Problem behavior or pain?

Untreated pain can lead residents with dementia to strike out

ARE THESE TYPICAL SCENARIOS ON THE DEMENTIA UNIT AT YOUR facility? When the nursing assistant attempted to put a sweater on Mrs. Jones after lunch, the resident struck at her, cursing loudly. Mr. Smith paced up and down the hail most of the morning. The therapy aide tried unsuccessfully to distract him with ball-toss activities; he left the activity to resume his pacing, but appeared distressed.

At shift's end the nursing assistant reported this to the nurse, adding that the residents were "about the same as always; nothing unusual about them."

What did the nurse do with this information? Were the behaviors totaled, then the numbers added to the behavior monitoring sheet? Was the next shift informed that Mrs. Jones and Mr. Smith had typical days--nothing "out of the ordinary"?

Or did someone assess for pain?

Did anyone consider that Mrs. Jones might have struck out because of pain in her shoulders while being dressed? Or that Mr. Smith was having pain but because of inability to verbalize or recognize it as pain, he used pacing to cope? Could it be that "ordinary," "usual," and "typical" days for Mrs. Jones and Mr. Smith are ordinarily, usually, and typically filled with pain--unassessed and untreated?

A recent University of Minnesota study by Karen Feldt, RN, PhD, Muriel Ryden, RN, PhD and Mary RN, nurse practitioner with Evercare in Minneapolis, suggests that pain contributes to aggressive behaviors in residents with severe cognitive impairment. In the November 1998, issue of Journal of Gerontological Nursing, the researchers discuss their study to describe the phenomenon of pain in this group, who because of the cognitive impairment, cannot respond to frequently used pain assessment tools.

This study explored pain in older adults who were cognitively impaired and attempted to determine a relationship between pain and aggressive behaviors. The study was based on the assumptions that chronic diseases commonly cause pain in older adults, people with dementia can experience pain, people with dementia are often unable to self-report their pain, and those with dementia who have pain may benefit from both pharmacological and nonpharmacological approaches.

The researchers focused on these questions:

* What proportion of cognitively impaired residents have pain reported by a family member and/or nursing assistant?

* What proportion of cognitively impaired residents have medical diagnoses commonly known to cause pain?

* What proportion of residents with pain-causing medical diagnoses are treated with analgesics?

* Are aggressive behaviors more prevalent in cognitively impaired residents with pain-related diagnoses?

The study's 38 Subjects were part of a larger one conducted at three metropolitan nursing homes to examine a relationship between dementia education and aggressive behavior. The smaller study looked only at residents of one nursing home. The group, 81.6 percent women, had a mean age of 86.9. All had neuropsychiatric diagnoses and 84 percent had been diagnosed with either dementia or Alzheimer's. They had a mean score of 6.4 on the Folstein Mini Mental Status Exam. Their mean case mix was 8 (in Minnesota, this measures dependency in activities of daily living and special nursing care, and is on a scale of 1 to 11; a higher number indicates more dependency).

The researchers interviewed families and nursing assistants for their perceptions of pain in the subjects, reviewed the medical record for pain-related diagnoses, identified use of analgesics in the previous month, and tallied aggressive behaviors using the Ryden Aggression Scale 2.

The findings offer these insights:

* Pain in residents was identified by nursing assistants--usually based on verbal or nonverbal cues--in 68.5 percent of the subjects while family members-who frequently based pain reports on knowledge of resident's history--identified it in 44.7 percent of subjects. In spite of this, more than half of the subjects for whom the nursing assistants suspected pain did not receive any pain medication in the previous month; 64 percent of subjects whom family members suspected of having pain had been treated with analgesics.

* Most residents (79 percent) had at least one pain-related diagnosis (arthritis, osteoporosis, history of cancer or fracture, localized pain). Half had two or more pain-related diagnoses. However, 60 percent of the subjects with one or more pain diagnoses had not received any pain medication in the previous month.

* Aggressive behaviors were significantly more frequent in subjects with two or more pain-related diagnoses; those with arthritis had significantly higher aggression scores than those without arthritis.

These researchers recommend that nurses consider diagnoses information from the medical record, information from the family and staff, and behavior of the resident when assessing pain in nursing home residents with dementia. Perhaps Mrs. Jones and Mr. Smith need to be assessed for pain

Janice Olson, RN, MEd, is a nurse educator based in Woodbury, Minnesota.