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 Study shows agitation in dementia may be pain 
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Joined: Fri Aug 11, 2006 1:46 pm
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Location: SF Bay Area (Northern CA)
Post Study shows agitation in dementia may be pain
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.) --> HTML version --> PDF version

Beneath the BBC News article is the abstract of the research article published in BMJ.


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)

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, Guy’s 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


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.

Cluster randomised controlled trial.

60 clusters (single independent nursing home units) in 18 nursing homes within five municipalities of western Norway.

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).

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).

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.

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 NCT01021696 and Norwegian Medicines Agency EudraCTnr 2008-007490-20.

Sun Aug 07, 2011 8:26 pm

Joined: Fri Dec 31, 2010 3:07 pm
Posts: 1039
Location: Minnesota
Post Re: Study shows agitation in dementia may be pain
Thank you, Robin. We are not currently dealing with agitation, but that could change at any time, so I'll tuck this away for future consideration.

Jeanne, 68 cared for husband Coy, 86. RBD for 30+ years; LDB since 2003, Coy at home, in early stage, until death in 2012

Sun Aug 07, 2011 9:01 pm

Joined: Fri Jan 15, 2010 9:33 pm
Posts: 3441
Location: Vermont
Post Re: Study shows agitation in dementia may be pain
That is very, very interesting. I kept wondering why my dad said he had no pain from his pressure sore all those months, and at the same time, his aggitation level was getting worse all the time. Wish they'd try the pain killer regimen on him but since he kept saying he had no pain, they didn't give him any for almost a year!

Lynn, daughter of 89 year old dad dx with possiblity of LBD, CBD, PSP, FTD, ALS, Vascular Dementia, AD, etc., died Nov. 30, 2010 after living in ALF for 18 months.

Sun Aug 07, 2011 9:14 pm

Joined: Fri Jun 05, 2009 4:15 pm
Posts: 82
Location: Onsted MI
Post Re: Study shows agitation in dementia may be pain
I'm pretty sure Wayne's agitation is the "sundowners" type. It only happens in the late afternoon. Thanks for the article tho. Will keep it in mind.

Sun Aug 07, 2011 9:30 pm

Joined: Wed Dec 30, 2009 1:46 pm
Posts: 3213
Location: WA
Post Re: Study shows agitation in dementia may be pain
Derek has been taking Tylenol daily for years. Maybe his agitation would have been 17% worse if he hadn't.

Pat [68] married to Derek [84] for 38 years; husband dx PDD/LBD 2005, probably began 2002 or earlier; late stage and in a SNF as of January 2011. Hospitalized 11/2/2013 and discharged to home Hospice. Passed away at home on 11/9/2013.

Sun Aug 07, 2011 10:47 pm

Joined: Fri Dec 31, 2010 3:07 pm
Posts: 1039
Location: Minnesota
Post Re: Study shows agitation in dementia may be pain
Pat: :P :P If you double the Tylenol, would it be 34% less bad?

Jeanne, 68 cared for husband Coy, 86. RBD for 30+ years; LDB since 2003, Coy at home, in early stage, until death in 2012

Sun Aug 07, 2011 11:18 pm

Joined: Tue Mar 29, 2011 3:02 pm
Posts: 386
Location: East TN
Post Re: Study shows agitation in dementia may be pain
I find this interesting…

my 'torture' level is increasing…my torture is 24/7 bombardment of sensations…too numerous to keep track off at one time...

my agitation level is increasing….

…but….my toxic people have increased too...

Craig - Patient - Male - 56 years old - Lewy Bodies diagnosed on March 23, 2011 - cognitive disorder NOS dx 2007 - RBD REM dx 2007 issues for 20+ years - intention tremor 1974 - other issues many years

Mon Aug 08, 2011 9:44 am
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