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Treating Pain to Reduce Agitation and Aggression in Long-Term Care Residents With Dementia
One of the most discussed subjects at the 2012 annual meeting of the American Academy of Hospice and Palliative Medicine (AAHPM), which took place in Denver in March, was a Norwegian and British cluster randomized trial that found that giving pain medication to nursing home residents with both dementia and agitation—regardless of their pain scores—significantly reduced the incidence of agitation and aggression in these individuals. In this study, researchers from the University of Bergen in Norway and from Kings College in the United Kingdom used a graduated pain treatment protocol based on guidelines developed by the American Geriatrics Society (AGS), which they reported led to an average reduction in agitation of 17%. That figure is particularly noteworthy because it is comparable to the reduction in agitation seen with use of antipsychotic drugs, which are associated with increased all-cause mortality in patients with dementia.1
“Given the prevalence of agitation among older people with dementia, and the adverse side effects associated with antipsychotic drugs, this is an extremely important finding,” said AAHPM meeting attendee Eric Widera, MD, assistant professor of medicine, University of California, San Francisco, and director, Hospice and Palliative Care Service, San Francisco VA Medical Center. “It suggests that, in a significant number of older adults with dementia, agitation and aggression may be due to untreated pain that these patients cannot communicate, and that pain medications may address these behaviors, without causing the serious side effects associated with antipsychotic drugs. The Norwegian pain medication protocol overcomes these barriers in a novel fashion by treating pain in everybody with dementia-related agitation.”
The findings of the study, which were previously reported in the July 2011 issue of the British Medical Journal, are particularly important because agitation and aggression are common among older people with dementia. It has been reported that as many as 80% of individuals with Alzheimer’s disease experience agitation. In addition, agitation and aggression are the two leading precursors to the institutionalization of older people with dementia.
This collaborative study, which is the first sufficiently powered, parallel group, randomized, controlled trial of pain management for agitation in older adults with moderate to severe dementia, included 352 nursing home residents with dementia and clinically significant behavioral problems. Residents were randomly assigned to receive either usual treatment or a stepwise protocol of pain treatment for 8 weeks. The stepwise protocol followed recommendations by the AGS Panel on Chronic Pain in Older Persons,2 such that residents taking no analgesic or only low-dose acetaminophen were prescribed full-dose acetaminophen at a maximum dose of 3 g daily. Those on full-dose acetaminophen or low-dose morphine received short-acting morphine at a maximum dose of 10 mg twice daily. Individuals taking low-dose buprenorphine and those unable to swallow were treated with transdermal buprenorphine at doses between 5 and 10 mcg per hour, and those with neuropathic pain received adjuvant pregabalin at doses up to 300 mg daily.
Not only did residents in the stepwise pain treatment group exhibit a 17% decline in agitation scores, as measured by the Cohen-Mansfield Agitation Inventory (CMAI), they also showed improvement in overall neuropsychiatric symptoms and pain levels, reported lead researcher Clive Ballard, MD, professor, King’s College, and director of research, UK’s Alzheimer’s Society, and his coauthors. By comparison, three earlier studies using CMAI scores as outcomes in randomized control trials of risperidone—the only licensed medication for agitation or aggression in patients with dementia—reported declines of 3%, 13%, and 18% in agitation compared with placebo.3-5 The results in the stepwise pain treatment group do not appear to be attributed to sedation, the authors emphasize, because more than 69% of those in the study who received medication were treated with nonsedating acetaminophen alone, and of the 25% who did get opioids, only three withdrew due to sedation or nausea.
“These findings emphasize the importance of assessing and treating pain effectively as part of the overall treatment and prevention of agitation and aggression in patients with dementia,” Ballard and colleagues conclude. “The results also highlight the potential value of effective treatment of pain as a key part of reducing the use of antipsychotics and other psychotropic drugs in residents of nursing homes.”
The Centers for Medicare & Medicaid Services (CMS) recently asked the AGS to assist with its newly launched initiative to improve behavioral health services and reduce the use of antipsychotic drugs among nursing home residents, particularly those with dementia. This initiative will raise public awareness of the risks of overuse of antipsychotics and the importance of alternatives to these drugs; advance research and training in the treatment and management of dementia-related behaviors and other health problems; enhance reporting and regulatory oversight; and provide technical assistance to nursing homes.
To help clinicians diagnose and treat pain and other symptoms in older adults, including those with dementia and complications of dementia, the AGS has developed a range of guidelines and recommendations. These include not only the report of the AGS Panel on Chronic Pain in Older Persons, but also several other AGS reports, including the Guide to Disorders and Management of Psychotic and Neuropsychiatric Syndromes of Dementia in Older Adults; Managing Psychosis and Behavioral Aspects of Dementia; and A Guide to Dementia Diagnosis and Treatment. These free resources can be found at www.americangeriatrics.org. In addition, a wealth of free, easily understood information about dementia, written expressly for older adults and their caregivers, can be found on the newly revised and redesigned Website of the AGS Foundation for Health in Aging, accessible at www.healthinaging.org. We hope you will take a look and advise your patients and those who care for them to do the same.
References
1. Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomized clinical trial. BMJ. 2011;343:d4065
2. American Geriatrics Society. The management of chronic pain in older persons: AGS Panel on Chronic Pain in Older Persons [published correction appears in J Am Geriatr Soc. 1999;47(1):119-120]. J Am Geriatr Soc. 1998;46(5):635-651.
3. Deberdt WG, Dysken MW, Rappaport SA, Feldman PD, Young CA, Hay DP, et al. Comparison of olanzapine and risperidone in the treatment of psychosis and associated behavioral disturbances in patients with dementia. Am J Geriatr Psychiatry. 2005;13(8):722-730.
4. Brodaty H, Ames D, Snowdon J, et al. A randomized placebo-controlled trial of risperidone for the treatment of aggression, agitation, and psychosis of dementia. J Clin Psychiatry. 2003;64(2):134-143.
5. De Deyn PP, Rabheru K, Rasmussen A, et al. A randomized trial of risperidone, placebo, and haloperidol for behavioral symptoms of dementia. Neurology.1999;53(5):899-901.
