An 80-year-old man who has a history of metastatic colonic carcinoma has been admitted to an acute hospital ward with a pathological fractured neck of femur. He has a history of Alzheimer’s disease.
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1. How are we going to assess pain in this patient?
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Observation of behaviour for pain assessment in patients who do not have the ability to communicate their pain can be helpful, but typical pain behaviours may be absent or difficult to interpret. The involvement of healthcare professionals, informal care providers and the family in the identification of pain is essential. The American Geriatric Society (2002) listed six categories of pain behaviours and indicators for older people with dementia:
- Facial expressions
- Verbalisations and vocalisations (shouting, crying, grunting and groaning)
- Body movements (rigidity, protecting the affected part)
- Changes in interpersonal interactions (increased withdrawal or aggressive behaviour)
- Changes in activity patterns or routines (sleeping or avoiding movements)
- Mental status changes
These behaviours have been incorporated into behavioural pain assessment scales to a lesser or greater degree. Also, we can talk to the relatives or formal carers to identify if there are any changes in behaviour to previous behaviours that could be indication of pain. For example, normal quiet withdrawn behaviour becomes agitated and aggressive, thus suggesting pain.
His pain was difficult to control with opioids and NSAIDs, especially the pain on movement. The acute pain team inserted an epidural catheter. Unfortunately the block was unilateral, blocking the uninjured side and decreasing mobility without any meaningful analgesia for the fractured limb. The fracture was considered inoperable and the patient was transferred to a specialist cancer hospital for consideration of further treatment. Analgesia continued to be problematic.
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2. How are we going to manage his pain?
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High doses of morphine managed to reduce rest pain but were associated with increased somnolence and continuing constipation. The patient and his relatives were unwilling to agree to another epidural catheter due to fear of a repeated unilateral block. After discussion, the patient was offered a lumbar plexus catheter, which was inserted easily when the patient was awake, using only local anaesthetic. A bupivacaine (0.1%) and fentanyl (2 mcg/mL) infusion at 10 mL/h into the lumbar plexus achieved good pain relief at rest and on movement. The increased analgesia on movement and the retained motor strength on the uninjured side allowed the patient to be mobilised, thus enabling him to be returned to the care home where his dementia could be managed more effectively.
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3. What other treatments may be available?
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Invasive techniques provide analgesic possibilities when conventional treatments fail. This might be because of the unacceptable side effects of opioids or if the pain is less opioid sensitive. Older adults with dementia or confusion may be more likely to become even more confused with the use of opioids and side effects such as drowsiness, nausea and particularly constipation can be problematic. Spinal and epidural infusions can be highly effective in relieving refractory severe pain, albeit requiring anaesthetic input and specialist equipment. However, they can reduce the need for oral opioid drugs that can increase confusion in the older population. Nerve blocks add to the treatment options available for pain that is challenging to manage, although achieving long-term benefits can be problematic. Nerve ablation provides a method of sustained relief but increases the risk of side effects. Direct tumour ablation or cement fixation of metastatic bony disease is being used more frequently for bone pain, with good results.
Interventional techniques are by definition more invasive, and often require significant nursing and medical input, and are associated with potential side effects and problems. However, the possibility of analgesia often outweighs the risks in patients with uncontrolled pain. Although the evidence base for many of these interventions is limited and some is extrapolated from other studies of cancer pains or non-malignant pain, interventional techniques are used extensively, safely and effectively. They form an integral part of the multi-disciplinary approach to cancer bone pain management, and their early consideration may often be warranted.
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4. Patients with Alzheimer’s disease can experience changes in behaviour, what are the other likely causes of changes in behaviour?
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Disruptive behaviour is also known as challenging behaviour. It refers to inappropriate, repetitive or dangerous behaviours that often occur in the hospital or nursing home environment with residents who have dementia. There are three most common behaviours cited in the literature: wandering, occurs in 40--60% of adults with dementia, aggression and agitation, which occurs in 50--80% of adults with dementia. It has recently been demonstrated that aggression and agitation are more likely to be associated with pain.
