Contact heat sensitivity and reports of unpleasantness in communicative people with mild to moderate cognitive impairment in Alzheimer's disease: a cross-sectional study

Immune receptors and aging brain

Aging brings about a myriad of degenerative processes throughout the body. A decrease in cognitive abilities is one of the hallmark phenotypes of aging, underpinned by neuroinflammation and neurodegeneration occurring in the brain. This review focuses on the role of different immune receptors expressed in cells of the central and peripheral nervous systems. We will discuss how immune receptors in the brain act as sentinels and effectors of the age-dependent shift in ligand composition. Within this 'old-age-ligand soup,' some immune receptors contribute directly to excessive synaptic weakening from within the neuronal compartment, while others amplify the damaging inflammatory environment in the brain. Ultimately, chronic inflammation sets up a positive feedback loop that increases the impact of immune ligand-receptor interactions in the brain, leading to permanent synaptic and neuronal loss.

Sex and Sleep Disruption as Contributing Factors in Alzheimer's Disease

Alzheimer's disease (AD) affects more women than men, with women throughout the menopausal transition potentially being the most under researched and at-risk group. Sleep disruptions, which are an established risk factor for AD, increase in prevalence with normal aging and are exacerbated in women during menopause. Sex differences showing more disrupted sleep patterns and increased AD pathology in women and female animal models have been established in literature, with much emphasis placed on loss of circulating gonadal hormones with age. Interestingly, increases in gonadotropins such as follicle stimulating hormone are emerging to be a major contributor to AD pathogenesis and may also play a role in sleep disruption, perhaps in combination with other lesser studied hormones. Several sleep influencing regions of the brain appear to be affected early in AD progression and some may exhibit sexual dimorphisms that may contribute to increased sleep disruptions in women with age. Additionally, some of the most common sleep disorders, as well as multiple health conditions that impair sleep quality, are more prevalent and more severe in women. These conditions are often comorbid with AD and have bi-directional relationships that contribute synergistically to cognitive decline and neuropathology. The association during aging of increased sleep disruption and sleep disorders, dramatic hormonal changes during and after menopause, and increased AD pathology may be interacting and contributing factors that lead to the increased number of women living with AD.

Psychophysics of Pain: A Methodological Introduction

For over 100 years, psychophysics ..÷ the scientific study between physical stimuli and sensation ... has been successfully employed in numerous scientific and healthcare disciplines, as an objective measure of sensory phenomena. This manuscript provides an overview of fundamental psychophysical concepts, emphasizing pain and research application..÷defining common terms, methods, and procedures.Psychophysics can provide systematic and objective measures of sensory perception that can be used by nursing scientists to explore complex, subjective phenomena..÷such as pain perception. While there needs to be improved standardization of terms and techniques, psychophysical approaches are diverse and may be tailored to address or augment current research paradigms. The interdisciplinary nature of psychophysics..÷like nursing..÷provides a unique lens for understanding how our perceptions are influenced by measurable sensations. While the quest to understand human perception is far from complete, nursing science has an opportunity to contribute to pain research by using the techniques and methods available through psychophysical procedures.

Galectin-3 activates spinal microglia to induce inflammatory nociception in wild type but not in mice modelling Alzheimer's disease

Musculoskeletal chronic pain is prevalent in individuals with Alzheimer's disease (AD); however, it remains largely untreated in these patients, raising the possibility that pain mechanisms are perturbed. Here, we utilise the TASTPM transgenic mouse model of AD with the K/BxN serum transfer model of inflammatory arthritis. We show that in male and female WT mice, inflammatory allodynia is associated with a distinct spinal cord microglial response characterised by TLR4-driven transcriptional profile and upregulation of P2Y12. Dorsal horn nociceptive afferent terminals release the TLR4 ligand galectin-3 (Gal-3), and intrathecal injection of a Gal-3 inhibitor attenuates allodynia. In contrast, TASTPM mice show reduced inflammatory allodynia, which is not affected by the Gal-3 inhibitor and correlates with the emergence of a P2Y12- TLR4- microglia subset in the dorsal horn. We suggest that sensory neuron-derived Gal-3 promotes allodynia through the TLR4-regulated release of pro-nociceptive mediators by microglia, a process that is defective in TASTPM due to the absence of TLR4 in a microglia subset.

MindingMe: A Feasibility Study on Conducting Neuroimaging Research Among Diverse Groups

BACKGROUND

Neuroimaging tools, such as functional magnetic resonance imaging, are useful in understanding differences in brain activity that predict behavior change. Designing interventions based on brain activity and response may enhance current self-management regimens. Yet, diverse groups, such as Black women with chronic illness, have historically been left out of neuroimaging research.

OBJECTIVES

The aims of this study were to assess (a) the feasibility of conducting neuroimaging research among Black women with hypertension and (b) the predictors of willingness to participate in future studies.

METHODS

A survey designed to assess interest in participating in neuroimaging research was distributed through a Facebook campaign targeting Metro-Detroit Blacks with hypertension. A 10-minute, 44-item survey queried the women regarding their perspectives related to participation in neuroimaging studies. Logistic regression analyses were conducted to predict willingness to participate in a future study; they included a range of predictors: demographic indicators, history of blood pressure diagnosis, systolic and diastolic blood pressure, and availability of a support person who could accompany the participant to a future study session.

RESULTS

Two hundred fifty-seven Black women completed the survey. On average, the women were 59 years old, had been diagnosed with hypertension for 14 years, and had a systolic blood pressure of 141 mmHg. Participants were willing to travel 40 miles to participate, and many preferred to drive a personal vehicle. Some women were claustrophobic (20%) or had metal in their bodies (13%) and, therefore, would likely be ineligible to participate in neuroimaging studies. Some were nervous about the "small space" of a scanner, but others stated they would "enjoy participating" and wanted to "help future people…get well." Women who had a support person to attend their appointment with them were almost 4 times more likely to state they would participate in future studies. Those who had been diagnosed with hypertension for more than 11 years (the median) were almost 3 times more likely to report interest in participating in a future study than those participants who had been diagnosed with hypertension for 11 years or less.

DISCUSSION

Black women with hypertension were interested and eligible to participate in neuroimaging research. Despite some of the facilitators and barriers we identified, the women in our sample were interested in participating in future studies. The presence of a support person and length of time with a hypertension diagnosis are important predictors of willingness to participate in a future study.

Increased Heat Pain Tolerance but Hyperalgesia to Tonic Inflammatory Pain in the CRND8 Mouse Model of Alzheimer's Disease

BACKGROUND

The effects of Alzheimer's disease (AD) pathology on the experience of pain are poorly understood.

OBJECTIVE

To understand the pathophysiological mechanisms underlying pain sensory transmission in the transgenic mouse model of AD, CRND8.

METHODS

We explored AD-related pathology in the spinal cord and dorsal root ganglia of 18-week-old female CRND8 mice. We assessed nociceptive responses to both acute heat stimuli and persistent inflammatory pain in CRND8 mice and non-transgenic (non-Tg) littermates. In addition, we searched for differences in biochemical correlates of inflammatory pain between CRND8 and non-Tg mice. Finally, we investigated the excitability of dorsal horn noc iceptive neurons in spinal cord slices from CRND8 and non-Tg mice.

RESULTS

We demonstrated the presence of intracellular AD-like pathology in the spinal cord and in the dorsal root ganglia nociceptive sensory neurons of CRND8 mice. We found that CRND8 mice had a reduced susceptibility to acute noxious heat stimuli and an increased sensitivity to tonic inflammatory pain. Tonic inflammatory pain correlated with a lack of induction of pro-opiomelanocortin in the spinal cord of CRND8 mice as compared to non-Tg mice. Electrophysiological recording in acute spinal cord slice preparations indicated an increased probability of glutamate release at the membrane of dorsal horn nociceptive neurons in CRND8 mice.

CONCLUSION

This study suggests that an increased thermal tolerance and a facilitation of nociception by peripheral inflammation can coexist in AD.

Increased pain unpleasantness and pain-related fMRI activation in the periaqueductal gray in Alzheimer's disease

Background

Pain continues to be underrecognized and undertreated in people with Alzheimer's disease (AD). The periaqueductal gray (PAG) is essential to pain processing and modulation yet is damaged by AD. While evidence exists of altered neural processing of pain in AD, there has not been a focused investigation of the PAG during pain in people with AD.

Purpose

To investigate the role of the PAG in sensory and affective pain processing for people living with AD.

Methods

Participants from a larger study completed pain psychophysics assessments and then a perceptually-matched heat pain task (warmth, mild, and moderate pain) during a functional MRI scan. In this cross-sectional study, we examined blood oxygenation level-dependent (BOLD) responses in the PAG and other pain-related regions in participants with AD (n = 18) and cognitively intact older adults (age- and sex-matched, n = 18). Associations of BOLD percent signal change and psychophysics were also examined.

Results

There were significant main effects of AD status on the temperature needed to reach each perception of warmth or pain, where people with AD reached higher temperatures. Furthermore, participants with AD rated mild and moderate pain as more unpleasant than controls. PAG BOLD activation was greater in AD relative to controls during warmth and mild pain percepts. No significant differences were found for moderate pain or in other regions of interest. Greater PAG activation during mild pain was associated with higher affective/unpleasantness ratings of mild pain in participants with AD but not in controls.

Conclusion

Results suggest a role for the PAG in altered pain responses in people with AD. The PAG is the primary source of endogenous opioid pain inhibition in the neuroaxis, thus, altered PAG function in AD suggests possible changes in descending pain inhibitory circuits. People with AD may have a greater risk of suffering from pain compared to cognitively intact older adults.

Clinical and radiomic features for predicting the treatment response of repetitive transcranial magnetic stimulation in major neurocognitive disorder: Results from a randomized controlled trial

Image-guided repetitive transcranial magnetic stimulation (rTMS) has shown clinical effectiveness in senior adults with co-occurring depression and cognitive impairment, yet the imaging markers for predicting the treatment response are less investigated. In this clinical trial, we examined the efficacy and sustainability of 10 Hz rTMS for the treatment of depression and cognitive impairment in major neurocognitive disorder (NCD) patients and tested the predictive values of imaging-informed radiomic features in response to rTMS treatment. Fifty-five major NCD patients with depression were randomly assigned to receive a 3-week rTMS treatment of either active 10 Hz rTMS (n = 27) or sham rTMS (n = 28). Left dorsolateral prefrontal cortex (DLPFC) was the predefined treatment target. Based on individual structural magnetic resonance imaging scans, surface-based analysis was conducted to quantitatively measure the baseline radiomic features of left DLPFC. Severity of depression, global cognition and the serum brain-derived neurotrophic factor (BDNF) level were evaluated at baseline, 3-, 6- and 12-week follow-ups. Logistic regression analysis revealed that advanced age, higher baseline cognition and randomized group were associated with the remission of depression. Increased cortical thickness and gyrification in left DLPFC were the significant predictors of clinical remission and cognitive enhancement. A 3-week course of 10 Hz rTMS is an effective adjuvant treatment for rapid ameliorating depressive symptoms and enhancing cognitive function. Pre-treatment radiomic features of the stimulation target can predict the response to rTMS treatment in major NCD. Cortical thickness and folding of treatment target may serve as imaging markers to detect the responders. ChiCTR-IOR-16008191, registered on March 30, 2016.

Race-Related Differences Between and Within Sex to Experimental Thermal Pain in Middle and Older Adulthood: An Exploratory Pilot Analysis

This brief report details a pilot analysis conducted to explore racial differences in pain sensitivity and unpleasantness between cognitively healthy Black and White adults, stratified by sex. A total of 24 cognitively healthy adults (12 Black and 12 White) from two completed studies were matched by age and sex, and divided into two groups based on race. Stratified analyses by sex demonstrated that Black females reported experiencing pain intensity ratings of all three intensity sensations at lower temperatures than White females. These findings will inform future research studies to determine if these results hold true in a fully-powered sample and should include mixed methodologies, incorporating neuroimaging data to further assess this phenomenon. Improving pain assessment and management across racial/ethnic groups will help healthcare providers such as nurses and physicians to ensure optimal quality of life for all.

A Cross-Sectional Study of Pain Sensitivity and Unpleasantness in People with Vascular Dementia

OBJECTIVE

Advanced age holds higher risk of both pain and dementia, with many studies finding dementia often heightens sensitivity to pain. VaD is the second most common type of dementia. Only a few observational or retrospective studies have examined pain responsiveness in VaD, suggesting it may increase pain unpleasantness (i.e., pain affect). This study compared thermal pain psychophysics between a cohort of vascular dementia (VaD) patients and healthy control (HC) subjects.

DESIGN

Single center, cross-sectional, between-subjects design.

SUBJECTS

Verbally communicative, probable VaD patients (N = 23) and age- and sex-matched HC (N = 23).

METHODS

A thermal psychophysics protocol assessed "mild pain" and "moderate pain" thresholds (oC temperature) and associated unpleasantness ratings (0-20 scale) in both VaD and HC groups. Psychophysics were compared between groups by way of a mixed-effects analysis, controlling for depressive symptoms.

RESULTS

There were no significant differences between groups for pain thresholds (main effect p = 0.086, Cohen's d: mild = 0.55, moderate = 0.27). However, unpleasantness ratings were higher in the VaD group compared to HC (main effect p = 0.003; mild pain p = 0.022, Cohen's d = 0.79; moderate pain p = 0.057, Cohen's d = 0.6).

CONCLUSIONS

These results are consistent with prior observational findings suggesting VaD may make patients more susceptible to pain, particularly its affective component.

Treating the most vulnerable: A discursive review of experimental pain in Alzheimer's disease

AIM

The purpose of this manuscript is to summarize research on how experimental pain is experienced by adults with Alzheimer's disease (AD) and to translate results into implications for nurses.

DESIGN

This discursive review synthesizes the results of three previous research studies exploring experimental pain in adults with AD.

METHODS

Using a series of fictional clinical vignettes, the authors discuss how the results from three previous papers using acute experimental pain can potentially be translated into clinical practice. The authors also introduce the reader to the concept of research-related psychophysics using introductory definitions and concepts with the impetus to encourage other nurses to consider this research methodology.

RESULTS

Pain characteristics in AD that differ from cognitively intact controls must be explored to properly address pain in this population. Nurses are well positioned to address these issues in order to provide a high quality of care to adults with AD.

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.

Experimentally evoked pain in Alzheimer's disease

BACKGROUND

Pain continues to be underrecognized and undertreated in Alzheimer's disease (AD) while existing guidance about pain assessment and management in dementia is not widespread. Brain regions involved in pain processing and modulation are damaged during AD, and the pain experience in AD is not well understood. Experimental pain studies using psychophysics can further our understanding of the pain experience in AD, which may lead to improved assessment and management of pain in people living with AD.

OBJECTIVE

A systematic review was conducted to explicate the current understanding of experimentally evoked pain in AD from primary research using psychophysical methods.

DATA SOURCES

Peer-reviewed publications were found via PubMed, CINAHL, and PsycINFO. A total of 18 primary research, peer-reviewed full articles that met inclusion criteria were included, representing 929 total participants.

CONCLUSIONS

Experimentally evoked pain in people with AD demonstrates that despite cognitive impairment and a reduced ability to effectively communicate, individuals with AD experience pain similar to or more unpleasant than cognitively intact older adults. This may mean amplified pain unpleasantness in people with AD.

IMPLICATIONS FOR PRACTICE

Our current best practices need to be widely disseminated and put into clinical practice. Self-report of pain continues to be the gold standard, but it is ineffective for noncommunicative patients and those unable to understand pain scales or instructions because of memory/cognitive impairment. Instead, pain treatment should be ethically initiated based on patient reports and behaviors, caregiver/surrogate reports, review of the medical record for painful conditions, analgesic trials, and regular reassessments.

Policy Implications for Pain in Advanced Alzheimer's Disease

Untreated pain in people with Alzheimer's disease continues to be a serious public health problem. Pain is a subjective and complex experience that becomes increasingly challenging to assess as cognition declines. Our understanding of pain processing is incomplete, particularly for special populations such as people living with Alzheimer's disease, and especially in the advanced stages of the disease. Pain-processing networks in the brain are altered in Alzheimer's disease, yet evidence suggests people living with Alzheimer's disease do not experience less pain. Rather, their pain is not adequately recognized or treated. Although scholarly publications provide important assistance, recent widespread reports and guidelines do not include sufficient guidance, especially as Alzheimer's disease progresses to the last stages. Additionally, current pain measurements may not accurately evaluate pain in this condition, and the existing definitions of pain are not adequate when considering the effects of Alzheimer's disease on pain-processing in the brain. There is a need for new, widespread policies, guidelines, and definitions to help clinicians adequately manage pain in people with Alzheimer's disease. These will need to hinge on continued research because it remains unclear how Alzheimer's disease impacts central pain processing, pain expression, and communication of pain. In the meantime, policies and guidelines need to highlight current best practices as well as the fact that pain continues in Alzheimer's disease.

Could Altered Evoked Pain Responsiveness Be a Phenotypic Biomarker for Alzheimer's Disease Risk? A Cross-Sectional Analysis of Cognitively Healthy Individuals

BACKGROUND

This study evaluated whether the apolipoprotein ɛ4 (APOE4) allele, a genetic marker associated with increased risk of developing late-onset Alzheimer's disease (AD), was associated with differences in evoked pain responsiveness in cognitively healthy subjects.

OBJECTIVE

The aim was to determine whether individuals at increased risk of late-onset AD based on APOE allele genotype differ phenotypically in their response to experimentally-induced painful stimuli compared to those who do not have at least one copy of the ɛ4 allele.

METHODS

Forty-nine cognitively healthy subjects aged 30-89 years old with the APOE4 allele (n = 12) and without (n = 37) were assessed for group differences in pain thresholds and affective (unpleasantness) responses to experimentally-induced thermal pain stimuli.

RESULTS

Statistically significant main effects of APOE4 status were observed for both the temperature at which three different pain intensity percepts were reached (p = 0.040) and the level of unpleasantness associated with each (p = 0.014). APOE4 positive participants displayed lower overall pain sensitivity than those who were APOE4 negative and also greater overall levels of pain unpleasantness regardless of intensity level.

CONCLUSION

Cognitively healthy APOE4 carriers at increased risk of late-onset AD demonstrated reduced thermal pain sensitivity but greater unpleasantness to thermal pain stimuli relative to individuals at lower risk of late-onset AD. These results suggest that altered evoked pain perception could potentially be used as a phenotypic biomarker of late-onset AD risk prior to disease onset. Additional studies of this issue may be warranted.

Thermal Psychophysics and Associated Brain Activation Patterns Along a Continuum of Healthy Aging

OBJECTIVE

To examine psychophysical and brain activation patterns to innocuous and painful thermal stimulation along a continuum of healthy older adults.

DESIGN

Single center, cross-sectional, within-subjects design.

METHODS

Thermal perceptual psychophysics (warmth, mild, and moderate pain) were tested in 37 healthy older adults (65-97 years, median = 73 years). Percept thresholds (oC) and unpleasantness ratings (0-20 scale) were obtained and then applied during functional magnetic resonance imaging scanning. General linear modeling assessed effects of age on psychophysical results. Multiple linear regressions were used to test the main and interaction effects of brain activation against age and psychophysical reports. Specifically, differential age effects were examined by comparing percent-signal change slopes between those above/below age 73 (a median split).

RESULTS

Advancing age was associated with greater thresholds for thermal perception (z = 2.09, P = 0.037), which was driven by age and warmth detection correlation (r = 0.33, P = 0.048). Greater warmth detection thresholds were associated with reduced hippocampal activation in "older" vs "younger" individuals (>/<73 years; beta < 0.40, P < 0.01). Advancing age, in general, was correlated with greater activation of the middle cingulate gyrus (beta > 0.44, P < 0.01) during mild pain. Differential age effects were found for prefrontal activation during moderate pain. In "older" individuals, higher moderate pain thresholds and greater degrees of moderate pain unpleasantness correlated with lesser prefrontal activation (anterolateral prefrontal cortex and middle-frontal operculum; beta < -0.39, P < 0.009); the opposite pattern was found in "younger" individuals.

CONCLUSIONS

Advancing age may lead to altered thermal sensation and (in some circumstances) altered pain perception secondary to age-related changes in attention/novelty detection and cognitive functions.

Narrative Review of Sensory Changes as a Biomarker for Alzheimer's Disease

Early recognition of Alzheimer's disease (AD) in the prodromal period has not been robust yet will be necessary if effective disease-modifying drugs are to be useful in preventing or delaying the condition. The objective of this narrative review was to describe the current, evidenced based understanding of alterations in sensory data as potential biomarkers for AD. Review of empirical studies that tested senses as biomarkers for AD and were published in English within the past 50 years was completed. Eighteen empirical studies were identified that met the strict criteria for inclusion, with 12 of these studies being related to the olfactory system. Two studies examined auditory, two examined vision, one examined proprioception, and one examined taste. Thus, only olfaction has been studied to any extent, leaving a clear gap in the literature for the use of other senses. A promising area of research has begun to be reported concerning differences in responses to pain stimuli in AD relative to cognitively normal subjects. Pain is not a single sense like the others but integrates several senses and may allow for use as an early biomarker for AD, as it integrates several brain areas and pathways. Unlike the other senses, simple devices can be used to measure changes in pain perception in cognitively normal adults with genetic predispositions for possible AD, making this potentially useful for clinicians in the future.

The Impact of Aliviado Dementia Care-Hospice Edition Training Program on Hospice Staff's Dementia Symptom Knowledge

CONTEXT

As the aging population grows, the incidence of dementia continues to increase substantially. However, the lack of a significant geriatric health care workforce as well as little dementia training among generalist health care workers leads to suboptimal care for persons living with dementia (PLWD). In particular, few evidence-based interventions exist to improve the quality of dementia care among hospice interdisciplinary teams caring for PLWD. Aliviado Dementia Care-Hospice Edition is a quality assurance and performance improvement program that includes training, mentoring, and workflow enhancements, which aims to improve quality of hospice care provided to PLWD and their caregivers.

OBJECTIVES

To determine the effectiveness of the Aliviado Dementia Care program in increasing dementia symptom knowledge of hospice interdisciplinary team members.

METHODS

About 53 hospice team members from two diverse hospices, consisting of social workers, chaplains, physicians, and nurses, participated in the Aliviado training program. In this prepost trial, 39 participants completed the Dementia Symptom Knowledge Assessment before and after completion of the program.

RESULTS

Paired t-tests showed significant differences before and after Aliviado training in depression knowledge and confidence, as well as behavioral and psychological symptoms of dementia (BPSD) knowledge, confidence, and interventions. The greatest percent change increases were in depression (15.2%) and BPSD (13.3%) confidence as well as BPSD interventions (18.4%). Qualitative feedback consistently emphasized that trainees could now effectively assess their patients for specific symptoms such as pain and agitation.

CONCLUSION

Aliviado is an evidence-based system-level intervention that improves clinical knowledge, attitudes, and confidence in treating PLWD enrolled in hospice.

Pain Management in Home Health Care: Relationship With Dementia and Facility Admissions

BACKGROUND

Pain is common yet under-studied among older Medicare home health (HH) patients with Alzheimer's disease and related dementias (ADRD).

AIMS

Examine (1) the association between ADRD and severe pain in Medicare HH patients; and (2) the impact of severe pain and ADRD on unplanned facility admissions in this population.

DESIGN

Analysis of the Outcome and Assessment Information Set (OASIS) and Medicare claims data.

SETTINGS/PARTICIPANTS

6,153 patients ≥65 years receiving care from a nonprofit HH agency in 2017.

METHODS

Study outcomes included presence of severe pain and time-to-event measures of unplanned facility admissions (hospital, nursing home, or rehabilitation facilities). ADRD was identified using ICD-10 diagnosis codes and cognitive impairment symptoms. Logistic regression and Cox proportional hazard models were used to examine, respectively, the association between ADRD and severe pain, and the independent and interaction effects of severe pain and ADRD on unplanned facility admission.

RESULTS

Patients with ADRD (n = 1,525, 24.8%) were less likely to have recorded severe pain than others (16.4% vs. 23.6%, p < .001). Adjusting for demographics, comorbidities, mental and physical functional status, and use of HH services, having severe pain was related to a 35% increase (hazard ratio [HR] = 1.35, p = .002) in the risk of unplanned facility admission, but the increase in such risk was the same whether or not the patient had ADRD.

CONCLUSIONS

HH patients with ADRD may have under-recognized pain. Severe pain is a significant independent predictor of unplanned facility admissions among HH patients.

Protocol for an embedded pragmatic clinical trial to test the effectiveness of Aliviado Dementia Care in improving quality of life for persons living with dementia and their informal caregivers

INTRODUCTION

Persons living with Alzheimer's disease and related dementias (ADRD) frequently experience pain and behavioral and psychological symptoms of dementia (BPSD) which decrease quality of life (QOL) and influence caregiver burden. Home healthcare professionals however may underrecognize or lack the ability to manage BPSD.

INTERVENTION

This protocol describes an ADRD palliative quality assurance performance improvement program for home healthcare, Aliviado Dementia Care-Home Health Edition. It includes training, mentoring, and a toolbox containing intervention strategies.

METHODS

This embedded pragmatic clinical trial will utilize a multi-site, cluster randomized control design. Recruitment will occur from three home healthcare agencies located in New Jersey, Utah, and Florida. At each agency, care teams will be randomized as clusters and assigned to either the Aliviado Dementia Care program or usual care. We plan to enroll 345 persons living with ADRD and their informal caregiver dyads. The primary outcome will be to measure QOL in both the person living with ADRD and their informal caregiver, and emergency department visits and hospital admissions. Secondary outcomes in the person living with ADRD will include the examination of pain, BPSD, antipsychotic and analgesic use. Secondary outcomes in caregivers include burden, depressive symptoms, functional health and wellbeing, and healthcare utilization.

CONCLUSION

This study will be the first large-scale embedded pragmatic clinical trial in home healthcare focused on care quality and outcomes in addressing QOL in ADRD. If proven successful, the intervention can then be disseminated to agencies throughout the country to improve the quality of care for this vulnerable, underserved population.

TRIAL REGISTRATION

Clinical Trials.gov: NCT03255967.

Multidimensional Pain Assessment Tools for Ambulatory and Inpatient Nursing Practice

BACKGROUND

One of the critical components in pain management is the assessment of pain. Multidimensional measurement tools capture multiple aspects of a patient's pain experience but can be cumbersome to administer in busy clinical settings.

AIM

We conducted a systematic review to identify brief multidimensional pain assessment tools that nurses can use in both ambulatory and acute care settings.

METHODS

We searched PUBMED/MEDLINE, PsychInfo, and CINAHL databases from January 1977 through December 2019. Eligible English-language articles were systematically screened and data were extracted independently by two raters. Main outcomes included the number and types of domains captured by each instrument (e.g., sensory, impact on function, temporal components) and tool characteristics (e.g., administration time, validity) that may affect instrument uptake in practice.

RESULTS

Our search identified eight multidimensional assessment tools, all of which measured sensory or affective qualities of pain and its impact on functioning. Most tools measured impact of pain on affective functioning, mood, or enjoyment of life. One tool used ecological momentary assessment via a web-based app to assess pain symptoms. Time to administer the varying tools ranged from less than 2 minutes to 10 minutes, and evidence of validity was reported for seven of the eight tools.

CONCLUSIONS

Our review identified eight multidimensional pain measurement tools that nurses can use in ambulatory or acute care settings to capture patients' experience of pain. The most important element in selecting a multidimensional pain measure, though, is that one tool is selected that best fits the practice and is used consistently over time.

Do Warmed Blankets Change Pain, Agitation, Mood or Analgesic Use Among Nursing Home Residents?

BACKGROUND

Pain, agitation, and thermal discomfort are common symptoms of older adults residing in nursing homes. Nonpharmacologic interventions are recognized as a best practice strategy for people living in nursing homes because of their low adverse effect profile and increased evidence of effectiveness. Warmed blankets have not been empirically tested for use in long-term care.

AIMS

The purpose of this quality improvement project was to describe the use of warmed blankets in a nursing home setting and determine if use was associated with changes in pain, agitation, mood, or analgesic use.

DESIGN

A pretest posttest design was used along with a comparison of intact groups.

SETTINGS

The setting was one 160-bed skilled long-term care facility.

PARTICIPANTS/SUBJECTS

There were 141 residents eligible since they did not have a condition that could be worsened by superficial heat.

METHODS

Warmed blankets were unfolded and placed over residents with pain, agitation, or thermal discomfort. Short-term pain measures included use of the Revised FACES Pain Scale, the PAINAD (Pain Assessment in Advanced Dementia) scale, and the Brief Agitation Rating Scale. Long-term measures were taken from the electronic medical record.

RESULTS

Of the 141 eligible residents, 24.1% (n = 34) received a warmed blanket over the 1- month study period. There were statistically significant decreases in both pain level and agitation among baseline, 20 minutes after application, and the subsequent shift assessments (p < .001). There were also long-term changes in the number of pain complaints (p = .040), severity of pain complaints (p = .009), and as-needed analgesic use (p = .011). There were no statistically significant differences between the treated group and comparison group on any long-term measures.

CONCLUSIONS

Warmed blankets are a low-cost intervention with a high potential for bringing comfort to nursing home residents.

White matter hyperintensities are related to pain intensity in an outpatient memory clinic population: preliminary findings

Background: The association between pain and dementia is complicated and may depend on underlying brain pathology. It was hypothesized that both medial temporal atrophy (MTA) and global cortical atrophy (GCA) predicted no/mild pain, while white matter hyperintensities (WMH) predicted moderate/severe pain.

Objectives: To study the association between pain intensity and measures of brain pathology, more specifically MTA, GCA, and WMH.

Methods: In total, 115 consecutive patients visiting an outpatient memory clinic were included. In total, diagnoses included dementia (N=70), mild cognitive impairment (N=30), and subjective cognitive impairment (N=15). Without administering stimuli, pain intensity was assessed with the Brief Pain Inventory. MTA, GCA, and WMH were measured with a MRI visual rating scale. Logistic regression analyses to examine the relationship between WMH, MTA, GCA, and self-reported pain intensity (no/mild pain versus moderate/severe pain) were adjusted for confounders.

Results: Mean age of the patients was 81 years (IQR: 78–85, 53% female). Moderate/severe pain was reported by 23.5% and associated with greater WMH (OR =3.34, 95% CI =1.01–10.97, p=0.047), but not MTA or GCA.

Conclusions: In contrast to the present results, earlier studies have reported either a positive or negative relationship between pain and brain volume. It is suggested that the presence of dementia may explain the absence of a relationship between pain and brain volume. WMH is positively related with pain in an older memory outpatient population. Considering the small sample size, our findings should be interpreted with caution. Hence, our conclusions are preliminary findings, warranting future replication.

Sex Differences in Associations of Cognitive Function with Perceptions of Pain in Older Adults

BACKGROUND

Sex differences in pain have been shown to exist in older adults with normal cognition and people with Alzheimer's disease. It is unknown if sex differences in pain in older adults exist in a range of communicative older adults with varying cognitive ability from no impairment to moderately severe cognitive impairment.

OBJECTIVE

This study proposes to compare the association between psychophysical responses to experimental thermal pain between males and females to determine if sex differences in pain exist across the cognitive spectrum.

METHODS

We conducted a secondary analysis of data from an age- and sex-matched between-groups cross-sectional study examining the psychophysical response to contact heat in people with and without dementia.

RESULTS

Median age of males (n = 38) and females (n = 38) was 73 (range: 68-87) with similar distributions of Mini-Mental State Examination (MMSE) scores (range: 11-30). Findings revealed inverse statistically significant associations with the threshold temperature of warmth (females: r = -0.41, p = 0.010; males: r = -0.33, p = 0.044). There was an apparent divergent pattern of MMSE associations with unpleasantness ratings between the groups. At the moderate pain threshold, that difference became statistically significant (p = 0.033). Females demonstrated a positive association of MMSE with unpleasantness (r = 0.30, p = 0.072), while males demonstrated an inverse association at that respective threshold (r = -0.20, p = 0.221).

CONCLUSIONS

Between-group findings suggest that patterns of responses to thermal stimulus intensity may differ between males and females with worsening cognition with females reporting significantly less unpleasantness with the percept of moderate pain and males reporting significantly higher unpleasantness with moderate pain perception.

Pain, aging and dementia: Towards a biopsychosocial model

Dementia is a progressive disease associated with irreversible impairment and loss of cognitive abilities. About half of older people with dementia experience pain. In this paper, we propose that pain in older people with dementia can be conceptualized as the final result of the interaction of three heterogeneous phenomena, pain, aging, and dementia, which are created and influenced by the interactions of predisposing, lifelong, and current biopsychosocial factors. We review pain assessment in people with dementia using both self-report and observational/behavioral measures. We then review the biological/sensory, psychological (cognitive and affective) and social dimensions of pain in dementia. The available data suggest that dementia does not impact pain threshold or tolerance. To date, there is little research on the social dimension of pain in dementia. Changes in the affective domain in response to experimental pain have been contradictory with evidence supporting both increased and decreased unpleasantness and emotional responsiveness in people with dementia compared to healthy controls. Clinically, depression is a significant burden for older people with dementia and chronic pain. The relationship between pain and other neuropsychiatric symptoms is controversial, and there is insufficient evidence on which to base conclusions. Some of the most important dementia-related changes may arise in the cognitive domain, including impairments of semantic and episodic memory for pain, executive function, and pain anticipation. Changes in brain activation and interconnectivity support many of these conclusions. Despite methodological limitations, we conclude there are compelling preliminary data to support a biopsychosocial framework of pain and dementia. Future research directions, especially the need for improved assessment tools, are highlighted.

Sex Differences in Brain Regions Modulating Pain Among Older Adults: A Cross-Sectional Resting State Functional Connectivity Study

Objective

A long-standing hypothesis is that when compared with males, females may be at increased risk of experiencing greater pain sensitivity and unpleasantness. The purpose of this study was to examine sex differences in pain psychophysics and resting state functional connectivity (RSFC) in core pain regions in an age- and sex-matched sample of healthy older adults.

Design

Between groups, cross-sectional.

Setting

Vanderbilt University and Medical Center.

Subjects

The sample in the analyses reported here consisted of 19 cognitively intact males matched with 19 cognitively intact females of similar ages (median ages: females = 70 years, males = 68 years).

Methods

Psychophysical assessment of experimental thermal pain and RSFC.

Results

There were no significant differences in perceptual thresholds or unpleasantness ratings in response to thermal stimuli. Older males showed greater RSFC between the affective and sensory networks and between affective and descending modulatory networks. Conversely, older females showed greater RSFC between the descending modulatory network and both sensory and affective networks. The strongest evidence for sex differences emerged in the associations of thermal pain with RSFC between the anterior cingulate cortex (ACC) and amygdala and between the ACC and periaqueductal gray matter in older females relative to older males.

Conclusions

We found no differences in pain sensitivity or pain affect between older males and older females. Additionally, we found that older females exhibited a greater association between thermal pain sensitivity and RSFC signal between regions typically associated with pain affect and the descending modulatory system. One interpretation of these findings is that older females may better engage the descending pain modulatory system. This better engagement possibly translates into older females having similar perceptual thresholds for temperature sensitivity and unpleasantness associated with mild and moderate pain. These findings contrast with studies demonstrating that younger females find thermal pain more sensitive and more unpleasant.

Pain interference and depressive symptoms in communicative people with Alzheimer's disease: a pilot study

OBJECTIVES

To examine pain interference in verbally communicative older adults with mild to moderate Alzheimer's disease (AD) and to examine the association of pain interference with cognitive function and depressive symptoms.

METHOD

For this pilot study, we used a cross-sectional design to examine pain interference (Brief Pain Inventory-Short Form), cognitive function (Mini-Mental State Exam), and depressive symptoms (15-item Geriatric Depression Scale) in 52 older (≥65) communicative adults with AD who reported being free from chronic pain requiring daily analgesics.

RESULTS

Pain was reported to interfere with general activity (13.5%), mood (13.5%), walking ability (13.5%), normal work (11.5%), enjoyment of life (11.5%), relationships with other people (9.6%), and sleep (9.6%). Pain interference was significantly positively correlated with both cognitive function (r_s = 0.46, p = 0.001) and depressive symptomology (r_s = 0.45, p = 0.001), indicating that greater reported pain interference was associated with better cognitive function and more depressive symptoms.

CONCLUSION

Among older people with AD who report being free from chronic pain requiring daily analgesics, 2 in 10 are at risk of pain interference and depressive symptoms. Those with better cognitive function reported more pain interference and depressive symptoms, meaning pain is likely to be under-reported as AD progresses. Clinicians should regularly assess pain interference and depressive symptoms in older persons with AD to identify pain that might be otherwise overlooked..

The Impact of Alzheimer's Disease on the Resting State Functional Connectivity of Brain Regions Modulating Pain: A Cross Sectional Study

BACKGROUND

It is currently unknown why people with Alzheimer's disease (AD) receive less pain medication and report pain less frequently.

OBJECTIVE

The purpose of this study was to determine the impact of AD on thermal psychophysics and resting-state functional connectivity (RSFC) among sensory, affective, descending modulatory, and default mode structures.

METHODS

Controls (n = 23, 13 = female) and age-matched people with AD (n = 23, 13 = females) underwent psychophysical testing to rate perceptions of warmth, mild, and moderate pain and then completed resting-state fMRI. Between groups analysis in psychophysics and RSFC were conducted among pre-defined regions of interest implicated in sensory and affective dimensions of pain, descending pain modulation, and the default mode network.

RESULTS

People with AD displayed higher thermal thresholds for warmth and mild pain but similar moderate pain thresholds to controls. No between-group differences were found for unpleasantness at any percept. Relative to controls, people with AD demonstrated reduced RSFC between the right posterior insula and left anterior cingulate and also between right amygdala and right secondary somatosensory cortex. Moderate pain unpleasantness reports were associated with increased RSFC between right dorsolateral prefrontal cortex and left ACC in controls only.

CONCLUSIONS

While AD had little effect on unpleasantness, people with AD had increased thermal thresholds, altered RSFC, and no association of psychophysics with RSFC in pain regions. Findings begin to elucidate that in people with AD, altered integration of pain sensation, affect, and descending modulation may, in part, contribute to decreased verbal pain reports and thus decreased analgesic administration.