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Janssens WH, Van Den Noortgate NJ, Mouton V, Desmet P, Van Puyvelde K, Steen E, Maere C, Van Mulders K, De Raes E, Dekoninck J, Kympers C, Werbrouck B, Delaere J, Piers RD. Opioids in geriatric units in 14 Belgian hospitals: prevalence, dosage and associated factors. Ann Med 2024; 56:2310132. [PMID: 38294956 PMCID: PMC10833115 DOI: 10.1080/07853890.2024.2310132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/19/2024] [Indexed: 02/02/2024] Open
Abstract
Introduction: Adverse effects of opioids are common among older individuals, and undertreatment as well as overuse can be an issue. Epidemiological data on opioid use in older individuals are available, but scarce in hospitalized patients.Aims: The aim of this study is to examine the one-day prevalence of opioid use among older inpatients and identify the factors associated with both opioid use and dosage.Materials and methods: One-day cross-sectional study with data collected from geriatric units across 14 Belgian hospitals. The primary focus of the study is to assess the prevalence of opioid use and dosage, along with identifying associated factors. To achieve this, a multiple binary logistic regression model was fitted for opioid use, and a multiple linear regression model for opioid dose.Results: Opioids were used in 24.4% of 784 patients, of which 57.9% was treated with tramadol, 13.2% with oxycodone or morphine and 28.9% with transdermal buprenorphine or fentanyl. The odds for opioid use were 4.2 times higher in patients in orthogeriatric units compared to other patients (OR=4.2, 95% CI=2.50-7.05). The prevalence of opioid use was 34% higher in patients without dementia compared to patients with dementia (OR=0.66, 95% CI=0.46-0.95). The overall mean daily dosage was 14.07mg subcutaneous morphine equivalent. After adjustment for age, gender and dementia, dosage was only associated with type of opioid: the estimated mean opioid dose was 70% lower with tramadol (mean ratio=0,30,95% CI=0,23-0,39) and 67% lower with oxycodone and morphine (mean ratio=0,33, 95% CI=0,22-0,48) compared to transdermal buprenorphine and transdermal fentanyl.Conclusions: One in four patients received opioid treatment. It is not clear whether this reflects under- or overtreatment, but these results can serve as a benchmark for geriatric units to guide future pain management practices. The utilization of transdermal fentanyl and buprenorphine, resulting in higher doses of morphine equivalent, poses significant risks for side effects.
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Affiliation(s)
- Wim Henri Janssens
- Department of Geriatrics, University Hospital Ghent, Ghent, Belgium
- Department of Geriatrics, AZ Oudenaarde, Oudenaarde, Belgium
| | | | - Veerle Mouton
- Department of Geriatrics, AZ Groeninge, Kortrijk, Belgium
| | - Peter Desmet
- Department of Geriatrics, VITAZ, Sint-Niklaas, Belgium
| | | | - Elke Steen
- Department of Geriatrics, AZ Sint-Lucas Gent, Ghent, Belgium
| | - Caroline Maere
- Department of Geriatrics, AZ Sint-Lucas Brugge, Bruges, Belgium
| | | | | | | | | | - Bart Werbrouck
- Department of Geriatrics, AZ Jan Yperman, Ypres, Belgium
| | | | - Ruth D. Piers
- Department of Geriatrics, University Hospital Ghent, Ghent, Belgium
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2
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El-Tallawy SN, Ahmed RS, Shabi SM, Al-Zabidi FZ, Zaidi ARZ, Varrassi G, Pergolizzi JV, LeQuang JAK, Paladini A. The Challenges of Pain Assessment in Geriatric Patients With Dementia: A Review. Cureus 2023; 15:e49639. [PMID: 38161929 PMCID: PMC10755634 DOI: 10.7759/cureus.49639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Pain in dementia patients is common, poorly measured, and undertreated. It is important to discuss the challenges in the pain assessment and management to find a possible solution for adequate pain management. The aim of this article is to discuss the challenges in the assessment of pain in geriatric patients with dementia. An extensive online database search was conducted via multiple websites using the following keywords: "dementia," "pain assessments," "pain assessment with dementia," "causes of pain with dementia," "pain assessments using recent technology," "geriatric," and "old age" to identify the relevant articles. Our inclusion criteria were articles that focused on pain in geriatric patients diagnosed with dementia, in English, published between January 2018 and January 2023, and available as free full text and those which were clinical trials, observational studies, review articles, systemic reviews, meta-analysis, or case series. The exclusion criteria were articles that did not have pain in geriatric patients diagnosed with dementia as their primary focus, involving geriatric or non-geriatric patients with major psychological distress, not in the English language, not published between January 2018 and January 2023, and not available as free full-text and those which were case reports and editorial articles. After manually excluding the articles that did not meet our inclusion criteria, we ended up with 38 articles. In conclusion, any instruments have been made for the pain assessment in patients with dementia. The two most common tools used to assess pain in this vulnerable population are the Pain Assessment in Advanced Dementia (PAINAD) and Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) scales. The utilization of new technology may offer promising solutions for the pain assessment in patients with dementia.
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Affiliation(s)
- Salah N El-Tallawy
- Department of Anesthesia and Pain Management, College of Medicine, King Saud University, Riyadh, SAU
- Department of Anesthesia and Pain Management, Faculty of Medicine, Minia University, Minia, EGY
- Department of Anesthesia and Pain Management, Faculty of Medicine, National Cancer Institute (NCI) Cairo University, Giza, EGY
| | - Rania S Ahmed
- Department of Family Medicine, College of Medicine, Alfaisal University, Riyadh, SAU
| | - Shamah M Shabi
- Department of Family Medicine, College of Medicine, Alfaisal University, Riyadh, SAU
| | - Fatoon Z Al-Zabidi
- Department of Family Medicine, College of Medicine, Alfaisal University, Riyadh, SAU
| | - Abdul Rehman Z Zaidi
- Department of Family Medicine, College of Medicine, Alfaisal University, Riyadh, SAU
| | | | | | - Jo Ann K LeQuang
- Department of Research and Development, NEMA Research, Inc., Naples, USA
| | - Antonella Paladini
- Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
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3
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Rekatsina M, Paladini A, Viswanath O, Urits I, Myrcik D, Pergolizzi J, Breve F, Varrassi G. Opioids in the Elderly Patients with Cognitive Impairment: A Narrative Review. Pain Ther 2022; 11:381-394. [PMID: 35380373 PMCID: PMC9098742 DOI: 10.1007/s40122-022-00376-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/10/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Assessment and management of pain in elderly people with cognitive impairment is particularly challenging. Physiological changes due to aging as well as comorbidities and polypharmacy are responsible for a complex clinical approach. Concomitantly, in cognitive impairment, including advanced dementia, changes in the central nervous system along with changes in the peripheral nervous system due to aging have a significant impact on pain perception. Sometimes clinicians decide to prescribe opioids to relieve pain, also without a clear indication. This review aims to investigate the effect of opioids in elderly patients with cognitive impairment. Methods A literature search of PubMed/Medline, Scopus, and Cochrane databases was conducted using keyword searches to generate lists of articles that were screened for relevance by title and abstract to give a final list of articles for full-text review. Further articles were identified by scanning the reference lists of the full-text articles. Discussion This review discusses the complex physiological and pharmacological changes in the elderly as well as the neurological changes that affect pain perception in this population. Additionally, it focuses on cognitive impairment and pain in Alzheimer’s disease and other dementias, the pain assessment in the elderly with cognitive impairment as well as the safety of opioid use in the elderly. Information regarding opioid prescription in nursing homes and recorded indications for opioid use, type and dosing of opioids, and compliance of treatment in advanced dementia are also provided. Conclusions Opioid prescription in the elderly population with cognitive impairment is particularly complex. All healthcare professionals involved in the care of such patients need to be aware of the challenges and strive to ensure analgesic use is guided by appropriate and accurate pain assessment.
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Affiliation(s)
- M Rekatsina
- Mid and South, Essex University Hospitals Group, Orsett Hospital, Grays, RM16 3EU, Essex, UK
| | - A Paladini
- Department MESVA, University of L'Aquila, 67100, L'Aquila, Italy
| | - O Viswanath
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - I Urits
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
- Southcoast Physician Group Pain Medicine, Southcoast Health, Wareham, MA, USA
| | - D Myrcik
- Department of Internal Medicine, Silesian University of Medicine, 42-600, Byton, Poland
| | | | - F Breve
- NEMA Research Group, Naples, FL, USA
| | - G Varrassi
- Paolo Procacci Foundation, 00193, Rome, Italy.
- NEMA Research Group (European Chapter), Naples, FL, USA.
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Gustafsson M, Lövheim H, Sjölander M. Pharmacological Pain Treatment in 2012 and 2017 Among Older People with Major Neurocognitive Disorder. Drugs Aging 2021; 38:1017-1023. [PMID: 34664213 PMCID: PMC8593018 DOI: 10.1007/s40266-021-00897-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 11/29/2022]
Abstract
Background and Objective Pain is highly prevalent among older people, and treatment is complicated because of comorbidities and polypharmacy. Among people with major neurocognitive disorder additional difficulties might arise. The aim of this study was to describe analgesic drug use in 2012 and 2017 and associated factors among older people with major neurocognitive disorder. Methods In this register-based study, the Swedish Dementia Registry and the Swedish Prescribed Drug Register were combined in order to obtain data regarding analgesic drug use among older people with major neurocognitive disorder. One or more filled prescriptions during the timeframe of 6 months (1 July–31 December 2012 and 1 July–31 December 2017) defined drug use during the respective period. A comparison between 2012 and 2017 was made, including a total of 56,101 people (20,889 and 35,212 respectively) with a mean age of 81.9 and 82.7 years, respectively. Results The overall use of analgesic drugs increased significantly from 41.6% of individuals to 46.0% between the years 2012 and 2017. Users of opioid analgesics (15.2% vs 17.3%) and paracetamol (37.0% vs 42.3%) increased, while the users of non-steroidal anti-inflammatory drugs (4.9% vs 2.7%) declined between the two data collections. Multiple logistic regression analyses were performed for different drugs and drug classes, and it was found that the use of opioids and paracetamol was associated with older age and a longer time since diagnosis. In contrast, non-steroidal anti-inflammatory drugs were associated with younger age and a shorter time since diagnosis. Conclusions The results indicate that on a population level, pharmacological drug treatment has changed in line with guidelines between 2012 and 2017, with an increase in paracetamol and strong opioids and a decrease in non-steroidal anti-inflammatory drugs and tramadol. The relatively high prevalence of opioids warrants concern given the significant risk of adverse effects among older people with major neurocognitive disorder. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-021-00897-9.
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Affiliation(s)
- Maria Gustafsson
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden.
| | - Hugo Lövheim
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Maria Sjölander
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
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5
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Mörttinen-Vallius H, Hartikainen S, Huhtala H, Seinelä L, Jämsen E. Factors associated with daily opioid use among aged home care clients: a cross-sectional analysis of Resident Assessment Instrument data. Eur Geriatr Med 2021; 13:185-194. [PMID: 34241822 PMCID: PMC8860789 DOI: 10.1007/s41999-021-00533-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 06/21/2021] [Indexed: 11/28/2022]
Abstract
Aim To examine which client characteristics and other factors, including possible adverse effects, identified in the Resident Assessment Instrument-Home Care (RAI-HC) are associated with daily opioid use among aged home care clients. Findings After adjustment for pain-related diseases, disabilities, depressive symptoms and the estimated severity of pain, daily opioid use was associated with osteoporosis, cancer within previous 5 years and greater disabilities in Instrumental Activities of Daily Living, and cognitive impairment was associated with less frequent opioid use. Constipation was the only adverse effect identified in the RAI-HC associated with daily opioid use. Message The pain of home care clients with cognitive impairment may not be treated optimally, whereas there might be prolonged opioid use without a sufficient evaluation of current pain among clients with osteoporosis, cancer within previous 5 years and disabilities in Instrumental Activities of Daily Living. Purpose To examine which client characteristics and other factors, including possible adverse effects, identified in the Resident Assessment Instrument—Home Care (RAI-HC) are associated with daily opioid use among aged home care clients. Methods The study sample comprised 2584 home care clients aged ≥ 65 years, of which 282 persons used opioids daily. Clients using opioids less than once daily were excluded. The cross-sectional data were gathered from each client’s first assessment with the RAI-HC during 2014. Multivariable logistic regression was used to study associations of daily opioid use with the clients’ characteristics and symptoms. Results Cognitive impairment was associated with less frequent opioid use after adjusting for pain-related diseases, disabilities and depressive symptoms (OR 0.43, 95% CI 0.32–0.58). The association was not explained by the estimated severity of pain. Osteoporosis, cancer within previous 5 years and greater disabilities in Instrumental Activities of Daily Living (IADL) were associated with daily opioid use regardless of the estimated severity of pain. Depressive symptoms and Parkinson’s disease were associated with daily opioid use only among clients with cognitive impairment, and disabilities in Activities of Daily Living, cancer, arthritis, fractures and pressure ulcers only among clients without cognitive impairment. Constipation was the only adverse effect associated with daily opioid use. Conclusion The pain of home care clients with cognitive impairment may not be treated optimally, whereas there might be prolonged opioid use without a sufficient evaluation of current pain among clients with osteoporosis, cancer within previous 5 years and disabilities in IADLs.
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Affiliation(s)
| | - Sirpa Hartikainen
- Research Centre of Geriatric Care, School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, N33014, Tampere, Finland
| | - Lauri Seinelä
- Faculty of Medicine and Health Technology, Tampere University, N33014, Tampere, Finland
| | - Esa Jämsen
- Faculty of Medicine and Health Technology and Gerontology Research Centre GEREC, Tampere University, FIN-33014, Tampere, Finland.,Tampere University Hospital, P.O. Box 2000, FIN-33521, Tampere, Finland
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Giménez-Llort L, Bernal ML, Docking R, Muntsant-Soria A, Torres-Lista V, Bulbena A, Schofield PA. Pain in Older Adults With Dementia: A Survey in Spain. Front Neurol 2020; 11:592366. [PMID: 33329344 PMCID: PMC7715009 DOI: 10.3389/fneur.2020.592366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/19/2020] [Indexed: 12/11/2022] Open
Abstract
The risk of suffering pain increases significantly throughout life, reaching the highest levels in its latest years. Prevalence of pain in nursing homes is estimated to range from 40 to 80% of residents, most of them old adults affected with dementia. It is already known that pain is under-diagnosed and under-treated in patients with severe cognitive impairment and poor/absent verbal communication, resulting in a serious impact on their quality of life, psychosocial, and physical functioning. Under-treated pain is commonly the cause of behavioral symptoms, which can lead to misuse of antipsychotic treatments. Here, we present two Regional and National Surveys in Spain (2015–2017) on the current practices, use of observational tools for pain assessment, guidelines, and policies. Results, discussed as compared to the survey across central/north Europe, confirm the professional concerns on pain in severe dementia, due to poor standardization and lack of guidelines/recommendations. In Spain, observational tools are scarcely used because of their difficulty and low reliability in severe dementia, since the poor/absent verbal communication and comprehension are considered limiting factors. Behavioral observation tools should be used while attending the patients, in a situation including rest and movement, should be short (3–5 min) and scored using a numeric scale. Among the pain items to score, “Facial expression” and “Verbalization” were considered essential and very useful, respectively. This was in contrast to “Body movements” and “Vocalizations,” respectively, according to the survey in central/north Europe. Scarce time availability for pain assessment and monitoring, together with low feasible and time-consuming tools, can make pain assessment a challenge. The presence of confounding factors, the low awareness and poor knowledge/education of specific tools for this population are worrisome. These complaints draw future directions to improve pain assessment. More time available, awareness, and involvement of the teams would also benefit pain assessment and management in cognitive impairment. The experiences and opinions recorded in these surveys in Spain and other E.U. countries were considered sources of knowledge for designing the “PAIC-15 scale,” a new internationally agreed-on meta-tool for Pain Assessment in Impaired Cognition and the “Observational pain assessment” in older persons with dementia.
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Affiliation(s)
- Lydia Giménez-Llort
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain.,Institut de Neurociències, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Maria Luisa Bernal
- Department of Pharmacology and Physiology, University of Zaragoza, Zaragoza, Spain.,Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | | | - Aida Muntsant-Soria
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain.,Institut de Neurociències, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Virginia Torres-Lista
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain.,Institut de Neurociències, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Antoni Bulbena
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Patricia A Schofield
- Abertay University, Dundee, United Kingdom.,Sheffield Hallam University, Sheffield, United Kingdom
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