Using Pain Management in Long term Care Pharmacy to Reduce Agitation and Aggression Among Residents With Dementia

By Jennifer Devinney, RPh, PharmD Agitation and aggression in elderly residents with cognitive disorders can be a common occurrence in long term care settings. Recently, there has been research published evaluating the role of untreated or undertreated pain in residents with dementia and the potential impact of proper treatment. Residents with Alzheimer’s disease are reported to have an incidence of agitation approaching 80 percent. Furthermore, agitation and aggression are leading causes of institutionalization in older people with dementia. The source of the agitation or aggression in the residents may not be entirely known; however, what is known is that dementia causes a biological change in an individual, which affects and impairs their ability to process new information and stimuli. As a result, their ability to communicate effectively about what is bothering them is inhibited. When a resident is experiencing agitation or aggression, there are a number of factors that should be evaluated from the environment to daily routines or perhaps most importantly comfort and pain.  

Long term Care Pharmacy for Residents With Dementia: An Evolution of Care

For many years, the primary method to control aggression and agitation in residents with dementia was the use of antipsychotic medications. While antipsychotic therapies may assist with lessening agitation and aggression in some residents, their use is also shown to increase fall risk, as well as negatively impact the overall mortality of residents.   Because agitation and aggressive behaviors themselves lend to an increased risk of falls, injury and hospitalization, it has become a primary focus in long term care to reduce these behaviors while abstaining from utilizing antipsychotics due to their own risk of falls and associated mortality. As a result of the Centers for Medicare & Medicaid Services’ initiative to reduce unnecessary antipsychotic medication use in long term care residents with dementia, antipsychotic utilization rates in skilled nursing facilities have begun to decrease significantly through the adoption of a resident-centered care approach. As the focus has changed to identifying the root cause of behaviors, care teams, including long term care pharmacy providers, are now looking outside of our standard boxes and previous comfort zones. Pain poses its own challenges in residents with cognitive impairment because the gold standard of pain assessment is self-report. If the resident is unable to communicate appropriately, self-report may manifest itself as agitation or aggression. [Tweet “Pain medication been shown to reduce aggression among #dementia patients. #longtermcarepharmacy”]

A Look at the Research

In a recent study, it was found that the treatment of pain in residents with dementia resulted in a 17 percent reduction in agitation and aggression, which is comparatively close to the reduction in the same behavior when an antipsychotic medication was used. Additionally, in the group that received pain treatment, there was documented improvement in overall neuropsychiatric symptoms and pain levels. The stepwise treatment initiated in the study conformed to the American Geriatric Society Panel on the Pharmacological Management of Persistent Pain in Older Persons, where residents taking no analgesics or only low-dose acetaminophen were switched to full-dose acetaminophen with a daily maximum dose of 3,000 milligrams. Residents already on full-dose acetaminophen or low-dose morphine received a maximum dose of 10 milligrams of short-acting morphine twice daily. Residents unable to take oral medications or already on low-dose buprenorphine were placed on transdermal buprenorphine at doses of 5 to 10 micrograms per hour. Finally, those with neuropathic pain received adjuvant pregabalin at doses up to 300 milligrams daily. The outcome, as previously stated, was a 17 percent reduction in the aggressive and agitative disorders seen in dementia. The stepwise therapy results were not due to sedation; as 69 percent of the total population received only acetaminophen. Of the 25 percent receiving opioids, only three stopped therapy due to sedation. A separate study focused on the use of acetaminophen alone in pain treatment for individuals with dementia and aggression or agitation. This study found that with a regularly scheduled acetaminophen treatment—not exceeding 3000 milligrams per day—individuals experienced a decrease in behavioral symptoms of agitation and aggression. In addition, this course of therapy also resulted in a 75 percent discontinuation rate of all psychotropic medications.  

Analyzing Resident Pain in Long term Care Pharmacy

Treatment of pain with acetaminophen may also be a benefit in this population due to the aforementioned communication barrier challenge that is present in cognitively impaired residents. Utilizing a Faces Pain Scale and scheduled acetaminophen dosing has the potential to provide caregivers, including long term care pharmacy providers, with necessary tools to assist with the communication barrier while effectively addressing pain. Barriers to communication are common in residents with dementia, but there are methods to encourage communication in otherwise confused or silent residents. Using slow, simple sentences and patiently waiting for a response can give residents time to comprehend the request, as well as respond in kind. Writing the questions down gives resident the opportunity to physically give an answer instead of verbally doing so. Avoid quizzing or distracting residents as this may increase the display of agitation or aggression. Through consistent and close relationships with residents, caretakers may also develop an understanding of their nonverbal communication of discomfort and pain.  This also can increase the ability to treat pain, thereby avoiding behavioral issues. Pain is a very subjective experience, which can be further complicated by cognitive impairment.  During the assessment and evaluation of behavioral disturbances, such as agitation and aggression, it is also valuable to solicit the feedback of family members and caregivers on prior experience with the resident.   Prior to initiating therapy with an antipsychotic medication, consideration may be given to pain evaluation and non-pharmacological interventions, such as exercise, massage, relaxation, and heat or cold therapy. As shown through these studies, scheduled treatment of pain may reduce agitation and aggression without the utilization of antipsychotic medications, producing a more appropriate outcome for the resident and facility alike. Grane Rx is dedicated to understanding and implementing the latest best practices in long term care pharmacy services. We offer a variety of clinical solutions designed to meet your center’s needs.]]>

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