Pain, agitation, and behavioural problems in people with dementia admitted to general hospital wards: a longitudinal cohort study

Intersection of pain and behavioural and psychological symptoms of dementia in Alzheimer's disease

BACKGROUND

Pain is highly prevalent but challenging to assess in individuals with dementia. Non-cognitive symptoms, such as behavioural and psychological symptoms of dementia (BPSD) and undetected pain, can severely impair functionality and degrade the quality of life for Alzheimer's disease patients. This study aims to examine the relationship between pain and BPSD in patients with Alzheimer's disease.

METHODS

A hospital-based, cross-sectional study using a convenience sampling technique was conducted with Alzheimer's disease patients attending an outpatient clinic at a tertiary care geriatric centre. Participants' cognitive impairment was assessed using the Mini-Mental State Examination (MMSE), pain severity was evaluated with the Numeric Rating Scale (NRS) and Pain Assessment in Advanced Dementia (PAIN-AD) scale, and BPSD was measured using the Behavioural Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD). Over 6 months, 50 participants who met the inclusion and exclusion criteria were included.

RESULTS

The median age of the participants was 69 years, with a median MMSE score of 16. All participants experienced some level of pain and exhibited at least one BPSD. Statistical analysis revealed a significant association between both subjective and objective pain and behavioural and psychological symptoms. A strong correlation was also observed between NRS and PAIN-AD scores with affective disturbances and anxieties.

CONCLUSION

Common occurrence of pain and BPSD in Alzheimer's disease among the Indian population underscores the importance of pain assessment and management for enhancing patient well-being.

The meaning of "total pain" in the context of living and dying with dementia

Background

Globally, there are 55 million people living with dementia (PLWD). PLWD have an uncertain prognosis. Most are approaching the end of life but are not overtly or immediately dying. Contemporary approaches to dementia care therefore promote the need to live and die well with dementia. Pain is highly prevalent but difficult to manage in PLWD. Originating in palliative care, "total pain" conceives of pain holistically, incorporating biological, psychological, social and spiritual elements. Pain management in dementia care tends to be pharmacologically focused. Total pain therefore offers an alternative approach-one consistent with person-centred philosophy underpinning contemporary dementia care. Due to important differences, concepts cannot simply be extrapolated from cancer-related to dementia-related palliative care however. Dementia-specific approaches are needed and require exploration.

Description and objective of the analysis

The objective of this paper is to explore the meaning of total pain in the context of living and dying with dementia, and its utility and implications for person-centred dementia care. Using a palliative care framework and existing literature, we critically consider the bio-psycho-socio-spiritual impact of dementia, to explore how total pain might manifest and be experienced in this context.

Findings and interpretation

We highlight the complexity, nuance and socially contingent nature of the impact of living and dying with dementia. We challenge binary understandings of "continuity or loss" (e.g., of identity, relationships), and totalising "loss" discourses, demonstrating that more subtle, varied and hopeful outcomes are possible. The way that the impact of dementia is articulated and understood has implications for the experience and management of total pain. The deficit-orientation of "total pain" paradoxically risks its perpetuation. A balanced understanding of dementia's impact (acknowledging both continuity and loss, alternatives and socially constructed aspects) better reflects the realities of dementia and creates new possibilities for supportive care practices to improve pain management and quality of life.

Conclusion and implications for practice

Applied to dementia care, "total pain" should be located within a critical context, emphasising complexity, contingency and nuance. The holistic focus of "total pain" should be extended to incorporate balanced consideration of "painful" and "functional" experience. We introduce a balanced model of total pain incorporating a dual focus on "pain" and "personhood" within a critical context, to facilitate translation to practice. There is a need to develop evidence-based supportive interventions in each domain of total pain, to support a balanced approach to total pain management in dementia care.

Behavioural disorders and sleep problems in Sanfilippo syndrome: overlaps with some other conditions and importance indications

Sanfilippo syndrome (MPS III) is one of the types of mucopolysaccharidoses (MPS), a group of inherited metabolic diseases in which the accumulation of glycosaminoglycans (GAGs) results from deficiency of different lysosomal enzymes. The hallmarks of MPS III are relatively minor somatic abnormalities with severe and progressive central nervous system (CNS) symptoms. An analysis of the literature showed that the biggest problems for carers of people with MPS III are behavioural disorders and sleep disorders. Despite extensive discussions on improving the quality of life of patients, little attention was paid to the families/carers of patients. The families/carers are providing appropriate medical and palliative care to the patient every day due to their loss of mobility, self-care skills, tube feeding, airway clearance and other supports continue to have an adverse effect on the quality of life of families/carers. However, a literature review of possible solutions showed that effective methods (both pharmacological and non-pharmacological) exist. The needs of carers of MPS III patients should receive as much attention as the search for new treatments. There are many options for dealing with such problems. The key issue is to identify the source of the problem and choose the most effective therapy. Alleviating behavioural disorders, pain complaints and sleep problems will have a positive impact not only on the quality of life of carers/families, but also on the patients themselves.

Pain-Induced Delirium in Patient with Dementia: A Case Report and Narrative Review

Pain management is the hallmark of palliative care; however, pain is commonly underassessed in cases of advanced dementia and delirium (acute confusional state). We present a case of a 66-year-old female patient with severe dementia who was hospitalized because of behavioral changes and sleep disturbance. Symptoms of confusion, disorientation, inattention, and agitation were most severe at night. The patient never complained of any pain. Thorough examination revealed delirium superimposed on dementia with behavioral and psychological symptoms of dementia, frozen shoulder, osteoarthritis, tooth pain, and geriatric syndrome. Treatment with tablets memantine 5 mg q.12 h, donepezil 10 mg q.day, haloperidol 1 mg q.12 h, lorazepam 1 mg q.day (if necessary), acetaminophen 500 mg q.8 h, and methylprednisolone 4 mg q.8 h, along with psychosocial support, improved her symptoms. Pain often manifests as neuropsychiatric symptoms, resulting in inappropriate use of antipsychotics. Precise pain assessment and effective treatment are imperative, particularly in advanced dementia. Underassessed and undertreated pain in dementia may lead to delirium and progression of dementia. It is paramount for future studies to emphasize comprehensive multidimensional pain assessment and total pain to better manage pain in advanced dementia, which will further enhance psychological well-being and quality of life in palliative care.

Incidence and factors associated with agitation in patients on mechanical ventilators in Amhara Region, North-West Ethiopia: a multi-center study

Agitation is a common psychomotor disorder among critically ill patients on mechanical ventilators, posing significant risks to patients and adding strain to clinical services. Despite its importance, there is a lack of data on the incidence and contributing factors of agitation in the study area and across Ethiopia. This study, therefore, aims to assess the incidence and factors associated with agitation in patients on mechanical ventilators in the intensive care units of comprehensive specialized hospitals in the Amhara Region, North-West Ethiopia. A multi-center prospective follow-up study was conducted among 253 critically ill adult patients on mechanical ventilators in the Amhara region of Ethiopia from April 17, 2024, to July 16, 2024. Data were collected using a semi-structured questionnaire through chart reviews, observations, and interviews. Participants were selected using a consecutive sampling technique. The data were entered into Epi-Data version 4.6 and transferred to Stata version 17 for analysis. Bivariable and multivariable logistic regression analyses were performed to identify factors associated with agitation. Variables with a p value of less than 0.2 in the bivariable analysis were included in the multivariable analysis. Crude and adjusted odds ratios with 95% confidence intervals were used to identify factors associated with agitation. The results were presented in the form of text, tables, and figures. In the multivariable analysis, variables with a p value of less than 0.05 were considered statistically significant predictors. The overall incidence of agitation among patients on mechanical ventilators in intensive care units was 87.35% (95% CI 82.6, 91.2). Anxiety (Adjusted Odds Ratio (AOR) 3.5; 95% CI 1.28, 9.45), delirium (AOR 3.01; 95% CI 1.13, 7.97), pain (AOR 3.23; 95% CI 1.18, 8.85), hyperthermia (AOR 3.49; 95% CI 1.004, 12.15), hyponatremia (AOR 3.64; 95% CI 1.009, 13.11), and the use of restraints (AOR 3.49; 95% CI 1.11, 8.67) were statistically significant factors associated with agitation. In this study, the majority of participants experienced agitation. To reduce the incidence of agitation, we recommend addressing or preventing the development of anxiety, pain, delirium, hyperthermia, and hyponatremia, as well as minimizing the use of restraints in intensive care units.

Evaluation of the psychometric properties of PainChek in older general hospital patients with dementia

BACKGROUND

Pain is common in people with dementia in general hospitals. This can be difficult to identify.

OBJECTIVES

To evaluate the psychometric properties of PainChek electronic pain assessment tool.

DESIGN

Cross-sectional psychometric study.

SETTING

Six medical care of older people wards from two general hospitals in greater London, UK.

SUBJECTS

63 people with clinical diagnosis of dementia: mean 84 years (SD 6.7), 59% female, 69% living in their own homes, 64% white British, 77% moderate/severe dementia.

METHOD

Psychometric evaluation of PainChek, a point-of-care electronic pain assessment tool combining artificial intelligence, facial analysis and smartphone technology. From a total of 216 assessments, we tested PainChek's inter-rater reliability (IRR) (Cohen's kappa), internal consistency (Cronbach's alpha) and concurrent validity (Pearson's coefficient) between PainChek and Pain Assessment in Advanced Dementia (PAINAD) scores at rest and post-movement [95% confidence interval (95% CI) where appropriate]. We assessed convergent validity with Symptom Management-End of Life in Dementia scale (SM-EOLD) (Pearson's coefficient) and discriminant validity (rest vs post-movement).

RESULTS

IRR was 0.714 (95% CI 0.562 to 0.81) (rest) and 0.817 (95% CI 0.692 to 0.894) (post-movement). Internal consistency was 0.755 (rest) and 0.833 (post-movement). Concurrent validity with PAINAD was 0.528 (95% CI 0.317 to 0.690) (rest) and 0.787 (0.604 to 0.891) (post-movement). Convergent validity with SM-EOLD was -0.555 (95% CI -0.726 to -0.318) (rest) and -0.5644 (95% CI -0.733 to -0.331) (post-movement). Discriminant validity was significant.

CONCLUSIONS

PainChek is a valid and reliable pain assessment tool for people with dementia in general hospitals. Further consideration will be needed for implementation into this setting.

Behavioural and psychological symptoms of people with dementia in acute hospital settings: a systematic review and meta-analysis

BACKGROUND

Behavioural and psychological symptoms of dementia (BPSD) can complicate acute hospital care, but evidence on BPSD in this setting is heterogeneous.

OBJECTIVE

To determine the prevalence of BPSD in acute hospitals and explore related risk factors, treatments, and outcomes (PROSPERO: CRD42023406294).

METHODS

We conducted a systematic review and meta-analysis by searching Cochrane Library, MEDLINE, and PsycINFO for studies on BPSD prevalence among older people with dementia during their acute hospital admissions (up to 5 March 2024). Independent double-review processes were used for study screening, selection, and data extraction. Data on 12 BPSD symptoms were extracted based on the Neuropsychiatric Inventory Questionnaire (NPI) and Behavioural Pathology in Alzheimer's Disease (BEHAVE-ad). Risk factors, treatments, and outcomes were summarised. Meta-analysis was used to synthesise results.

RESULTS

Out of 15 101 records, 30 articles from 23 studies were included. Most studies were rated as moderate (n = 12) to poor (n = 17) quality. Meta-analysis revealed a pooled prevalence of overall BPSD (one or more BPSD symptoms) at 60% (95% CI = 43-78%) among older inpatients with dementia in acute hospitals (N = 11 studies). Subgroup analysis showed variations in the overall BPSD prevalence based on assessment tools (BEHAVE-ad = 85%, NPI = 74%, Others = 40%). Common BPSD symptoms included aggression/agitation (39%), sleep problems (38%), eating problems (36%), and irritability (32%). BPSD were linked to delirium, pain, increased use of uncomfortable interventions, psychotropic medication uses and higher caregiver distress. Poor patient-staff interactions and fragmented discharge plans often led to frequent emergency admissions and hospital readmissions.

CONCLUSION

Healthcare systems should implement tailored approaches for managing BPSD in acute hospitals, enhance staff training, improve caregiver communication, and develop integrated discharge plans.

Nurses' Beliefs About Pain Assessment in Dementia: A Qualitative Study Informed by the Theory of Planned Behaviour

AIM

To explore registered nurses' beliefs regarding pain assessment in people living with dementia.

DESIGN

A descriptive exploratory qualitative study informed by the Theory of Planned Behaviour.

METHODS

Online semi-structured in-depth interviews were conducted from January to April 2023 with a purposive sample of 15 registered nurses caring for people with dementia. Following transcription, data were analysed using direct content analysis.

FINDINGS

Registered nurses believe pain assessment improves the well-being of people with dementia and informs and evaluates practice. However, there is a possibility of misdiagnosing pain as agitation or behavioural problems, leading to inaccurate pain management. Interpersonal factors, such as registered nurses' knowledge and experience, beliefs and motivation to improve care provision, were the primary facilitators of pain assessment. Physical and behavioural dimensions of the pain of the dementia syndrome were the most reported barriers to pain assessment. Registered nurses reported that multidisciplinary team members expect them to do pain assessments. Most did not experience disapproval when performing pain assessments.

CONCLUSION

Registered nurses hold beliefs about pain assessment benefits, consequences, enablers, barriers, approvals and disapprovals regarding dementia. The findings could inform interventions to enhance pain assessment practices.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Policymakers should provide education opportunities for registered nurses to improve their knowledge, skills and beliefs about pain assessment in dementia. Future research should develop and implement multidisciplinary, multifaceted pain assessment protocols to enhance the accuracy of pain assessment practices.

IMPACT

Pain is underassessed in dementia, and this could stem from registered nurses' beliefs about pain assessment in dementia. The findings could inform interventions to enhance pain assessment beliefs and practices.

REPORTING METHOD

This study adhered to the COREQ criteria.

PATIENT OR PUBLIC CONTRIBUTION

Registered nurses caring for people living with dementia participated as interview respondents.

Impact of Hospitalizations on Problematic Medication Use Among Community-Dwelling Persons With Dementia

BACKGROUND

Hospitalizations are frequently disruptive for persons with dementia (PWD) in part due to the use of potentially problematic medications for complications such as delirium, pain, and insomnia. We sought to determine the impact of hospitalizations on problematic medication prescribing in the months following hospitalization.

METHODS

We included community-dwelling PWD in the Health and Retirement Study aged ≥66 with a hospitalization from 2008 to 2018. We characterized problematic medications as medications that negatively affect cognition (strongly anticholinergics/sedative-hypnotics), medications from the 2019 Beers criteria, and medications from STOPP-V2. To capture durable changes, we compared problematic medications 4 weeks prehospitalization (baseline) to 4 months posthospitalization period. We used a generalized linear mixed model with Poisson distribution adjusting for age, sex, comorbidity count, prehospital chronic medications, and timepoint.

RESULTS

Among 1 475 PWD, 504 had a qualifying hospitalization (median age 84 (IQR = 79-90), 66% female, 17% Black). There was a small increase in problematic medications from the baseline to posthospitalization timepoint that did not reach statistical significance (adjusted mean 1.28 vs 1.40, difference 0.12 (95% CI -0.03, 0.26), p = .12). Results were consistent across medication domains and certain subgroups. In one prespecified subgroup, individuals on <5 prehospital chronic medications showed a greater increase in posthospital problematic medications compared with those on ≥5 medications (p = .04 for interaction, mean increase from baseline to posthospitalization of 0.25 for those with <5 medications (95% CI 0.05, 0.44) vs. 0.06 (95% CI -0.12, 0.25) for those with ≥5 medications).

CONCLUSIONS

Hospitalizations had a small, nonstatistically significant effect on longer-term problematic medication use among PWD.

Technological interventions in European dementia care: a systematic review of acceptance and attitudes among people living with dementia, caregivers, and healthcare workers

Background

Alzheimer's and other neurodegenerative forms of dementia affect 8 million Europeans. Assistive technologies are suggested to reduce the burden of care and improve the quality of life of person living with dementia. Nonetheless, the acceptance and attitudes toward technological interventions pose challenges not only for people living with dementia and caregivers but also for healthcare workers. This review specifically aims to investigate how these key groups perceive and accept technology in European dementia care settings.

Methods

This systematic review was conducted to identify studies, published between 2013 and 2023, that examined the acceptance and attitude of assistive technologies in Alzheimer's and other dementia European settings, following the PRISMA guidelines. Rayyan AI was used for data extraction, and bias was assessed using the Mixed Methods Appraisal Tool.

Results

Among the 1,202 identified articles, 13 met the inclusion criteria, revealing a prevailing positivity toward technological interventions in dementia care. Nonetheless, several barriers to adoption, including technological unfamiliarity, and specific dementia-related symptoms that complicate usage were identified. They also unveiled varying attitudes, influenced by factors such as familiarity with technologies, perceived usefulness, and the broader context of the COVID-19 pandemic which accelerated telemedicine and digital solution acceptance during restricted mobility and social distancing.

Conclusion

Understanding attitudes toward technology in dementia care is crucial as it influences the adoption and utilization of tech-based interventions, impacting symptom management and quality of life. Addressing these attitudes through tailored interventions and education can enhance well-being and quality of life for people living with dementia, caregivers, and healthcare professionals.

Management of Large Ovarian Tumors in Elderly Patients Using the Aron Alpha Method and Principles of Enhanced Recovery after Surgery

Objectives

We performed preoperative evaluations of giant ovarian tumors in older adult patients using the comprehensive geriatric assessment (CGA) and estimation of physiologic ability and surgical stress (E-PASS) scoring systems. We report a case in which the Aron Alpha method was performed, and perioperative management was performed using enhanced recovery after surgery (ERAS).

Materials and Methods

We performed preoperative evaluations using the E-PASS scoring system and CGA on older adult patients with giant ovarian tumors, followed by the minimally invasive Aron Alpha method and perioperative management using ERAS.

Results

The mean patient age was 75.8 ± 8.8 years; comorbidities included hypertension in three patients, hyperlipidemia in two, angina pectoris in one, cholecystitis in one, and lower extremity varicose veins in one. The mean tumor size was 21.0 ± 5.4 cm. The E-PASS scoring system showed a preoperative risk score of 0.7 ± 0.4, a surgical stress score of 0, and a comprehensive risk score of 0.3 ± 0.3. CGA showed that two patients had problems with activities of daily living and cognitive function. The mean duration of surgery was 89.0 ± 16.6 min, and the mean blood loss was 56.0 ± 65.4 mL. No surgery-associated complications were observed. No patients had prolonged hospitalization or a decline in activities of daily living.

Conclusion

We showed the usefulness of performing detailed preoperative evaluations using CGA and the E-PASS system, followed by the minimally invasive Aron Alpha surgical method and perioperative management using ERAS in improving surgical outcomes in older adult patients with giant ovarian tumors.

Pain in non-communicative older adults beyond dementia: a narrative review

Aging is associated with an increased risk of developing pain, especially in the presence of concurrent chronic clinical conditions. Similarly, multimorbidity can affect the perception and ability of older adults to appropriately respond to and communicate pain, and there is a clinical heterogeneity in the processing of painful sensations in different neurological conditions. The present narrative review is aimed at assessing the prevalent diseases associated with poor communication and pain in older adults, together with the available diagnostic instruments for the clinical assessment of pain in such a vulnerable population. Dementia was the most described pathology identified in the current literature associated with poor communication in older adults affected by pain, along with Parkinson's disease and stroke. Notably, a common pattern of pain behaviors in these neurological disorders also emerged, indicating potential similarities in the clinical presentation and appropriate diagnostic workout. At the same time, there are many differences in the way patients express their pain according to their main neurological pathology. In addition to this, although a plethora of observation-based tools for pain in patients with dementia have been developed, there is no gold standard, and the clinical utility of such measurements is still largely unaddressed. Meanwhile, there is substantially no standardized observation-based tool for pain in non-communicative patients with Parkinson's disease, and only a few for stroke. Overall, the present narrative review provides an update on the prevalent diseases beyond dementia associated with a communicative disability and a painful condition in older adults.

Efficacy of therapeutic intervention with NanoBEO to manage agitation and pain in patients suffering from severe dementia: a pilot clinical trial

Background

An estimated 57.4 million people live with dementia worldwide, with the social burden of the disease steadily growing. Despite the approval of lecanemab and ongoing trials, there is still a lack of effective and safe treatments for behavioral and psychological symptoms of dementia (BPSD), which affect 99% of patients. Agitation is one of the most disabling BPSD, with a cross-sectional prevalence of ≥50% in nursing homes, and refers to help-seeking behavior in response to various sources of discomfort, among which pain is a crucial component.

Methods

This pilot phase of the BRAINAID (NCT04321889) trial aimed to assess the effectiveness of the patented nanotechnological device NanoBEO in older (≥65 years) people with severe dementia. This randomized placebo-controlled trial, with quadruple masking that involved all operators and participants, followed the SPIRIT and CONSORT statements. A total of 29 patients completed the trial. The patients were randomly allocated in a 1:1 ratio to the NanoBEO or placebo group, and the corresponding product was applied on both arms once daily for 4 weeks, with a 4-week follow-up period. The primary endpoint was efficacy against agitation. The secondary endpoints were efficacy against agitation at follow-up and efficacy against pain. Any adverse events were reported, and biochemical analyses were performed.

Results

The NanoBEO intervention reduced the frequency (28%) and level of disruptiveness of agitated behaviors. The effect on frequency was statistically significant after 2 weeks of treatment. The efficacy of NanoBEO on agitated behaviors lasted for the entire 4-week treatment period. No additional psychotropic drugs were prescribed throughout the study duration. The results after 1 week of treatment demonstrated that NanoBEO had statistically significant analgesic efficacy (45.46% improvement in pain intensity). The treatment was well tolerated.

Discussion

This trial investigated the efficacy of NanoBEO therapy in managing agitation and pain in dementia. No need for rescue medications was recorded, strengthening the efficacy of NanoBEO in prolonged therapy for advanced-stage dementia and the usefulness of the intervention in the deprescription of potentially harmful drugs. This study provided a robust rationale for the application of NanoBEO in a subsequent large-scale pivotal trial to allow clinical translation of the product. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT04321889.

The interactive effects of different exercises and hawthorn consumption on the pain threshold of TMT-induced Alzheimer male rats

Exercise increases the pain threshold in healthy people. However, the pain threshold modulation effect of exercise and hawthorn is unclear because of its potential benefits in people with persistent pain, including those with Alzheimer's disease. Accordingly, after the induction of Alzheimer's disease by trimethyl chloride, male rats with Alzheimer's disease were subjected to a 12-week training regimen consisting of resistance training, swimming endurance exercises, and combined exercises. In addition, hawthorn extract was orally administered to the rats. Then, their pain threshold was evaluated using three Tail-flick, Hot-plate, and Formalin tests. Our results showed that Alzheimer's decreased the pain threshold in all three behavioral tests. Combined exercise with hawthorn consumption had the most statistically significant effect on Alzheimer's male rats' pain threshold in all three experiments. A combination of swimming endurance and resistance exercises with hawthorn consumption may modulate hyperalgesia in Alzheimer's rats. Future studies need to determine the effects of these factors on the treatment and/or management of painful conditions.

The Impact of Dementia on Patients with Hip Fracture

Hip fractures are a serious global health concern with a substantial impact on senior patients' mobility, quality of life, and morbidity. Patients with psychiatric pathology may experience heightened levels of distress, making pain management more challenging. The presence of multiple comorbidities may complicate the therapeutic management of hip fractures. Treatment plans must be carefully tailored to accommodate each individual's unique medical history and current health status. We looked for improving pain evaluation and management in patients with dementia and choosing the best treatment according to age and comorbidities. This study highlights the mortality rate in surgically and non-surgically treated patients and possible correlations with other factors. We conducted a prospective study on 184 patients over 60 years old, with dementia and hip fractures, between 2018 and 2020 in Romania, within the Galati County Clinical Hospital. We applied the Charlson Comorbidity Index, ACE III test, EQ5D5L, and Harris test scores to assess the comorbidities, respectively, pain levels, mobilization in daily life activities, self-care and severity of dementia to exert the optimal treatment for patients with dementia and hip fracture. Our study pointed out that pain was frequently excruciating in non-operated patients compared to those who were operated. Most non-operated patients were immobilized in bed, they required careful and permanent care, while most of the operated patients experienced lower pain levels. While some risk factors of morbidity and mortality, such as comorbidities, severity of dementia, high age, and previous living situations are not preventable, delayed surgery, and general anesthesia risks may be prevented. Despite the treatment, mortality was high both at 6 months and 2 years, with increased survival rate in surgical treated patients. Our study addresses issues such as the importance of mental state evaluation in elderly patients in therapeutic decisions, the surgical intervention and the particularities in pre- and postoperative pain control in patients with dementia, topics that are insufficiently established in the current practical guidelines.

A Scoping Review on Nurse's Pain Management of Older Patients with Dementia in a Hospital Environment

OBJECTIVES

Hospitalized persons living with dementia often experience unrelieved pain. Unmanaged pain during hospitalization has a significant negative effect on quality of life for persons living with dementia. Despite the central role of nurses in pain management, little is known about how nurses manage pain in this patient population in the hospital environment.

DESIGN

A scoping review explored the nurses' pain management practices when caring for persons living with dementia in a hospital setting.

DATA SOURCES AND REVIEW/ANALYSIS METHODS

After an extensive search for all available evidence on how nurses manage pain in hospitalized persons living with dementia, data were extracted on pain management methods that included assessment, intervention, effectiveness of pain management, and the barriers nurses encountered when managing pain. A descriptive content analysis was used to extract data from qualitative studies.

RESULTS

Six articles published between 2016 and 2021 met the inclusion criteria; four utilized qualitative methods, and the others used mixed-methods and quantitative study designs. A narrative description of the findings was summarized after data were categorized into pain management data elements and barriers nurses encountered when managing pain. Barriers were grouped into the subcategories of communication challenges (nurse to patient), information sharing (nurse to nurse), lack of knowledge, time constraints, and nursing stressors.

CONCLUSION

We identified six articles that met our inclusion criteria, highlighting a noticeable gap in the literature. Managing pain in this population is complex and lacks organizational support. Review findings indicate that pain management methods lack consistency and standardization, making it difficult to assess their effectiveness. Nurses also described knowledge deficits resulting in practice gaps that, when combined with barriers and challenges, result in underrecognized and undermanaged pain.

Development of a decision-support framework to support professionals and promote comfort among older hospital inpatients living with dementia

BACKGROUND

Acute hospital wards can be difficult places for many people living with dementia. Promoting comfort and wellbeing can be challenging in this environment. There is little evidence-based support for professionals working on acute care wards on how to respond to distress and maximise comfort and wellbeing among patients living with dementia.

OBJECTIVES

Our overall aim was to codesign an evidence-based easy-to-use heuristic decision-support framework, which was acceptable and practical but acknowledges the complex and acute nature of caring for patients with dementia in the hospital. This paper presents the development process and resulting framework.

METHODS

A codesign study was informed by data from (1) a literature review of the care and management of people living with dementia in acute hospitals; (2) a cohort study of comfort and discomfort in people with dementia in acute hospitals; and (3) interviews with family carers and health care professionals. We synthesised evidence from these data sources and presented to key stakeholders through codesign meetings and workshops to produce our decision-support framework.

RESULTS

The framework consists of a series of flowcharts and operates using a three-stage process of: (1) assess comfort/discomfort; (2) consider causes of discomfort; and (3) address patient needs to manage the discomfort.

CONCLUSION

Working with key stakeholders, synthesising diverse quantitative and qualitative evidence to build a clinical framework is a feasible approach to help address the needs of patients living with dementia in an acute hospital setting. The result is a framework which is now ready for evaluation and implementation.

PATIENT AND PUBLIC CONTRIBUTION

We worked closely with people living with dementia and family carers throughout this study, including the development of the study protocol with input on study development and design, through to inclusion in stakeholder workshops and codesign of the decision support framework.

Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis

BACKGROUND

No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population.

OBJECTIVE

To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI.

METHODS

In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention.

RESULTS

Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%).

CONCLUSIONS

Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.

Factors Associated With Function-Focused Care Among Hospitalized Older Adults Living With Dementia

This article reports a study that was designed to describe the incidence of pain among older hospitalized patients with dementia and to evaluate the factors that influence pain among these individuals. It was hypothesized that function, behavioral and psychological symptoms of dementia, delirium, pain treatment, and patient exposure to care interventions would be associated with pain. Patients who performed more functional activities had less delirium. They also experienced higher quality-of-care interactions and were less likely to have pain. The findings from this study support the relationship between function, delirium, and quality-of-care interactions and pain. It suggests that it may be useful to encourage patients with dementia to engage in functional and physical activity to prevent or manage pain. This study serves as a reminder to avoid neutral or negative care interactions among patients with dementia as a strategy to mediate delirium and pain.

A Descriptive Study of Treatment of Pain in Acute Care for Patients Living With Dementia

BACKGROUND

During the hospital stay pain is very common among patients living with dementia.

METHODS

Descriptive data was obtained from chart review and included age, gender, race, comorbidities and admitting diagnosis.

AIMS

The purpose of this study was to describe pain among patients living with dementia, the use of pharmacologic and nonpharmacologic treatment, and to compare treatments among those with and without pain.

DESIGN

This was a descriptive study using baseline data from the first 233 participants from the study "Testing the Implementation of Function Focused Care for Acute Care Using the Evidence Integration Triangle (FFC-AC-EIT)".

PARTICIPANTS/SUBJECTS

The mean age of participants was 83 (SD=5) and the majority was female (65%) and White (67%) with evidence of dementia (based on a mean Saint Louis University Mental Status Test = 7.23, SD=5.85).

RESULTS

Overall 98 (42%) participants had pain and 135 (58%) no pain. Only 14 (6%) participants received no nonpharmacologic or pharmacologic interventions for pain and five of these individuals had pain. The most frequently used pharmacologic intervention among all participants was acetaminophen (n = 121, 52%), then tramadol (n = 19, 8%). Comfort measures and general nonpharmacologic approaches were the most frequently used non-pharmacologic approaches, then physical activity and therapeutic communication. From admission to discharge, there was a trend towards a decrease in pain. There was more use of opioids, physical activity, and therapeutic communication in the no pain group versus the pain group.

CONCLUSIONS

The majority of hospitalized medical patients living with dementia were treated for pain, but an ongoing focus is needed to assure optimal pain management for all patients.

A Purine Derivative Containing an Organoselenium Group Protects Against Memory Impairment, Sensitivity to Nociception, Oxidative Damage, and Neuroinflammation in a Mouse Model of Alzheimer's Disease

In the present study, the effect of 6-((4-fluorophenyl) selanyl)-9H-purine (FSP) was tested against memory impairment and sensitivity to nociception induced by intracerebroventricular injection of amyloid-beta peptide (Aβ) (25-35 fragment), 3 nmol/3 μl/per site in mice. Memory impairment was determined by the object recognition task (ORT) and nociception by the Von-Frey test (VFT). Aβ caused neuroinflammation with upregulation of glial fibrillary acidic protein (GFAP) (in hippocampus), nuclear factor-κB (NF-κB), and the proinflammatory cytokines interferon-γ (IFN-γ) and tumor necrosis factor-α (TNF-α) in cerebral cortex and hippocampus. Additionally, Aβ increased oxidant levels and lipid peroxidation in cerebral cortex and hippocampus, but decreased heme oxygenase-1 (HO-1) and peroxiredoxin-1 (Prdx1) expression in the hippocampus. Anti-neuroinflammatory effects of FSP were demonstrated by a decrease in the expression of GFAP and NF-κB in the hippocampus, as well as a decrease in proinflammatory cytokines in both the hippocampus and cerebral cortex FSP protected against oxidative stress by decreasing oxidant levels and lipid peroxidation and by increasing HO-1 and Prdx1 expressions in the hippocampus of mice. Moreover, FSP prevented the activation of nuclear factor erythroid 2-related factor 2 (Nrf-2) in the hippocampus of mice induced by Aβ. In conclusion, treatment with FSP attenuated memory impairment, nociception sensitivity by decreasing oxidative stress, and neuroinflammation in a mouse model of Alzheimer's disease.

Complementary and integrative medicines for behavioral and psychological symptoms of dementia: Overview of systematic reviews

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSDs) are major contributing factors to disease burden in dementia patients. Complementary and integrative medicine (CIM) has received attention in the management of dementia in patients with BPSDs. This overview aimed to comprehensively and critically review previous systematic reviews (SRs) of CIM modalities for BPSD management.

METHODS

Thirteen databases were searched in November 2021 to identify SRs on CIM for BPSDs. The methodological quality of the included studies was assessed using A MeaSurement Tool to Assess systematic Reviews 2.

RESULTS

Among 38 SRs, aromatherapy was the most commonly studied intervention, followed by herbal medicine (HM), acupuncture/acupressure, mindfulness-based interventions, relaxation, and Taichi. Half of the studies on aromatherapy reported significantly improved BPSDs, especially agitation, while the remainder reported mixed results/insufficient evidence. Most studies (85.71%) on HM supported its significant benefits in BPSDs. Yokukansan, an individual HM, was most frequently studied for BPSDs, with a significant beneficial effect on delusions, hallucinations, and agitation/aggression. Moreover, some meta-analyses supported the benefits of HM as an adjunct to psychotropic drugs in BPSD management. Other CIM interventions had insufficient clinical evidence. The methodological quality of the included studies was poor, and most were rated low or critically low (92.11%).

CONCLUSION

Aromatherapy, the most frequently investigated CIM for BPSD, had mixed results or insufficient evidence. HM, as an adjunct to psychotropic drugs including antipsychotics, exhibited additional benefits regarding the efficacy and safety for BPSDs. This overview emphasizes the requirement for greater quantity and quality of research in this field.

REGISTRATION NUMBER

Open Science Framework registry (g5f3m) (https://osf.io/g5f3m), PROSPERO (CRD42020211009) (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020211009).

The association of physical activity and behavioral and psychological symptoms among a sample of hospitalized older adults living with dementia

OBJECTIVES

The aims of this study were to: (1) describe the prevalence of behavioral and psychological symptoms of dementia in hospitalized older adults living with dementia and (2) examine the association of physical activity and behavioral and psychological symptoms of dementia among hospitalized older adults living with dementia, after controlling for covariates.

METHODS

Physical activity was measured using the Physical Activity Survey and behavioral and psychological symptoms of dementia were measured using the Neuropsychiatric Inventory. Descriptive analysis and multiple linear regressions were run using baseline data on 294 older adults with dementia hospitalized on general medical units from an ongoing study entitled Function Focused Care for Acute Care Using the Evidence Integration Triangle.

RESULTS

Participants performed an average of 7.92 (SD = 4.49) of 34 possible activities "in the last 24 h" prior to the Physical Activity Survey administration. A total of 132 participants (45.5%) had at least one behavioral and psychological symptom of dementia. We found that physical activity was not associated with behavioral and psychological symptoms of dementia (b = 0.01; p = 0.56), after controlling for covariates.

CONCLUSIONS

Although this study found no evidence of an association between physical activity and behavioral and psychological symptoms of dementia, evidence of physical activity did not exacerbate these behaviors. Thus, given the benefits of physical activity, it is important to continue to encourage patients living with dementia to engage in activity.

Chronic pain in people living with dementia: challenges to recognising and managing pain, and personalising intervention by phenotype

Pain is common in people with dementia, and pain can exacerbate the behavioural and psychological symptoms of dementia. Effective pain management is challenging, not least in people with dementia. Impairments of cognition, communication and abstract thought can make communicating pain unreliable or impossible. It is unclear which biopsychosocial interventions for pain management are effective in people with dementia, and which interventions for behavioural and psychological symptoms of dementia are effective in people with pain. The result is that drugs, physical therapies and psychological therapies might be either underused or overused. People with dementia and pain could be helped by assessment processes that characterise an individual's pain experience and dementia behaviours in a mechanistic manner, phenotyping. Chronic pain management has moved from a 'one size fits all' approach, towards personalised medicine, where interventions recommended for an individual depend upon the key mechanisms underlying their pain, and the relative values they place on benefits and adverse effects. Mechanistic phenotyping through careful personalised evaluation would define the mechanisms driving pain and dementia behaviours in an individual, enabling the formulation of a personalised intervention strategy. Central pain processing mechanisms are particularly likely to be important in people with pain and dementia, and interventions to accommodate and address these may be particularly helpful, not only to relieve pain but also the symptoms of dementia.

Psychometric evaluation of the Pain Assessment in Advanced Dementia scale in an acute general hospital setting

BACKGROUND

People with dementia are at risk of unplanned hospital admissions and commonly have painful conditions. Identifying pain is challenging and may lead to undertreatment. The psychometric properties of the Pain Assessment in Advanced Dementia (PAINAD) scale, in medical inpatients with dementia have not been evaluated.

METHODS

A secondary data analysis from a longitudinal study of 230 people with dementia admitted to two acute general hospitals in London, UK. Internal consistency, inter-rater reliability, test-retest reliability, concurrent validity, construct validity and discriminant validity of PAINAD were tested at rest and in movement.

RESULTS

This predominantly female (65.7%) sample had a mean age of 87.2 (Standard Deviation; SD = 5.92) years. Inter-rater reliability showed an intra-class correlation (ICC) of 0.92 at rest and 0.98 in movement, test-retest reliability ICC was 0.54 at rest and 0.66 in movement. Internal consistency was 0.76 at rest and 0.80 in movement (Cronbach's α). Concurrent validity was weak between PAINAD and a self-rating level of pain (Kendall's Tau; τ = 0.29; p > 0.001). There was no correlation between PAINAD and a measure of behavioural and psychological symptoms of dementia, suggesting no evidence of convergent validity. PAINAD scores were higher during movement than rest, providing evidence of discriminant validity (z = -8.01, p < 0.001).

CONCLUSIONS

We found good inter-rater reliability and internal consistency. The test-retest reliability was modest. This study raises concerns about the validity of the PAINAD in general acute hospitals. This provides an insight into pain assessment in general acute hospitals which may inform further refinements of the PAINAD.

Nursing care of people with dementia in an orthopaedic acute care setting: An integrative literature review

AIMS AND OBJECTIVES

This integrative literature review is to collect what is known about the care of people with dementia when they require a hospital admission for an orthopaedic surgical procedure and to contribute to developing an evidence-base to support nursing practice when caring for people with dementia in an orthopaedic setting.

BACKGROUND

People with a dementia diagnosis are increasingly common in acute orthopaedic care settings and the admission exposes people with dementia to risks during their hospital stay. In addition, nurses find people with dementia challenging to care for due to the complexity of dual conditions. Little is known specifically about the care requirements for people with dementia in orthopaedic settings.

DESIGN

Integrative literature review.

METHODS

An integrative literature review and qualitative deductive content analysis using McCormack and McCance's theoretical nursing framework (Person-Centred Nursing Framework) of nine studies were undertaken. The process of the review was guided by PRISMA checklist.

RESULTS

The care environment and resistance either in passive form, or through physical intervention, is common in orthopaedic nursing. Planning and delivering care for physical, cognitive and emotional needs is identified as being difficult, resulting in a lack of inclusion for patients, partly due to communication challenges. Finding ways to implement tailored care plans within standard ward routines proves difficult, and the consequence is a less than optimal care experience with adverse effects on patients characterised by an increase in dementia symptoms.

CONCLUSIONS

Care for people with dementia in an orthopaedic setting is complex. It needs to be further studied so that more evidence and supporting literature can contribute to improved care for this group of patients.

RELEVANCE TO CLINICAL PRACTICE

This study describes the complexity of providing fundamental care for people with dual conditions of dementia and orthopaedic injury and suggests opportunities for improvement.

Wrist accelerometry for monitoring dementia agitation behaviour in clinical settings: A scoping review

Agitated behaviour among elderly people with dementia is a challenge in clinical management. Wrist accelerometry could be a versatile tool for making objective, quantitative, and long-term assessments. The objective of this review was to summarise the clinical application of wrist accelerometry to agitation assessments and ways of analysing the data. Two authors independently searched the electronic databases CINAHL, PubMed, PsycInfo, EMBASE, and Web of Science. Nine (n = 9) articles were eligible for a review. Our review found a significant association between the activity levels (frequency and entropy) measured by accelerometers and the benchmark instrument of agitated behaviour. However, the performance of wrist accelerometry in identifying the occurrence of agitation episodes was unsatisfactory. Elderly people with dementia have also been monitored in existing studies by investigating the at-risk time for their agitation episodes (daytime and evening). Consideration may be given in future studies on wrist accelerometry to unifying the parameters of interest and the cut-off and measurement periods, and to using a sampling window to standardise the protocol for assessing agitated behaviour through wrist accelerometry.

Analgesic Characteristics of NanoBEO Released by an Airless Dispenser for the Control of Agitation in Severe Dementia

Chronic pain is one of the most common causes of the need for clinical evaluation, acquiring more importance in the elderly with cognitive impairment. Reduced self-reporting capabilities cause unrelieved pain contributing to the development of agitation. Safe and effective pain treatment can afford the management of agitation without the serious increase in death risk associated with neuroleptics. To this aim, the essential oil of bergamot (BEO), proven by rigorous evidence to have strong preclinical anti-nociceptive and anti-allodynic properties, has been engineered (NanoBEO, patent EP 4003294) to allow randomized, double-blind, placebo-controlled trials (BRAINAID, NCT04321889). The present study: (1) assesses the analgesic effects of a single therapeutic dose of NanoBEO, as supplied by an airless dispenser for clinical translation, in models of inflammatory, neuropathic, and sensitization types of pain relevant to clinic; (2) provides a dose-response analysis of the efficacy of NanoBEO on scratching behavior, a typical behavioral disturbance occurring in dementia. A single therapeutic dose of NanoBEO confirms efficacy following thirty minutes pre-treatment with capsaicin and on the central sensitization phase induced by formalin. Moreover, it has an ID50 of 0.6312 mg and it is efficacious on static and dynamic mechanical allodynia. Altogether, the gathered results strengthen the potential of NanoBEO for clinical management of pain and agitation.

Pharmacotechnological Advances for Clinical Translation of Essential Oils for the Treatment of Pain and Agitation in Severe Dementia

The demand for natural products is steadily increasing, and pharmacotechnological engineering is needed to allow rigorous investigation of their efficacy and safety in clinical conditions representing still unmet needs. Among aged patients affected by dementia, up to 80% of residents in nursing homes suffer from chronic pain and 97% from fluctuant neuropsychiatric symptoms (NPS), of which the most challenging is agitation. It is, at least in part, due to undertreated pain and treated with antipsychotics almost doubling the risk of death. In the frame of a scoping review assessing the existence of essential oils undergoing engineering pharmacotechnological processes using solid lipid nanoparticle delivery systems for clinical translation in pain and/or neuropsychiatric symptoms of dementia following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), here we identified that the sole essential oil engineered to overcome the criticisms of aromatherapy clinical trials in pain and dementia is the essential oil of bergamot (BEO). Therefore, we present the process leading to the actually ongoing randomized, double-blind, placebo-controlled NCT04321889 clinical trial to assess the efficacy and safety of intervention with bergamot in the management of agitation and pain in severe dementia to be followed also for the proof of concept of efficacy and safety of other essential oils.

Hospital nurses' management of agitation in older cognitively impaired patients: do they recognise pain-related agitation?

BACKGROUND

cognitively impaired hospital patients often experience agitation and aggression due to pain. Agitation complicates care, increasing the risk of adverse outcomes and patient-to-nurse violence. Managing agitation is challenging for nurses. Literature suggests they may rely on antipsychotics while missing other more appropriately targeted treatments. However, nurses' management of agitation remains unclear and under-researched.

OBJECTIVE

the aim of this study was to investigate hospital nurses' management of agitation in older cognitively impaired patients with pain.

DESIGN

this was a descriptive correlational study using virtual simulation.

SETTING AND PARTICIPANTS

a total of 274 registered medical and surgical nurses from 10 public hospitals in Queensland, Australia participated in the study.

METHODS

nurses undertook a virtual simulation requiring them to manage agitation in a patient with dementia and an injury. Nurses also completed a post-simulation questionnaire. Their simulation performances were correlated with demographics such as seniority, workplace, training, experience and gerontology-specific knowledge. Constructed from an original, validated vignette, the simulation included branching pathways, video scenarios and an avatar that could converse with participants.

RESULTS

thirteen nurses (4.7%) recognised and treated the virtual patient's agitation as pain-related. Most nurses (89%) gave antipsychotics of which 207 (78%) gave these first-line and 102 (38%) used them twice. Independent of other variables, nurses most likely to diagnose pain were dementia-unit nurses (OR = 8.7), surgical-unit nurses (OR = 7.3) and senior nurses (OR = 5).

CONCLUSIONS

hospital nurses predominately managed agitation with antipsychotics, a decision that most made after undertaking inadequate patient assessments. This confirmed a common gap in practice that may lead to the missing of pain in the clinical care of agitated patients with dementia and/or delirium.

Pain and agitation treatment in severe dementia patients: The need for Italian Mobilization-Observation-Behavior-Intensity-Dementia (I-MOBID2) pain scale translation, adaptation and validation with psychometric testing

The 97% of dementia patients develops fluctuant neuropsychiatric symptoms often related to under-diagnosed and unrelieved pain. Up to 80% severe demented nursing home residents experiences chronic pain due to age-related comorbidities. Patients lacking self-report skills risk not to be appropriately treated for pain. Mobilization-Observation-Behavior-Intensity-Dementia (MOBID2) is the sole pain scale to consider the frequent co-occurrence of musculoskeletal and visceral pain and to unravel concealed pain through active guided movements. Accordingly, the Italian real-world setting can benefit from its translation and validation. This clinical study provides a translated, adapted and validated version of the MOBID2, the Italian I-MOBID2. The translation, adaptation and validation of the scale for non-verbal, severe demented patients was conducted according to current guidelines in a cohort of 11 patients over 65 with mini-mental state examination ≤ 12. The I-MOBID2 proves: good face and scale content validity index (0.89); reliable internal consistency (Cronbach's α = 0.751); good to excellent inter-rater (Intraclass correlation coefficient, and test-retest (ICC = 0.902) reliability. The construct validity is high (Rho = 0.748 p < 0.05 for 11 patients, Spearman rank order correlation of the overall pain intensity score with the maximum item score of I-MOBID2 Part 1; rho=0.895 p < 0.01 for 11 patients, for the overall pain intensity score with the maximum item score of I-MOBID2 Part 2) and a good rate of inter-rater and test-retest agreement was demonstrated by Cohen's K = 0.744. The average execution time is of 5.8 min, thus making I-MOBID2 a useful tool suitable also for future development in community setting with administration by caregivers.

A Harmful Care: The Association of Informal Caregiver Burnout With Depression, Subjective Health, and Violence

Providing informal care to a relative can lead to informal caregiver burnout, which is expected to lead to deleterious consequences. Among these consequences lie the risk of perpetrating violent behaviors against the care-recipient, the caregivers' risk of depression, and their low subjective health. To investigate these associations, a sample of 499 informal caregivers completed a questionnaire addressing informal caregiver burnout, depression, subjective health, and violence. Hierarchical regression models were used to investigate the potential association of burnout with these potential consequences, while controlling for sociodemographic variables and received violence. The results show that burnout, and especially emotional exhaustion, is significantly associated with depression, low subjective health, and perpetrated physical violence, but not with perpetrated psychological violence. For both psychological and physical violence, it appears that receiving violence is one of the best predictors of perpetrating violence. With these results, this cross-sectional study confirms the association of informal caregiver burnout with deleterious consequences-even if this observation must be pondered-and the central role of received violence in predicting perpetrated violence, suggesting the risk of violence escalation. The implications of these results suggest that the emotional state of informal caregivers is one of the indicators of potential deleterious consequences and should, as such, be considered as a warning signal by field workers.

Trigeminal Neuralgia Is a Dementia Risk Factor: A Retrospective Cohort Study

Background: Dementia, a worldwide public-health issue, is regarded as a disorder rather than a normal aging process. Trigeminal neuralgia (TN) is a chronic debilitating pain disorder that impairs daily activities. Both are most prevalent in females and in patients older than 50 years. Recent studies reveal that pain and dementia may have a reciprocal interaction with each other. Objective: In response, we estimated whether adults with TN have an increased dementia risk. Methodology: By means of Taiwan's National Health Insurance Research Database, between 1996 and 2010, 762 patients aged over 50 years in the TN group were matched with 3048 patients in the non-TN group at a ratio of 1:4. Kaplan-Meier method and Cox proportional hazard regression models were also used to determine the cumulative incidence and compare the hazard ratios of dementia in each group. Results: The incidence of dementia was higher in the TN group compared to the non-TN group. After adjusting for covariates, the TN group had a 4.47-fold higher risk of dementia compared to the non-TN group. Additionally, the impact of TN on dementia risk was larger in young-aged patients than in old-aged patients. As well, the age at the time of dementia diagnosis was younger in the TN group compared to the non-TN group. Conclusions: TN is a dementia risk factor. Given the lack of a curative therapy for dementia, early identification of TN patients may help to prevent dementia sequelae.

Requirements for translation in clinical trials of aromatherapy: the case of the essential oil of bergamot (BEO) for the management of agitation in severe dementia

Abstract:

Due to the tight link between undertreated pain and agitation in dementia patients, aromatherapy can be a useful approach if an essential oil (EO) with powerful analgesic activity is used. The methodological difficulties of most aromatherapy trials have not allowed any definitive conclusion about the effectiveness of aromatherapy in dementia. The objective of the present perspective is to illustrate the long rigorous process leading from preclinical research to clinical translation of the EO of bergamot (BEO) for the management of agitation in dementia. A nanotechnology-based delivery system consisting of odorless alpha-tocopheryl stearate solid lipid nanoparticles (SLN) loaded with EO of bergamot (BEO) (NanoBEO), has been proven active on acute and neuropathic pain models confirming the strong antinociceptive and anti-allodynic efficacy reported for BEO in preclinical studies. In particular, prolonged physicochemical stability of NanoBEO and titration in its main components are remarkable advantages allowing reproducible antinociceptive and anti-itch responses to be measured. Furthermore, the possibility to perform double-blind clinical trials, made impossible so far because of the strong smell of essential oils used in aromatherapy. Demented patients receive limited treatment for chronic pain, particularly neuropathic. The BRAINAID (NCT04321889) trial will assess the effectiveness of NanoBEO on agitation and pain in severely demented patients to offer a safe tool able to provide relief to this fragile population. This double-blind clinical trial will be the first to assess the efficacy and safety of an engineered essential oil and will provide the rationale for the safer treatment of neuropsychiatric symptoms of dementia and pain in clinic.

Pharmacological Treatment of Pain and Agitation in Severe Dementia and Responsiveness to Change of the Italian Mobilization–Observation–Behavior–Intensity–Dementia (I-MOBID2) Pain Scale: Study Protocol

Up to 80% of Alzheimer’s disease (AD) patients in nursing homes experiences chronic pain and 97% develops fluctuant neuropsychiatric symptoms (NPS). Agitation, associated with unrelieved pain, is managed through antipsychotics and may increase the risk of death. Evidence is accumulating in favor of analgesia for a safer, effective therapy of agitation. The Italian version of Mobilization–Observation–Behavior–Intensity–Dementia, I-MOBID2, recently validated in the Italian setting, shows: good scale content validity index (0.89), high construct validity (Spearman rank-order correlation Rho = 0.748), reliable internal consistency (Cronbach’s α coefficient = 0.751), good-excellent inter-rater (intraclass correlation coefficient, ICC = 0.778) and test-retest (ICC = 0.902) reliability, and good inter-rater and test-retest agreement (Cohen’s K = 0.744) with 5.8 min completion time. This study intends to identify the responsiveness of the I-MOBID2 based on COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) recommendations, assessing the a priori hypotheses of (1) the efficacy of painkillers administered to severe AD patients after proper pain assessment and (2) the effect of reduction of the Cohen-Mansfield Agitation Inventory (CMAI) score and of agitation rescue medications. This protocol is approved by Calabria Region Ethics Committee protocol No. 31/2017 and follows the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines.

Documented nursing practices of pain assessment and management when communicating about pain in dementia care

AIM

To evaluate nurses' documented practice when communicating about pain for people with dementia in hospital.

DESIGN

Retrospective medical record review.

METHOD

Medical records were retrieved from four inpatient units in a district and a tertiary teaching hospital of people aged 65 years and over with documented dementia. Data were extracted on nurses' documented pain assessment and management. Pain frequency and association between patient self-report, pain scores, cognition levels and analgesics used during hospitalization were analysed using descriptive and inferential statistics. Multivariate regression examined patient characteristics, pain characteristics and length of hospital stay.

RESULTS

One-hundred patient records met the inclusion criteria between 1 January and 31 August 2017. Sixty-six percent of patients with dementia had pain documented at least once during hospitalization with 58% reported as moderate to severe pain intensity. Patients' pain severity during admission was associated with their length of hospital stay. Ninety-three percent of nurses used a self-reporting pain tool and 7% used an observational pain tool. Pain scores were not associated with patients' cognition level, nurses' pain reports or analgesic management.

CONCLUSION

Pain frequently occurs in people with dementia during hospitalization. Fragmented pain reporting influences the translation of pain messages. Disproportionate pain tool application and non-association between pain scores and analgesic management suggest a potential knowledge gap among nurses about the practical use of pain tools and practice gap between pain assessment and management in dementia care.

IMPACT

Pain was regularly assessed by nurses and implemented as a fifth vital sign for people with dementia in hospitals. However, the high frequency of pain affects care outcomes. Areas for improvement include nursing practice of pain assessment and management in dementia care in hospitals. Further understanding of the usefulness of pain tools and the efficacy of pain scores when communicating about pain in dementia care in hospitals is required.

Dementia and COVID-19: A Case Report and Literature Review on Pain Management

The coronavirus disease 2019 (COVID-19) pandemic imposes an unprecedented lifestyle, dominated by social isolation. In this frame, the population to pay the highest price is represented by demented patients. This group faces the highest risk of mortality, in case of severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection, and they experience rapid cognitive deterioration, due to lockdown measures that prevent their disease monitoring. This complex landscape mirrors an enhancement of neuropsychiatric symptoms (NPSs), with agitation, delirium and reduced motor performances, particularly in non-communicative patients. Due to the consistent link between agitation and pain in these patients, the use of antipsychotics, increasing the risk of death during COVID-19, can be avoided or reduced through an adequate pain treatment. The most suitable pain assessment scale, also feasible for e-health implementation, is the Mobilization-Observation-Behaviour-Intensity-Dementia (MOBID-2) pain scale, currently under validation in the Italian real-world context. Here, we report the case of an 85-year-old woman suffering from mild cognitive impairment, subjected to off-label treatment with atypical antipsychotics, in the context of undertreated pain, who died during the pandemic from an extensive brain hemorrhage. This underscores the need for appropriate assessment and treatment of pain in demented patients.

A systematic review and narrative synthesis of the research provisions under the Mental Capacity Act (2005) in England and Wales: Recruitment of adults with capacity and communication difficulties

BACKGROUND

The Mental Capacity Act (MCA, 2005) and its accompanying Code of Practice (2007), govern research participation for adults with capacity and communication difficulties in England and Wales. We conducted a systematic review and narrative synthesis to investigate the application of these provisions from 2007 to 2019.

METHODS AND FINDINGS

We included studies with mental capacity in their criteria, involving participants aged 16 years and above, with capacity-affecting conditions and conducted in England and Wales after the implementation of the MCA. Clinical trials of medicines were excluded. We searched seven databases: Academic Search Complete, ASSIA, MEDLINE, CINAHL, PsycArticles, PsycINFO and Science Direct. We used narrative synthesis to report our results. Our review follows Preferred Reporting Items for Systematic Reviews and is registered on PROSPERO, CRD42020195652. 28 studies of various research designs met our eligibility criteria: 14 (50.0%) were quantitative, 12 (42.9%) qualitative and 2 (7.1%) mixed methods. Included participants were adults with intellectual disabilities (n = 12), dementia (n = 9), mental health disorders (n = 2), autism (n = 3) and aphasia after stroke (n = 2). We found no studies involving adults with acquired brain injury. Diverse strategies were used in the recruitment of adults with capacity and communication difficulties with seven studies excluding individuals deemed to lack capacity.

CONCLUSIONS

We found relatively few studies including adults with capacity and communication difficulties with existing regulations interpreted variably. Limited use of consultees and exclusions on the basis of capacity and communication difficulties indicate that this group continue to be under-represented in research. If health and social interventions are to be effective for this population, they need to be included in primary research. The use of strategic adaptations and accommodations during the recruitment process, may serve to support their inclusion.

Oral Health Assessment Tool (OHAT) deputized to informal caregivers: Go or no go?

OBJECTIVE

Investigating the usability of the Dutch version of the Oral Health Assessment Tool (OHAT-NL) with informal caregivers of community-dwelling older people with suspected dementia, without specific training.

MATERIALS AND METHODS

In accordance with guidelines for establishing the cultural equivalency of instruments, the OHAT was translated into Dutch. Fifteen informal caregivers of community-dwelling older people with suspected dementia and, as a reference standard, a dentist assessed the oral health of the older people using the OHAT-NL. The caregivers' scores were compared with the dentist's scores. The usability of the OHAT-NL was rated on a 10-point scale (0 = incomprehensible, and 10 = very user friendly) and investigated further through short structured interviews.

RESULTS

There were differences between the dentist's and caregivers' assessments of the individual categories of the OHAT-NL. The specificity of the need to visit an oral health care professional was 100.0%, while the sensitivity was 78.6%. The informal caregivers concluded that the tool made them more aware of different aspects of oral health. The tool was rated with a mean score of 7.7 (SD 1.7).

CONCLUSION

The OHAT-NL could be a useful tool for informal caregivers without specific training to indicate whether the person they care for should visit an oral health care professional.

Bergamot rehabilitation AgaINst agitation in dementia (BRAINAID): Study protocol for a randomized, double-blind, placebo-controlled trial to assess the efficacy of furocoumarin-free bergamot loaded in a nanotechnology-based delivery system of the essential oil in the treatment of agitation in elderly affected by severe dementia

Pain is underdiagnosed and often not adequately treated, contributing to behavioral and psychological symptoms of dementia (BPSD). BPSD are treated with atypical antipsychotics that are associated with severe cerebrocardiovascular effects. Interestingly, treatment of pain may reduce agitation. Research is focusing on nonpharmacological treatment, such as aromatherapy, for pain and BPSD in dementia. This clinical study will assess the effect on agitation in severely demented elderly of BEO loaded in a nanotechnological odorless cream indistinguishable from placebo. This is a protocol for a randomized, double‐blind, placebo‐controlled trial (NCT04321889). A total of 134 patients aged ≥65 years with severe dementia (mini‐mental state examination <12) will be recruited and randomly allocated 1:1 to either BEO or placebo group. After baseline screening, BEO (80 mg) cream or placebo cream will be trans‐dermally applied on both arms twice a day for 4 weeks with a 4‐week follow‐up period. The effect on agitation will be the primary endpoint. Any adverse events will be reported. A double‐blind, clinical trial evaluating efficacy and safety of an essential oil endowed with strong analgesic properties has never been carried out before. This study could form the basis for a safer and more effective treatment of BPSD in severe dementia.

Pain treatment and functional improvement in home health care: Relationship with dementia

BACKGROUND

Pain management is important to post-acute functional recovery, yet older persons with Alzheimer's disease and related dementias (ADRD) are often undertreated for pain. The main objectives were (1) to examine the relationship between ADRD and analgesic use among Medicare home health care (HHC) recipients with daily interfering pain, and (2) to examine the impact of analgesic use on functional outcome in patients with and without ADRD.

METHODS

We analyzed longitudinal data from the Outcome and Assessment Information Set, Medicare HHC claims, and HHC electronic medical records during a 60-day HHC episode. The sample included 6048 Medicare beneficiaries ≥65 years receiving care from an HHC agency in New York in 2019 who reported daily interfering pain. Analgesic use was assessed during HHC medication reconciliation and included any analgesic, non-opioid analgesic, and opioid. ADRD was identified from ICD-10 codes (HHC claims) and cognitive impairment symptoms (Outcome and Assessment Information Set [OASIS]). Functional outcome was measured as change in the composite Activity of Daily Living (ADL) limitation score in the HHC episode.

RESULTS

ADRD was related to a lower likelihood of using any analgesic (odds ratio [OR] = 0.66, 95% confidence interval [CI]: 0.49, 0.90, p = 0.008) and opioids (OR = 0.54, 95% CI: 0.47, 0.62, p < 0.001), but not related to non-opioid analgesic use (OR = 0.94, 95% CI: 0.74, 1.18, p = 0.58). Stratified analyses showed that any analgesic use (β = -0.43, 95% CI: -0.73, -0.13, p = 0.004) and non-opioid analgesic use (β = -0.31, 95% CI: -0.56, -0.06, p = 0.016) were associated with greater ADL improvement in patients with ADRD, but not in patients without ADRD. Opioid use was not significantly related to ADL improvement regardless of ADRD status.

CONCLUSIONS

HHC patients with ADRD may be undertreated for pain, yet pain treatment is essential for functional improvement in HHC. HHC clinicians and policymakers should ensure adequate pain management for older persons with ADRD for improved functional outcomes.

Uncontrolled Pain and Risk for Depression and Behavioral Symptoms in Residents With Dementia

OBJECTIVES

Limited cohort studies have assessed the association between uncontrolled pain and risk for behavioral and psychological symptoms of dementia (BPSDs). We conducted a longitudinal cohort study to examine whether associations exist between uncontrolled pain and risk for 2 common BPSDs-depression and behavioral symptoms-among long-term care (LTC) residents with Alzheimer disease and related dementia (ADRD).

DESIGN

This retrospective cohort study analyzed quarterly data from the 5% Medicare sample linked to Minimum Data Set (MDS) 3.0 between January 1, 2011, and December 31, 2015.

SETTING AND PARTICIPANTS

LTC residents aged 50 years or older with ADRD who had chronic pain and at least 2 quarterly MDS 3.0 assessments.

METHODS

LTC residents were followed up quarterly from first observed quarterly MDS 3.0 until first outcome event or last observed quarterly MDS 3.0. Uncontrolled pain was defined as numerical rating scale >4, verbal descriptor scale of moderate or severe pain, or ≥1 pain indicators on the Checklist of Nonverbal Pain Indicators. Depression was defined as ≥10 on the Patient Health Questionnaire 9; behavioral symptoms were defined as the presence of psychotic (delusions or hallucinations) or disruptive behaviors (rejection of care, or physical, verbal, or other aggressive behaviors). Generalized linear models (GLMs) with marginal structural modeling (MSM) stabilized weights were used to examine uncontrolled pain and outcome risk.

RESULTS

The incidence rate of depression and behavioral symptoms during follow-up was 9.4 and 23.1 per 100 resident-years, respectively. Results from the MSM-GLMs showed that LTC residents with uncontrolled pain had a higher risk than those with controlled pain for developing depression [hazard ratio 1.67, 95% confidence interval (CI) 1.54-1.81] and behavioral symptoms (hazard ratio 1.28, 95% CI 1.19-1.37).

CONCLUSIONS AND IMPLICATIONS

Uncontrolled pain was associated with elevated risk for depressive and behavioral symptoms in dementia, underscoring the importance of pain assessment and control among LTC residents with ADRD.

Pain in Dementia: Prevalence and Association With Neuropsychiatric Behaviors

CONTEXT

Pain is linked to behaviors and psychological symptoms of dementia (BPSD); however, it often remains underrecognized in this population.

OBJECTIVES

We aimed to investigate the prevalence and intensity of pain in people living in aged care homes with BPSD and by dementia subtypes and the association between pain intensity and BPSD.

METHODS

A 1-year retrospective cross-sectional analysis was conducted on BPSD and the presence of pain in referrals to a national BPSD support service using the Neuropsychiatric Inventory and PainChek®, respectively. Referrals were categorized into two groups: pain group and no pain group.

RESULTS

Of the 479 referrals (81.9 ± 8.3 years old) included in the analysis, two-thirds (65.6%) had pain identified, with almost half (48.4%) of these categorized as experiencing moderate-severe pain. Pain was highly prevalent (range: 54.6-78.6%) in all subtypes of dementia, particularly in mixed dementia and dementia with Lewy bodies. Compared with the no pain group, the pain group had 25.3% more neuropsychiatric behaviors, 33.6% higher total severity of these behaviors, and 31.4% higher total distress caused to caregivers. For all results, effect sizes were small to medium (η²p = 0.04-0.06). Despite a high prevalence of aggressive or agitated behaviors across the entire group, the pain group was 3.8 times more likely to experience these behaviors than referrals not in pain.

CONCLUSION

There is a strong need to consider the possibility of pain as a contributor to behavioral changes in aged care residents living with dementia.

Altered nociception in Alzheimer disease is associated with striatal-enriched protein tyrosine phosphatase signaling

ABSTRACT

Alzheimer disease (AD) is the most common form of dementia, accounting for approximately 60% of cases. In addition to memory loss, changes in pain sensitivity are found in a substantial proportion of patients with AD. However, the mechanism of nociception deficits in AD is still unclear. Here, we hypothesize that the nociception abnormality in AD is due to the aberrant activation of striatal-enriched protein tyrosine phosphatase (STEP) signaling, which modulates proteins related to nociception transduction. Our results indicated that the transgenic mice carrying human amyloid precursor protein (APP) gene had lower sensitivity to mechanical and thermal stimulation than the wild-type group at the ages of 6, 9, and 12 months. These APP mice exhibited elevated STEP activity and decreased phosphorylation of proteins involved in nociception transduction in hippocampi. The pharmacological inhibition of STEP activity using TC-2153 further reversed nociception and cognitive deficits in the APP mice. Moreover, the phosphorylation of nociception-related proteins in the APP mice was also rescued after STEP inhibitor treatment, indicating the key role of STEP in nociception alteration. In summary, this study identifies a mechanism for the reduced nociceptive sensitivity in an AD mouse model that could serve as a therapeutic target to improve the quality of life for patients with AD.

Sex Differences in Behavioral and Psychological Signs and Symptoms of Dementia Presentation Regarding Nursing Home Residents with Cognitive Impairment Suffering from Pain - Results of the Services and Health for Elderly in Long-Term Care Study

OBJECTIVE

Behavioral and psychological symptoms of dementia (BPSD) place a heavy burden on patients as well as caregivers. Recently, pain was identified as an important determinant of BPSD. However, it is not yet known what influence sex has on BPSD and pain. Thus, the present study aimed to identify possible associations between BPSD, pain, and sex.

DESIGN

A retrospective evaluation of cross-sectional data derived from the Services and Health for Elderly in Long-Term Care (SHELTER) Study database, a cross-national European study on nursing home residents.

SETTING AND PARTICIPANTS

The study involved 4156 residents who were assessed using the interRAI instrument for Long-Term Care Facilities. Included in the analysis were only patients with cognitive impairment (n = 2822) (67.9%) of which 712 (25.2%) were male and 2110 (74.8%) were female.

METHODS

Differences in prevalence were tested using the χ² test while bivariate logistic regression models were used to evaluate factors associated with sex.

RESULTS

Men showed behavioral symptoms such as wandering, verbal and physical abuse as well as sexual uninhibited behavior significantly more often than women. Regarding psychiatric symptoms, only depression was significantly more frequent in women. Surprisingly, in the presence of pain these differences in BPSD incidence between men and women were no longer detectable. Logistic regression analysis showed that in women with dementia/communication problems, the presence of pain could be indicated by resistance to care, sleeping disorders, and possibly by the presence of delusions and anxiety whereas in men it was related to abnormal thought processes, and in both sexes to depression CONCLUSIONS AND IMPLICATIONS: From a clinical point of view, resistance to care and sleeping disorders in women and abnormal thought processes in men as well as depression in both sexes should be seen as indicators of possible underlying pain in noncommunicative people. Thus, knowledge of sex-specific BPSD presentations can improve pain management in this particularly patient group.