Pain Assessment in Patients with Minimal Cognitive Deficit and Mild DementiaPublished on 16 December 2021
The self-report of the affected person is also the "gold standard" for the assessment of pain in people with minimal cognitive deficit and mild dementia. It is recommended to conduct a multidimensional pain assessment in the form of an interview even in the case of acute pain, which includes both pain-specific (localization, quality and quantity) and functional findings (especially daily living skills, mobility, cognition).
Not everyone will develop dementia if they live long enough. Nevertheless, dementia-related illnesses are, along with strokes, the diseases of old age that pose the greatest threat to the independent lifestyle of older people. The number is expected to rise to 2.4 million people in Germany by 2030. Reliable data on pain in the very old (>80-85 years) are still not available for Germany, on the one hand because many epidemiological studies do not take this age group into account, and on the other hand because pain is defined very differently (temporal dimension, intensity, impairment by pain, etc.). The recording of pain in the elderly, especially with minimal cognitive deficit and mild dementia, is time-consuming and generally only valid in interview form. Self-completed questionnaires are only answered very inadequately due to sensory and cognitive impairments. In geriatric facilities, about 40% of patients report pain. In nursing homes, 40% to 80% suffer from persistent pain. Accordingly, the likelihood of minimal cognitive deficit, dementia, and pain occurring together is very high. The diagnosis of both a cognitive disorder and a pain problem is usually made by taking a conscientious history of oneself and others. Psychological tests, laboratory chemistry and technical examinations can narrow down the aetiology of a cognitive disorder. Clinical and technical examinations help to clarify the cause of pain.
Contrary to the common perception that the elderly complain a lot about their ailments, it has been scientifically proven that the elderly, especially those with cognitive impairment, tend to express pain spontaneously less often. The following views are cited as reasons by those affected: Pain as a natural consequence of aging, pain as a metaphor for serious illness or impending death, pain as atonement for past deeds, pain as one's weakness, pain as a positive challenge, fear of invasive diagnosis and therapy, fear of loss of control, fear of side effects of therapy, fear of dependence. Finally, a "good" person does not complain about his or her complaints. In addition, there are often: communication problems and memory problems. Therefore, perhaps the most important measure to improve the pain situation of the elderly is the frequent asking about pain or possibly the recording of changed mobility and behaviour patterns. Experimental results suggest that pain thresholds remain largely unchanged under the influence of AD, whereas pain tolerance thresholds are significantly elevated and autonomic pain responses are sometimes substantially reduced. In contrast, the pain tolerance threshold tends to decrease with increasing age in people without dementia as a function of the pain stimulus. Comparative clinical studies in multimorbid, geriatric patients initially confirm the differences between chronic and acute pain known in younger people. Chronic pain is more multilocular, the pain description is more varied, it is more often accompanied by depressive symptoms and sleep disturbances, and stronger analgesics are used, with only a smaller reduction in pain intensity during treatment. If cognitive impairments are added, patients find it more difficult to clearly name a circumscribed pain location in acute pain (diffuse pain localization). Overall, older pain patients are less able to describe the character of their pain. On the other hand, the intensity of pain (sensory dimension) appears to be rather independent of the severity of the cognitive impairment, at least in those people who can still perform an intensity assessment.
Gathering information in older people, especially those with cognitive impairments, is more time-consuming than in younger people. However, this should not lead to the initiation of potentially dangerous therapies on the basis of vague assumptions or to lapse into diagnostic and therapeutic nihilism. In many cases, all the necessary information can be obtained from the patient's own history and that of others, if the pain assessment is adapted to the linguistic, sensory and cognitive circumstances of the person concerned. The simplest way to ask about pain is to ask questions that can be answered yes or no, relate to the current situation, and are asked in the patient's familiar (colloquial) language. If these questions are deliberately asked in both a rest and an activity situation, or if they can be combined with other observations, additional information can be obtained about the movement dependence of the pain. Questions about pain in the last few days or weeks should be avoided, as deficits in short-term memory are considered a cardinal symptom of cognitive impairment, which is why prompt documentation is obvious. Differentiating between average, maximum or minimum pain levels is also generally difficult for people with only minor cognitive impairments.
Pain and functionality
Information on pain (location, character, course, etc.) is required for adequate treatment. In addition, cognition, daily living skills, emotional well-being and social network are important. While assessment-based instruments have been developed for chronic pain patients to record these various dimensions, even in the case of multimorbid and cognitively impaired patients, the CAREPATH project also offers the possibility of observing and evaluating these aspects virtually in real time. All relevant pain-related information and, as an orientation, all important functions (cognition, daily living skills, depressiveness) are directly or indirectly provided or documented. All relevant pain-related information and all important functions (cognition, physiological parameters) are recorded. Experience with multidimensional pain assessments is available for multimorbid elderly people (>75 years). Up to moderately severe cognitive impairment (minimal status according to Folstein >10 points), all dimensions of the instrument can often be recorded by communicative pain patients in interview form. When grading complaints (e.g. pain intensity), the 11-point numerical estimation scale should be used first. If this cannot be answered by patients, the use of a verbal scale with four pain intensities (no -weak - moderate - strong pain) with the help of a written template is recommended, in our project if necessary also as a mood symbol on a tablet.
External assessment of pain
Especially the pain intensity is often assessed differently by the elderly pain patients themselves than by relatives or by professional caregivers. The knowledge about a pain problem strongly depends on the professional qualification. Geriatric nurses seem to be particularly knowledgeable about their patients' pain. In all professional groups of a geriatric team (physicians, physiotherapists. Occupational therapists. Speech therapists, nursing therapists etc.) the knowledge about pain decreases especially due to frequent changes in care. Here, a trend plot of the data in the CAREPATH project, correlated with other measures, might be helpful. It is expected that the use of structured observation and feasible self-report would improve these results significantly. Therefore, the recommendation for documented, close-meshed monitoring of the pain process in the form of intensity assessments by the patients themselves, supported by their caregivers, seems to be correct, especially for people with pain and cognitive impairment. Only when self-assessment is no longer possible should external assessments be used. In this case, however, the persons concerned would no longer be able to fulfil the other criteria of the project.
Quality of life and dementia
Even in people with cognitive impairments, pain therapy should not only aim at reducing pain intensity, but at improving quality of life (a goal of the CAREPATH project). In the usual observation instruments for the experience of pain, the multidimensionality of quality of life (washing, dressing, movement, etc.) is already at least partially taken into account. Using these in the course of pain treatment, and combining them with other data from the CAREPATH project, especially in order to be able to check the results of pain therapy, offers possibilities for improvement. Since pain experience and function (quality of life) correlate only poorly with each other, especially in the case of older people with chronic pain, it is important to carry out a comprehensive pain assessment in which morbidity, everyday competence, cognition, depression and mobility are also assessed. This pain assessment could be performed in real time by using machine-learning components. This could significantly expand treatment options. Concentrating on analgesics alone can lead to treatment failure. Multimorbid pain patients in old age and with cognitive impairment have a high risk of not being treated adequately. The so-called multimodal pain therapy should already begin in the acute pain therapy for the patient clientele discussed here. Pain in patients with cognitive impairment is a daily challenge for practitioners. Information on pain experience should be documented for the assessment of pain severity and pain behaviour, as well as to monitor success when multiple therapeutic interventions are implemented. The CAREPATH project could make a significant contribution to automated, non-invasive pain recording.