The Assignment on Developing End of Life Healthcare

Running head: LITERATURE REVIEW
LITERATURE REVIEW
Name of the student
Name of the university
Author’s name

LITERATURE REVIEW
Abstract:
In recent times, substantial progress has been made in developing end-of-life healthcare, but
individuals suffering from dementia still die with inadequate pain control, feed tubes in place
and hospice care. Individuals of neurological conditions like dementia are vulnerable classes of
people in which the discomfort is often under recognized, misunderstood and undertreated. A
major barrier to effective treatment is the failure to effectively express pain in moderate-severe
dementia, and several observational studies have shown that pain is being undertreated in
elderly people with cognitive issues. Neuropsychiatric dementia signs such as anxiety, assault
and mood disturbance, as well as issues with sleep have associated discomfort. Successful pain
management has been shown to be effective to mediate or relieve these effects. This review thus
focuses on exploring the barriers to pain management in these patients and also provides
recommendation to improve care and treatment plan for these patients and improve their overall
health outcome.

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Introduction:
Patient suffering from dementia are at a high risk of experiencing pain as they are unable
to express or communicate about their problems as a result of their cognitive impairment.
Therefore, this population group is more susceptible to pain because of their inability to self-
report. Their pain is often left undertreated and under assessed and therefore, for these patients, a
comprehensive and palliative care is needed by addressing and accessing their health concerns.
Studies show that self-reporting is an important factor to manage as well as assess the pain, and
incapacity to communicate is a significant barrier in effective pain management in older patients
with dementia. Dementia belongs to a group of diseases characterised with a gradual and
progressive and in certain cases an irreversible deterioration in mental functioning. It is mainly
characterised by a reduced cognitive abilities due to damage in the neurons in some areas of the
brain complemented by a deteriorated emotional control, motivation and social behaviour which
over time intensifies and increases. In Ireland, it has been reported that the prevalence of
dementia is exponentially increasing with age and are almost doubling every five years. Females
are found to be more prevalent to suffer fromdementia in their old age. It has been reported that
about 35 million people worldwide, are affected by dementia. The increasing rate of older people
suffering from dementia, pressurizes the healthcare providers and healthcare services to meet the
need for treatment and care for these people since pain management is a significant challenge in
patients with dementia.
Search strategy:
For conducting this literature review several online databases such as CINAHL, Pub Med
and Google Scholar were searched to find the appropriate articles relevant to the research area. A

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total of 25 articles were found to be relevant to the topic, however, out of those 25 articles, only
10 articles were found to be matching with the inclusion criteria. All the papers which did not
have conclusive research findings and lack proper analysis and supporting studies were
excluded. The articles extracted or filtered based on the information they have which could be
accessed by skimming through the abstract of the articles. Each articles were analysed based on
the criteria of including and the articles that did not match the criteria were excluded from the
study. Certain keywords like “Dementia”, “Dementia and pain”, “Pain management in older
patients”, “Barriers to pain management in older dementia patients:’ “causes of pain in dementia
patients”, “Chronic pain in older patients with dementia”, “barriers to pain management”, “older
patients and dementia” were searched. The studies that were included in the review were
conducted from 2010-19 to get the current findings on this topic.
Critical appraisal:
Corbett, A., Nunez, K.M., Smeaton, E., Testad, I., Thomas, A.J., Closs, S.J., Briggs, M.,
Clifton, L., Gjestsen, M.T. and Lawrence, V., 2016. The landscape of pain management in
people with dementia living in care homes: A mixed methods study. International journal of
geriatric psychiatry, 31(12), pp.1354-1370.
Questions/Criteria Response and Justification
Was there a clear statement of the
aims of the research?
Yes. The study aims to approach the current pain
management landscape in the homecare providing
places for the people with dementia.
Is a qualitative methodology Yes. Stakeholder consultation triangulation and pain
management advice standard assurance have been

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appropriate? conducted.
Was the research design appropriate to
address the aims of the research?
Yes.
Was the recruitment strategy
appropriate to the aims of the
research?
No such strategies have been mentioned in the study.
Was the data collected in a way that
addressed the research issue?
Yes. In order to identify themes and sub-themes, the
data is subjected to thematic review. Reports were
checked and suggestions were provided by an expert
panel.
Has the relationship between
researcher and participants been
adequately considered?
No such information has been provided.
Have ethical issues been taken into
consideration?
Yes.
Was the data analysis sufficiently Yes. There have been 15 existing guidelines, three
designed for dementia use and no adapted to the

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rigorous? home setting. Six main trends of pain management in
dementia were observed in the area of thematic
analysis: significance of personal centering, current
pain sensitivity of staff empathy as a central element,
difference of staffing accountability and confidence,
need for consistent treatment and the lack of training
for workers currently in progress. The expert panel
identified promising candidates for pharmacological
therapy in relation to the medical requirements that
require clinical evaluation.
Is there a clear statement of findings? Yes. The findings of this study clearly explain the
need for a pain management system based on
evidence for nursing homes that is centered on
stakeholder feedback and on a conceptual framework
for this purpose.
How valuable is the research? The aim of this study is to explore the present pain
management landscape in people living in health care
facilities with dementia. In this patient group, pain is
very common, but health professionals are guided by
very little.

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Duncan, R., Francis, R.M., Collerton, J., Davies, K., Jagger, C., Kingston, A., Kirkwood,
T., Robinson, L. and Birrell, F., 2011. Prevalence of arthritis and joint pain in the oldest
old: findings from the Newcastle 85+ study. Age and ageing, 40(6), pp.752-755.
Questions/Criteria Response and Justification
Did the study address a clearly
focused issue?
Yes. They present longitudinal findings from an unelected
sample of 1,029 individuals born in 1921 about the
incidence of arthritis and joint pain from the Newcastle 85
+ study.
Was the cohort recruited in an
acceptable way?
Yes.
Was the exposure accurately
measured to minimize bias?
No bias has been introduced in the study.
Was the outcome accurately
measured to minimise bias?
No bias has been introduced in the study.
Have the authors identified all
important confounding factors?
Yes. Using a single year of age cohort, a complete picture
of the health spectrum within this age group, unfounded by
age differences and secular trends, was obtained.

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Have they taken account of the
confounding factors in the
design and/or analysis?
Yes.
Was the follow up of subjects
complete enough?
Yes.
Was the follow up of subjects
long enough?
Yes.
What are the results of this
study?
Eligible persons were classified 1,040% (71.6%) with
1,029 completed GPRR and 845 already performed
MDHA. Eligible individuals were listed, including 1,033
individuals. While comparing both the participants with
complete GPRR and MDHA (n= 845) to those with GPRR
only (n= 184), men who were diagnosed with' Any
Arthritis' (67,3 versus 56,6% P= 0.005) and Arthritis (OA)
(53,5 versus 54,6% P= 0.003) were more likely than GPRR
only (37,8 versus 27,2% P= 0.007).
How precise are the results? The incidence over the lifespan of all ' arthritis ' was high
and was more prevalent in women than in men (79.1 vs
58.8 percent P = 0.001) among 673 participants [ 65.4

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percent (95% CI: 62.5–68.3) ].
Do you believe the results? Yes.
Can the results be applied to the
local population?
Yes.
Do the results of this study fit
with other available evidence?
Yes. This is because arthritis is a disease strongly linked to
age but few detailed research to date, interestingly, have
investigated how arthritis affects the aged 85.
What are the implications of this
study for practice?
 The oldest generation is highly prevalent for fatigue
and joint pain.
 The most specific diagnosis have been knee OA
and cervical spondylosis.
 Pain was more common in women in all fields in
the 11 joint areas surveyed.
 The amount of sore joints recorded by women has
grown.
 A total of 13.5% of the participants were replaced
by hip or knee.

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Husebo, B.S., Kunz, M., Achterberg, W.P., Lobbezoo, F., Kappesser, J., Tudose, C.,
Strand, L.I. and Lautenbacher, S., 2012. Pain Assessment and Treatment Challenges in
Patients with Dementia 1This article is a modified version of the article „Pain in patients
with dementia: An overview of pain assessment and treatment challenges” that will be
printed in the Journal of NorskEpidemiologi. ZeitschriftfürNeuropsychologie.
Did the review address a clearly focused
question?
Yes.
Did the authors look for the right type of
papers?
Yes to some extent. In this paper, the authors have
reviewed literature on dementia and pain and
summarized on the best evidence available related to
degree of pain and diagnosis of pain in these patients.
However, the study has not found any adequate
randomized controlled studies on pain treatment
efficiency in dementia patients with the fact that
most of the recommendations for the treatment of
pain were not grounded on highest level of evidence.
Do you think all the
important, relevant studies
were included?
Yes. Since the authors have included best available
evidences on the topic.
Did the review’s authors do enough to Yes.

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assess quality of the included studies?
If the results of the review
have been combined, was it
reasonable to do so?
Yes.
What are the overall results of the review? The findings of the study indicates that age is linked
with an increased in the respective pain and
dementia. As the trait of reporting about pain
depends on the insight, expectation and memory,
dementia patients are at an increasing risk for being
underdiagnosed and therefore, untreated.
How precise are the results? The findings of the research suggests a high
requirement of research with a proper
implementation of the concepts related to pain
assessment and treatment in older patients suffering
from Dementia.
Can the results be applied to the local
population?
Yes.
Were all important outcomes considered? Yes.
Are the benefits worth the harms and costs? Yes.

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Sampson, E.L., White, N., Lord, K., Leurent, B., Vickerstaff, V., Scott, S. and Jones, L.,
2015. Pain, agitation, and behavioural problems in people with dementia admitted to
general hospital wards: a longitudinal cohort study. Pain, 156(4), p.675.
Questions/Criteria Response and Justification
Did the study address a clearly focused
issue?
Yes. They aimed at investigating the incidence of pain in
people suffering from dementia who are admitted to the
general hospital. The study also explores the relationship
between pains with that the behavioural and psychiatric
symptoms of dementia (BPSD). In order to accomplish
this, they have conducted a longitudinal study including
230 people who are aged above 70 having dementia and
an unplanned admission to two hospitals in UK.
Was the cohort recruited in an
acceptable way?
Yes. As stated by the authors, this cohort can be
represented and the results can be generalised.
Was the exposure accurately measured
to minimize bias?
Yes.
Was the outcome accurately
measured to minimise
bias?
Yes. They have attempted the study for overcoming
reporting bias achieved by gathering information from
various sources including family carers, primary data
(their own observations) and numerous medical as well as
nursing notes. According to the authors, recollection of
bias can seriously lead to over reporting of bothersome

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behaviors.
Have the authors identified
all important confounding
factors?
Yes. For analyzing pain while moving, they have first
determined the crude association followed by adjustments
for potential confounders for the relationship between pain
and the psychiatric and behavioural symptoms of dementia
including gender, age, FAST score, acute illness or cause
of admission and hospital site. They have also controlled
for many potential confounders that includes delirium,
however, residential confounding may also have occurred,
specifically, mood can also impact the relationship
between anxiety and pain. The authors have conducted
numerous analyses and some other important findings
might be also because of chance.
Have they take account of the
confounding factors in the design and/or
analysis?
Yes.
Was the follow up of subjects complete
enough?
Was the follow up of subjects long
enough?

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What are the results of this study? Pain was found to be common in people suffering from
dementia and admitted in the hospital and linked with
BPSD. The study also supported the fact that an enhanced
pain management can significantly decrease distressing
behaviours and hence, improve the hospital care quality
for people suffering from dementia.
How precise are the results? The findings of the study suggested that the association of
aggression and anxiety was the highest.
Do you believe the results? Yes.
Can the results be applied to the local
population?
Yes. This is because according to the authors, the results
can be generalized.
Do the results of this study fit with
other available evidence?
Yes. Since, the study gave generalized findings.

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What are the implications of this study
for practice?
The study findings suggest that improving pain assessment
will not enhance or enable effective pain management in
people with dementia. The study has also found that
though 75% of the participants of the study were
prescribed with analgesics, particularly, paracetamol, pain
was still persistent indicating that medications according
to the requirement may not have given. NSAIDs and
opiates usually have serious side effects in older people
therefore, the clinical implication is to practice by
balancing the above identified risks with those having
untreated pain that these can cause.

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Literature review:
Prevalence of dementia and chronic pain among older adults:
Dementia affects more than 35 million people worldwide, primarily a disease of elderly
people, and it is predicted that it will impact 115 million by 2050. The increased number of
elderly, especially people with dementia, put pressure on health care providers and servers to
fulfil their medical and care needs, as pain is a major need for care and a concern for dementia
treatment (Wortmann 2012).The incidence of pain in the aged who live in the community is
reported to be between 25-50 percent and in those who stay in care homes from 30-49 percent. It
is estimated that 25-50 per cent of pain in elderly individuals are suffering from dementia and
receive fewer pain relief agents than their cognitively intact counterparts (Kaye, Baluch and
Scott 2010). Three-quarters of care homes were observed not using structured pain management
methods in one report. Patients and nurses can have major attitudes and beliefs that impede an
optimal diagnosis of pain.Older individuals with cognitive disabilities, and particularly those
with dementia, may not always be able to report their distress because of communicative
difficulties. Consequently, even if people with dementia are similarly prone to discomfort, they
undergo less analgesics than their healthy counterparts. Self-reporting is vital both for pain
assessment and treatment, and while the failure of older people to interact is a major obstacle,
research suggests that there are other barriers (Booker and Haedtke 2016). The absence of
research in this area means that the knowledge of these problems is limited.
Barriers to effective pain management among patients with dementia:
Pain can go unrecognized, unheard or overlooked by healthcare workers and is often
unnoticed, especially for people with cognitive impairment. Pain or verbal behaviour

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manifestations may remain unrecognized or erroneously diagnosed in people with dementia; this
is due to difficulties when interpreting the meaning of altered or difficult behaviour(Sampson et
al. 2015). Changes in behaviour or dementia disease are deemed mainly neurological or medical,
while suffering is only believed to be the ultimate cause. Confusion and ambiguity about how
behavioural disturbances decipher meaning can lead to a deliberately delayed or untreated pain
management. Patients with dementia can still read painful indications and behavioural symptoms
if they experience difficulty (Sampson et al. 2015).
The incidence of dementia and chronic pain are two major health problems faced by older
people.Dementia patients have very complex needs, particularly when residing in home care,
along with recurrent co-morbidities that are often confused with chronic pain. Treatment and
care choices reflect a delicate balance between medical and psychosocial interventions, rendered
even more difficult by the lack of verbal communication and diminished awareness into their
situation that hinders a person's self-reporting capacity (Booker and Haedtke 2016).The most
common causes are musculoskeletal disorders, previous or new trauma and chronic pain that
underlie co-morbidity, which impacts 80 per cent of people with dementia staying in care homes.
Pain is typically chronic with functional impairment in conjunction with severity physicians
often need to focus on ‘pain behaviours’ interpretation to diagnose pain.In the research, the main
types of speech were verbal and non-verbal signals from residents where the key barriers were
cognitive and physical impairments (Corbett et al. 2016).
The challenges to effective pain control in residential care settings include medical
beliefs and pain behaviours, coping deficiencies and cognitive disabilities, pharmacotherapy
frailty and consequences as well as limited evidence of systematic dementia pain-management

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strategies. Training initiatives, clinical scale innovations and pain control procedures have
provided for good progress in addressing these challenges and enhancing patient outcomes.
Studies have reported that, in clinical settings, pain in elderly patients having with verbal
capacity is irrespective of mild cognitive impairment is usually assessed through the means of
self-report. Self-reporting is a fundamental and important criteria in measuring or evaluating
pain, however, older patients with dementia are unable to do so and often left undiagnosed and
untreated. Since, the evolution of dementia compromises with the ability of communicating,
therefore, verbal reports of pain for these patients are less reliable. There are certain tools that are
helpful in the assessing painful nonverbal behaviour in older adults with dementia. With the
scientific validity of these tools, painful behaviours must be assessed that present manifestations
present in psychogeriatric disorders.
Research suggests that the hindrances in the path of effective pain management in older
patients with dementia include difficulties in the accurate pain assessment, underreporting on
patient’s part, unusual expressions of pain in the older patients, a need in terms of increased
pharmacodynamic changes of aging, pharmacokinetic appreciation and and misunderstanding
about tolerance to opioids. Healthcare professionals must effectively manage pain by
comprehending several types of pain both (Nociceptive and neuropathic) and proper
implementation of opioid, non-opioid and other adjuvant medications (Cavalieri 2005).
Pain assessment and pain management among older people with dementia:
It is projected that globally there are 35 million people with dementia, with daily
suffering at 50 percent. Nonetheless, the pain assessment and management in this category was
inadequate. In addition to discomfort and physical agitation, it often contributes to ineffective

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therapies for antipsychotic pharmaceutical drugs and the underlying cause of psychiatric
symptoms. Pain also serves to hinder diagnosis and recovery more.Prevailing pain is very much
associated with age, with a prevalence of 72 per cent higher than 85 years of age in the oldest
population (Duncan et al. 2011). In these cases, it is clear that pain under people with dementia is
actually very normal; however, current knowledge is low, sometimes contributing to inadequate
diagnosis and care.The effect of neuropathological alterations in dementia on pain-perception is
another critical and often unanswered issue (Ballard et al. 2011). Dementia symptom logy also
means that pain assessment is especially difficult as communication skills are lost, which are
usually present during the illness. It indicates that traditional measurement methods are not
accurate, effective and challenging to use. In fact, clinical and interpersonal deficiencies in the
sense of dementia also impact care and treatment efficiency, including the control of pain or
discomfort.
Accurate pain management is an important requirement for an effective regulation of pain
and the determination of the (positive) impact of analgesic treatment and its possible adverse
effects. Pain evaluation is especially difficult in people with dementia because of the lack of
communication abilities involved in the diagnosis of the disorder, reducing the accurate
measurement of pain normally expected in cognitively healthy adults. A patient's evaluation of
pain attempts to explain triggering and sustaining causes that can contribute to suffering, whether
somatic or mental, or both.Therefore, the results of an investigation can be to identify
predominant sources or mechanisms of pain such as nociceptive (that is, musculoskeletal) or
visceral (that is, internal), neuropathic (that is, diabetic neuropathy), functional or psychosomatic
pain (that is, fibromyalgia). Evidence suggests that some 60-80% of patients with dementia in

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health care facilities feel daily pain mainly related to musculoskeletal, gastrointestinal and
cardiac problems, and genitourinary inflammation and pressure ulcers.
Types of pain experienced by patients with Dementia:
Evidences show that aging has a strong relationship with a high degree of painful
conditions regardless of their cognitive status. Older adults, more than 65 years old are more
susceptible to chronic pain functionally impairing them in nursing homes. Common pains
include musculoskeletal like arthritis, or neuropathic pain because of diabetes or stroke. Older
patients with dementia are more susceptible to experience persistent painful conditions lasting
from 6 months or more than that. Research shows that although, these affected individuals
experience a high prevalence of pain, both the assessment as well as the management of pain in
this population is challenging because of the impairment of communicative and cognitive
abilities. Thus, the research conducted in this area focuses on how dementia patients perceive
pain and how that pain can be accessed or managed (Gibson and Lussier 2012).
Orofacial discomfort often occurs frequently (Lobbezoo, Weijenberg and Scherder 2011).
Various forms of pain have various challenges. When contrast with symptoms linked to the
muscle-skeletal system, discomfort in the inner organs, the head and skin are more difficult to
detect. Sudden pain, such as dropping or sudden heart attacks, is easier to evaluate than chronic
pain, sometimes inducing discomfort aversion through increased activity or stimulation.
There are various factors that can explain the lack of pain management in people with
dementia. That is mainly because of the limited understanding of the pharmacodynamic of
medicinal products in this group of people. This is due to a lack of pharmacologic studies.
Therefore, the optimal treatment is mainly based on experience in these clinicians. Without a

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clear knowledge of the effects of neurological comorbidity of their condition, clinicians will
decide on the form and dose of analgesia.A lack of knowledge exists to health professionals,
including nurses and pharmacists, who work with people with dementia. It is possible the under-
and over-treatment would contribute to this. For patients with dementia, effectiveness trials of
analgesics are challenging but workable and more study in this field is urgently needed.
The idea that the pain is often conveyed by problematic actions, particularly in advanced
dementia, has contributed to several studies exploring the effects of pain and behavioural
treatments to alleviate behavioral symptoms. The available evidence suggests that pain therapies
to reduce both discomfort and comportability effects of dementia, aimed toward behavioural
disorders and pain (Husebo et al. 2012).
Appropriate pain treatment is required when evaluating pain. It is also important to
identify whether a therapeutic solution is available to provide effective treatment. A pain
monitoring tool that can monitor pain level shifts during diagnosis is essential to make that
happen (Achterberg et al. 2013).
Pain assessment tools:
Several tools for pain assessment in residential aging facilities can be utilized and divided
into tools such as observational behavioural tools, self-reporting, and sensory testing tools
(Schofield 2018).
Self-report tools
Although there are potential obstacles to patients reporting their pain accurately, self-
reporting remains the gold standard. Self-reporting measures contain phrases, images or figures.

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In the most effective measures, the numerical rating Scale (with pain from zero to Dix) and the
verbal classification scale (rated pain as "no pain," "medium pain," "normal pain," "severe pain,"
"the worst or" the most intense pain imaginable) "are simply defined and understandable. The
ratings are easily understandable. The Brief Pain Inventory is a more nuanced and multi-
dimensional system, which can track severity of pain and involvement relevant to pain in
patient's life (Schofield 2018).
Observational tools
Cognitive patients typically identify themselves with pain in a consistent and accurate
manner, while proxy rates may escalate as dementia worsens. Such devices usually detect the
presence or lack of discomfort when self-reporting is ineffective in dementia patients. The tests
usually assess actions that can be pain-like but not differentiable from identical pain-like
behaviors, which leads to high false-positive levels of 25 to 30 percent. No decision is found on
which method to make it suitable for geriatric environments.
Although several observing scales exist, key pain-indicative behaviors are commonly
used. The top 3 habits include face expressions, including frowning, frustration, squabbling,
body language, and unpleasant vocalizations. (Rigidity, suffering, verbal aggression, scoffing,
crying, groaning). All three elements are established in all dementia non-verbal pain assessment
measures.
Sensory testing tools
Neuropathic pain detection also includes the use of sensory monitoring tools. The
assessments are non-invasive approaches for peripheral nerve function evaluation. Extensive

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testing is comprehensive. Clear brush and pinprick checks are more appropriate for a specialist
attending an aged care facility. Brush assessments are useful in order to identify allodynia, a
neuropathic condition where non-distressing sensations are usually thought to be bland. Pinprick
assessments are sufficient for treatment of neuropathic hyperalgesia. Hyperalgesia is linked to
heightened intense pressure intensity.
Pain management approaches
A multidisciplinary treatment methods combine pharmacology and non-pharmacology
therapy. Muscular and non-pharmacology (e.g. physical therapy, foot orthotic or patellar taping
for knee arthritis), and occupations (joint safety care, assistive training) are the primary pain
disorders in residential elderly facilities.
Non-pharmacological
The value for pain management during the aged care may be physical therapy or
workout, medication and relaxation or neurological or comfortably treatment. Exercise related
exercises in osteoarthritis patients have been shown to reduce pain and increase physical
function. Acupuncture and relaxation are also prescribed for alternative treatments and evidence
shows that both methods will alleviate osteoarthritis pain and physical weakness, even if a recent
meta-analysis suggests that acupuncture is more moderate of chronic pain (Savvas and Gibson
2015).
Pharmacological
In residential aging facilities, pharmacological pain management can be complex, since
increasing age accompanies changes in physiology that can reduce physiological reserve and

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increase friction. The reaction to drugs is heterogeneous in older patients, partly due to aging
related changes in the composition of the body (increase in fat mass, decrease in muscle mass
and water) and organ function (central nervous system, clearing and deterioration of the renal
system). Pharmacokinetic and pharmacodynamic changes are anticipated in elderly patients and
therefore altered medication reactions.Paracetamol, particularly muscle skeletal pain, is
considered the most suited first-line treatment for persistent pain. Oral non-steroidal anti-
inflammatory drugs (NSAID), which are usually not recommended because of gastrointestinal or
cardiac effects, are typically more effective for chronic inflammable pain (eg rheumatoid
arthritis-related pain).

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Recommendation:
An important non-pharmacological intervention for pain can be a routine record for the
recording and analysing the disease progression.Primary nurses are present 24 hour a day, seven
days a week in nursing homes, meaning they have a thorough understanding, needs, and
responses of dementia patients.Thus they are useful for assessing the suffering condition of the
aged in nursing homes.Specific daily activities of one-to - one patient care, adequate food and
drink, breathing exercises and ergonomic changes in daily activities are equally important
(Koppitzet al. 2017).
It is better to include an initial requirements assessment of the current pain management
services, the development of a pain reduction team driven by a systematic method model for the
implementation, consistent quality metrics established and a continuous education component. It
is also better to evaluate and treat pain in people with dementia using evidence-based cline
decision-making algorithms. All of the members of the team, including in-house staff, clinicians,
prescriber and medical assistants at all stages, collaborate together to make improvements
regarding pain management systems. Pharmaceuticals and communities must specifically aim at
team building to facilitate better contact between patients and nurses on the issue of pain. It is
equally important to incorporate in efforts to guarantee the sustained implementation of new
strategies the program for frequent regular reviews of the pain management procedures (eg
recording of pain assessments and planned administration of analgesic drugs) and for resident
outcomes, particularly pain intensity and satisfaction. Using pain management specialist advisors
and on-site consultation process development techniques. Regular practice is often advocated
with the use of evidence-based observational assessment instruments. Although the current

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devices have significant room for improvement, their use is definitely always encouraged and
can enhance and strengthen pain treatment, in particular where self-reporting is not
practicable.The development and application of these proven tools is a crucial step in improving
pain management. Actual instrument adoption and use is poor and tends to be absent often
(Koppitzet al.2017).
Conclusion:
Neuroimaging, neuropathological, clinical and experimental research shows the impact
on pain treatment and perception of dementia neuropathology. One could predict the atrophy of
gray matter to lead to increased pain tolerance, while the lesions of white matter lead to
decreased tolerance. Nevertheless, in the core nociception the effects of the disrupted equilibrium
in excitatory and inhibitory processes are far from clear.
Pain is a common issue in people with older people with dementia. Nevertheless, only a
small minority are treated for daily painkillers, this is an important problem because pain when
left untreated may result in a lower quality of life and the chances of behavioral and
psychological symptoms such as agitation are increasing. Better evaluation and treatment of pain
are therefore mandatory in this fragile patient group.
As patients age, certain pain syndromes are increasing incidence and prevalence. Because
some older patients wrongly believe that pain is a normal aging process, pain may be under-
reported. A full medical history and physical exam, equipment analysis and related testing
reports, mri scans and diagnostic tests are included in a detailed pain examination. Pain

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practitioners will consider the pharmacological and physiological shifts in the geriatric
community in a broad way.

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References:
Achterberg, W.P., Pieper, M.J., van Dalen-Kok, A.H., De Waal, M.W., Husebo, B.S.,
Lautenbacher, S., Kunz, M., Scherder, E.J. and Corbett, A., 2013. Pain management in patients
with dementia. Clinical interventions in aging, 8, p.1471.
Ballard, C., Smith, J., Corbett, A., Husebo, B. and Aarsland, D., 2011. The role of pain treatment
in managing the behavioural and psychological symptoms of dementia (BPSD). International
journal of palliative nursing, 17(9), pp.420-424.
Booker, S.Q. and Haedtke, C., 2016. Controlling pain and discomfort, part 1: assessment in
verbal older adults. Nursing, 46(2), p.65.
Cavalieri, T.A., 2005. Management of pain in older adults. The Journal of the American
Osteopathic Association, 105(3_suppl), pp.12S-17S.
Corbett, A., Nunez, K.M., Smeaton, E., Testad, I., Thomas, A.J., Closs, S.J., Briggs, M., Clifton,
L., Gjestsen, M.T. and Lawrence, V., 2016. The landscape of pain management in people with
dementia living in care homes: A mixed methods study. International journal of geriatric
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