Many dementia patients are being treated with antipsychotic medications, but a new study shows that simple pain relievers may be a better alternative.
Nearly one in five patients in the study became significantly less agitated and aggressive after treatment with painkillers. The project is a collaborative effort between researchers in Norway and England.
Pain management for aggression and agitation
The study included 352 patients with moderate to serious dementia who exhibited significant behavioural problems such as aggression and agitation. During the eight-week study, all patients received their usual treatment, but half of them received pain treatment in addition.
Agitation is a common symptom of dementia; patients can become anxiety-ridden, upset and short-tempered. Many receive antipsychotic medications intended to reduce their behavioural disturbances, but antipsychotics have a powerful sedative effect and can even exacerbate other dementia symptoms and increase the risk of stroke.
Pain leads to aggressiveness
"The improvement the patients experienced was greater than would have been expected from treatment with antipsychotics," says Bettina Husebø.
Dr Husebø is carrying out post-doctoral research at the University of Bergen's Department of Public Health and Primary Health Care. The study, which she heads, receives funding from the Research Programme on Health and Care Services (HELSEOMSORG) under the Research Council of Norway.
"We hypothesised that behavioural disturbances in dementia patients are sometimes due to pain," she explains. "These patients cannot always communicate to their caregivers that they are in pain, and aggression and agitation become their way of expressing it."
Recurrence after reduction
In the intervention group, patients who were not already taking pain medication were given paracetamol (acetaminophen). Patients who were already taking some form of analgesic painkiller received low doses of morphine or buprenorphine, while those who appeared to suffer neuropathic pain received an antiepileptic drug.
After the eight weeks, the pain treatment was gradually reduced and the intervention-group patients showed marked improvement. But four weeks later the behavioural disturbances began recurring.
"Some people may explain away these positive results by claiming we further sedated the patients. But throughout the study we took control measurements that showed the activity level (in daily living and cognition) of both groups remained unchanged during the eight weeks of pain management," emphasises Dr Husebø.
"Pain assessment training needed"
She believes the results indicate that pain management should be integrated into the clinical treatment of people with dementia in nursing homes.
"Pain assessment is critical in managing pain properly. In the future we must ensure that all nursing home databases have standardised tools for assessing pain based on observation of the patients. Personnel will need training to use these tools, and routines need to be developed to make certain that the tools are actually employed."
Dr Husebø stresses, however, that pain management is not a complete solution but rather part of a comprehensive plan in which activity and communication are essential elements.
Hawthorne effect triggered
The researchers in the study recorded some behavioural improvement in control-group patients as well, i.e. those who did not receive pain medication. This may be explained by the Hawthorne effect - that taking part in a study can in itself produce temporary, positive changes.
"The nursing home personnel in the study received good training and follow-up. This enhanced knowledge and awareness of the issue in general," explains Dr Husebø, "which in turn had an impact on all patients, not only those whose treatment was altered."
The results have been published in the British Medical Journal.