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      Are Chronic Pain Patients with Dementia Being Undermedicated?

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          Abstract

          In dementia, neuropathological changes alter the perception and expression of pain. For clinicians and family members, this knowledge gap leads to difficulties in recognizing and assessing chronic pain, which may consequently result in persons with dementia receiving lower levels of pain medication compared to those without cognitive impairment. Although this situation seems to have improved in recent years, considerable geographical variation persists. Over the last decade, opioid use has received global attention as a result of overuse and the risk of addiction, while the literature on older persons with dementia actually suggests undertreatment. This review stresses the importance of reliable assessment and the regular evaluation and monitoring of symptoms in persons with dementia. Based on current evidence, we concluded that chronic pain is still undertreated in dementia.

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          Most cited references 64

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          Pain management in patients with dementia

          There are an estimated 35 million people with dementia across the world, of whom 50% experience regular pain. Despite this, current assessment and treatment of pain in this patient group are inadequate. In addition to the discomfort and distress caused by pain, it is frequently the underlying cause of behavioral symptoms, which can lead to inappropriate treatment with antipsychotic medications. Pain also contributes to further complications in treatment and care. This review explores four key perspectives of pain management in dementia and makes recommendations for practice and research. The first perspective discussed is the considerable uncertainty within the literature on the impact of dementia neuropathology on pain perception and processing in Alzheimer’s disease and other dementias, where white matter lesions and brain atrophy appear to influence the neurobiology of pain. The second perspective considers the assessment of pain in dementia. This is challenging, particularly because of the limited capacity of self-report by these individuals, which means that assessment relies in large part on observational methods. A number of tools are available but the psychometric quality and clinical utility of these are uncertain. The evidence for efficient treatment (the third perspective) with analgesics is also limited, with few statistically well-powered trials. The most promising evidence supports the use of stepped treatment approaches, and indicates the benefit of pain and behavioral interventions on both these important symptoms. The fourth perspective debates further difficulties in pain management due to the lack of sufficient training and education for health care professionals at all levels, where evidence-based guidance is urgently needed. To address the current inadequate management of pain in dementia, a comprehensive approach is needed. This would include an accurate, validated assessment tool that is sensitive to different types of pain and therapeutic effects, supported by better training and support for care staff across all settings.
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            An English translation of Alzheimer's 1907 paper, "Uber eine eigenartige Erkankung der Hirnrinde".

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              An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia

              This systematic overview reports findings from systematic reviews of randomized controlled trials of pharmacological and non-pharmacological interventions for behavioural and psychological symptoms of dementia (BPSD). The Cochrane Database of Systematic Reviews, DARE, Medline, EMBASE, and PsycINFO were searched to September 2015. Fifteen systematic reviews of eighteen different interventions were included. A significant improvement in BPSD was seen with: functional analysis-based interventions (GRADE quality of evidence moderate; standardized mean difference (SMD) −0.10, 95%CI −0.20 to 0.00), music therapy (low; SMD −0.49, 95%CI −0.82 to −0.17), analgesics (low; SMD −0.24, 95%CI −0.47 to −0.01), donepezil (high; SMD −0.15 95% CI −0.29 to −0.01), galantamine (high; SMD −0.15, 95%CI −0.28 to −0.03), and antipsychotics (high; SMD −0.13, 95%CI −0.21 to −0.06). The estimate of effect size for most interventions was small. Although some pharmacological interventions had a slightly larger effect size, current evidence suggests functional analysis-based interventions should be used as first line management of BPSD whenever possible due to the lack of associated adverse events. Music therapy may also be beneficial, but further research is required as the quality of evidence to support its use is low. Cholinesterase inhibitors donepezil and galantamine should be trialled for the management of BPSD where non-pharmacological treatments have failed. Low-quality evidence suggests that assessment of pain should be conducted and a stepped analgesic approach trialled when appropriate. Antipsychotics have proven effectiveness but should be avoided where possible due to the high risk of serious adverse events and availability of safer alternatives.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                jpr
                jpainres
                Journal of Pain Research
                Dove
                1178-7090
                15 February 2021
                2021
                : 14
                : 431-439
                Affiliations
                [1 ]Department of Public Health and Primary Care, Leiden University Medical Center , RC Leiden, 2300, the Netherlands
                [2 ]Department of Global Public Health and Primary Care, University of Bergen , Bergen, 5020, Norway
                [3 ]Department of Medical Psychology, University of Augsburg , Augsburg, 86156, Germany
                [4 ]Department of Physical Psychology, University of Bamberg , Bamberg, Germany
                Author notes
                Correspondence: Wilco P Achterberg Department of Public Health and Primary Care, Leiden University Medical Center , Hippocratespad 21, Postzone V0-P, Room V6-76, PO Box 9600, RC Leiden, 2300, the NetherlandsTel +31 71 5268412/8427; + 31 6 23668980 Email w.p.achterberg@lumc.nl
                Article
                239321
                10.2147/JPR.S239321
                7894836
                © 2021 Achterberg et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 0, References: 64, Pages: 9
                Categories
                Review

                Anesthesiology & Pain management

                pain, dementia, assessment, analgesic treatment

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