scales; 3) Due to differences in pharmacokinetic and pharmacodynamics drug profiles when administered to older patients and/ or persons with dementia, individual titration of analgesics that considers the individual risks and benefits of treatment is important. Dosage deemed
future science group
Treating pain in patients with impaired cognition appropriate in cognitively intact patients may be inadequate in older persons with dementia; 4) Pain relief may not be the sole end point. Improving function or protecting existing body systems, minimizing harm or side effects, improving quality of life, mental health or even maintenance of existing cognitive function, may have equal or greater merit in evaluating treatment success.
ASK THE EXPERTS
and anxiety [18] . Treating negative affect globally in the patient in pain with dementia may secondarily improve pain catastrophizing. Cognitivebehavior treatment approaches that modify pain beliefs and coping skills may also have some use [19] , though the evidence base is limited and dementia severity would be a limiting factor. Looking forward, what needs to be implemented in the clinic in order to ensure the best possible care? QQ
Observer-rated pain assessment instruments for people with dementia have proliferated in recent years. What are, currently, the best options? QQ
There is no consensus on which tool is best, and tool selection may vary according to setting and need. For example, the NOPPAIN is easy to use for carers and nursing assistants, whilst the PAINAD may be more appropriate for more highly trained staff in aged care. The ABBEY is quick to administer and the CNPI requires little training. The ALGOPLUS is designed for monitoring acute pain and the DOLOPLUS has been widely translated into other languages and is suitable in a number of settings. The PACSLAC is a comprehensive assessment scale, though somewhat lengthy to administer. How much of a problem is pain catastrophizing in this population and how can a clinician measure and treat it? QQ
The relationship between catastrophizing and pain in persons with dementia is largely unknown. In the cognitively intact, pain catastrophizing contributes to the pain experience [16] , and typically manifests as increased fear in anticipation of pain (magnification), perceived lack of control to avoid that pain (helplessness), and an inability to stop thinking about the pain (rumination). Appropriate measurement tools include the catastrophizing section in the Pain-Related Self-Statements Scale or the Pain Catastrophizing Scale, but their use in those with dementia has never been reported. There is a gap in the knowledge base as we are unaware of a scale that can measure pain catastrophizing by observation (such as using behavior as a proxy). Conceptually, pain catastrophizing also has a strong negative affective component with one study reporting that negative mood accounts for most of pain catastrophizing’s psychological impact on pain [17] . However contesting research suggests that pain catastrophizing is distinct from negative affect and has its own unique contribution on pain disability, independent of depression
future science group
Pain is a complex perceptual phenomenon made evermore complex with comorbid impaired cognition. Multidisciplinary approaches to pain management will need greater integration with existing systems to ensure best care. Both pharmacological and non-pharmacological approaches to pain management may be useful for persons with dementia, with limited evidence for the efficacy of non-pharmacological approaches [20,21] . The contributing role of depression in those with pain and dementia may also need greater scrutiny. Benchmarks for a successful treatment may also need adjustment. Complete pain relief is not always the most appropriate goal. Improved function may be an entirely reasonable marker of success. Another appropriate outcome is improved mental health. For patients with severe impairment, lengthy direct observation may be the most viable assessment tool to gauge treatment outcome. What exciting developments do you foresee in the pain management of people with impaired cognition? QQ
There is increasing recognition that pain may be a cause of problematic behaviors in persons with dementia [22] . With a foundation of appropriate assessment tools, a greater emphasis on pain management approaches would be of benefit. Neuroimaging that identifies objective markers of pain will further advance the field, as may future technologies (such as identifying behavioral indicators of pain using facial recognition software). However, current and future studies on improving the evidence base that guides routine clinical practice may be the most exciting development of all in the field of pain management of persons with dementia. Disclaimer The opinions expressed in this interview are those of the interviewees and do not necessarily reflect the views of Future Medicine Ltd.
www.futuremedicine.com
337
ASK THE EXPERTS Savvas & Gibson Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes
References 1
2
3
4
5
6
7
338
Proctor WR, Hirdes JP. Pain and cognitive status among nursing home residents in Canada. Pain Res. Manag. 6(3), 119–125 (2001). Wu N, Miller SC, Lapane K, Roy J, Mor V. Impact of cognitive function on assessments of nursing home residents’ pain. Med. Care 43(9), 934–939 (2005).
employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
8
Kunz M, Mylius V, Scharmann S, Schepelman K, Lautenbacher S. Influence of dementia on multiple components of pain. Eur. J. Pain 13(3), 317–325 (2009).
9
Jensen-Dahm C, Werner MU, Dahl JB et al. Quantitative sensory testing and pain tolerance in patients with mild to moderate Alzheimer disease compared with healthy control subjects. Pain 155(8), 1439–1445 (2014).
Walid MS, Zaytseva N. Pain in nursing home residents and correlation with neuropsychiatric disorders. Pain Physician 12(5), 877–880 (2009).
10 Ferrell BA, Ferrell BR, Rivera L. Pain in
Leong IY-O, Nuo TH. Prevalence of pain in nursing home residents with different cognitive and communicative abilities. Clin. J. Pain 23(2), 119–127 (2007).
11 Benedetti F, Arduino C, Costa S et al. Loss of
Patel KV, Guralnik JM, Dansie EJ, Turk DC. Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study. Pain 154(12), 2649–2657 (2013).
12 Husebo BS, Achterberg WP, Lobbezoo F
Monroe TB, Gore JC, Chen LM, Mion LC, Cowan RL. Pain in people with Alzheimer disease: potential applications for psychophysical and neurophysiological research. J. Geriatr. Psychiatry Neurol. 25(4), 240–255 (2012). Benedetti F, Arduino C, Vighetti S, Asteggiano G, Tarenzi L, Rainero I. Pain reactivity in Alzheimer patients with different degrees of cognitive impairment and brain electrical activity deterioration. Pain 111(1–2), 22–29 (2004).
cognitively impaired nursing home patients. J. Pain Symptom Manage. 10(8), 591–598 (1995). expectation-related mechanisms in Alzheimer’s disease makes analgesic therapies less effective. Pain 121(1–2), 133–144 (2006). et al. Pain in patients with dementia: a review of pain assessment and treatment challenges. Nor. Epidemiol. 22(2), 243–251 (2012). 13 Haasum Y, Fastbom J, Fratiglioni L, Kåreholt
I, Johnell K. Pain treatment in elderly persons with and without dementia: a populationbased study of institutionalized and home-dwelling elderly. Drugs Aging 28(4), 283–293 (2011). 14 Lövheim 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(9), 912–918 (2008). 15 Husebo BS, Ballard C, Sandvik R, Nilsen
OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents
Pain Manag. (2014) 4(5)
of nursing homes with dementia: cluster randomised clinical trial. Br. Med. J. 343, d4065 (2011). 16 Wood BM, Nicholas MK, Blyth F, Asghari A,
Gibson S. Catastrophizing mediates the relationship between pain intensity and depressed mood in older adults with persistent pain. J. Am. Pain Soc. 14(2), 149–157 (2013). 17 Hirsh AT, George SZ, Riley JL 3rd, Robinson
ME. An evaluation of the measurement of pain catastrophizing by the coping strategies questionnaire. Eur. J. Pain 1(1), 75–81 (2007). 18 Sullivan MJ, Stanish W, Waite H, Sullivan
M, Tripp DA. Catastrophizing, pain, and disability in patients with soft-tissue injuries. Pain 77(3), 253–260 (1998). 19 Smeets RJEM, Vlaeyen JWS, Kester ADM,
Knottnerus JA. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J. Pain 7(4), 261–271 (2006). 20 Bradford A, Shrestha S, Snow ALet al.
Managing Pain to Prevent Aggression in People With Dementia A Nonpharmacologic Intervention. Am. J. Alzheimers Dis. Other Demen. 27(1) 41–47 (2012). 21 Pieper MJC, van Dalen-Kok AH, Francke AL
et al. Interventions targeting pain or behaviour in dementia: A systematic review. Ageing Res. Rev. 12(4), 1042–1055 (2013). 22 Gibson SJ. What does an increased prevalence
of behavioral and psychological symptoms of dementia in individuals with pain mean? Pain 153(2), 261–262 (2012).
future science group
