Living with dementia magazine October 2011
Reducing agitation through pain relief
Agitated behaviour is a common symptom of dementia but it is often not treated in the best way. Researchers in Norway have shown that people with dementia treated with pain medication had their agitation significantly reduced, on average, by 17 per cent. These results show that painkillers can be as effective as the antipsychotic drugs that are frequently prescribed for people with dementia who are restless, anxious or acting aggressively.
Antipsychotic drugs can make the symptoms of dementia worse as well as increasing the chances of stroke or even death. It's generally agreed that these powerful drugs are overused; 40 to 60 per cent of nursing home residents with dementia are currently prescribed them and it is estimated that around two thirds of these prescriptions are inappropriate.
It is therefore important to look for ways to reduce agitation, without prescribing antipsychotic drugs, and pain relief could be a good option.
There are many possible causes of pain, from short-term problems such as headaches or sore gums to long-term conditions like arthritis, but it can be very hard to recognise when a person with dementia is in pain. If people are unable to communicate that they are in pain it is often overlooked and remains as a cause of agitation.
The trial involved 352 residents in 60 nursing homes. The residents were divided into two groups. One group were carefully assessed and given suitable painkillers with every meal for eight weeks, while residents from the other group received care as usual.
Agitation was measured using a scorecard system known as the Cohen-Mansfield agitation inventory. Care workers rated 29 agitated behaviours (such as pacing, restlessness and swearing) depending on how often they appeared for each individual. Measurements were taken before the treatment began, at regular points during the eight weeks, and then four weeks after the treatment had concluded.
The results showed that levels of agitation experienced by people taking the painkillers reduced by an average of 17 per cent when compared to the other group.
Professor Clive Ballard, Director of Research at Alzheimer's Society, helped to design the study. He says,
'Simple painkillers like paracetamol had a very substantial impact on symptoms of agitation like aggression and in fact compared to previous studies of antipsychotics a slightly bigger effect.'
What this shows is that doctors have an additional treatment opportunity, that treating pain could be a way of stopping agitation.'
This research was the first substantial randomised controlled trial into the role of pain management as a treatment for agitation.
Careful assessment of the possible causes of any behavioural and psychological symptom of dementia (known as BPSD) is vital in deciding the most suitable treatment. Painkillers should be considered as treatment for agitation when pain is the most likely cause of agitation.
In addition to pain relief, simple psychological interventions, such as frequent short conversations between residents and staff and training staff in person-centred care, have been shown to reduce levels of BPSD in residential homes.
The emphasis must be on not using antipsychotics as a first treatment. It's also important not to rush into treatment as many people's symptoms improve or stop over four to six weeks.
Dr Anne Corbett, Research Communications Manager at Alzheimer's Society says,
'Reducing the use of antipsychotic drugs prescribed to people with dementia is a national priority, but we know at times they can seem like the only way forward. We called together a group of experts to review all of the available evidence about managing and treating BPSD, but also how best to prevent them in the first place.'
The result is a practical, evidence-based framework to support health and social care professionals to provide the best available treatment and care for people with dementia. Alzheimer's Society and the Department of Health have produced the guide called Optimising treatment and care for people with behavioural and psychological symptoms of dementia. The Society is now working with the Royal College of General Practitioners and the Royal College of Psychiatrists to distribute the guide.