Week 9-Pain in Children and Elderly People

Question 1

How does pain perception differ across life? (Tucker et al., 1989)

Answer 1

-Pain is not steady and consistent across the lifespan

-We need less energy when we are younger to elicit a pain response but more energy as we get older

Question 2

What is the prevalence of chronic pain in children? (King et al., 2011)

Answer 2

-Headaches: median prevalence 23%, about half of headaches are migraines, the rest are tension-type headaches.

-Greater prevalence in older children and prevalence continuously on the rise. Low socio-economic background contributes to prevalence.

Recurrent abdominal pain: median prevalence 12%. Prevalence also increases with the age of children, and it is larger in girls than boys.

Low-back pain: median prevalence 21%. Prevalence also increases with the age of children, and it is about equal in boys and girls

Musculoskeletal/limb pain: median prevalence 28%. Prevalence also increases with the age of children, and it is larger in girls than boys.

Prevalence of different types of pain, accidental or chronic, is much larger in children with developmental impairments compared to healthy children (Breau et al., 2003).

Question 3

How do children of different ages interpret their pain? (Goldschneider et al., 2001)

Answer 3

Children younger than 2 years react in a Stimulus-Response manner:
* no sense of permanence,
* no anticipation of pain/causality + worrying about it
* Pre-toddler reacts positively to swaddling, cuddling, warm environment and soothing voices.

Toddlers have some sense of permanence but:
* approach the world in egocentric manner (i.e., how long will it last? they make their pain the primary importance).
* Pain is viewed as punishment.

School children can express pain well:
* Pain is not a punishment any longer.
* Children have a sense of causality so….
* Patient controlled Analgesia can be used.
* May worry about body image or have misplaced feeling of invulnerability.

In stress, such as hospitalisation, regression to a previous development stage can occur

Question 4

Pain in neonates: What is the Impact?

Answer 4

• Ongoing research area. Pain in infants is still not fully understood
• The evidence base is smaller compared to research in adults.
• Infants, especially those in NICU, undergo many painful procedures.
• Averting or minimising pain in infants was not a primary clinical consideration as recently as the late 1980’s

Question 5

Pain in neonates: What did two seminal papers from the Oxford Analgesia group find?

Answer 5

Anand & Hickey (1987)
* Summarised anatomy and physiology of pain processing in infancy
* Concluded no evidence to justify treating pain in infants and children differently to adults.

Anand, Sippel and Green (1987)
* Fentanyl (analgesia) for infant surgery outperforms muscle relaxant treatment (nitrous oxide) in terms of reduced post-operative indicators of stress.

Question 6

What are pain pathways like in neonates?

Answer 6

Pain pathways are complete at the time of birth:
* first nociceptors: 7-10 weeks of gestation
* primary afferents (i.e., connections) to the spinal cord: week 19
* thalamo-cortical synapses in the cortex: week 21-28
* At the week of 25, it is possible to record cortical response to pain. (Slater et al., 2007)

Inhibitory pathways do not develop until later, therefore:
* neonates feel pain more strongly than adults

Question 7

What are sources of neonatal pain?

Answer 7

• colic
• heel lance (done to run blood tests), circumcision
• neonatal diseases (e.g., infections)

Question 8

What is the Brain responses to pin prick stimulation on the heel in adults and infants (~40 weeks)? (Goksan et al., 2015)

Answer 8

20 regions active in adults, 18 in infants - inactive regions in infants: amygdala and orbitofrontal cortex (which are involved in more complex aspects of pain perhaps psychological). Therefore adults and infants seems to respond to pain quite similarly.

Question 9

What are Preterm newborns’ sensitivity to pain?

Answer 9

-Prematurely born infants show sensitisation to repeated noxious stimuli (unlike adults) as they are further away from developing inhibitory control to pain. Closer to normal gestational age, the more likely to show habituation (i.e., desensitisation) to repeated noxious stimuli (Fitzgerald et al., 1988).

This is a problem because:
-Preterm infants are exposed on average to 50 painful procedures/day, compared to 14/day in full-term babies

• In 2007 20% of neonatal units in UK have a protocol for analgesia in newborns
• Less than 60% of units use any analgesia in preterm infants (Slater et al., 2007).

Question 10

Do Pre-term infants show stronger responses to heel lance than normal-term infants? (Slater et al., 2010)

Answer 10

Yes

-The noxious heel lance has a big dip indicating that there was an exaggerated electrophysiological response to the heel lance in premature infants compared to normal-term (showing an exaggerated pain response).

-The electrophysiological response was matched in both groups in the non-noxious condition, indicating that this result is pain-specific.

Question 11

What did Hartley et al. (2020) find about pain in neonates?

Answer 11

-POPPI Trial (Procedural Pain in Premature Infants) assessed whether morphine can provide effective pain relief in babies during invasive medical procedures.

-POPPI trial used a PIPP measure and the magnitude of noxious-evoked brain
activity after heel lancing.

-31 infants were randomly allocated to either morphine or placebo 1 h before a clinically required heel lance

-Eligible infants were born prematurely at less than 32 weeks’ gestation

-None of the co-primary outcome measures differed significantly between groups.

Interpretation:
-Administration of oral morphine to premature infants has the potential for harm without analgesic efficacy (so not a pathway to go down)

Question 12

Assessment of Pain in newborns: How can we assess facial expressions as an assessment of pain?

Answer 12

-NFACS = Neonatal Facial Action System
(Grunau and Craig, 1987) e.g., square mouth shape, lowered drawn together brows etc.,

-Machine learning- face recognition algorithms (Brahman, Applied Computing and Informatics, 2019).

-Best machine learning methods are shown to outperform the human judges.

Question 13

Assessment: What are Composite, multimodal measures of pain in newborns? (Hartley & Slater, 2013)

Answer 13

• PIPP = Premature Infant Pain Profile, composite measure of 3 facial action units: broadening the nose base, eye closure, lowering eye brows
• PIPP also utilises two physiological measures (heart rate, oxygen saturation): suitable for preterm and full-term neonates

Question 14

Do Cortical responses correlate with facial expressions of pain in infants? (Slater et al., 2007)

Answer 14

Yes!

• Concentration of the hemoglobin in the
  somatosensory cortex (an approximation of
  ‘pain processing in the brain’) measured
  using fNIRS correlates with the PIPP score
• The facial expression score shows a nice correlation with the hemoglobin response in the primary somatosensory cortex
• Adding the the other physiological measures improves the accuracy and sensitivity of your measures

Question 15

What is the Effect of early pain experience on subsequent acute pain in children?

Answer 15

Taddio et al. (1997):
-Analysed behavioural pain responses to vaccinations in 4-6 months old boys who had undergone circumcision at day 5. There were three groups: circumcision, circumcision plus analgesic cream, circumcision plus placebo cream. Circumcision without analgesic cream was associated with greater pain during vaccination compared to circumcision with cream (so previous experiences of pain contributes to subsequent acute pain even if a few months later)

Taddio et al. (2002):
-Reported similar results for children of
diabetic mothers who have been heel
lanced after birth and showed increased
pain during venipuncture the next day

Question 16

What are the Long-term consequences of early life exposure to frequent pain in children? (Hermann et al., 2006)

Answer 16

-A retrospective study compared different pain measures in children 9-14 years who
were born prematurely and were at a Neonatal Intensive Care Unit (NICU), or were born at normal gestation age and were also at NICU, or control babies (normal age, no NICU).

Tonic heat stimulation:
-We would expect to see some desensitisation to the tonic pain
-However for both the pre-term and full-term group who went to NICU, there was actually a raise in sensitisation.

Heat pain threshold:
-In the NICU groups, they required more heat to tell us about a pain experience compared to the control group.

• These patterns in both conditions are patterns seen in chronic pain populations as a phenomena showing this may relate to the early pain experience in children

Question 17

What are some Psycho-social interventions for neonatal pain? (McGrath, 2004)

Answer 17

Environmental adjustments:
* decreasing overall lighting, proper day/night cycle
* decreasing noise from equipment/staff
* decreasing handling
* limiting painful procedure to essential

Behavioural interventions:
* nesting, swaddling
* non-nutritive pacifier (dummy)
* sucrose
* rocking (sensory stimulation)

Question 18

What is Pain like in children from 1 to 12 years? (McGrath, 2004)

Answer 18

Sources of pain:
* Minor injuries
* Routine medical procedures (immunisation)
* Beginning of recurrent pains

Behavioural interventions:
* Distraction of attention during painful procedures (e.g. games)
* Pain-management techniques (e.g., CBT etc) feasible >9 years
* Strong role of parents and family in pain reducing behaviour

Question 19

How can we assess pain in children?

Answer 19

-Pre-verbal children: behavioural and physiological responses

Self-report pain instruments should be appropriate to the development and cognitive capacities of a child:
~ 3 years : categorical scale (“Does your tummy hurt?”)
> 5 years : Colour Analogue Scale (shades of red)
> 6 years : Visual Analogue Scale (depends on capability)
> 6 years : FACES (series of 6 faces from neutral to most painful)

-Oucher (vertical series of 6 facial expressions of pain, and numerical scale ranging from 0 to 100), can be used from age 3 to 12 years (Beyer, 1984).

Question 20

How can we measure Facial expressions in children?

Answer 20

-CFACS = Child Facial Action Coding System
(Breau et al., 2001): for children 1.5-6 years (especially beneficial if non-communicative) e.g., lip raise and jaw drop is not seen in infants but is in children

-Like NFACS earlier, excellent reliability and
validity, and are relatively free of learning
effects.

-PIPP can also be utilised in young children to include two physiological measures (heart rate, oxygen saturation)

Question 21

Give examples of Validated behavioural observation scales for children (Beltramini et al., 2017)

Answer 21

-Older children can express their pain in more diffuse physical movement. Scales evaluate gross body movements
(withdrawal, cradling), vocalisation, body postures, and interactions with environment.

1. CHEOPS (Children’s Hospital of Eastern Ontario Pain Scale): evaluates pain using 6 categories: cry, facial, verbal, torso, touch, and legs
2. FLACC (Face Legs Activity Cry and Consolability): suitable for children 0.5-5 years in acute pain and in critically ill children.

Question 22

How does the Mother’s own pain response during CPT shape the child’s pain?

Answer 22

• Goodman and McGrath (2003) analysed the pain responses of children to the cold pressor test. The children were tested after they have watched an exaggerated, normal or minimised pain response of their mother.
• Pain reported by children and observed
  from facial reactions was stronger in the
  group which observed exaggerated pain
  response of their mother compared to the
  group observing minimisation of pain by
  mother.

Question 23

How does a Parent’s reassurance worsen a child’s experimental pain? (Chambers et al., 2002)

Answer 23

-When mothers showed pain promoting
behaviour (reassuring, empathy, apologies, mild criticism) during cold pressor testing of their daughters they experienced more pain.

-If the mother showed pain-reducing
behaviour (humour, distraction) the
pain ratings were lower.

-Effects were seen primarily in mother-
daughter dyads.

Question 24

What is Distress-promoting and coping-promoting parent’s behaviour?

Answer 24

-Distress-promoting behavior: reassuring, empathy, apologizing etc. increase child’s distress and pain during immunization (Cohen et al., 2000; Moon et al., 2011).

-Coping-promoting behavior: distraction, non-procedural talking, humour, coping commands (“focus on your breathing”) are associated will reduced distress (Manimala et al., 2000).

-Reassuring constitutes a large proportions of spontaneous verbalisations from parents during children’s painful procedures.

-Training parents to avoid reassuring during child’s painful procedures did not abolish
reassuring which constituted ~50% of parents’ distress promoting verbalisations
(Chambers et al., 2002)

Question 25

What are the Mechanisms underlying the effects of reassurance on children’s pain? (McMurtry et al., 2006)

Answer 25

* Reassurance serves as a warning signal to the child that the parent is anxious, or knows that something bad is involved. * Reassurance reinforces the distress behavior of the child. Caregiver’s response to child’s anxiety or distress prompts the child to issue even more signals to the caregivers. * Parental reassurance gives the child the “permission” to overtly express his/her distress. * Connects with the concept of pain catastrophising

Question 26

What are research outcomes on pain catastrophising in children?

Answer 26

-Child’s catastrophising predicts the unpleasantness (Page et al., 2012) and intensity (Esteve et al., 2014) of post-operative pain. -Catastrophising correlates with depression in children with chronic pain (Kashikar-Zuck et al., 2001). -PCS-C, Crombez et al. (2003) is an adaptation of the pain catastrophising scale for children (is simplified so children can understand and react to the statements).

Question 27

What is the impact of Parent pain catastrophising on child pain outcomes?

Answer 27

-Parental form of Pain Catastrophizing Scale (PCS-P) (Goubert el al., 2006) “When I am in pain, I worry all the time whether the pain will end” “When my child is in pain, I worry all the time whether the pain will end” Parent’s catastrophizing: * Predicts the amount of painful events and distress in children (Goubert et al., 2006) * Associated with overestimating their child’s pain intensity (Esteve et al., 2014) * Associated with the parent’s tendency to stop pain-related activities of the child (Caes et al., 2011; Caes et al., 2012) – This is important for the concept of FEAR AVOIDANCE

Question 28

What is the Pediatric fear-avoidance model? (Asmudson et al., 2012)

Answer 28

* Parent catastrophising affects their (parent) response to child pain, and to child pain responses. * Can lead to ‘protecting‘ the child and stopping child’s engagement life activities – Escape and avoidance. * Contributes to development of child catastrophising (which perpetuate the cycle), but also avoidance and escape behaviours which leads to pain-related disabilities.

Question 29

What are some rules on psychological handling of clinical pain in children by clinicians? (Goldschneider et al., 2001)

Answer 29

1. Health Care Professionals should not lie about painfulness of therapeutic procedure. 2. Explain the pain and the procedures leading to pain in a manner that corresponds to the development and cognitive capacities of the child. 3. Apply psyc-informed techniques, in addition to analgesia, during painful procedures (books, cartoon movies, music, interesting toy, video game, virtual reality). 4. Ensure the presence of a parent or caregiver (specify no reassuring).

Question 30

What are the Epidemiological aspects of pain in older people?

Answer 30

~50% of elderly people report some recent pain (Patel, 2013) ~45-80% of residents in nursing homes (USA) show substantial pain -often intermittent and varying in intensity Myth 1: pain is normal in old people + Myth 2: there is not much what can be done about pain in old people = under-detection and under-treatment

Question 31

What are Types of chronic pain in elderly people (community based home in USA)? (Ferrell, 2004)

Answer 31

1. Arthritis (70%) 2. Old fractures/Prosthetic joints (13%) 3. Neuropathy (10%) 4. Cancer-related (4%) 5. Other (2%) In nursing homes, patients who reported chronic pain where predominantly suffering from arthritis

Question 32

What are some Methodological problems for pain research in the elderly?

Answer 32

1. Lack of longitudinal studies on evolution of pain sensitivity and pain states; only the cross-sectional studies are available allowing only statements about differences between young and old persons 2. The birth-cohort effect: people born at different times differ in their original psycho-social environments, and attribute different meanings to the pain 3. Lack of definition of an “old” person: 60, 70 or 90 years? 4. Harkins (2001) suggested the categories “young-old” (65-75 years) and old-old (76-90) but no consensus has been established.

Question 33

How is pain assessed in older people who do NOT have cognitive impairments?

Answer 33

-Self-reports in old people, if possible, have the same reliability and validity as in young adults (Hadjistarvropoulos et al., 2014) -The psychometric characteristics of the McGill Pain Questionnaire are equally good in old and young people (Gaghliese & Melzack, 2003; Gagliese & Katz, 2003). -Numerical scale is still accepted by patients -Elderly people sometimes do not like VAS (the rating of pain on a scale from no pain to pain is bad) because they find this instrument difficult for use and tend to make errors (Gagliese & Melzack, 2006; Gagliese et al., 2005) -Modified “Faces” pain scales, used in children, can also be useful

Question 34

What are Pain beliefs and attitudes toward pain in the elderly: older people show stoic attitudes towards pain

Answer 34

-Yong et al. (2001) developed the Pain Attitude Questionnaire that measured attitudes toward chronic pain. The PAQ was administered to 373 healthy persons, and four age groups were created. 1. Stoicism * retinence “No good complaining“ * superiority “We were built differently in my day“ 2. Cautiousness * self-doubt “I don’t trust myself” * reluctance “Reluctant to label”

Question 35

What are the Age effects on nociceptors and spinal cord neurons?

Answer 35

1. Ageing is associated with reduce numbers of myelinated tactile and pressure receptors (Large - Aδ fibres which conveys pain). 2. No (or lesser) reductions seen in C-fibres (Small fibres as more likey to stick around). 3. Loss of dorsal horn neurons in older people contributes to decrease in endogenous inhibition (i.e., the control of pain). Based on these changes we can hypothesise that elderly people would show: * Reliance on C fibre mediated pain * Increased temporal summation of pain * Decreased descending nociceptive control

Question 36

What Brain activations are found during pressure pain in old and young people (Cole et al., 2010)?

Answer 36

* 15 young (~26 years) and 15 old (~76 years) people exposed to pressure pain in the right thumbnail. Activations seen in all well-known pain regions in both groups. * However, young people showed a stronger activation in som regions (putamen and caudate) relative to older people. * Important to note that this is a small study and the vast majority brain responsiveness to pain was the same

Question 37

What are the primary afferents seen in ageing and experimental pain? (Chakour et al., 1996)

Answer 37

* Analysed pain threshold during laser stimulation in 15 young (~26 years) and 15 old (~74 years) subjects. * Stimuli were before, during or after an A-fiber blockade. * During blockade, only c-fibres are activated by stimuli. * Pain threshold was greater in old compared to young people – BUT ONLY when A fibers were blocked. * Indicates that older people do not have same A fiber density. * Evidence of reliance on c-fibre mediated pain

Question 38

What is the evidence of Increased temporal summation of thermal pain in the elderly? (Edwards and Fillingim, 2001)

Answer 38

-Groups of young (mean 22 years) and old (mean 62 years) were given a series of 10 heat pulses on the left volar forearm -Older subjects showed greater pain intensity and unpleasantness during the late pulses (Indicative of enhanced summation i.e., temporal summation due to changes in the spinal cord potentially)

Question 39

What evidence is there showing Decreased functioning of the endogenous pain modulation in healthy elderly people? (Edwards et al., 2003)

Answer 39

-Groups of young (mean 22 years) and old (mean 63 years) were given a cold pressor task and concurrently repetitive noxious thermal stimuli in other part of the body to test their conditioned pain modulation or CPM. -Thermal summation of heat stimuli applied to the left arm (CPT on the right hand) was smaller in young than in old subjects with lower temporal summation suggesting decreased pain modulation (opioid-receptor mediated) in old people. Older people actually exhibited enhanced pain in early trials (bottom slide – facillitation of pain greater than inhibition?)

Question 40

What is the link between Pain thresholds, pain tolerance and CPM with age?

Answer 40

-Lautenbacher (2012) conducted a meta-analysis of 52 studies analysing age effects on pain functions -Pain thresholds increase with age -Females show slightly stronger age-related increases in pain thresholds than males.

Question 41

Pain tolerance thresholds, do they really change with age?

Answer 41

-Pressure stimuli showed some age-related decreases in pain tolerance. -Lautenbacher et al. (2017) did not confirm age effects in pain tolerance -Pain modulation is either reduced inhibition or even facilitation of pain in the presence of a conditioning pain stimulus

Question 42

What's the link between Pain thresholds, pain tolerance, modulation with age? Lautenbacher et al. (2017)

Answer 42

-Pain threshold differences are enhanced in studies which compared larger age difference. CONFIRMATORY -Tolerance does not appear to be consistently affected across studies. DISPUTES EARLIER SUGGESTION

Question 43

What is the Plenary of evidence for age effects on experimental pain?

Answer 43

* Cole et al (2010) Activations seen in all well-known pain regions in both age groups. However, young people showed a stronger activation in the left putamen and caudate than old people. * Chakour et al. (1996), older people do not show as much change in pain threshold during nerve block of A fibers as younger people. Suggests reliance on c-fibres and explains reduced thresholds? * Edwards and Fillingim (2001) older people show increased pain ratings during conditioned pain modulation experiment – Reduced descending modulation of pain (endogenous opioid system) * Lautenbacher (2017) meta analysis suggests increased pain thresholds in elderly, 2012 review suggests reduced levels of pressure pain tolerance This is not replicated in 2017. Both meta-analyses indicate reliable reduction in endogenous pain inhibition, possibly even facilitation of pain when we would see reduction in younger people.

Question 44

What is the Summary of age effects on experimental pain?

Answer 44

* In spite of large variability in the methodology, age groups, stimulations etc., there is a prevailing view that pain thresholds, especially for thermal and visceral pain, increase with age. * This is termed presbyalgesia similar to other senses (presbyacusis – hearing loss, presbyopia-eyesight reduction). It may increase the risk of injury due do poor detection of pain signals. * Pain threshold increases but the strength of descending nociceptive control decrease with age. * Increased threshold for engagement of inhibitory processes implicates a greater pain in clinical situations in elderly than in young adults.

Question 45

What is Postoperative pain like in elderly patients?

Answer 45

-Post-operative pain is reduced in older (~66 years) than young (~56 years) patients (Gagliese and Katz, 2003). -The difference demonstrated in MPQ but not in VAS (more affective or psychosocial factors that were missed or failure of VAS?) -Old people used less morphine than younger people, however, younger people dropped their morphine doses over successive days faster than old people

Question 46

What is the Intensity of chronic pain in elderly patients?

Answer 46

* MPQ measures indicate less pain in elderly than in young patients with chronic pain (Gagliese and Melzack, 2003; 2006) * Results are not always clear cut in other studies, may be due to prevailing use of VAS. *Quality of chronic pain in elderly (N=139, age 70) and young (N=139, age 43) chronic pain patients * The quality or type of chronic pain differs in young and old E.g., Tight-tearing type pain sensation is much more prevalent in older people. * Related to neurophysiological changes?

Question 47

More illness, more pain: How does comorbidity in older people contribute to overall pain?

Answer 47

-Leong et al. (2007) analysed the effects of comorbidity on the general level of pain in 562 patients. -Comorbidity was measured using Cumulative Illness Rating Scale. -Patients with high comorbidities (4+) score higher on current pain, pain sensory and affective ratings.

Question 48

How does Dementia present serious complications in the management of pain in elderly people?

Answer 48

-Patients with dementia are at very high risk of untreated pain and suffering due to diminished interest to communicate their perceptions (apathy). -According to the Alzheimer's Society there are around 850,000 people in the UK with dementia. One in 14 people over 65 will develop dementia, and the condition affects 1 in 6 people over 80. -Alzheimer’s dementia is associated with degeneration in several well-known pain matrix structures, e.g., locus coeruleus, PAG, thalamus, amygdala, cingulate cortex and other regions (Scherder et al., 2003). -50% of dementia patients show some form of pain (Husebo et al., 2014)

Question 49

What are Pain and pain assessment problems in dementia?

Answer 49

Individuals are at increased risk of: -Dementia-associated musculoskeletal, cardiovascular, and gastrointestinal problems -Ulcers, injuries, and oral and dental problems, i.e., related to neglect. -Normal ageing itself –arthritis risk increased as in non-dementia elderly Assessing pain in patients with dementia is hard as: -Symptoms of dementia include withdrawal or agitation/aggression, which are confounding factors in behavioural assessment of pain -Self-report not viable in about 50% of dementia patients: the only solution is to employ observational methods (facial expressions, behaviour observation scales) -Administration of analgesics has been shown to decrease agitation in many dementia patients – an indication that some patients experienced pain (Husebo et al., 2014)

Question 50

What is Agitation/aggression and depression like in dementia patients with a pain condition (van Dalen-Kok et al., 2015)

Answer 50

Review of 22 studies involving dementia patients showing clinical pain: -8 studies focusing on agitation/agrresion: * 5 studies found positive associations between pain and agitation/aggression * 3 studies found negative associations Out of 11 studies focusing on depression in the same type of patients (dementia + pain): -7 found positive associations between pain and depression -4 no association

Question 51

What is Pain assessment like in cognitively impaired older people? (Sampson et al., 2015)

Answer 51

-Longitudinal cohort study of 230 people, aged above 70, with dementia -Participants were assessed at baseline and every 4 days for self-reported pain (yes/no question and FACES scale) and observed pain (Pain Assessment in Advanced Dementia scale [PAINAD]) at movement and at rest, for agitation (Cohen–Mansfield Agitating Inventory [CMAI]) and BPSD (Behavioural Pathology in Alzheimer Disease Scale [BEHAVE-AD]) -Half of them were able to complete the FACES scale, Pain was associated with total BEHAVE-AD scores, particularly aggression and anxiety -We found that although 75% of participants were prescribed analgesics (mainly paracetamol), persistent pain was common, suggesting that as-required medication may not have been given or that pain symptoms may have been difficult to manage. Nonsteroidal anti-inflammatory drugs (NSAIDs) and opiates can have severe side effects in older people; NSAIDs have significant cardiac, gastrointestinal, and renal risks, whereas opiates can cause delirium and constipation. -Unfortunately, the complexities of this problem are challenging and, in our ageing society, they are not going away!

Question 52

What evidence shows that Dementia patients show stronger facial expressions of pain compared to age-matched healthy old people?

Answer 52

* Kunz et al., Pain (2007) applied 5 different pressure stimuli to groups of old people with and without dementia. * Self-report measures showed a linear relationship with pressure intensity in both groups. * However, dementia patients showed much stronger facial expressions for every level of pressure compared to healthy old people.

Question 53

What are Alternative pain responses in dementia patients?

Answer 53

-Kunz et al. (2009) recorded the spinal RIII reflex (leg withdrawal after applying a painful stimulus to the foot), self-reports, facial expressions, and skin conductance in old people with or without dementia -46% of dementia patients were not able to give a report -Incapacity to provide pain rating correlated with scores of mental impairment -Intensity of facial expressions of pain was increased in people with dementia -When they self-report, the pain doesn't seem to be reduced therefore we shouldn't assume that experimental pain in this population is reduced due to the reduction of responses such as skin conductance

Question 54

What were the Brain activation patterns of pain in Alzheimer’s dementia and healthy subjects (Cole et al., 2006)

Answer 54

-AD patients show stronger and longer fMRI activations in pain relevant cortices during mechanical pain when compared to age-matched healthy subjects. -Pain ratings in AD and the in the control group were similar (P>0.05)

Question 55

Assessment: what are the recommended Pain behaviours used in clinical observational scales? (Hadjistavropoulos et al., 2014)

Answer 55

A combination approach where we take in: 1. Facial expressions 2. Verbalisations 3. Body movements 4. Changes in mental status 5. Changes in personality 6. Changes in interpersonal interactions

Question 56

What are Pain assessment tools in people with dementia?

Answer 56

-A number of scales are available for assessment of pain in people with dementia; they include behavioural measures and measures of social interactions (reviewed in Hadjistavropoulos et al., 2014). -PACSLAC (Pain Assessment Checklist for Seniors with Limited Ability to Communicate, Hadjistavropoulos et al., 2002) 60 items evaluating 4 dimensions (facial expressions; activity/body movements; social (personality, mood); physiology (eating, sleeping, vocalisation)) -DOLOPLUS2 (Behavioral Pain Assessment in Elderly, Wary et al., 1992) 10 items evaluating 3 dimensions (somatic; psychomotor; psycho-social)