Several people emailed me info about a study published last month that suggests that agitation in dementia patients may be caused by pain. Treating dementia patients with painkillers significantly reduced agitation in the group of 352 patients in Norway being studied. These patients, residents of nursing homes, were randomized to receive a "stepwise protocol for the treatment of pain" (which included acetaminophen, morphine, etc.) or to receive the "usual treatment."
Copied below is a BBC News article on the study. The Alzheimer's Society of the UK is trying to get MDs to consider using painkillers rather than antipsychotic drugs.
Here are links to the research article itself on the British Medical Journal website. At the present time, the full article is available at no charge. (Things can change so copy the article to your hard drive now if you are interested.)
http://www.bmj.com/content/343/bmj.d4065.full --> HTML version
http://www.bmj.com/content/343/bmj.d4065.full.pdf --> PDF version
Beneath the BBC News article is the abstract of the research article published in BMJ.
Robin
http://www.bbc.co.uk/news/health-14138884 17 July 2011
Painkillers 'may ease agitation' in dementia patients
By Jane Hughes
Health correspondent, BBC News
Many dementia patients being prescribed "chemical cosh" antipsychotic drugs could be better treated with simple painkillers, research says.
The British and Norwegian study, published on the BMJ website, found painkillers significantly cut agitation in dementia patients.
Agitation, a common dementia symptom, is often treated with antipsychotic drugs, which have risky side effects.
The Alzheimer's Society wants doctors to consider other types of treatment.
Experts say that each year about 150,000 patients in the UK are unnecessarily prescribed antipsychotics, which have a powerful sedative effect, and can worsen dementia symptoms, and increase the risk of stroke or even death.
They are often given to patients whose dementia makes them aggressive or agitated.
But researchers from Kings College, London, and Norway speculated that the behaviour may sometimes be caused by pain, which patients were unable to express in other ways.
They studied 352 patients with moderate or severe dementia in nursing homes in Norway.
Half were given painkillers with every meal, the rest continued with their usual treatments.
Supervised treatment 'key'
After eight weeks, there was a 17% reduction in agitation symptoms in the group being given painkillers - a greater improvement than would have been expected from treatment with antipsychotics.
The researchers concluded that if patient's pain was properly managed, doctors could reduce the number of prescriptions for antipsychotic drugs.
Professor Clive Ballard, one of the report authors and director of research at the Alzheimer's Society, said the finding was significant.
"At the moment, pain is very under-treated in people with dementia, because it's very hard to recognise," he said.
"I think this could make a substantial difference to people's lives - it could help them live much better with dementia."
However, he said painkillers should only be given to patients under the supervision of a doctor.
The Alzheimer's Society is issuing new guidance calling on doctors to think much harder before prescribing antipsychotics, and to look at prescribing pain medication instead.
The National Care Association said the study highlighted some of the complexities of dementia.
"Pain in itself is debilitating, so to identify it as the route cause of agitation and aggressive behaviour is a major breakthrough which will enable us to support people appropriately," said its chairman, Nadra Ahmed.
A government programme to reduce the inappropriate prescription of antipsychotic drugs is already under way in England.
The care services minister Paul Burstow welcomed the study.
"It should act as a further call for GPs to carefully examine the reason why those with dementia display agitated behaviour, rather than immediately resorting to antipsychotic medication," he said.
Here's the abstract of the BMJ article:
BMJ 2011; 343 (Published 17 July 2011)
Research
Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial
Bettina S Husebo, postdoctoral fellow1, Clive Ballard, professor2, Reidun Sandvik, registered nurse1, Odd Bjarte Nilsen, statistician3, Dag Aarsland, professor4
1Department of Public Health and Primary Health Care, University of Bergen, 5020 Bergen, Norway
2Wolfson Centre for Age-Related Diseases, Wolfson Wing and Hodgkin Building, Guyâs Campus, Kings College, London SE1 1UL, UK
3Department of Psychiatry, Stavanger University Hospital, 4011 Stavanger, Norway
4Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Karolinska Institute-Alzheimer Disease Research Center, Novum, Stockholm, Stavanger University Hospital, Department of Psychiatry, Stavanger, Norway, and University of Oslo, Oslo, Norway
Abstract
Objective
To determine whether a systematic approach to the treatment of pain can reduce agitation in people with moderate to severe dementia living in nursing homes.
Design
Cluster randomised controlled trial.
Setting
60 clusters (single independent nursing home units) in 18 nursing homes within five municipalities of western Norway.
Participants
352 residents with moderate to severe dementia and clinically significant behavioural disturbances randomised to a stepwise protocol for the treatment of pain for eight weeks with additional follow-up four weeks after the end of treatment (33 clusters; n=175) or to usual treatment (control, 27 clusters; n=177).
Intervention
Participants in the intervention group received individual daily treatment of pain for eight weeks according to the stepwise protocol, with paracetamol (acetaminophen), morphine, buprenorphine transdermal patch, or pregabaline. The control group received usual treatment and care.
Main outcome measures
Primary outcome measure was agitation (scores on Cohen-Mansfield agitation inventory). Secondary outcome measures were aggression (scores on neuropsychiatric inventory-nursing home version), pain (scores on mobilisation-observation-behaviour-intensity-dementia-2), activities of daily living, and cognition (mini-mental state examination).
Results
Agitation was significantly reduced in the intervention group compared with control group after eight weeks (repeated measures analysis of covariance adjusting for baseline score, P<0.001): the average reduction in scores for agitation was 17% (treatment effect estimate -7.0, 95% confidence interval -3.7 to -10.3). Treatment of pain was also significantly beneficial for the overall severity of neuropsychiatric symptoms (-9.0, -5.5 to -12.6) and pain (-1.3, -0.8 to -1.7), but the groups did not differ significantly for activities of daily living or cognition.
Conclusion
A systematic approach to the management of pain significantly reduced agitation in residents of nursing homes with moderate to severe dementia. Effective management of pain can play an important part in the treatment of agitation and could reduce the number of unnecessary prescriptions for psychotropic drugs in this population.
Trial registration
ClinicalTrials.gov NCT01021696 and Norwegian Medicines Agency EudraCTnr 2008-007490-20.
