Reduced use of analgesics in Alzheimer’s disease
Assessment of pain in dementia
Reduced use of analgesics in Alzheimer’s disease • Possible explanations:
• Possible explanations: - A change in pain experience - A decline in communication
Autonomic responses to pain
• Rainero et al. 2000
- A change in pain experience - A decline in communication
Relatively intact in Alzheimer Medial pain system
Lateral pain system SI
SII
Alzheimer’s disease
ACC
SII PO
PO Hypo
Insula
TMN
Insula PVN RN
IL
Medial Vcpc
Vcpor
Amyg
Hippo
IL
Medial Lateral
Sens/discrim Motiv/affect
Mesencephalon
SMT
Cogn/e valuat
PAG
Pain memory Autono mic
Reticular formation
SRT STT
PBN LC
STT
Later stages/ partly aff. AD< FTD AD>FTD No studies
Dorsal + ventral horn
Dorsal horn
1
Assessment vital sensitivity • Sensory-discriminative aspects of pain -pinprick -touch (cotton wool) -temperature
Bijdragen aan pijndiagnostiek bij dementie
Pain assessment in communicative patients Verbal Rating Scales
• • • • • •
Neuropsychologie Autonome reacties op pijn (?) Onderzoek vitale sensibiliteit Self-report pain rating scales Observatie-schalen Pijn-meetmomenten in de zorg
•Verbal Descriptor Scale; no pain → worst pain •Verbal Rating Scale; words like ‘distressing’
Pain aspects Intensity Intensity/affect
Visual Rating Scales •Visual Analogue scale; no pain → worst pain •Faces Pain Scale; no pain → worst pain
Pain aspects Intensity Intensity/affect
Numerical Rating Scales •Numeric Rating Scale; 1–10 horizontal line •21-point Box Scale; no pain → worst pain
Pain aspects Intensity Intensity
The Coloured Analogue Scale (McGrath et al., 1996)
Ferrell et al., 1995
2
The Facial Affective Scale (McGrath et al., 1996) The Faces Pain Scale (Bieri et al., 1990)
Comprehension of the scales 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
no-AD early AD midstage AD
CAS
FPS
FAS
Pain assessment in non-communicative patients
Facial Action Coding System (FACS)
Observationscales •DS-DAT; 9 indicators •CNPI; 6 indicatoren, e.g. pain faces •NOPPAIN; e.g. pain faces •PACSLAC; e.g. pain faces •Doloplus 2 •PAINAD
Pain aspects Intensity/affect Intensity/affect Intensity/affect Intensity/affect Intensity/affect Intensity/affect
www.cityofhope.org/prc/elderly.asp
Buigen Staan
Rust
DS-DAT: Discomfort Scale-Dementia of Alzheimer Type CNPI: Checklist of Nonverbal Pain Indicators NOPPAIN: Non-Communicative Patient’s Pain Assessment Instrument PACSLAC: Pain Assessment Checklist for Seniors with Limited Ability to Communicate
3
PACSLAC-D (Zwakhalen et al., 2006)
Gelaat
o
a
Uitdrukking van pijn Een specifiek geluid of uiting van pijn ‘au’ of ‘oef’ Wenkbrauwen fronsen Grimas Rimpels in het voorhoofd Kreunen en kermen
Verzet/afweer Verbale agressie Fysieke agressie (bijv. mensen en/of voorwerpen wegduwen, anderen krabben, anderen slaan, stompen, schoppen) Geërgerd (geagiteerd) Achteruitdeinzen Niet aangeraakt willen worden Niet-coöperatief/weerstand tegen zorgverlening Sociaal emotioneel/stemming Nors/prikkelbaar
Verandering in de ogen (scheel kijken, mat, helder, meer bewegingen) Pijnlijke plek aanraken en vasthouden
Schreeuwen/krijsen Donkere blik Verdrietige blik
Pijnlijke plek beschermen Terugtrekken
Geen mensen in de buurt laten komen Ontsteld (ontdaan) Blozend, rood gelaat Rusteloos
Pijn-meetmomenten in de zorg • Ook belangrijk bij mensen die zelf GEEN pijn aangeven • Dagelijks, twee keer • Tijdens ADL en moment zonder interactie
4
Dank voor uw aandacht !
Pain experience in dementia: its relationship with cognition
Erik J.A. Scherder, PhD Institute for Human Movement Sciences Rijksuniversiteit Groningen The Netherlands Email:
[email protected]
Sensory-discriminative aspects
Sensory-discriminative aspects
Lateral pain system
Lateral pain system
Medial pain system
Medial pain system
EF
Cogn.
Medial pain system
evaluat.
Medial pain system
aspects
Episodic memory
Motivational-affective aspects
Participants • • • • • • •
19 AD patients: 20 controls: MMSE AD-group: MMSE controls: Level of education: Comorbidity: Painful conditions:
mean age: 86.37 years mean age 85.70 years mean: 19.63 (17-24) mean: 27.30 (24-30) no significant difference no significant difference arhrosis/arthritis of the lower extremty or at the lumbar spine
5
The Coloured Analogue Scale (McGrath et al., 1996) The Faces Pain Scale (Bieri et al., 1990)
‘Medial pain system’
‘Medial pain system’
Vital and gnostic sensitivity • Vital sensitivity -sensory-discriminative aspects of pain -simultanous extinction -temperature • Gnostic sensitivity -position sense
Neuropsychological tests • Focused on: – Executive functions – Memory – Significant differences between both groups
Lateral pain system
Depressie en Angst • Beck Depression Inventory (max. 63) • Symptom Check List (SCL-90) -depression: max. score = 80 -anxiety: max. score = 50
BDI -AD group: -control group:
mean/sd: 4.26/4.17 mean/sd: 9.75/5.39
t(37) = 3.54, p = .001
6
SCL90 Depression • AD group: • Control group:
mean/sd: 18.28/4.31 mean/sd: 24.05/6.01
Results
• t(37) = 3.43, p = .002
Pain scales
AD patients
M
SD
M
SD
F
df
p<
η2
21.55 27.00
22.69 29.67
50.85 45.89
23.24 23.36
5.79 4.50
1,34 1,34
.02 .04
.14 .12
CAS Pain Affect 1 CAS Pain Affect 2
15.79 20.89
21.34 27.17
41.20 40.83
29.01 27.59
2.33 4.77
1,35 1,34
.136 .036
.06 .12
Faces Pain Scale 1 Faces Pain Scale 2
.56 .79
.70 1.05
2.39 2.33
1.69 1.45
8.81 5.53
1,32 1,26
.006 .027
.22 .18
NWC-A 1 NWC-A 2
2.00 2.35
2.69 3.64
4.42 3.78
2.67 3.00
.517 .15
1,34 1,32
.477 .701
.02 .01
Older persons without dementia
EF
Memory
CAS Pain Intensity
CAS Pain Affect
Faces Pain Scale
NWC-A
-
.618*
-.102
-.353
-.084
-.322
Memory
.618*
-
.069
-.192
-.230
-.262
.190
Depression
-.099
-.428
.453
.465
.347
.587*
.480
SCL-90 Anxiety
.280
.267
.072
-.153
-.033
.105
EF
Memory
CAS Pain Intensity
CAS Pain Affect
-
-.030
.400
.328
.713**
.034
EF
Memory
-.030
-
.409
.517
.149
.206
Depression
-.014
.042
.038
.109
-.207
SCL-90 Anxiety
-.345
.067
.020
.218
-.366
EF
ANCOVA
CAS Pain Intensity 1 CAS Pain Intensity 2
Patients with Alzheimer’s disease
Faces Pain Scale
Older persons without dementia
NWC-A
7
Neuropsychology: contribution to pain assesment in dementia?
Pain assessment in the nursing homes • 2 moments of measurement in 24 h • Improvement in assessment and treatment
8
