The Hospice Clinician Blog

A systematic approach to the management of pain may significantly reduce agitation in residents of nursing homes with moderate to severe dementia. Agitation and aggression are common in people with dementia, in particular those with moderate to severe dementia living in nursing homes. Agitation is distressing to patients, caregivers and healthcare professionals, and is one of the most challenging symptoms to manage. Antipsychotics are often used as first-line drug treatment for agitation and aggression, but this practice has been called into question with a growing body of research indicating that antipsychotics increase the risk of stroke and death in elderly patients with dementia.

It has been proposed that untreated pain may manifest as agitation in patients with dementia who are often unable to verbalize their pain. With this in mind, a group of Norwegian investigators sought to evaluate whether systematic use of analgesics can reduce agitation in residents of nursing homes with moderate to severe dementia. The results of their study were presented at the Fourth International Conference on Pain and Impaired Cognition and previously published in the British Medical Journal.

In this study, 352 residents with moderate to severe dementia and clinically significant behavioral disturbances were randomized to a stepwise pain management protocol (n=175) or to usual treatment (n=177). Participants in the intervention group received individualized daily treatment of pain for eight weeks according to a stepwise protocol.  The control group received usual treatment and care, which could include antipsychotics or other psychotropic medications.

The stepwise pain management protocol included the following steps:

Step 1: Paracetamol (acetaminophen), up to 3,000 mg per day

Step 2: Morphine 5 mg BID, could be increased up to 10 mg

BID

Step 3: Buprenorphine transdermal patch 5 mcg/hr, could be increased up to 10 mcg/hr

Step 4: Pregabalin 25 mg daily, could be increased up to 300 mg per

day

Patients already receiving acetaminophen automatically started at either Step 2, Step 3 (if unable to swallow), or Step 4 (if known neuropathic pain). Combination therapy was allowed, and if the patient did not tolerate treatment the dose was reduced or the participant was withdrawn from the study. The medications were offered at breakfast, lunch and dinner.

In the treatment group, the researchers found a significant reduction in agitation after eight weeks (P<0.001), based on scores on the Cohen-Mansfield Agitation Inventory (CMAI). The average reduction in CMAI score after the treatment period was 17% with analgesia treatment compared with standard care (P<0.001). After the pain treatment was withdrawn at week 8, there was a worsening of agitation scores in the treatment group so that there was no difference in agitation scores between the two groups at week 12. As would be expected, pain scores were significantly lower with stepwise analgesia. Patients in the treatment group also experienced significant relative reductions in aggression during the study and the follow-up period, but there were no significant improvements in activities of daily living or cognition.

“Individual pain treatment can reduce the severity of agitation in patients with moderate or severe dementia,” concluded lead investigator Bettina Husebo, PhD. Patients with an expected survival of 6 months or less were excluded from this study, which does limit the applicability of the results to our hospice population. However, these findings do emphasize the importance of assessing and treating pain effectively as part of the overall treatment and prevention of agitation and aggression in patients with dementia. The results also highlight the potential value of effective treatment of pain as a key part of reducing the use of antipsychotics and other psychotropic drugs in residents of nursing homes. “With the exception of severe and dangerous symptoms, analgesics should be considered for this condition before initiating symptomatic treatment with antipsychotic drugs,” said Husebo.

Reference

Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomized clinical trial. BMJ 2011; 343: d4065.