Pain in a Special Population: The Cognitively Impaired
When cognitive impairmentstrikes, life can turn upsidedown for patients and theircaretakers. Many cognitively impairedpatients communicate poorly if at all, orare unable to describe pain or discomfortaccurately. Lacking the capability toengage in meaningful dialogue with prescribersor caregivers, cognitively impairedpatients may express problemsbehaviorally—sometimes using combativeor agitated behaviors that often areprone to misinterpretation by others.
Conversely, patients who have painoften report cognitive changes, such asforgetfulness and poor concentration.1This situation creates a conundrum forclinicians: how can they identify andtreat pain in these patients and ensurethat the medications used are appropriateto the patients' needs?
Cognitive impairment is a broad termthat includes many symptoms (Table)and describes a wide range of conditionsthat develop from numerous possiblecauses. It may stem from physical problems,such as a neurologic disorder (eg,dementia, developmental disability),musculoskeletal problems, delirium, orsleep deprivation. It may be iatrogenic orpatient-mediated, with medication orchronic alcohol/drug abuse a frequentcause. Cognitive impairment also mayhave psychological or psychiatric causes,including poor coping skills, stressful circumstances,anxiety, emotional instability,or, often, depression.2-4 Pain relief cansometimes improve cognitive performanceand behavior.4
Cognitive impairment is usually graded."Mild" represents a score ≥18 on theMini Mental State Examination (a brief30-point questionnaire that is used toassess cognition). "Moderate" means ascore of 13 to 17, and "severe" reflects ascore of ≤12. Often, the cognitivelyimpaired patient is an older adult whohas dementia or the cumulative ravagesof drug or alcohol abuse. More than 60%of older adults have comorbidities—suchas arthritis, cancer, and neuropathy—that elevate the likelihood of pain.5-8Cognitive impairment can be a significantbut not insurmountable barrier to painassessment and management.9
Many patients who are cognitivelyimpaired can rate pain as reliably as otherscan, provided that the pain assessmenttool selected is appropriate. Researchindicates that 83% of patientswith mild-to-moderate cognitive impairmentcan complete pain assessmentscales for the pain they are experiencingat the moment. Not all pain assessmentscales are useful for all patients, however.Cognitively impaired patients may bepoor historians,making tools that assesspain duration less helpful.
The popular visual analogue scale(VAS) can be challenging for many cognitivelyimpaired people. Using a list ofwords to describe their pain may be better.Once dementia becomes severe,most patients no longer can use a painassessment 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 painimaginable?"), a faces VAS, a 21-pointbox scale, and other scales for rating pain(Figures). Rating scales with word (ratherthan picture) anchors seem to be best forpatients with mild-to-moderate cognitiveimpairment.10
The Nonverbal Patient
Once cognitive impairment becomessevere, verbal skills diminish. The burdenof pain assessment and interventionshifts to those who can observe thepatient. Clinicians and caregivers mustrely on the patient's nonverbal behaviors,vocalizations, and changes in functionalstatus as pain indicators.5,6 If a patient'sbasic comfort needs are being met andno cause for the status change can befound, but the patient's behavior, expression,or verbalizations change, pain is astrong possibility.
Facial expressions such as grimacing,furrowing of the brow, squinting, rapidblinking, and nose wrinkling can indicatepain,5,6 as can physical movementsincluding restlessness, agitation, withdrawal,guarding, bracing, resistance tomovement, rigidity, combative behavior,and especially aggression.5,11 Patientsmay sigh, moan, scream, chant, breathenoisily, or curse.
The best pain assessment by proxy isthat provided by caregivers or familymembers who know the patient. Onlythey can identify changes from apatient's baseline behaviors that maysignify pain.5,11-13
Medicating for Pain
Cognitively impaired patients frequentlyare undermedicated for pain.14,15 In itsguidelines for treating pain in the cognitivelyimpaired person, the HospiceFoundation recommends that cliniciansuse this guide: if the clinician wouldexpect a cognitively intact person toexperience pain in the cognitivelyimpaired patient's circumstances, he orshe should assume that the patient isexperiencing pain.16 Analgesia should beprovided in the same way that it is providedfor cognitively intact individuals.
Mild pain can be treated with as-neededacetaminophen, nonsteroidal antiinflammatorydrugs (NSAIDs), or opioids.Chronic pain treatment should follow theWorld Health Organization's pain ladder,taking into account the caveats providedby the American Geriatrics Society Panelon Persistent Pain in Older Persons17 withregard to the analgesic ladder. For example,the panel advises caution and frequentrenal function monitoring whenNSAIDs and cyclooxygenase-2 inhibitorsare prescribed.
The treatment also becomes an assessmenttool, with a positive outcome substantiatingthat pain was present.Treatment with analgesics will of necessitybe empiric (derived from trial andobservation) in the cognitively impairedpatient. Pharmacists shouldencourage caregivers to make specificnote of those behaviors they think aremanifestations ofpain, including thefrequency and durationof behaviorsor verbalizations.Once they administeranalgesics,they should monitorto ensure thatthe manifestationsare improving, keepingin mind thatmild sedation andcognitive changesare side effects ofopioids.
If the mild tomoderately impairedindividualused a pain scalesuccessfully beforetreatment, thesame scale shouldbe used periodicallyafter. If the patientexperiencessome relief butdoes not return tobaseline, the doseor frequency ofmedication canbe increased. If the pain persists, othercauses should be considered, includingside effects of the medication used.16
Pain assessment among cognitivelyimpaired patients requires vigilant observation.When clinicians detect cognitivechanges, they need to distinguish carefullythose associated with disease pathologyfrom those that are symptomatic ofpain. Consulting with others, as well asmaking caregivers part of the team, isoften the prudent course of action.
Ms. Wick is a senior clinical researchpharmacist at the National CancerInstitute, National Institutes ofHealth. The views expressed arethose of the author and not those ofany government agency.
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