Posted .November 18, 2015
Pain is a subjective complaint for which health care professionals usually depend on patient self-report to determine whether the patient
is suffering from it and whether it is severe enough to warrant being addressed.
However, geriatric patients may suffer from impairments in communication due to problems such as strokes, Alzheimer disease, and Parkinson disease. Thus, commonly used instruments to assess pain, such as the Visual Analogue Scale and Verbal Numeric Rating Scale, may have limited roles for these patients.6 Other instruments, most of which were originally developed for young children, have been employed for older patients. These include the Faces Scale, where patients are asked to rate their level of discomfort based on facial expressions ranging from smiling to crying, and the Pain Thermometer, which uses the image of a thermometer and asks the patient to rate the pain according to this.
However, even these instruments require a degree of ability to communicate in order to obtain valid and useful information, and thus they may be unusable for certain cognitively impaired patients. For them, health care professionals must change their focus from waiting for these patients to complain about pain before addressing it to careful observation of them to identify behaviors that indicate discomfort, such as grimacing or inability to sit or lie comfortably.
The role pain plays in behavioral and psychiatric symptoms in patients with cognitive impairment is often overlooked, but it has been shown that pain can be associated with socially inappropriate behavior, resistance to care, abnormal thought process, and delusions.9 Instead of treating these problems with psychotropic medications as is commonly done, treating the pain, the probable underlying cause, makes more sense. Addressing and reducing pain can have a significant impact on behavioral disturbances in patients with dementia.
A study that examined the association between analgesic medications and delirium found that for patients in whom severe acute pain is likely to be present, most notably in patients with hip fractures, lower doses of opioids were associated with an increased risk of delirium. The authors speculated that this may have resulted from undertreatment of the pain and that this contributed to the development of delirium. They specifically noted that although opioids need to be used cautiously in patients at increased risk for delirium, fear of this should not prevent the appropriate treatment of pain.
Unfortunately, even when physicians recognize the presence of pain among these patients, their attempts to alleviate the pain may fail because they do not take into account the patient’s status. For example, in hospitals it is common to prescribe analgesic medications to be administered when the patient requests them. Obviously, patients who are unable to communicate will not be able to ask for them. The physicians may feel they have addressed the pain by prescribing medications in this manner without recognizing that it is unlikely that the patients will ever receive them.