The Journal of Pain, Vol 8, No 5 (May), 2007: pp 373-378 Available online at www.sciencedirect.com
Pain in Persons With Dementia: Complex, Common, andChallenging
Joseph Shega, Linda Emanuel, Lisa Vargish, Stacie K. Levine, Heide Bursch, Keela Herr,Jordan F. Karp, and Debra K. Weiner
Editor’s Note: This article is one in a series of “Case
Her vital signs are normal, but she lost 7 pounds since
Reviews in Pain” to be presented by The Journal, de-
her last visit 1 month ago. The right ankle was swollen
signed to share scientific and clinical knowledge in a
and painful with range of motion, but no skin break or
case review format. This report presents a discussion of
erythema were noted. An x-ray of the ankle did not re-
pain management in a cognitively impaired older adult.
veal a fracture. Ibuprofen was continued and liquid mor-phine 5 mg orally every 6 hours was added along with an
Case Study
appropriate bowel regimen. Within a few days, the pa-tient’s pain decreased to a mild intensity, her appetite
An 82-year-old woman with moderate Alzhei- improved, she became more social, and the agitation
mer’s dementia presents to clinic with worsen-
resolved without increased confusion or sedation. This
ing agitation, aggression, and social with-
allowed the quetiapine dose to be decreased to the pre-
drawal for the past 2 weeks. Her family reports that
around the same time the patient injured her right anklewhile transferring from the wheelchair to bed. Since that
Case provided by Joseph Shega, MD*
time, the patient reports moderate to severe pain con-
Linda Emanuel, MD, PhD†
tinuously in the ankle with little relief from around-the-
*Division of Hematology-Oncology †
clock ibuprofen. Because of the change in her behaviors,
Director, Beuhler Center on Aging
the dose of her antipsychotic drug, quetiapine, was in-
Northwestern University Feinberg School of Medicine
On review of systems, the patient complains of a poor
Chicago, IL
appetite, difficulty sleeping, and not wanting to leavethe house. Other pertinent history includes spinal steno-sis and knee arthritis (treated with as needed acetamin-
Manifestations of Pain in Cognitively
ophen), depression (treated with sertraline 100 mg
Impaired Older Adults
daily), and blindness. She ambulates 2 to 3 steps withmoderate assistance, mostly related to spinal stenosis
Dementia is one of the leading causes of disability and
and knee arthritis. The patient was diagnosed with Alz-
diminished quality of life in older adults. The prevalence
heimer’s dementia 4 years ago and is dependent in all of
in the United States is expected to quadruple over the
her instrumental activities of daily living; she is continent
next 50 years such that 1 out of 45 Americans will be
and can feed herself, but needs assistance with bathing,
afflicted with the Pain is also a leading contrib-
dressing, and transferring. Cognitively she is oriented to
utor to disability in older adults and occurs in up to 80%
person, place, and year. She can recall 3 out of 3 words
of nursing home residents and 50% of community-dwell-
immediately, but 0 out of 3 words at 5 minutes. Her
ing Older adults often suffer from multiple
coexisting illnesses such as musculoskeletal disorders andperipheral neuropathies that predispose to acute andchronic pain The patient in this case has sev-
Address correspondence to Judith A. Paice, PhD, RN, Editor, Case Reviews inPain; Director, Cancer Pain Program, Northwestern University, Feinberg
eral conditions which increase the risk of developing
School of Medicine, Chicago, IL 60611. E-mail: J-Paice@northwestern.edu
pain, including physical (spinal stenosis, arthritis), cogni-
tive (dementia, depression), and sensory impairments
2007 by the American Pain Societydoi:10.1016/j.jpain.2007.03.003
(blindness). Moreover, she requires assistance with sev-
Physical and psychological impairments due to un-
Table 1. Common Sources of Pain in Older
treated pain can lead to learned helplessness, social iso-
lation, and rising healthcare costs as dependency in ac-
tivities of daily living require more help from caregivers
and medical staff. Undertreated pain has also been asso-
ciated with a decreased self-rated overall health assess-
ment which has shown to be an independent predictor
of The patient in this case exhibited many fac-
tors associated with untreated pain in persons with de-
mentia including poor appetite, weight loss, difficulty
sleeping, and social isolation. Once the painful condition
was treated, her symptoms abated and she returned toher baseline.
The importance of performing thorough evaluations
in cognitively impaired individuals with behavior
eral Activities of Daily Living, such as ambulation, which
changes cannot be underestimated. A patient demon-
puts her at risk for falls and other injuries.
strating new or worsening agitation or social withdrawal
Despite the high prevalence of pain in this population,
may be responding to an unmet need such as hunger,
studies have shown that older patients receive inade-
loneliness, or fear. Behavioral changes may also be due
quate pain control compared with younger individu-
to easily treatable physical discomforts such as constipa-
Cognitively impaired patients may be at great-
tion, urinary retention, improper positioning, or the ex-
est risk of poor pain control due to underrecognition and
acerbation of an underlying painful Because
undertreatment of pain. Alzheimer’s disease leads to
this patient has a history of depression and challenging
pathological changes in the brain that afflict neurologic
behaviors, it was initially thought that an adjustment in
pathways associated with the affective component of
the antipsychotic was indicated. However, treating chal-
pain. It is thought that persons with dementia may per-
lenging behaviors without searching for other etiologies
ceive a painful stimulus normally; however, the ability to
first may lead to unnecessary use of restraints or psycho-
remember, interpret, and respond to pain is
tropics without correcting the root cause. The aggressive
Instead, patients may manifest discomfort through chal-
treatment of pain in this case demonstrates that a pro-
lenging behaviors such as agitation, physical combative-
active approach to screening for, detecting and treating
ness, verbal aggression, disruptive behavior, wandering,
pain can positively impact the quality of life of older
or social withdrawal. These changes can impede care,
adults by effectively controlling symptoms with appro-
create distress in caregivers, and lead to physical re-
straints and psychotropic Identification of
Lisa Vargish, MD
pain in these patients can be challenging as up to 90% of
Stacie K. Levine, MD
cognitively impaired individuals will develop behavioral
Section of Geriatric Medicine
and psychological symptoms from progression of the pri-
Department of Medicine
mary disease Caregivers and clinicians may as-
University of Chicago
sume that worsening behaviors are due to the underly-
Chicago, IL
ing disease process, rather than from a new source ofdiscomfort.
The consequences of unrelieved pain can profoundly
Challenges in Pain Assessment: How Do
impact the quality of life of elderly patients
We Know When the Patient Cannot
Persistent pain leads to functional disturbances such as
impaired ambulation, gait abnormalities, and decreasein recreational Moreover, higher pain scores
Dementia patients experience pain but are often un-
are correlated with increasing levels of physical disability
able to interpret or communicate the sensation in a way
and number of impairments in Activities of Daily Liv-
that is recognizable. Typical presentations of pain such as
Undertreated pain can also lead to impaired psy-chosocial function in older adults. Persons with chronicnonmalignant pain perform lower on neuropsychologi-
Table 2. Consequences of Unrelieved Pain in
cal tests and have poorer mental flexibility than those
Persons With Dementia
without Undertreated pain also results in sig-
nificant mood disturbances such as depression, anxiety,and self-reported loss of enjoyment in In ad-
dition, increased pain intensity is independently associ-
ated with appetite impairment in community-dwelling
older Last, older adults with a history of chronic
bodily pain are more likely to report significant sleep
guarding, bracing or moaning may be replaced by ex-
calling out or asking for help); body movements (eg,
pressions of fear, combativeness, agitation, and with-
rigid and tense, fidgeting, pacing or rocking); interper-
The complexities involved in the identification
sonal interactions (eg, change in aggressive, disruptive
of pain contribute to underdiagnosis and undertreat-
or resistive behaviors or social withdrawal); changes in
ment of pain in the cognitively impaired older patient
activity patterns (eg, eating and sleeping and physical
population as has been highlighted in recent litera-
movement routines); and metal status changes (eg, tear-
fulness and worsening confusion and irritability). Our
A comprehensive pain assessment serves several pur-
patient demonstrated a worsening of agitation, aggres-
poses: to identify the physiological etiology and comor-
sion and social withdrawal, as well as weight loss. These
bidities that contribute and shape the experience of
are all triggers for a comprehensive pain assessment.
pain, to determine the severity of pain and its impact on
Corroboration with knowledgeable informants to
function and quality of life, to develop an intervention
complete items on multidimensional instruments that as-
plan tailored to the individual’s strengths and limita-
sess pain behaviors, mood, quality of life, coping re-
tions, and to monitor and evaluate response to treat-
sources, and social support is an important effort to val-
ment. Clinical practice recommendations for pain assess-
idate presence of pain when obvious etiologies are not
ment in patients with advanced dementia triangulate
present. Caregivers with longstanding patient-relation-
the search for physiological etiologies of pain with self-
ships are in the best position to identify subtle changes in
report, behavioral observation, proxy report, and re-
behavior but all must be educated in recognizing atypi-
cal behavioral presentations as potential pain indica-
This 82-year-old patient has chronic pain due to osteo-
arthritis with spinal stenosis limiting her overall mobility.
If potential pain behaviors persist after basic needs are
Her pain experience is further worsened by depression,
ascertained, pathologic processes are addressed and
Alzheimer’s disease, and blindness. Ideally, her primary
nonpharmacologic interventions attempted, an analge-
caregivers or family members are familiar with her typi-
sic trial is Here, this was done successfully
cal pain behaviors most likely elicited during movement-
only after the patient’s antipsychotic medication dose
based activities such as dressing or transfers. The recent
was increased. When suspecting pain as the cause of a
ankle injury has added severe acute pain and resultant
behavior change, it is advantageous to perform an anal-
anxiety to her controlled persistent pain. Despite cogni-
gesic trial first because it yields a quicker response in
tive impairment this patient is able to localize and rate
normalizing behavior, any adverse reaction to analgesics
her pain, assisting in the differentiation of acute and
are generally less serious, and pain is actually relieved
rather than masked by the sedative effects of the anti-
Many mild to moderately cognitively impaired older
patients are able to report pain in the here and
The Interdisciplinary Expert Consensus Statement on
Standardized pain scales are available to track pain in-
Assessment of Pain in Older offers a compre-
tensity from diagnosis through treatment response with
hensive review of recommendations, tools, and proce-
good reliability and validity. They are easily administered
dures available to clinicians caring for both cognitively
in the clinical setting but should be matched to the pa-
intact and impaired older patients. Adequate assessment
tient’s cognitive and sensory This blind
is essential for clinical decision-making, implementation
patient may be able to use a numeric descriptor scale
and ongoing evaluation of care. As more assessment
although the verbal version requires additional abstract
tools become available and clinicians grow more skilled
thought and is often challenging for persons with cogni-
in detecting pain in the cognitively impaired there is
tive impairment. While a braille formatted pain intensity
hope that this fastest-growing segment of our older
scale may be an option, the use of a simple verbal de-
population will receive the pain relief it deserves but may
scriptor scale that includes none, mild, moderate, and
severe pain is a reasonable alternative. Heide Bursch, RN, MSN
As cognitive impairment progresses to Mini-Mental
Keela Herr, PhD, RN, FAAN, AGSF
Status Exam Scores Ͻ13 and patients become unable to
College of Nursing
respond even to prompting, clinicians and caregivers
University of Iowa
have to rely on observation of pain behaviors. State-of-
Iowa City, IA
the-science reviews of currently available behavioral as-sessment tools provide guidance in selection of a toolthat is clinically usable and psychometrically
Weighing Treatment Options in Older
Assessment of pain behaviors in persons with dementia
Adults With Pain and Dementia
can be comprehensive taking note of changes in baselinebehaviors or focused directly on behaviors as they are
Pain is one of the most common medical symptoms of
apparent during the examination. The American Geriat-
late life, and cognitive dysfunction is the most prevalent
rics organized pain behaviors into six main cat-
psychiatric disturbance. Managing comorbid pain and
egories including facial expressions (eg, fear with frown-
dementia may be challenging because of the potential
ing, grimacing, closed or tightened eyes, or rapid
overlap in their expression. Agitation, confusion, de-
blinking); vocalizations (eg, chanting, noisy breathing,
pressed mood, anorexia, apathy, and impaired sleep may
Table 3. Potential Benefits and Risks of Opioids in Older Adults With Dementia
No change in severity but exposure to potential risks.
Perhaps no change in total number of drugs given; likely need
Increased if concern about dependence/addiction.
Not known – perhaps reduced risk of delirium
May cause cognitive slowing as well as sedation; delirium is possible.
May cause depression and/or agitation.
Nausea and/or constipation may cause impaired appetite.
manifest in patients experiencing pain as well as those
key. That is, the health care provider should educate the
with Practitioners, therefore, must evalu-
patient and their caregiver about the meaning of addic-
ate new symptoms or exacerbation of existing ones as
tion (ie, as compared with dependence) and the very
potential manifestations of either or both disorders.
In addition to the potential for overlap in expression of
Another important consideration in the patient with
pain and dementia, some of the medications used to
comorbid pain and dementia is the concomitant risk of
treat pain, particularly opioid analgesics, may cause
depression. Our patient has prominent neurovegetative
overlapping symptoms such as depression, delirium, and
symptoms including weight loss, poor appetite and dif-
ficulty sleeping as well as agitation, aggression, and re-
ing to initiate these medications, therefore, their associ-
clusiveness. While sleep, appetite, and mood are all af-
ated risks and benefits must be weighed carefully. Our
fected by pain, these symptoms are all also consistent
patient was still in pain despite treatment with both ibu-
with a diagnosis of depression. Given her history of de-
profen and acetaminophen. She also appeared to be de-
pression (which appears to be undertreated at sertraline
pressed despite treatment with sertraline, was becoming
100 mg/d), undertreated pain, dementia, and blindness,
socially isolated, losing weight, and was not sleeping—
she is at risk of developing a major depressive
symptoms associated with poor quality of life and in-
Depression and pain are mutually exacerbating condi-
creased mortality She was also agitated, result-
tions. Although this patient lives in the community, for
ing in increased use of quetiapine. Of note, while the useof such atypical antipsychotics are valuable for the man-
many older adults with dementia, especially those living
agement of agitated older adults with dementia, they
in nursing homes, depression is underdetected and un-
are not without risk and have been associated with in-
To optimize the treatment of painful condi-
creased rates of adverse effects when used for the treat-
tions in older adults with cognitive impairment, aggres-
ment of psychosis, aggression, or agitation in patients
sive treatment of psychiatric comorbidity such as
depression, anxiety, and sleep impairment will improve
analgesia and minimize polypharmacy.
should be considered when weighing the potential risks
Optimal management of the older adult with comor-
and benefits of prescribing opioids for older adults with
bid pain and dementia requires both attention to detail
dementia. Although pain and its attendant comorbidi-
as well as a balanced perspective of the big picture. A
ties may be reduced, opioids are associated with numer-
formulaic approach does not exist. There are no substi-
ous potential side effects such as an increased risk of falls
tutes for careful comprehensive assessment, frequent re-
(less pertinent in our wheelchair-bound patient), seda-
assessment, and ongoing communication with the pa-
tion, delirium, depression, agitation, impaired sleep, and
diminished appetite secondary to nausea and/or consti-pation. Clearly careful monitoring of the older adult in
Jordan F. Karp, MD
whom opioids are initiated is key; it is crucial that the
Department of Psychiatry
practitioner assesses frequently for an appropriate stop
Western Psychiatric Institute and Clinic
date and terminates therapy with the opioid when it is
Pittsburgh, PA
no longer needed. For the opioid-naïve patient, it is also
Debra K. Weiner, MD
important to initiate treatment with a low-dose short
Department of Medicine, Department of Psychiatry
acting agent (eg, liquid morphine, as in this case). Re-
and Department of Anesthesiology
garding the risk of increasing caregiver burden because
University of Pittsburgh School of Medicine
of caregiver concerns about addiction, prevention is the
Pittsburgh, PA References
tients: a systematic review. Anesth Analg 102:1255-1266,2006
1. Bagley H, Cordingley L, Burns A, Mozley CG, Sutcliffe C,
18. Gruber-Baldini AL, Zimmerman S, Boustani M, Watson
Challis D, Huxley P: Recognition of depression by staff in
LC, Williams CS, Reed PS: Characteristics associated with de-
nursing and residential homes. J Clin Nurs 9:445-450, 2000
pression in long-term care residents with dementia. Geron-tologist 45 Spec No 1:50-55, 2005
2. Becker N, Bondegaard Thomsen A, Olsen AK, Sjogren P,Bech P, Eriksen J: Pain epidemiology and health related
19. Hadjistavropoulos T, Herr K, Turk DC, Fine PG, Dworkin
quality of life in chronic non-malignant pain patients re-
RH, Helme R, Jackson K, Parmelee PA, Rudy TE, Lynn Beattie
ferred to a Danish multidisciplinary pain center. Pain 73:393-
B, Chibnall JT, Craig KD, Ferrell B, Ferrell B, Fillingim RB,
Gagliese L, Gallagher R, Gibson SJ, Harrison EL, Katz B, KeefeFJ, Lieber SJ, Lussier D, Schmader KE, Tait RC, Weiner DK,
3. Benedetti F, Arduino C, Vighetti S, Asteggiano G, Tarenzi
Williams J: An interdisciplinary Expert Consensus Statement
L, Rainero I: Pain reactivity in Alzheimer patients with dif-
on Assessment of Pain in Older Persons. Clin J Pain 23:S1-S43,
ferent degrees of cognitive impairment and brain electrical
activity deterioration. Pain 111:22-29, 2004
20. Herr K, Coyne P, Key T, Manworren R, McCaffery M,
4. Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C,
Merkel S, Pelosi-Kelly J, Wild L: Pain assessment in the non-
Dunlop R, Lipsitz L, Steel K, Mor V: Management of pain in
verbal patient: position statement with clinical practice rec-
elderly patients with cancer: SAGE Study Group: Systematic
ommendations. Pain Manag Nurs 7:44-52, 2006
Assessment of Geriatric Drug Use via Epidemiology. JAMA279:1877-1882, 1998
21. Kaasalainen S, Crook J: A comparison of pain-assess-ment tools for use with elderly long-term-care residents.
5. Bosley BN, Weiner DK, Rudy TE, Granieri E: Is chronic
nonmalignant pain associated with decreased appetite inolder adults? Preliminary evidence. J Am Geriatr Soc 52:247-
22. Karp JF, Reynolds CF 3rd, Butters MA, Dew MA, Mazum-
dar S, Begley AE, Lenze E, Weiner DK: The relationship be-tween pain and mental flexibility in older adult pain clinic
6. Boustani M, Zimmerman S, Williams CS, Gruber-Baldini
AL, Watson L, Reed PS, Sloane PD: Characteristics associatedwith behavioral symptoms related to dementia in long-term
23. Kawas CH, Brookmeyer R: Aging and the public health
care residents. Gerontologist 45 Spec No 1:56-61, 2005
effects of dementia. N Engl J Med 344:1160-1161, 2001
7. Brown MN, Lapane KL, Luisi AF: The management of de-
24. Kay DC: Human sleep during chronic morphine intoxica-
pression in older nursing home residents. J Am Geriatr Soc
tion. Psychopharmacologia 44:117-124, 1975
25. Kovach CR, Logan BR, Noonan PE, Schlidt AM, Smerz J,
8. Bruce ML: Psychosocial risk factors for depressive disor-
Simpson M, Wells T: Effects of the Serial Trial Intervention
ders in late life. Biol Psychiatry 52:175-184, 2002
on discomfort and behavior of nursing home residents withdementia. Am J Alzheimers Dis Other Demen 21:147-155,
9. Chibnall JT, Tait RC: Pain assessment in cognitively im-
paired and unimpaired older adults: a comparison of fourscales. Pain 92:173-186, 2001
26. Landi F, Onder G, Cesari M, Russo A, Barillaro C, Berna-bei R, Group S-HS: Pain and its relation to depressive symp-
10. Cipher DJ, Clifford PA, Roper KD: Behavioral manifesta-
toms in frail older people living in the community: an obser-
tions of pain in the demented elderly. J Am Med Dir Assoc
vational study. J Pain Symptom Manage 29:255-262, 2005
27. Lyketsos CG, Lopez O, Jones B, Fitzpatrick AL, Breitner J,
11. Closs SJ, Cash K, Barr B, Briggs M: Cues for the identifi-
DeKosky S: Prevalence of neuropsychiatric symptoms in de-
cation of pain in nursing home residents. Int J Nurs Stud
mentia and mild cognitive impairment: results from the car-
diovascular health study. JAMA 288:1475-1483, 2002
12. Cohen-Mansfield J, Creedon M: Nursing staff members’
28. Lynskey MT, Day C, Hall W: Alcohol and other drug use
perceptions of pain indicators in persons with severe de-
disorders among older-aged people. Drug Alcohol Rev 22:
13. Davis MP, Srivastava M: Demographics, assessment and
29. Moore P, Dimsdale JE: Opioids, sleep, and cancer-re-
management of pain in the elderly. Drugs Aging 20:23-57,
lated fatigue. Med Hypotheses 58:77-82, 2002
30. Morrison RS, Siu AL: A comparison of pain and its treat-
14. Dew MA, Hoch CC, Buysse DJ, Monk TH, Begley AE,
ment in advanced dementia and cognitively intact patients
Houck PR, Hall M, Kupfer DJ, Reynolds CF 3rd: Healthy older
with hip fracture. J Pain Symptom Manage 19:240-248, 2000
adults’ sleep predicts all-cause mortality at 4 to 19 years offollow-up. Psychosom Med 65:63-73, 2003
31. AGS. The management of persistent pain in older persons. Available at:
15. Ferrell BA, Ferrell BR, Osterweil D: Pain in the nursing
16. Foley D, Ancoli-Israel S, Britz P, Walsh J: Sleep distur-
32. Reyes-Gibby CC, Aday L, Cleeland C: Impact of pain on
bances and chronic disease in older adults: results of the
self-rated health in the community-dwelling older adults.
2003 National Sleep Foundation Sleep in America Survey.
33. Schneider LS, Tariot PN, Dagerman KS, Davis SM, Hsiao
17. Fong HK, Sands LP, Leung JM: The role of postoperative
JK, Ismail MS, Lebowitz BD, Lyketsos CG, Ryan JM, Stroup TS,
analgesia in delirium and cognitive decline in elderly pa-
Sultzer DL, Weintraub D, Lieberman JA, Group C-AS: Effec-
tiveness of atypical antipsychotic drugs in patients with
prevalence, characteristics, and outcomes in nursing home
Alzheimer’s disease. N Engl J Med 355:1525-1538, 2006
residents. J Am Geriatr Soc 52:762-767, 2004
34. Scudds RJ, Ostbye T: Pain and pain-related interference
38. Weiner DK, Rudy TE, Morrow L, Slaboda J, Lieber S: The
with function in older Canadians: the Canadian Study of
relationship between pain, neuropsychological perfor-
Health and Aging. Disabil Rehabil 23:654-664, 2001
mance, and physical function in community-dwelling olderadults with chronic low back pain. Pain Med 7:60-70, 2006
35. Sullivan MD, Edlund MJ, Steffick D, Unutzer J: Regularuse of prescribed opioids: association with common psychi-
39. Won AB, Lapane KL, Vallow S, Schein J, Morris JN, Lipsitz
LA: Persistent nonmalignant pain and analgesic prescribingpatterns in elderly nursing home residents. J Am Geriatr Soc
36. Teno JM, Weitzen S, Wetle T, Mor V: Persistent pain in
nursing home residents. JAMA 285:2081, 2001
40. Zwakhalen SM, Hamers JP, Berger MP: The psychometric
37. Teno JM, Kabumoto G, Wetle T, Roy J, Mor V: Daily pain
quality and clinical usefulness of three pain assessment tools
that was excruciating at some time in the previous week:
for elderly people with dementia. Pain 126:210-220, 2006
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