By Susannah Stewart, BScPT
Nurses have much-needed expertise in pain medication and management. Physiotherapists, as members of a team of pain-assessment specialists, are well trained to assess pain in people with a limited ability to communicate. Recognizing and understanding pain behaviour enables the team to provide high-quality care for people with dementia. Collaboration between physiotherapists and nurses is a cornerstone of the comfort and rehabilitation of people with dementia.
Mr. George is an elderly man with dementia whose hip was pinned after a fall at his long-term care facility. When the acute care physiotherapist went to visit Mr. George three days later he was frowning, shifting about in bed and looking restless. When asked how he was doing, his response was incoherent yelling. As the therapist raised the head of the bed to sit him up, Mr. George’s grimace deepened—he moaned loudly and took a swing at the therapist. The therapist ducked and quickly retreated to the nurses’ station saying she could not get Mr. George up that day. For the next two days, the therapist met with the same response. Mr. George was discharged back to the long-term care facility with a discharge summary reading: “Patient is inappropriate for rehabilitation.”
Using clinical reasoning to examine this case history, what can be learned about how to improve Mr. George’s outcome? If all behaviours have meaning, what is the meaning of Mr. George’s behaviour? Could raising the head of the bed have caused increased hip pain? Could this have contributed to his agitation and attempt to strike the therapist? With adequate pain management, could the outcome have been different?
Communicating for comfort
People with advanced dementia, although they might still be able to speak, cannot always understand what the word “pain” means or be able to reliably put the experience of pain into words. The usual approach of asking for a verbal report of pain or for a number out of 10 is ineffective for this population. The health care team must become more observant of the person’s body language, which communicates pain much more reliably. Agitated and aggressive behaviours are strongly correlated with pain for people with dementia, and are often mistakenly attributed to the dementia itself.
Two pain-assessment tools are commonly used for people with advanced dementia: PAINAD (Pain Assessment in Advanced Dementia) and PACSLAC (Pain Assessment Checklist for Seniors with Limited Ability to Communicate). These tools quantify the severity and presence of pain, respectively, and can be used to communicate with other members of the team, including physicians and family members.
In the case of Mr. George, is it safe for the physiotherapist to assume that he has received adequate pain medication? Not necessarily, as the following quote illustrates.
“…not only are patients with dementia prescribed less analgesia, they are also at risk of not receiving analgesia even when it is prescribed (Horgas & Tsai, 1998). Morrison and Siu’s study (2000) revealed that 83% of patients with dementia did not have a standing order for postoperative analgesia, despite the high likelihood of communication impairment, which has been identified as a major barrier to pain detection, especially in people with severe dementia. Subsequent studies have found that actual administration of prescribed analgesia does not eventuate in up to 83% of patients (Cunningham, 2006).”
Morrison and Siu (2000) studied pain management after hip fracture and found that people with dementia received one-third the dose of opioid pain medication of those without dementia. Therefore, it is helpful for physiotherapists to understand that, in many cases, their clients may not have received adequate pain medication before assessment.
Collaborating with nurses
In light of this information, how can Mr George’s participation and comfort be optimized? Before the assessment, the therapist must seek help from the nurse by asking the following questions:
• Is Mr. George receiving pain medication?
• Is he receiving medication regularly or PRN (as needed)?
• When was his most recent dose of pain medication?
• Has it had time to take effect?
The information received from the nurse can guide the physiotherapist’s assessment and goal setting for Mr. George. Ideally, the assessment should be conducted once the pain medication has taken effect. If Mr. George is not receiving any pain medication, or is receiving it infrequently, then the therapist’s assessment will add to his suffering and his participation will be limited. There may even be a risk of injury to the physiotherapist if Mr. George expresses pain by striking out.
Discharge home to the long-term care facility
When Mr. George returned to the long-term care facility, the physiotherapist and a nurse collaborated on his assessment. They made eye contact with Mr. George before speaking and told him what they were about to do before they did it: “I’m going to move your leg now.” The physiotherapist gently flexed Mr. George’s hip and he screamed out. The high intensity of his response prompted the therapist to stop the assessment. The nurse informed the physiotherapist that Mr. George was not receiving pain medication on a regular basis. The physiotherapist and nurse decided it was in Mr. George’s best interest to minimize movement until pain management was improved.
After a few days of receiving regular pain medication, the therapist reassessed Mr. George and found that he grimaced only slightly when his hip was flexed. She was then able to progress to assisting him to sit at the edge of the bed with minimal discomfort. With every movement, the therapist monitored Mr. George very closely for pain.
The next day Mr. George was able to stand up from his bed with two people assisting him. Communication was enhanced by short and simple directions from the therapist. For example, instead of saying “Could you please stand up now?” the physiotherapist said “Stand up.”
When asking about pain, many different questions were used, such as, “Are you hurt?” “Are you aching?” When no response was elicited, the therapist grimaced, rubbed her hip and simply asked, “Pain?” To assess the pain intensity, rather than asking for a number out of 10, she asked, “Is it a little, medium or a lot?”
One day, the physiotherapist observed that Mr. George limped and grimaced when putting weight on his left leg, and reported this to the nurse. Extra pain medication was then given prior to physiotherapy sessions and a week later, Mr. George was able to ambulate with two-person assist and a two-wheeled walker. Soon he was
out in the garden with his four-wheeled walker, visiting with his grandson and smelling the roses!
Physiotherapists and nurses need each other to provide excellent dementia care. With this teamwork, Mr. George benefited from a thorough pain assessment and treatment that recognized his unique way of communicating. The team will continue to collaborate and strive for the highest possible quality of life for people with dementia.
References available upon request.
Susannah Stewart is a palliative care physiotherapist with a passion for elders with dementia. She specializes in pain assessment for people who have limited verbal skills or who can no longer speak. Her ultimate hope is for every hospital and long term care facility to become dementia friendly.