In Part I & II, we talked about non-verbal pain indicators in patients with cognitive incapacitation or dementia and how we assess those patients using objective measurements that are widely accepted and used in the medical community. In Part III, I will talk about how I then treat these unique patients for whom compassionate and ethical care is my first consideration and coordination and partnership with their caregivers is next on the priority list.
Ethical Considerations
- Informed Consent – When patients may lack the capacity to consent to treatment, it necessitates surrogate decision-making
- Balancing Benefits and Potential Risks – Pain relief must be weighed with the potential side effects of treatments
- End-of-Life Care – Addressing pain compassionately and completely ensures comfort and dignity in the final stages of life
Family and Caregiver Involvement
Educating and involving family members and caregivers is crucial. They should be trained to recognize pain indicators and implement non-pharmacological interventions. Support groups and resources can also provide much-needed assistance and emotional support.
Treatments
Pharmacological Interventions
- Non-Opioid Analgesics – Acetaminophen is often the first-line treatment due to its safety profile.
- Adjuvant Medications – Antidepressants, anticonvulsants, and topical agents can be useful, especially for neuropathic pain.
- Opioids – Used with extreme caution due to risks of sedation, delirium, and constipation. Regular review and dose adjustment are essential. I would really hesitate to use these in any patient with dementia unless there was a really pressing reason to do so.
Non-Pharmacological Interventions
- Physical Therapy – Gentle exercises and physical activities can help maintain mobility and reduce pain. Modalities feel good and help to increase circulation or reduce inflammation as needed. Patients who have more advanced dementia may not participate in exercises or understand instructions.
Psychological and Behavioral Approaches
- Cognitive-Behavioral Therapy (CBT) – Modified CBT can help address pain perception and coping mechanisms. Again, this therapy would be for patients with milder cognitive impairment, not for those with greater dementia.
- Distraction Techniques – Activities that engage the patient, such as music, art, or pet therapy, can divert attention from pain. These are appropriate for all levels of impairment and have proven to be therapeutic and beneficial.
How do we know the Pain Management Regimen is Helping?
In the same way that we used the assessment tools to measure pain, we can also use the assessment tools to measure a lack of pain or a decrease in pain. We can compare the results of our first assessment to the results of our assessment after treatment for pain. There will also be obvious physical indicators to look for as well:
- Relaxed body posture
- Smiling or relaxed face
- No moaning, crying or howling
- Consolable
- Interested in surroundings
- Has an appetite for food and drink
- May verbalize feeling better!
- Behavior indicates they feel better!