Behavioral Manifestations of Pain in the Demented Elde - PDF document

Behavioraldisturbancesarebelievedtobeapossibleindi-catorofphysicaldiscomfortamongthecognitivelyimpaired UniversityofNorthTexasHealthScienceCenter,FortWorth,TX(D.J.C.);Mind-BodyWellnessInstitute,SeniorConnectionsofDallas,Dallas,TX(P.A.C.,AddresscorrespondencetoDaishaJ.Cipher,PhD,UNTHealthScienceCenter,3500CampBowieBoulevard,FortWorth,TX76107.E-mail:dcipher@hsc.Copyright©2006AmericanMedicalDirectorsAssociationDOI:10.1016/j.jamda.2005.11.012ORIGINALSTUDIESCipheretal. percentageofpsychiatriccomorbidity.20–22Intheyoungerpopulation,chronicpainisusuallytreatedeffectivelywithanalgesicsalone,andthisislikelytoalsobethecasewithLTCresidents.Giventhedifferencesbetweentheacuteandchronicpainexperience,itispossiblethatacutepainismanifested,assessed,andtreateddifferentlythanchronicpainamongdementedLTCresidents.Inapreviousstudy,weinvestigatedthebehavioralandemotionalwaysinwhichpainmaybeexpressedbythosewithSpecically,wetestedapathmodelcomposedofvariablesrepresentingcognitiveimpairment,emotionaldis-tress,pain,activitiesofdailyliving,andbehavioraldistur-bances.Pathanalysesrevealedthatamediationalmodelhadthebestmodelt.Wefoundthatpainlevelsdidnotinuenceactivitiesofdailylivingdirectly,butratherinuencedbehav-ioraldisturbancesanddepression,whichinturninuencedactivitiesofdailyliving.Thesendingssuggestthatamongpersonssufferingfromdementiawhocannotexpresspaindirectly,painmaybeexpressedviabehavioralandemotionaldisturbances.Becauseofthecorrelationalnatureofthemeth-odology,wedidnottestthekindofpain(acuteversuschronic)experiencedbytheresidents,nordidwedelineatebetweenthedifferenttypesofbehavioraldisturbances.There-fore,furtherinvestigationwaswarrantedinordertotesttherelationshipsbetweenspecictypesofpain,categoriesofdementia,andspecickindsofbehavioraldisturbancesthatresidentsmayexpress.Thepurposeofthisstudywastoinvestigatetherelation-shipsbetweenpainandbehavioraldisturbancesamongLTCresidentsofdifferinglevelsofdementia.Threehy-pothesesguidedthestudy:(1)therelationshipbetweenpainlevelsandoverallbehavioraldisturbanceswillbesignicantlystrongeramongLTCresidentssufferingfromlater-stagedementiathanthatofresidentssufferingfromearlier-stagedementia;(2)thoseLTCresidentswithmod-eratetoseveredementiawhoaresufferingfromacutepainassociatedwitharecentfallarelikelytoexhibitmoreintense,frequent,andlonger-lastingbehavioraldistur-bancesthanthoseresidentswithmild,earlystagedemen-tia;and(3)thoseLTCresidentswithmoderatetoseveredementiawhoaredocumentedtobesufferingfromchronicpainintheabsenceofacutepainarelikelytoexhibitmoreintense,frequent,andlonger-lastingbehavioraldistur-bancesthanthoseresidentswithmild,earlystagedemen-Thestudysampleconsistedof277residentslivinginatotalof16LTCfacilitiesintheDallas,Texas,area.FourteenofthecarefacilitieswereLTC/skillednursingunits,1wasaninpa-tientrehabilitationunit,and1wasalong-termacutecarefacility.Seventy–vepercentoftheresidentsinthesamplewerefemales,andthemeanagewas82years(SD9.3).Thesamplewaspredominantlywhite(89%),followedbyAfricanAmerican(4%),andAsianAmerican(2%).Residentswerediagnosedwithmorethan2chronicmedicalconditionsonaverage(X2.7,SD1.8),themostcommonconditionbeinghypertension(47%)followedbycoronaryarterydisease(38%),cerebralvasculardamage(29%),diabetes(24%),con-gestiveheartfailure(24%),atrialbrillation(20%),chronicobstructivepulmonarydisease(17%),andkidneydisease(8%).Themajorityoftheresidentswerefunctioningatthelevelofmoderatedementiaorworse(63%)and37%sufferedfrommildtominimalcognitiveimpairmentasindicatedbythecriteriaoutlinedbyReisbergandcolleaguesTable1UsingtheReisbergetalcriteriafromtheFunctionalAssess-mentStagingTool,wedividedourresidentsinto3demen-tiacategoriesforanalyticpurposes:Mild,Moderate,andSe-vere.Therst3criteriafellintoour“Mild”category,thenext3criteriafellintoour“Moderate”category,andthelast2criteriafellintoour“Severe”category.GeriatricLevelofDysfunctionScale(GLDS)Residentswereratedontheintensity,frequency,duration,andnumber(count)ofeachof19possiblebehavioralcate-gories,includingagitation,verbalaggression,withdrawal,andphysicalaggression.Intensityratingsweremadeona7-prongedscale,withlowernumbersrepresentingtheleastintensity(1ble),andprogressiveratingsofmildlydistressing,moderatelydistressing,disruptivetoselforothers,interferinginmedicalcare,possibledangertoselfofothers,and(7DangertoSelforOthers).Frequencyratingsweremadeona7-prongedscale,withlowernumbersrepresentingfewerepi-sodes(1Lessthantwicepermonth)andprogressiveratingsofonceperweek,2to6timesperweek,onceaday,afewtimesperday,severaltimesperdayand(7Durationratingsweremadeona7-prongedscale,withlowernumbersrepresentingshorterduration(1Lessthanorequalto1to2minutesperday),andprogressiveratingsoflessthanorequalto30minutesperday,lessthanorequalto1hourperday,lessthanorequalto2hoursperday,lessthanorequalto4hoursperday,lessthanorequalto6hoursperday,and(7Greaterthan6hoursperday).TheseratingsTable1.FrequencyTableofStudyDementiaCategoriesCreatedUsingReisbergCategories StudyDementiaReisbergetalDementiaCategoriesMildNone,Normal176.1MildVerymild,Forgetfulness4215.2MildMild,Earlyconfusion5218.8ModerateModerate,Late4917.7ModerateModerateÐEarly6423.1SevereSevere,Middle3914.1SevereVerySevere,Late145.1Total277100.0Cipheretal.JAMDAÐJuly2006 havebeenevidencedtohaveexcellentinternalconsistency0.96).Test-retestcoefcientshaverangedbetween0.86and0.94among3raters.Anyofthebehavioralcategoriesthatwerenotexhibitedatallweregivena“0”entry.Com-positevariableswerealsocomputedforeachresidenttoin-dicatetheiraveragebehavioralintensity,frequency,anddu-rationratingsacrossthe19behavioralcategoriesbycomputingmeans,inadditiontocountingtheoverallnumberofdysfunctionalbehaviorstorepresentnumberofdysfunc-tionalbehaviorsperresident.TheGeriatricMultidimensionalPainandIllnessInventory(GMPI)TheGMPIisa12-itemclinician-ratedinstrumentdesignedtoassesspainanditsfunctional,social,andemotionalcon-sequencesinLTC.Therstitemis,“Howbadisyourpainrightnow?”Otheritemsinclude,“Howmuchhaveyousuf-feredbecauseofyourpainthislastweek?”“Howmuchhasyourpainaffectedyourabilitytoleavetheroomforsocialorrecreationalactivities?”and“Howirritablehaveyoubeenthislastweekbecauseofyourpain?”Allitemsareratedona10-pointscale,witheachpointassociatedwithspecicbe-havioralcriteria.ThescalingoftheitemsisbehaviorallyorientedbecausetheGMPIisratedbyaclinicianwhocanonlyratebasedonwhattheraterandthestaffmemberscanobserve.TheGMPIhasbeenevidencedtohavehighinternalconsistency(0.88),andtest-retestreliabilitiesforthe3subscaleshaverangedfrom0.62to0.96.Highervaluesareindicativeofhigherlevelsofpainand/orhigherlevelsoffunctional/social/emotionaldifculties.FunctionalAssessmentStagingTool(FAST)TheFASTwasdevelopedtoassistprofessionalsandcare-giverstochartthedeclineofpatientswithAlzheimerdiseaseandotherdementia-associateddisorders.Thistoolconsistsofratingscalesthatculminateindesignatingaphaseofdemen-tiaforthepatient(see7phasesinTable1NeurobehavioralCognitiveStatusExaminationTheNCSEisaclinician-administeredexaminationofim-pairmentinorientation,repetition,naming,attentionspan,comprehension,short-termmemory,constructionalability,socialjudgment,abstraction,andcalculation.TheNCSEusesadifferentiatedapproachtoassessvariousaspectsofcognitivefunctioning,andwasdevelopedtoovercomeweaknessesofotherbriefinstruments.Highervaluesareindicativeofhighercognitivefunctioning;lowervaluesareindicativeofimpair-ment.TheNCSEhasgoodreliabilityandvalidityindicators,andhasbeenevidencedtohavealowfalse-negativerate.TheGLDS,GMPI,FAST,andNCSEwereadministeredaspartofaneuropsychologicalevaluationthatwasadministeredby3licenseddoctoral-levelclinicalgeropsychologists,afterobtaininginformedconsentandcaregiverassentforthoseparticipantssufferingfromlaterstagesofdementia.Thissam-pleconsistedofconsecutivepatientreferralsfromattendingphysicianstoaclinicalpsychologistfor1of3reasons:(1)changeincognitivefunctioning;(2)emotionaldistress;or(3)behavioraldysfunctionassociatedwithdementia.Eachinstru-mentwasadministeredby1ofthe3clinicalgeropsychologistsafterinterviewingtheresident,nursingstaff,andfamilymem-berswhowereinvolvedwiththeresident’scare.DescriptivestatisticsandintercorrelationsfortheGLDSintensity,frequency,anddurationitemsareshowninTable2below.Residentsexhibitedameanof3.04(SDbehavioraldisturbances.Themeanfrequencyofbehavioraldisturbanceswas6.15(SD1.17).Themeanintensityofbehavioraldisturbanceswas4.39(SD0.78).Themeandurationofbehavioraldisturbanceswas6.60(SDThemostcommonlyoccurringbehavioraldysfunctionwasdepressiveandwithdrawal-relatedbehavior(74%ofthesam-ple),followedbylossofweightorappetite(38%),lowactivitylevels(38%),noncompliantbehavior(22%),andunsafeim-pulsivebehaviors(18%).Theleastfrequentlyoccurringbe-havioraldysfunctionwaspillaging,hoarding,andstealingOnaverage,residentsreportedthattheircurrentpain(GMPIPainandSufferingscale)wasatalevelof“distressing”(painisdistractingmorethan40%oftheday).Residentsreportedhighlevelsofactivityinterferenceassociatedwiththeirpain(GMPIActivityInterferencescale),andmoderatelevelsofemotionaldistressduetopain(GMPIEmotionalDistressscale).Whenthesedataweredividedintoourde-mentiacategories,thoseresidentsintheMilddementiacat-egoryreportedthemostamountofpainandassociatedse-quelae,andthoseresidentsintheSeveredementiacategoryTable2.DescriptiveStatisticsandIntercorrelationsforIntensity,Frequency,andNumberofDysfunctionalBehaviors MeanSDMeanIntensityofAllMeanFrequencyofAllBehaviorsMeanDurationofAllNumber(Count)ofDysfunctionalMeanIntensityofAllBehaviors4.530.75ÑMeanFrequencyofAllBehaviors6.171.070.30*ÑMeanDurationofAllBehaviors6.610.740.23*0.70*ÑNumber(Count)ofDysfunctional3.321.570.110.18*Ñ*r(275)0.12;r(275)ORIGINALSTUDIESCipheretal. RepetitiveBehaviors,DelusionalTerritorialBehaviors,So-ciallyDisruptiveBehaviors,andWanderingthanthoseresi-dentswithModerateorMilddementia(Table6).However,theresidentswithMilddementiaexhibitedsignicantlyhigherbehavioralintensitiesofUnrealisticDemandsandDysfunctionalPainandIllnessBehaviors.Whenthe3dementiagroupswerecomparedoneachGLDSfrequencyrating,Depression,Withdrawal,LossofweightorAppetite,andLowActivitylevelbehaviorsre-ceivedthehighestorhighratings,regardlessofdementiagroup.ThoseresidentswithSeveredementiaexhibitedsig-nicantlyhigherGLDSfrequencyratingsonPhysicalCom-bativeness,Agitation/Sundowning,DistressingRepetitiveBe-haviors,DelusionalTerritorialBehaviors,andWanderingthanthoseresidentswithModerateorMilddementia().However,theresidentswithMilddementiaexhibitedsignicantlyhigherfrequenciesofUnrealisticDemandsandDysfunctionalPainandIllnessBehaviors.Whenthe3dementiagroupswerecomparedoneachGLDSdurationrating,onceagain,Depression,Withdrawal,LossofWeightorAppetite,andLowActivitylevelbehaviorsreceivedthehighestorhighratings,regardlessofdementiagroup.ThoseresidentswithSeveredementiaexhibitedsig-nicantlyhigherGLDSdurationratingsonPhysicalCombat-iveness,Agitation/Sundowning,DistressingRepetitiveBe-haviors,DelusionalTerritorialBehaviors,SociallyDisruptiveBehaviors,andWanderingthanthoseresidentswithModer-ateorMilddementia(Table8).However,aswithbehavioralintensitiesandfrequencies,theresidentswithMilddementiaexhibitedsignicantlyhigherbehavioraldurationsofUn-realisticDemandsandDysfunctionalPainandIllnessThepurposeofthisstudywastoinvestigatetherelation-shipsbetweenpainandbehavioraldisturbancesamongLTCresidentswithdifferinglevelsofdementia.OurrststudyhypothesiswasthattherelationshipbetweenpainlevelsandoverallbehavioraldisturbanceswouldbesignicantlystrongeramongLTCresidentssufferingfromlater-stagedementiathanthatofresidentssufferingfromearlier-stagedementia.Thishypothesiswaspartiallyconrmed.Painhadastrongerinu-enceonnumberofdysfunctionalbehaviorsandmeanfre-quencyofdysfunctionalbehaviorsamongtheresidentswithseveredementiaascomparedtoresidentswithmilddementia.However,painhadastrongerinuenceonthemeanintensityofdysfunctionalbehaviorsamongtheresidentswithdementia.Finally,painhadthesameinuenceonmeandurationofdysfunctionalbehaviors,regardlessoflevelofOursecondstudyhypothesiswasthattheLTCresidentswithmoderatetoseveredementiawhoaresufferingfromacutepainassociatedwitharecentfallarelikelytoexhibitmoreintense,frequent,andlonger-lastingbehavioraldistur-bancesthanthoseresidentswithmild,earlystagedementia.Thishypothesiswassupportedtoacertainextent.Theresi-dentswithseveredementiahadsignicantlymoreintense,frequent,andlong-lastingphysicalcombativenessandunsafeimpulsivebehaviorsthandidthoseresidentswithmoderateorTable6.ComparisonofGLDSIntensityRatingsBetweenDementiaGroupsAmongResidentsSufferingFromChronicPain(n GLDSCategoryDementiaGroupFValueMildModerateSevereabababPhysicalCombativeness0.134.000.353.711.524.1012.44*VerbalAggression0.513.560.413.880.633.400.28Agitation/SundowningSyndrome0.00Ñ0.524.331.224.718.65*NoncompliantBehavior1.14.931.044.881.674.500.94DistressingRepetitiveBehavior0.00Ñ0.114.000.744.008.48*DelusionalTerritorialBehaviors0.334.200.393.631.153.884.05*Yellingand/orRepetitiveBehaviors0.134.000.133.330.413.671.40SociallyDisruptiveBehaviors0.064.000.00Ñ0.304.003.13*Depression,Withdrawal3.634.403.644.333.044.321.13UnrealisticDemands0.893.730.313.830.113.004.95*DysfunctionalPain/IllnessBehaviors1.324.610.805.000.00Ñ5.05*PublicDisrobing,SexualBehaviors0.051.500.043.000.00Ñ0.26WantingToGoHome0.333.500.314.600.154.000.27Wandering0.053.000.124.500.73.805.62*LossofWeightorAppetite2.054.611.885.042.045.000.09Pillaging,Hoarding,Stealing0.085.000.00Ñ0.154.001.01UnsafeImpulsiveBehaviors0.525.500.634.701.115.001.14LowActivityLevels2.374.812.164.761.485.001.26SleepProblems0.403.570.23.750.34.000.58GLDS,GeriatricLevelofDysfunctionScale;a,includesthosepatientsforwhomthegivenbehavioraldisturbancewasabsent;b,includesonlythosepatientsforwhomthebehavioraldisturbancewaspresent;Ñ,rareincidence,frequenciesweretoosmalltosubmittocomputations.*F(2,162)3.06;F(2,162)ORIGINALSTUDIESCipheretal. thoseresidentsdocumentedtoexhibitchronicpainsymptomswithoutevidenceofacutepain,thoseresidentswithseveredementiaexhibitedsignicantlymoreintense,frequent,andlongerlastingPhysicalCombativeness,Agitation/Sundown-ing,DistressingRepetitiveBehaviors,DelusionalBehaviors,SociallyDisruptiveBehaviors,andWanderingthanthoseresidentswithmoderateormilddementia.However,wefoundtheresidentswithmilddementiaexhibitedsignicantlymoreintense,frequent,andlonger-lastingUnrealisticDe-mandsandDysfunctionalPainandIllnessBehaviorsthanthoseresidentswithseveredementia.WhentheGLDSitemswerecorrelatedwiththeNCSEitems,wefoundthatGLDSmeanintensity,frequency,dura-tion,andnumberofbehaviorsweremildlytomoderatelyassociatedwithcognitiveimpairment.Specically,residentswithlowercognitivefunctioningtendedtohavehighermeanbehaviorintensityratingsandnumbersofdysfunctionalbe-haviors.Ontheotherhand,residentswithlowercognitivefunctioningtendedtohavelowerfrequencyanddurationofdysfunctionalbehaviors.Basedonoursample,residentswhoweremorecognitivelyimpairedtendedtopresentwithdys-functionalbehaviors.Thesebehaviorswerenotaspersistentamongthelesscognitivelyimpairedresidents.Residents’meanbehavioralintensityandfrequencyratingswerepositivelyassociatedwithpainlevels.Higherpainlevels(asmeasuredbythePainandSufferingsubscaleoftheGMPI)wereassociatedwithhigherbehavioralintensityandfre-quency.Higherpainlevelswerealsosignicantlypositivelyassociatedwithresidents’numberofdysfunctionalbehaviors.Functionalimpairmentduetopain(asmeasuredbytheAc-tivityInterferencesubscaleoftheGMPI)wassignicantlyassociatedwithresidents’meanbehavioralintensity,fre-quency,anddurationratings.Morefunctionalimpairmentduetopainwasassociatedwithhigherbehaviorintensity,frequency,andduration.However,emotionaldistressduetopain(asmeasuredbytheEmotionalDistresssubscaleoftheGMPI)wasnotsignicantlyassociatedwithbehavioralin-tensity,frequency,duration,ortheresidents’numberofdys-functionalbehaviors.Inlightofthesecollectivendings,itislikelythatresidentssufferingfrompainmaymanifestthatpainintheformofdysfunctionalbehaviors,especiallywhencognitiveimpair-mentlimitstheirabilitytocommunicatepain.Thesendingsappeartobeespeciallyapplicabletothoseresidentswhoaresufferingfromchronic,persistentpainintheabsenceofacutepainsymptoms.Ourresultssupportpriorevidencethatper-sonssufferingfromchronicpainneedamultidisciplinaryapproachtoimprovingqualityoflife.Becauseresidentssuf-feringfrompainareexhibitingbehavioralandemotionaldisturbances,theyarelikelytobenetfrombiomedicalandpsychologicalapproachestodecreasingpainandincreasingfunctionalcapacity.Theinclusionof“intensity”and“duration”ratingswithfrequencyratingsisalsoanimportantcontributiontointer-disciplinarycareandconsultationinLTC.Priorassessmentinstrumentsofbehavioraldysfunctionhavefocusedsolelyonthefrequencyofthebehavior,withouttheinclusionofthelevelofdangertoselforothers.Priorbehavioralassessmentsalsohavenotincludedtheextenttowhichthebehaviorlasts.Intensityratingscontributetotheassessmentofmedicalne-cessityintheconsultativeconsiderationofpharmacologicalandcognitive-behavioralformsoftherapy.Physicians,psy-chologists,nurses,socialworkers,andspeech/physical/occu-pationaltherapistscanusetheGLDSanditscomponentstoestablishtheneedforspecicinterventions,aswellastheefcacyoftheseinterventionsovertime.Futureresearchisencouragedtovalidatetherelationshipbetweenpainandbehavioraldisturbancesamongothersam-plesofLTCresidents.Oursampleconsistedlargelyofchron-icallyillresidents,mostofwhomwerenotambulatory,whowerereferredtoapsychologistforevaluationandcognitive-behavioraltreatmentbecauseofbehavioralproblemsassoci-atedwithdementiaordepressionthatwereinterferingwithactivitiesofdailyliving(ADLs)andqualityoflife.Moreover,theassessmentofpersonalitycharacteristicsmaybeanim-portantpredictorofbehavioraldisturbancesinLTC.Inyoungersamplesofpersonssufferingfromchronicpain,per-sonalitycharacteristicsarestrongandreliablepredictorsofgoodcompliancewithandresponsetomultidisciplinaryCLINICALIMPLICATIONSAsstatedabove,thereferralsforpsychologicalevaluationinthisstudywereprecipitatedbyobservedmentalstatuschanges,symptomssuggestingdepression,orbehavioraldis-turbancesassociatedwithdementia.Althoughthisstudyfo-cusedonthedifferencesbetweenacuteandchronicpainanddysfunctionalbehaviorsobservedacrossdifferinglevelsofdementia,aconsistentndinginthisstudywasthatpainismostoftenassociatedwithbehavioralexpressionsofanhedo-nia,depressedmood,withdrawal,lowactivitylevels,andlowappetiteandweightloss.Thesesymptomswerehighacrossalldementialevelsandthisndingisconsistentwithobserva-tionsofyoungerchronicpainpatients.Depression,lowactiv-itylevels,andunintentionalweightlossareproblemsinLTC,andourstudyndingssuggestthatpainmaycontributetothedevelopmentoftheseproblematicqualityoflifeindicators.Therefore,whenresidentsreportthatthey“can’tenjoylife,”orthatthey“don’tfeellikedoinganything,”andresistgettingoutofbedorrequesttobeinbedmostofthetime,orthatthey“don’tfeellikeeating,”providersmustassessforthepresenceofchronicpainconditions,evenifresidentsdenypaininitially.CliniciansworkinginLTCsettingsoftenhavedifcultyassessingandmanagingpainamongresidentswithprogressivelevelsofdementiabecauseofindividualdifferencesorunre-liableself-reportingofpain.Behavioralsignsofdepression,socialwithdrawal,anddecreasedappetiteorweightlosscanoftenserveasindicatorsthatpainassessmentandtreatmentarewarranted.Ourndingssuggestthatpainexperiencedbyresidentswithseveredementiaislikelytobemanifestedinhighernumbersofbehavioraldisturbancesthattendtooccurfrequently.Thus,whenLTCstaffobserveresidentswho,becauseoftheirstageofdementiaareexhibitingavarietyoffrequentbehavioraldisturbancesinvolvingphysicalcombat-iveness,agitation,distressingrepetitivebehaviors,delusionalORIGINALSTUDIESCipheretal. 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