Pain As A Driver For Agitation For People With Dementia

If you think about it  most of us can be pretty dysfunctional if we’re in  severe pain.   We might cry, whine, withdraw social contact or get needier,  find it harder to pay attention and avoid normal activity.     In extreme cases we might lash out verbally and physically at those who cause or exacerbate the pain.  Some would argue that this behaviour under certain circumstances is reasonable.  I remember once a friend telling me that they’d been labelled as violent in hospital when they’d hit out at a therapist who insisted on making them walk when they were in agony.  It was later found that they had a spinal fracture.
People with dementia are likely to respond in similar ways when troubled with pain.    They may however be less able to communicate their distress or control their pain responses.   If their disease has progressed to a stage where they cannot easily articulate what is wrong there is a risk that  these responses can be labelled as challenging behaviour without proper consideration being given to determining the underlying cause.   As an exercise please follow  this link  to the Cohen Mansfield Agitation Inventory, a commonly used assessment tool for recording the troubled ways in which a person with dementia might behave.    How many of these might be an indication that a person is in pain?  I believe that you’ll come to the same conclusion that I did.   Although there may be other reasons to account for why a person with dementia might be acting in a certain way pain needs to be considered as a possible cause in the majority of cases.
Clues That A Person with Dementia Might Be In Pain
Physical Signs:  Grimacing,  holding certain postures, contractures, increased blood pressure or heart rate, reluctance to move, crying, moaning or groaning, disturbed sleep.
Medical Reasons:   Arthritis, diabetes, wounds from accidents or falls, urinary tract infections, constipation, headaches, pressure sores,  migraine, cancer, osteoporosis, dental or oral pain, any condition that causes reduced mobility.
Environmental Factors:  Uncomfortable or unsafe furniture, ill fitting or roughly textured footwear,clothes and medical appliances, contaminants, toxins and allergens.
Personal Factors:  Increased falls and accidents,  inconsistently taking prescribed medication for pain,  engaging in activities that might exacerbate pain for example excessive pacing or self harm, withdrawing from social contact and activity.
This is not a comprehensive list. However I hope it has given you an idea of how many issues may be relevant.
Treatment for Pain
Seek advice from a prescriber or pharmacist about analgesia, medication for pain and how often it should be taken.   In my experience the effectiveness of well known drugs taken consistently is often under appreciated.   The fact that they are commonly available through prescription and over the counter appears to cause people to under value their effectiveness.   Think about how medication aides such as pill dispensers or blister packs can be used to ensure that a person takes the medication as prescribed.   Be aware that analgesia is available in other forms, for example liquid or patches if there are issues around the person taking tablets.  Even if a person is on medication for pain don’t be afraid to ask for a review if symptoms of agitation change or re-emerge.    There may be good reasons why existing drugs are no longer effective.  Speak to the prescriber and consider whether covert medication is appropriate if a person refuses medication.  Are there advance directives or longstanding attitudes about medication that might guide this decision?
And don’t forget that non pharmacological treatment also plays a role in pain management too.  Physiotherapy,  ergonomic seating and bedding,  pressure equipment,  exercise, massage, TENs, hot and cold compresses, acupuncture and activity used to divert thinking away from pain may also be effective.   Greater awareness and a considered approach to assessment and treatment of pain routinely in dementia care could make a significant difference to the wellbeing of many.



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