When cognitive impairment strikes, life can turn upside down for patients and their caretakers. Many cognitively impaired patients communicate poorly if at all, or are unable to describe pain or discomfort accurately. Lacking the capability to engage in meaningful dialogue with prescribers or caregivers, cognitively impaired patients may express problems behaviorallysometimes using combative or agitated behaviors that often are prone to misinterpretation by others.
Conversely, patients who have pain often report cognitive changes, such as forgetfulness and poor concentration.1 This situation creates a conundrum for clinicians: how can they identify and treat pain in these patients and ensure that the medications used are appropriate to the patients' needs?
Cognitive impairment is a broad term that includes many symptoms (Table) and describes a wide range of conditions that develop from numerous possible causes. It may stem from physical problems, such as a neurologic disorder (eg, dementia, developmental disability), musculoskeletal problems, delirium, or sleep deprivation. It may be iatrogenic or patient-mediated, with medication or chronic alcohol/drug abuse a frequent cause. Cognitive impairment also may have psychological or psychiatric causes, including poor coping skills, stressful circumstances, anxiety, emotional instability, or, often, depression.2-4 Pain relief can sometimes improve cognitive performance and behavior.4
Cognitive impairment is usually graded. "Mild" represents a score ≥18 on the Mini Mental State Examination (a brief 30-point questionnaire that is used to assess cognition). "Moderate" means a score of 13 to 17, and "severe" reflects a score of ≤12. Often, the cognitively impaired patient is an older adult who has dementia or the cumulative ravages of drug or alcohol abuse. More than 60% of older adults have comorbiditiessuch as arthritis, cancer, and neuropathy that elevate the likelihood of pain.5-8 Cognitive impairment can be a significant but not insurmountable barrier to pain assessment and management.9
Many patients who are cognitively impaired can rate pain as reliably as others can, provided that the pain assessment tool selected is appropriate. Research indicates that 83% of patients with mild-to-moderate cognitive impairment can complete pain assessment scales for the pain they are experiencing at the moment. Not all pain assessment scales are useful for all patients, however. Cognitively impaired patients may be poor historians,making tools that assess pain duration less helpful.
The popular visual analogue scale (VAS) can be challenging for many cognitively impaired people. Using a list of words to describe their pain may be better. Once dementia becomes severe, most patients no longer can use a pain assessment scale.9,10
Tools that can be used include a 5-point verbal scale ("On a scale of 1 to 5, where 1 is no pain and 5 is the worst pain imaginable?"), a faces VAS, a 21-point box scale, and other scales for rating pain (Figures). Rating scales with word (rather than picture) anchors seem to be best for patients with mild-to-moderate cognitive impairment.10
The Nonverbal Patient
Once cognitive impairment becomes severe, verbal skills diminish. The burden of pain assessment and intervention shifts to those who can observe the patient. Clinicians and caregivers must rely on the patient's nonverbal behaviors, vocalizations, and changes in functional status as pain indicators.5,6 If a patient's basic comfort needs are being met and no cause for the status change can be found, but the patient's behavior, expression, or verbalizations change, pain is a strong possibility.
Facial expressions such as grimacing, furrowing of the brow, squinting, rapid blinking, and nose wrinkling can indicate pain,5,6 as can physical movements including restlessness, agitation, withdrawal, guarding, bracing, resistance to movement, rigidity, combative behavior, and especially aggression.5,11 Patients may sigh, moan, scream, chant, breathe noisily, or curse.
The best pain assessment by proxy is that provided by caregivers or family members who know the patient. Only they can identify changes from a patient's baseline behaviors that may signify pain.5,11-13
Medicating for Pain
Cognitively impaired patients frequently are undermedicated for pain.14,15 In its guidelines for treating pain in the cognitively impaired person, the Hospice Foundation recommends that clinicians use this guide: if the clinician would expect a cognitively intact person to experience pain in the cognitively impaired patient's circumstances, he or she should assume that the patient is experiencing pain.16 Analgesia should be provided in the same way that it is provided for cognitively intact individuals.
Mild pain can be treated with as-needed acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), or opioids. Chronic pain treatment should follow the World Health Organization's pain ladder, taking into account the caveats provided by the American Geriatrics Society Panel on Persistent Pain in Older Persons17 with regard to the analgesic ladder. For example, the panel advises caution and frequent renal function monitoring when NSAIDs and cyclooxygenase-2 inhibitors are prescribed.
The treatment also becomes an assessment tool, with a positive outcome substantiating that pain was present. Treatment with analgesics will of necessity be empiric (derived from trial and observation) in the cognitively impaired patient. Pharmacists should encourage caregivers to make specific note of those behaviors they think are manifestations of pain, including the frequency and duration of behaviors or verbalizations. Once they administer analgesics, they should monitor to ensure that the manifestations are improving, keeping in mind that mild sedation and cognitive changes are side effects of opioids.
If the mild to moderately impaired individual used a pain scale successfully before treatment, the same scale should be used periodically after. If the patient experiences some relief but does not return to baseline, the dose or frequency of medication can be increased. If the pain persists, other causes should be considered, including side effects of the medication used.16
Pain assessment among cognitively impaired patients requires vigilant observation. When clinicians detect cognitive changes, they need to distinguish carefully those associated with disease pathology from those that are symptomatic of pain. Consulting with others, as well as making caregivers part of the team, is often the prudent course of action.
Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health. The views expressed are those of the author and not those of any government agency.
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15. Nygaard HA, Jarland M. Are nursing home patients with dementia diagnosis at increased risk for inadequate pain treatment? Intl J Geriatr Psychiatry. 2005;20:730-737.
16. Herr K, Decker S; Hospice Foundation. Older adults with severe cognitive impairment: assessment of pain. Available at: www.hospicefoundation.org/hfaPublications/books/lwg2006/herr_decker.pdf. Accessed June 25, 2006.
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