Management of Pain in Hospitalized Patients With Cognitive Impairment

Paracetamol should be the first choice for pain treatment in older patients with pain and cognitive impairment, indicated a recently published study in BMC Geriatrics. The drug is both effective and relatively safe in these individuals. Pain is a personal and subjective experience, which could be disabling both physically and psychologically. Untreated pain could have major implications on the health, functioning and quality of life of an older adult. Most often the older adults suffer from multiple medical conditions, consequently could have multiple types and sources of pain. Although it is highly prevalent, evidence suggests that pain is often poorly assessed and poorly managed, especially in older adults and particularly in those with cognitive impairment due to dementia and/or delirium.

The assessment and treatment of pain in persons with cognitive impairments unique challenges, one of them being that they are unable to communicate clearly about their level of pain and discomfort. Research has shown that pain is often under recognized and under treated in people with dementia mainly because they are less likely to ask for and receive analgesics.

Due to the complexity of the problem in elderly people with cognitive impairment, it is very challenging to conduct randomized controlled trials in these patients, leading to an overall lack of high quality evidence base for this group of population. However, there is no dearth of expert opinions in this matter, which in fact could be considered as a useful database for clinical practice.

The aim of the study recently published in BMC Geriatrics was to collect information and expert opinion on management of pain in hospitalized older people who were cognitively impaired. Many Consultant Geriatricians/Dementia Leads listed in the National Dementia Audit were contacted electronically. They were provided with a questionnaire with case scenarios to try and see the different pain management strategies they used.

Of the 88 individuals who were successfully contacted, 37 responses were finally included in the analysis. Nearly 85% of individuals rated themselves as 7 or above when asked to rate their confidence level in managing each case on a scale of 1 to 10 where 1 = Not confident and 10 = Very confident.

Use of analgesic medication

• There was a general consensus that paracetamol, whether used orally or intravenously should be the first line of treatment since its efficacy profile is well established, its side effects are minimal and it has no effect on cognition.
• Respondents stressed the need for weighing the side effects of opiates like delirium before prescribing them.
• It was also seen that weak opiates such as co-codamol, codeine and dihydrocodeine were not a preferred choice mainly due to their unwanted side effects on cognitive and bowel function; opioid drugs are commonly associated with constipation.
• Tramadol was also not a drug of choice for the elderly due to its potential to precipitate delirium.
• Nearly 91% of respondents suggested using morphine sulphate after checking the patient’s renal function.
• Nearly 77% used oxycodone due to a favorable side effect profile when compared to morphine.
• 80% of respondents agreed that nefopam should be avoided mainly due to its anticholinergic properties with significant risk of delirium.
• Most respondents advised against the use of oral NSAIDs in patients with cognitive impairment. They could be used for short periods along with anti-ulcer medications or for local use.
• Most respondents either avoided amitriptyline or advised use with extreme caution. Amitriptyline is effective in neuropathic pain but can worsen delirium. Pregabalin and gabapentin can also worsen sedation and confusion.

Monitoring and reviewing

There was a general awareness that since all pain medications have potential side effects, it was important to review and monitor patients and possibly co-prescribe medications to minimize these side effects e.g., gastric protection during NSAID use.

Whereas most of the respondents agreed that assessment and re-assessment of pain was crucial, about one third of respondents used clinical assessment alone. Others used established pain assessment tools such as ABBEY, PAINAID etc.

Strengths of the study

• Respondents participated willingly without any pressure being put on them.
• The response rate to the questionnaire was 48% and most of respondents were quite confident in the management of different pain scenarios.
• Results were analyzed using mixed method approach.

Limitations of the study

• Results are based on expert opinion and there is evidence gap in the management of pain
• The total number of respondents is small even though the response rate is good.

The study revealed lack of consensus regarding management of pain in cognitively impaired hospitalized older people, which just highlight the complexity of this clinical field. Patients should be comprehensively assessed and analgesics should be selected with the aim of minimizing side effects.

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Source-Medindia