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Letters to the Editor: Nonpharmacologic Management of Behavioral and Psychological Symptoms of Dementia in Long-Term Care Residents / Overcoming the Painful Regulations Surrounding the Prescription of Pain Medications
Drs Allison H Burfield, RN, MSN, PhD, and James W Cooper, PhD, BCPS, FASCP, make three recommendations to the November 2015 articles “Nonpharmacologic Management of Behavioral and Psychological Symptoms of Dementia in Long-Term Care Residents” by Catic and “Overcoming the Painful Regulations Surrounding the Prescription of Pain Medications” by Stefanacci to which Dr Stefanacci responds.
We have noted the excellent reviews of “Nonpharmacologic Management of Behavioral and Psychological Symptoms of Dementia in Long-Term Care Residents” by Catic1 and “Overcoming the Painful Regulations Surrounding the Prescription of Pain Medications” by Stefanacci2 in the November 2015 issue of Annals of Long Term Care: Clinical Care and Aging®. We would like to suggest three additional strategies that may be considered: (1) total fall risk assessment with psychoactive drug load calculation/reduction; (2) non-verbal assessment of pain; and (3) consideration of a regular schedule of acetaminophen intervention to reduce the need for psychoactive medications including opioids. We have previously noted the need for these strategies and provided free, unvalidated risk assessment forms in our article published in the May 2014 issue of Annals of Long-Term Care3 and in the accompanying resources, “Checklist of Nonverbal Indicators of Chronic Pain in Elderly Residents” and “Fall Risk Assessment Guidelines,” which have been published online.4,5
The Catic review addressed both the management of and available nonpharmacologic treatment options for behavioral and psychological symptoms of dementia (BPSD), including cognitive- and emotion-oriented interventions, behavioral management techniques, and sensory stimulation interventions.1 In addition, we suggest that a nonverbal assessment of pain using a standard scale can help to quantitate the nonpsychotic and psychotic behaviors mentioned in Table 1 of Catic’s article and add to the strategies listed in Table 2. The use of pharmacologic treatments of BPSD addressed within the Catic article may be additionally quantitated and addressed by the use of a fall risk assessment. Finally, the use or absence of use of acetaminophen intervention should be noted. The benefits of a regular schedule of acetaminophen 3 g daily for decreasing the behavioral symptoms of agitation, inappropriate outbursts, and aggression as well as enabling a 75% discontinuation rate of all psychotropics were first demonstrated in a 1998 article by Douzjian,6 also published in Annals of Long Term Care: Clinical Care and Aging. Our 2014 article was inspired by this study.
The second article we mentioned, by Stefanacci,2 dealt with overcoming the painful regulations surrounding the prescription of pain medications. The article detailed recent Joint Commission on Accreditation of Hospitals (JCAH) measures and recommendations suggesting that pain be considered the fifth vital sign. The US Food and Drug Administration (FDA) has placed restrictions on acetaminophen dose to ≤ 325 mg when combined with an opioid and restrictions on opioid medications themselves; these are in addition to restrictions enforced by the Drug Enforcement Agency (DEA) on pain management and, specifically, pain management in long-term care facilities (LTCFs).
We would suggest that the three strategies we’ve proposed apply here as well. Our fall risk assessment4 incorporates total psychoactive drug load as well as all other patient factors, conditions, and diagnoses that affect the outcomes noted for the patient both before and after interventions. Excessive polypharmacy evident in patients may be better documented by the use of this fall risk assessment. The nonverbal pain scale5 specifically addresses the points made by Dr Stefanacci that contribute to inadequate pain management in nursing homes. Finally, our suggestion of a regular schedule of acetaminophen as the first medication to titrate for pain (which may be better recognized by the use of the nonverbal pain scale) can reduce the need for an opioid and/or dose of the opioid and/or other psychoactive medications that may have greater restrictions on their use.
In regards to each strategy, the fall risk assessment incorporates all the factors known to contribute to fall risk and the outcomes of interventions.4 The results of the use of this instrument, in combination with the cooperation of prescribers in reducing the total psychoactive drug load by the careful tapering of these medications, are detailed by prior research, which noted that falls, emergency department visits, and hospitalizations may be reduced while the length of stay in long-term care may be extended by the use of this instrument.7-11
Our research has also shown that the recognition and reporting or documentation of chronic pain is diminished with decreasing cognition.12,13 This concept and the attribution of this problem to the appropriate factors that need to be addressed have been reviewed by both Catic and Stefanacci; we suggest that readers consult both authors’ articles for best comprehension of the relationship of this letter to their excellent reviews of the subject of nonpharmacolgic management of BPSD and pain in LTC.
In summary, the use of regularly-scheduled acetaminophen intervention with the cognitively impaired patient may also facilitate psychoactive drug tapering and result in fewer of the symptoms mentioned in the review by Catic,1 lessen the need for opioid medications as discussed by Stefanacci,2 and reduce the risk of falls and related morbidity, as noted in our prior article in Annals of Long-Term Care.3 The use of a regular schedule of acetaminophen, which is available in 325-mg, 500-mg and 650-mg single tablets or oral suspension, may also be considered as a daily dose, depending on the patient’s current liver function tests, total load of liver-metabolized medications of up to 2–2.6 g per day with periodic follow-up on these liver function tests, and outcomes of regular fall risk and pain assessments.
Thank you for these considerations.
References
1. Catic AG. Nonpharmacologic management of behavioral and psychological symptoms of dementia in long-term care residents. Annals of Long Term Care: Clinical Care and Aging. 2015; 23(11):23-29.
2. Stefanacci RG. Overcoming the painful regulations surrounding the prescription of pain medications. Annals of Long Term Care: Clinical Care and Aging. 2015; 23(11):31-35.
3. Burfield AH, Cooper JW. Assessing pain and falls risk in residents with cognitive impairment: associated problems with overlooked assessments. Annals of Long-Term Care: Clinical Care and Aging. 2014;22(5):36-38.
4. Burfield AH, Cooper JW. Checklist of Nonverbal Indicators of Chronic Pain in Elderly Residents. 2014. Annals of Long-Term Care website. https://s3.amazonaws.com/ALTC-CG/CooperBurfield_FallRiskGuidelines.pdf. Accessed January 16, 2016.
5. Burfield AH, Cooper JW. Fall Risk Assessment Guidelines. 2014. Annals of Long Term Care website. https://s3.amazonaws.com/ALTC-CG/CooperBurfield_NonverbalPainChecklist.pdf. Accessed January 16, 2016.
6. Douzjian M, Wilson C, Schults M, et al. A program to use pain control medication to reduce psychotropic drug use in residents with difficult behavior. Annals of Long-Term Care. 1998;6(5):174-178.
7. Cooper JW. Consultant pharmacist assessment and reduction of fall risk in nursing facilities. Consult Pharm. 1997;12:1294-1304.
8. Cooper JW. Consultant pharmacist assessment of fall injury incidence and costs within a nursing facility. Consult Pharm. 1997;12:1305-1309.
9. Cooper JW, Cobb HH, Burfield AH. A one year study of psychotropic load reduction and buspirone conversion possible effects on behavioral disturbances and global deterioration in a rural nursing home population. Consult Pharm. 2001;16(4):358-363.
10. Cooper JW, Freeman MH, Cook CL, Burfield AH. Psychotropic and psychoactive drug load assessment and falls in nursing facility residents. Consult Pharm. 2007:22:483-489.
11. Cooper JW, Freeman MH, Cook CL, Burfield AH. Psychotropic and psychoactive drugs and hospitalization rates in nursing facility residents. Pharmacy Practice. 2007;5(3):140-144.
12. Burfield AH, Won TTH, Sole ML, Cooper JW. Behavioral cues to expand a pain model of the cognitively impaired elderly in long-term care. Clin Interv Aging. 2012;(7):207-223.
13. Burfield AH, Won TTH, Sole ML, Cooper JW. A study of longitudinal data examining concomitance of pain and cognition in an elderly long-term care population. J Pain Research. 2012;5:1-10.
A response from Richard G Stefanacci, DO, MGH, MBA, AGSF, CMD, Thomas Jefferson University, College of Population Health; The Access Group; and Mercy LIFE, Philadelphia, PA
I applaud the letter of Drs Burfield and Cooper for several reasons that have broader applications than just our use of scheduled dosing of acetaminophen. While the approach outlined by the authors is certainly safer for most patients than opioids or psychotropic medications, there are questions regarding the efficacy of acetaminophen.1 These types of questions can be addressed by our consideration of the following: (1) LTC providers should aggressively seek out safer treatment alternatives. (2) Safety needs to be evaluated against efficacy on an individual patient basis to determine optimum treatment for each patient. (3) These type of conversations raised by Drs Burfield and Cooper are critical to improving patient outcomes through challenging our typical thinking, such as pro re nata acetaminophen or 14-day antibiotic courses for positive urinalyses. A lot of old thinking needs to be challenged in order to best serve patients.
References
1. Buffum MD, Sands L, Miaskowski C, Brod M, Washburn A. A clinical trial of the effectiveness of regularly scheduled versus as-needed administration of acetaminophen in the management of discomfort in older adults with dementia. JAGS. 2004;52:1093-1097.
