Apr 27, 2016

Reader Asks About Pain Management for a Dementia Patient

I was wondering if you had any resources or information that is credible on pain management in dementia patients.

Pain Management for Dementia Patients | Alzheimer's Reading Room

We just found out my Mom has cancer and is terrible pain. I suspect Hospice will be involved soon but until then they aren't giving her anything except Tylenol and I can't bear to watch the pain.

Searching the web is like an endless confusing pit. I appreciate any insight you might have.

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Here is the answer we obtained from our expert Dr. Rita Jablonski-Jaudon.

Rita Jablonski-Jaudon, PhD, CRNP, FAAN is an internationally recognized researcher and expert on non-drug ways to handle dementia-related behaviors. She is an Associate Professor at the School of Nursing at the University of Alabama at Birmingham and a nurse practitioner in The Memory Disorders Clinic at the Kirklin Clinic, UABMC, Birmingham, Alabama. She can be reached at rjablonski@uabmc.edu

Hi, Bob.

We field questions like this all of the time in my practice.

First of all, if persons with dementia look like they are in pain, they probably are. Period. There are outdated beliefs, such as people with dementia are less sensitive to pain, but that is utter nonsense.

I would recommend that the reader speak to a prescribing clinician (CRNP, MD) in the hospice group and share her concerns.

Also, this article does a nice job of discussing pain management in persons with dementia.

There is a table with behaviors that convey pain.

This other site is a pdf written by a physician from UNC - Pain Management in Dementia.

First of all, a person with dementia may not be able to say, "I hurt," the way you or I would.

But they can communicate "I hurt"
  • through fidgeting, 
  • crying, 
  • moaning, 
  • holding the affected area, 
  • rubbing the affected area, 
  • becoming rigid or restricting their own movments, 
  • and showing agitation (pushing the caregiver away, yelling, even thrashing. 

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Older adults, because of changes in body fat composition and metabolism of drugs, may require smaller dosages of pain medication initially.

The available research recommends a stair-step approach. Start with non-narcotic pain relieving medications such as Tylenol, but stair-step upwards if those medications are not effective.

Ibuprofen and naproxen can be introduced, initially at over-the-counter dosages and then at prescription dosages.

Opiates are appropriate.

I have found that patches, such as fentanyl patches, that release constant low levels of the medication, are effective.

Short-acting opiates can be used for break-through pain. The dosages of these medications can be stair-stepped upwards until the person with dementia is comfortable.

I have also seen persons with dementia on hospice receive non-narcotics, such as antidepressants and seizure medications, in combination with the narcotics, to address types of nerve pain.

Non-drug therapies are also helpful and can be used in combination with drug therapies. Massage, moist heat, or cold compresses (depending on location and type of pain) can be helpful.

Sometimes, clinicians shy away from the more powerful narcotic medications because of side effects like constipation or sedation.

Constipation can be addressed through sufficient liquids and high dietary fiber, or psyllium supplements (e.g. Benefiber), or gentle laxatives. Or a combination of all of the above, depending on the choice of narcotics.

Sedation can accompany an increase in dosage but usually resolves in a day or two. If sedation remains a problem, then the dosages of the medications can be pulled back.

Hope this helps.

Rita A. Jablonski-Jaudon, PhD, CRNP, FAAN

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