Neurology Central

Pain in adults with dementia: does it exist?

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As we are seeing a significant increase in the older population, we are also aware that the population with some form of dementia is increasing. We believe that currently there are around 850,000 adults with dementia in the UK [1] and we anticipate that there will be over 44 million worldwide by 2020 [2].

Dementia, as with any form of cognitive impairment, prevents effective communication of pain. In the past, this failure to articulate pain in a language that we can understand has resulted in poor pain management and often older adults with communication difficulties have not received analgesic drugs following surgery. This in itself is a major failing of our healthcare system. Similarly, we have examples of underprescribing, underadministration and even the belief that older adults feel pain ‘differently’ or that pain perception reduces with age [3].

Measuring pain – opportunities and challenges

One of the difficulties in pain management for the older population is our lack of resources to enable identification of pain. Whilst we have many recognized tools available to help us measure pain intensity in the general adult population, for example visual analog scales or verbal descriptors, these tools are not always appropriate for the older population.

Generally the rule of thumb for the older population is to use either verbal descriptors (none, mild, moderate, severe) or the numerical rating scale (0-10). These scales are purported to be useful in older adults even where mild to moderate cognitive impairment exists [4], but it is important to ask questions in different ways. For example: “does it hurt?”, “is it sore?” may elicit a response where “do you have pain?” does not.

Where severe cognitive impairment exists, it may be useful to adopt one of the behavioral pain assessment tools. A recent review of the literature suggests that there are 12 tools in total [5]; PainAd, PacSlac, PADE and Doloplus are just four examples and we can certainly recommend that no more scales need to be developed. More research to investigate and support the most appropriate scale is however desperately needed.

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