Dementia patients “suffering in silence”

University College London | September 2018 | Dementia patients “suffering in silence”

A new study from University College London (UCL) reports that one-third of patients with dementia who may also experience delirium (a state of acute confusion) are frequently unable to express that they are in pain.  The study has originality, as it is the first of its kind  in a hospital context. It has been funded by the Alzheimer’s Society and Bupa Foundation, and supported by the terminal illness charity Marie Curie. The research was conducted in two acute hospitals in the UK and followed more than 200 patients over the age of 70 (via UCL).

intravenous-141551_1920.jpg

At the outset the researchers asked patients if they were in pain. If the patient was then unable to communicate, researchers assessed people for signs of pain in their facial expression and body language. They recorded the number of people who were unable to communicate that they were in pain, and measured delirium with a standard confusion assessment method.

The researchers found that almost half (49%)  of the participants experienced pain at rest, while a quarter (25%)  experienced pain during activity. A little over a  third (35%) of participants who were delirious and unable to self-report pain,  of these patients 33%  experienced pain at rest, and 56% experienced pain during activity.

The odds of being delirious were 3.26 times higher in participants experiencing pain at rest.

Senior Author Dr Liz Samson from the Marie Curie Palliative Care Research Department, UCL Psychiatry says, ” In the UK, almost half of people admitted to hospital over the age of 70 will have dementia. We know that they are a high-risk group for delirium and yet delirium is often under treated.”  She elaborated, “It’s deeply troubling to think that this vulnerable group of patients are suffering in silence, unable to tell healthcare professionals that they are in pain.” (Source: UCL)

Read the full story at UCL

The research findings have now been published in the journal  Age and Ageing, where the full article is available to read

Parents’ reactions can lessen or worsen pain for injured kids

New research (yet to be published) has looked at family coping and distress during a dressing change following a burn injury in kids | The Conversation

desperate-2048905_960_720

The 18-month study observed 92 families during their young child’s (one to six years) first burn dressing change at a Brisbane hospital.

Parents who reported they were more anxious or distressed were less able to support their child during the procedure. This decreased the child’s ability to cope and increased the child’s distress, which was measured by their ability to be distracted by toys and conversation, compared to crying or screaming during the dressing change.

Ratings of child anxiety and pain during the dressing change were also greater for children of parents who were less able to support their child during the dressing change.

Read the full blog post by  Erin Brown & Justin Kenardy here

Assessment and management of pain for people with dementia in hospital

Closs, S.J. et al. NIHR. Published online: October 2016

face-1370955_960_720

It is difficult for people with dementia to communicate their pain to health-care professionals. Pain often has damaging effects on mental and physical health, and research has shown that pain is often poorly managed in people with dementia in hospital.

We aimed to develop a new system that would help staff to manage pain. To this end, we first identified any accurate and reliable pain assessment tools available for use with hospital patients who have dementia. We then explored how pain is currently recognised, assessed and managed in people with dementia in four hospitals in England and Scotland.

We found 28 pain assessment tools which had been reviewed, but none had been tested rigorously. Seven had potentially useful features, but no single tool could be recommended for wider use. The 11 hospital wards studied were all different, with their own complex pain assessment and management practices. Information from different staff and carers was produced at different times and in different formats, and was recorded in separate documents. This information was mentally pulled together into an ‘overall picture’ of pain by each staff member for each individual patient.

We suggest developing a combined education package and electronic health record, the Pain And Dementia Decision Support (PADDS) intervention, to help staff recognise, assess and manage pain. This should incorporate carer input, staff narratives, pain histories, intensity assessments, medication and other interventions provided, and present an overall picture of pain in an integrated and easily accessible visual format. This will require thorough development and testing.

Read the full report here

Cancer patients not getting adequate pain relief

Many terminal cancer patients are not getting adequate pain relief early enough, according to an English study.| Science Daily | PAIN

poppy-1573061_960_720

Many terminal cancer patients are not getting adequate pain relief early enough, according to a University of Leeds study.  The researchers found that, on average, terminal cancer patients were given their first dose of a strong opioid such as morphine just nine weeks before their death.  Yet many people with terminal cancer suffer with pain a long time before that, the researchers said.

The research team used UK Cancer Registry data to study a sample of 6,080 patients who died of the disease between 2005 and 2012. They found that 48 per cent of the patients were issued a prescription in general practice (primary care) for a strong opioid medication, such as morphine, during the last year of their life.

The study, published in the medical journal Pain, said efforts to improve treatment of cancer pain may be being hindered by concern over the ongoing ‘opioid epidemic’.

They cited NHS data which showed that overall opioid prescribing increased by 466 per cent between 2000 and 2010, but only increased by 16 per cent for patients with cancer.

Full reference: Lucy Ziegler et. al. Opioid prescribing for patients with cancer in the last year of life. PAIN, Published Ahead of Print 2016

Psychological interventions in managing postoperative pain in children: a systematic review

Davidson, F. et al. (2016) Pain. 157(9). pp. 1872–1886

balloon-898682_960_720

Pediatric surgeries are common and painful for children. Postoperative pain is commonly managed with analgesics; however, pain is often still problematic. Despite evidence for psychological interventions for procedural pain, there is currently no evidence synthesis for psychological interventions in managing postoperative pain in children.

The purpose of this review was to assess the efficacy of psychological interventions for postoperative pain in youth. Psychological interventions included Preparation/education, distraction/imagery, and mixed. Four databases (PsycINFO, PubMed, EMBASE, and Certified Index to Nursing and Allied Health Literature) were searched to July 2015 for published articles and dissertations.

We screened 1401 citations and included 20 studies of youth aged 2 to 18 years undergoing surgery. Two reviewers independently screened articles, extracted data, and assessed risk of bias. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated using RevMan 5.3. Fourteen studies (1096 participants) were included in meta-analyses. Primary outcome was pain intensity (0-10 metric).

Results indicated that psychological interventions as a whole were effective in reducing children’s self-reported pain in the short term (SMD = −0.47, 95% CI = −0.76 to −0.18). Subgroup analysis indicated that distraction/imagery interventions were effective in reducing self-reported pain in the short term (24 hours, SMD = −0.63, 95% CI = −1.04 to −0.23), whereas preparation/education interventions were not effective (SMD = −0.27, 95% CI = −0.61 to 0.08).

Data on the effects of interventions on longer term pain outcomes were limited. Psychological interventions may be effective in reducing short-term postoperative pain intensity in children, as well as longer term pain and other outcomes (eg, adverse events) require further study.

Read the full review here

Managing Pain in Children: Helping to Improve the Use of Evidence in Practice

Twycross, A. BMJ Evidence-based Nursing Blog. Published online: 18 April 2016

By Alison Twycross (@alitwy), Head of Department for Children’s Nursing and Professor of Children’s Nursing, London South Bank University.

https://commons.wikimedia.org/wiki/File:Children%27s_pain_scale.JPG
Image source: Robert Weis // CC BY-SA 4.0

I have been editor of Evidence Based Nursing since August 2010 and during that time I have worked with a team of associate editors to make the evidence to guide practice more accessible to nurses working in clinical practice. Alongside this I have also carried out research relating to managing pain in children. My current research focuses on the management of acute, post-operative and cancer-related pain in children and in particular on supporting parents to manage their child’s pain at home. I have also edited three books pulling together the evidence for managing pain in children. Details of the 2014 book can be found at: http://eu.wiley.com/WileyCDA/WileyTitle/productCd-0470670541.html

The observational studies demonstrate that current practices confirm to clinical guidelines in some but not all areas and we still have:

  • Inconsistent pain assessment practices – for example, not all children have pain scores recorded
  • Pain management is seen by many nurses as synonymous with administering analgesic drugs
  • Decision-making about which pain relieving interventions to use is not guided by pain scores
  • Non-drug methods are not seen as a nursing role – instead they are seen as a parents’ role or something for the play specialist
  • Limited communication with child and parents about pain management
  • Limited documentation about pain management
  • Children experiencing moderate to severe pain unrelieved pain during a hospital stay

Read the full post here

By Alison Twycross (@alitwy), Head of Department for Children’s Nursing and Professor of Children’s Nursing, London South Bank University.

I have been editor of Evidence Based Nursing since August 2010 and during that time I have worked with a team of associate editors to make the evidence to guide practice more accessible to nurses working in clinical practice. Alongside this I have also carried out research relating to managing pain in children. My current research focuses on the management of acute, post-operative and cancer-related pain in children and in particular on supporting parents to manage their child’s pain at home. I have also edited three books pulling together the evidence for managing pain in children. Details of the 2014 book can be found at: http://eu.wiley.com/WileyCDA/WileyTitle/productCd-0470670541.html

The observational studies demonstrate that current practices confirm to clinical guidelines in some but not all areas and we still have:

  • Inconsistent pain assessment practices – for example, not all children have pain scores recorded
  • Pain management is seen by many nurses as synonymous with administering analgesic drugs
  • Decision-making about which pain relieving interventions to use is not guided by pain scores
  • Non-drug methods are not seen as a nursing role – instead they are seen as a parents’ role or something for the play specialist
  • Limited communication with child and parents about pain management
  • Limited documentation about pain management
  • Children experiencing moderate to severe pain unrelieved pain during a hospital stay

Read the full post here

Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain

Good practice in prescribing opioid medicines for pain should reflect fundamental principles in prescribing generally. The decision to prescribe is underpinned by applying best professional practice; understanding the condition, the patient and their context and understanding the clinical use of the drug. This resource, developed by UK healthcare professionals and policymakers, provides the information to support a safe and effective prescribing decision.

fpm-opioid-graphic3-2
Image source: FPM 

Resources available include:

  • Best practice and the law.
  • Assessment and long-term pain challenges
  • Clinical use of opioids
  • A structures approach to prescribing
  • Information for patients

View the full resource here