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Pain in different demographics

Updated: Mar 7, 2022




Paediatric considerations


Elderly considerations


Neurocognitive (dementia) considerations


Epidemiology

60-80% of people with dementia regularly experience pain

1 in 3 have moderate to severe pain

Nociceptive is the most common type (70%)

Types of chronic pain are different in the elderly e.g orofacial pain due to poor oral health


Identifying/testing for pain

Pain is usually signaled by verbal communication - this is more difficult in dementia due to cognitive and communicative limitations


Tools:


Self-report

Asked in interviews or standardised forms in pain scales

Generally with MMSE <18 cannot reliably report pain

Visual analogue scale may be beyond the understanding of dementia patients

Numerical scales, or simply 'yes' or 'no' can be useful


Observer ratings

Necessary in moderate to severe dementia

Three behavioural demains to observe - Facial response, vocalisation, and body posture/movement

Interobserver rating scale variability leads to unproven reliability and low validity

However, simply TRYING to use a scale leads to improved recognition in nursing homes

Pain Assessment in Impaired Cognition (PAIC-15) - awaits testing


Assessing psychological comorbidities is even harder!


Automatic pain recognition

Often video based and target facial responses to pain

However machine learning is often on younger individuals which skews the results


Negative outcomes of pain

Chronic pain leads to increased levels of memory decline

Worse pain can lead to worse behavioral symptoms

Pain consequences are more severe in the elderly due to lower functional independence and increased social isolation


Implementation

Comprehensive treatment plan creation with a focus on interdisciplinary approaches and multimodal pain management plans


Non-pharmacological management options

Most research is in cognitively intact adults - as those with cognitive impairment are often excluded from trials


Exercise is 'assumed' to be beneficial for pain in individuals with dementia

This needs to be tailored to the individual of course


Psychological is likely to be difficult in moderate to severe dementia due to inability for cognitive processing required for therapies such as CBT, mindfulness etc.


Music therapy has evidence in the treatment of the behavioral and psychological symptoms of dementia (BPSD). It may assist with pain but there is a lack of evidence


Other considerations include: Massage, heat therapy, rocking chair therapy, rest, reiki


Pharmacological

Analgesic use in nursing homes is increasing world-wide


Paracetamol

For mild/moderate pain in advanced dementia


NSAIDs

SHOULD BE AVOIDED


Opioids

Buprenorphine is popular as can be given via patch. Side effects include the normal's but specifically in dementia - Personality change, confusion, sedation, somnolence

There are only studies on morphine and oxycodone - and these are limited


Adjuvants

No clinical trials on their safety. Likely to be risky due to significant psychotropic risk


Ref: Achterberg, Wilcoa,*; Lautenbacher, Stefanb; Husebo, Bettinac; Erdal, Anec; Herr, Keelad Pain in dementia, PAIN Reports: January/February 2020 - Volume 5 - Issue 1 - p e803


Males vs females




ATSIH patients

  1. Important to ask about whether they identify as indigenous

  2. Clear and respectful identification of roles

  3. Confidentiality needs to be assured

  4. Respectful discussion includes consideration of cultural values

  5. Conversational or ‘yarning’ style of consult with open questions may be best

  6. Recognise and use Aboriginal providers and supports

  7. Person centred, or even family centred approaches are best

  8. Registration forms and questionnaires may be viewed with mistrust given a general cultural divide of respect between government and ATSI peoples

  9. understand impact of cultural days and events e.g. sorry periods

  10. Flexible approach to appointment times is important

  11. Consider both general and health literacy

  12. Aim to have multiple contact numbers

  13. Consider affordability and socio-economic disadvantage

  14. Cultural, historical, and spiritual factors need to be considered

  15. Gender comfort may impact consult and needs to be asked about

  16. There may be reluctance to express pain due to shame concerns





Pregnancy



References:




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