Dementia and pain management during hospital admission
Information below is specific to the use of medicines in the adult setting.
One in four general hospital beds in the UK are occupied by someone over 65 years who has dementia. Almost all staff groups will interact with people with dementia and must be aware of the needs of this patient group and the impact that an admission to hospital may have. All staff should have the recommended skills and knowledge, as described in the Promoting Excellence Framework. Supporting modules for learning are available on Turas.
As dementia progresses, a person living with dementia may have difficulties in communicating their thoughts, feelings and needs with resultant distress, this applies equally to pain. Challenges in communication may mean staff pick up the distress but not that pain is the underlying cause. Sadly pain is a common cause of distressed behaviour in people with dementia. Studies have shown that:
- A systematic approach to pain management can significantly reduce agitation and distress in nursing home residents with moderate/severe dementia.
- Post operatively, people with dementia received one third of the pain relief offered to cognitively intact adults who could express their pain.
KEY MESSAGES FOR PAIN MANAGEMENT
On admission:
- Determine if the patient’s past medical history includes persistent pain. Check if the patient has been admitted with pain or a painful condition that may require analgesia.
- Ensure that Medicines Reconciliation has been completed and includes the patient’s analgesic history and whether this is regular or when required at home.
During admission:
- Ensure that an appropriate pain assessment has been undertaken. The Abbey pain tool (StaffNet link) can be used to assess pain in people who are not able to self-report pain. As per the pain tool, consider physiological signs that could indicate pain e.g. changes in pulse, blood pressure.
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Consult the Adult Therapeutics Handbook GGC Medicines - Prescribing Notes for Palliative Care and Persistent Pain in Older Patients for advice on the choice of analgesic; consider also the adverse effect profile of the analgesic e.g. confusion, drowsiness, constipation.
- HEPMA defaults to ‘PRN’ administration when prescribing paracetamol – take care to change this to regular administration if necessary to reflect patient’s analgesic requirements.
- Consider liquid or patch formulations if the patient has difficulty swallowing tablets.
- Regularly assess and review the pain management plan.
On discharge:
- Discharge is a key time for the review of the pain management plan. Do not revert to the analgesia plan on the admission medicines reconciliation if this is no longer appropriate.
- When prescribing analgesia for discharge, consider the practicalities for administration of medicines at home (e.g. measuring liquids, use of compliance aid) as well as the patient’s clinical requirements for pain management.
REMEMBER
- Pain identification should be a multidisciplinary assessment.
- Patients with dementia may not be able to identify or describe pain. These patients may need to be observed e.g. during movement/examination to allow for assessment of their pain.
- Behavioural changes in people with dementia could be due to pain - analgesia should be trialled before antipsychotics.
- Reduce paracetamol dose if <50kg. Also consider a dose reduction in patients with nutritional deficiency. Refer to the Adult Therapeutics Handbook GGC Medicines - Prescribing Notes for Palliative Care and Persistent Pain in Older Patients for further information.
- Many people in hospital will have undiagnosed dementia or delirium so the above tips should be considered for all people with cognitive impairment. Further information on delirium can be found here.
Further learning on pain management and how to use the Abbey pain tool can be found here.
Published: 27/05/2022. Medicines Update blogs are correct at the time of publishing
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