Systematic Literature Review: Pain Experience in Dementia Patients

This report presents a systematic literature review focused on the experience of pain among elderly patients diagnosed with dementia. The review addresses the research question: "Do the elderly diagnosed with dementia experience pain?" The methodology includes a detailed search strategy with defined keywords, inclusion and exclusion criteria, and a flow chart illustrating the literature search process across databases such as CINHAL, PubMed, MedLine, and PsycInfo. The report includes an annotated bibliography summarizing key findings from selected studies, focusing on methodologies, participant demographics, and significant outcomes. Key findings highlight the positive correlation between dementia and pain, the impact of pain on the quality of life for dementia patients, the use of analgesics, and the challenges in pain assessment and management. The report also discusses the reduced pain tolerance and the potential for persistent pain to accelerate cognitive decline. The review emphasizes the need for effective pain management strategies tailored to the specific needs of dementia patients, considering the limitations of current treatment approaches and the importance of comprehensive pain assessment using tools like the MOBID-2 scale.

Running head: PAIN IN DEMENTIA PATIENTS
Pain in Dementia Patients
Name of the Student
Name of the University
Author Note

1PAIN IN DEMENTIA PATIENTS
Introduction
The following assessment aimed to construct a literature review by using a systematic
literature review approach. The main research question that will be assessed in this review
comprises “Do the elderly diagnosed with dementia experience pain?”. For addressing this
research question initially a literature search will be conducted and the search strategy is
presented in a tabular format. This table will be followed by table 2 that contains the
summary of the articles. At the end, the key findings are discussed in a brief manner.
Search Strategy
Key words
Keyword 1: Dementia OR pain in adults OR analgesics used by elderly patients,
Alzheimer or cognitive impairment or memory loss
AND
Keyword 2: Aged care facilities OR Nursing home residents OR Disturbances in mental
process regarding reasoning, thinking abilities
AND
Keyword 3: Palliative care patients OR Challenges regarding pain management in
elderly, joint pain AND prevalence or incidence or epidemiology or frequency or
occurrence OR joint pain
AND
Keyword 4: Pharmacological intervention OR non- pharmacological intervention for
pain management

2PAIN IN DEMENTIA PATIENTS
Inclusion Criteria
Inclusion Criteria
Year of publication: 2013 to 2018
Type of article: Only Primary and secondary
research articles will be used for the
systematic review
Type: Peer reviewed
Language: English
Exclusion Criteria
Exclusion Criteria
Year of publication: Before 2013
Article type: Frey literatures and case
studies
Type: Non-peer reviewed
Other than English
Databases used for article search
1. CINHAL
2. PubMed
3. MedLine
4. PsycInfo
5. Crochane

3PAIN IN DEMENTIA PATIENTS
Flow Chart of Literature Search
Records identified through
database searching
(n = 1039 )
Additional records identified
through other sources
(n = 0 )
Records after duplicates removed
(n = 919 )
Records screened
(n = 919 )
Records excluded
(n = 767 )
Full-text articles assessed
for eligibility
(n = 152 )
Full-text articles assessed for
eligibility
(n = 147 ) due to following
reasons-
 Not being a original
research paper
 Not dealing with
primary dementing
illnesses (e.g.,
demena due to HIV,
etc.)
 Not English language
 Not
investigating/definin
g pain treatment
procedures.
Studies included in the
systematic Review
(n = 5 )

4PAIN IN DEMENTIA PATIENTS
PICO Question
P= Elderly patients with Dementia
I= Application of analgesics
C= Intervention vs control group
O= Effect on pain level of dementia patients
Annotated Bibliography
Author Year Country Methodolog
y
Participants Key findings
Husebo, B.
S., Ostelo,
R. W. J. G.,
& Strand, L.
I.
2014 Norway Randomized
Control Trial
In this study,
approximately 352
patients with advanced
dementia were
recruited in this study
from 18 different
nursing homes of
Norway. The test-
retest reliability of the
patients at week 2
(n=163) and at week 4
(n= 159) was
examined by using the
intraclass correlation
coefficient (ICC),
standard error of
measurement (SEM)
and smallest detectable
change (SDC).
The study result showed that the ICCs of the
total MOBID-2 scores were approximately 0.81 at
week 2 and during the time period of week 2-4
was almost 0.85. SDC and SEM score was 3.1
and 1.9 respectively in between week 0-2 and 2.3
and 1.4 during week 2-4. MOBID-2 score showed
discriminated result in between patients with or
without having a stepwise protocol for treatment
of pain. The study result conclude that the patients
dementia faced severe pain and the score of
MOBID-2 along with the SEM and SDC score
indicated that, using a stepwise protocol for
addressing the pain among the patients was
clearly beneficial for the dementia patients.
Hendriks et
al.
2014 Netherland Retrospective
cohort study
The data of 330
residents of the
nursing homes with
dementia in the Dutch
End of Life was
The study result showed that, pain was the most
common symptoms among the patients with
dementia followed by the problem of agitation.
Among the 330 residents of the nursing homes, 52
per cent of the patients reported about their pain.

5PAIN IN DEMENTIA PATIENTS
collected (2007-2011).
A linear regression
model was used to
measure the
association in between
the quality of life and
late of stage of
dementia patients.
the pain among was treated by using the opioids
and it was reported that, there was a direct
correlation in between pain and reduced quality of
life among the dementia patients.
Neumann-
Podczaska
et al.
2016 Poland Quantitative
analysis
In this study,
approximately 392
nursing home residents
within the age group
of 75 years or above
were recruited in this
study and each of the
participants of this
study were diagnosed
with pain and pain
related problems such
as rheumatoid
arthritis , deep vein
thrombosis, back pain,
osteoarthritis, and
pressure ulcers. The
pain related issues of
the patients were
treated by using
analgesics and
particular attention
was provided to those
patients who received
nonsteroidal anti-
inflammatory drugs
(NSAIDs). The
patients who were
given NSAIDs were
further examined for
finding further
contradictions such as
congestive heart
The result showed that, approximately 113
residents of this study (28.8 per cent approx.)
received analgesics for their pain. Among all the
patients received analgesics 84 residents used the
medicines in a regular manner (24.1 per cent) and
25 patients received the medications in pro re
nata (PRN) manner and only 1 patient used the
pain management medicines in both routinely and
PRN manner. Apart from that, non opioid
analgesics were given to the 53 residents of the
nursing home routinely. Moreover, three
individuals of the study received combination of
acetaminophen and tramadol. The MSME scores
of the participants stated that, the participants
with MSME score between 0-9 points had higher
rates of receiving pain treatment than that of the
patients with MSME score in between 24 to 30
points. The overall study result showed that, the
incidents of pain among the patients with
dementia was quite high and evaluation for
managing the pain among the patients is required.

6PAIN IN DEMENTIA PATIENTS
failure, bleeding
disorders, kidney
insufficiency,
stomatitis, and
hypertension.
Jensen-
Dahm et al.
2014 Denmark Quantitative
Study
In this study,
approximately 29
patients with mild to
moderate Alzheimer’s
Disease (AD) and 29
age and gender
matched healthy
individual were
recruited in this study
in order to examine the
pain and threshold of
pain for the
individuals` Along
with this, the study
also aimed to find the
tolerance level of the
patients as well. In this
study pressure
algometry, cold
pressor test), and
assessments of
tolerance (pressure
algometry,
assessments of
detection threshold
(warmth detection
threshold [WDT]) and
pain threshold (heat
pain threshold [HPT],
cold pressor test) were
performed for
assessing the pain and
tolerance level of the
study participants. All
the participants
The study result showed that, there was no
significant differences in between the groups for
WDT (patient vs control subjects with a mean
value of 35.5 degree centigrade (33.4 degree
centigrade to 37.6 degree centigrade) vs 35.4
degree centigrade (34.3 degree centigrade to 36.5
degree centigrade)and the confidence interval for
this test was 95%. The p value was measured as
0.8 (p=0.8). No differences were found for the
cold pressor test. Therefore, the study reported
that in case of mild to moderate AD the pain
tolerance was reduced and this study findings
supported the fact that, the reduced processing of
the pain stimuli among the AD patients was not
true for the AD patients.

7PAIN IN DEMENTIA PATIENTS
participated in these
tests twice a day with
an interval of 1 hour in
between the tests. On
day 2 participants
repeated the tests.
Whitlock et
al.
2017 US Longitudinal
Cohort Study
In this study a biennial
interviews of 10,065
community dwelling
old adults in the age
group of 62 years or
older were recruited in
the study. The
interview was
conducted in 2000 and
they answered
questions related to
pain and cognition in
1998 and 2000. The
data analysis was
performed between
June 24th and 31st
October, 2016. in this
study the researchers
measured the
outcomes in terms of
the composite
memory scores and
dementia probability
and these were
estimated by
combining
neuropsychological
test results and
informant and proxy
interviews taken from
2000 through 2012.
Along with the
random slope and
intercept in linear
The study result showed that, the among the
participants of the study, approximately 10.9 per
cent of the participants were affected by the
persistent pain at the baseline and it was
associated with the severe depressive symptoms
among the patients and thereby affected the
activity of daily life of those patients in a negative
manner. after adjusting the covariate adjustment,
it was reported by the researchers that persistent
pain was correlated with the 9.2 per cent more
with rapid memory decline cases while comparing
the rate of memory declining with the patients
without having the persistent pain. After 10 year
follow up, it was reported that, the persons with
accelerated memory declining issue, had the 15.9
per cent higher chances of developing medicine
management disability and 11.8 per cent higher
chances of developing the inability of managing
the financial condition of themselves. The
adjusted probability of developing dementia was
7.7 per cent greater among the patients with
persistent pain while comparing with the patients
without persistent pain. After 10 years, there was
an absolute 2.2 per cent enhance in the dementia
probability for the patient with the persistent pain.
therefore the study concluded that, the dementia
patients were positively correlated with the
chances of having persistent pain.

8PAIN IN DEMENTIA PATIENTS
mixed-effects model
was used to examine
the correlation in
between the slope of
the subsequent
cognitive trajectory
and persistent pain
among the patients
with dementia was
used in this study. The
author hypothysed that
elevated chances of
dementia among the
patients was positively
correlated with the
persistent pain among
the study participants.
Summary of the Selected Study
From the above systematic review study, it can be easily stated that there is a positive
correlation in between dementia and pain among the elderly patients. According to the study
of Whitelock et al. (2017) reported that, there are positive correlation in between the
dementia and pain among the patients. However the study, failed to explain any impact of
pain on the cognitive power of the individual. Therefore, the study concluded that ongoing
pain due to dementia among the patient further promote the risks of worsening the dementia
condition among the patients. In the study of Jensen-Dahm et al. (2014), the issue of pain is
very common among the dementia patients, however the level of tolerance of pain among the
patients is not identical for all the patients. On the contrary, the reported cases of pain among
the dementia patients were less but it might not be associated with the altered thermal
processing and pain processing mechanism. Furthermore, the study was unable to explain the
cases of severe dementia patients. The application of opioids in for reducing the pain among

9PAIN IN DEMENTIA PATIENTS
the dementia patients was reported in the study of Hendricks et al. (2014) and pain sensation
among the dementia patients’ is associated with poor quality of life. They showed that, due to
increased pain in dementia, the patients of the hospital settings also had higher rate of opioids
consumption. However, the study failed to suggest about the most effective treatment for
reducing the pain symptoms among the patients. On the other hand, the study of Husebo et al.
(2014), reported about the use of MOBID-2 scale in examining the pain among the patients
with dementia. The study result confirmed that pain is a frequent symptom of dementia
patients and patients reported about hip and leg joint pain in most of the cases. The study also
reported about high use of analgesics among the dementia patients indicating the cases of
pain among the patients. The study of Neumann-Podczaska et al. (2016), stated that, the pain
is the most common underrecognized symptom of dementia patients. However, the
prevalence of analgesic treatment of the dementia patients is very low in Poland while
comparing it with the data of the other countries. Furthermore, the study also reported that,
acetaminophen is the first line of treatment for the pain among the dementia patients.
Moreover, this study failed to assess the pain of the patients as the data were obtained from
the files of the patients. Along with this, this study also reported about the issue of
hypertension among the patients after taking NSAIDs for managing their pain and the
findings are supported by various other studies. Furthermore, it is reported that use of
NSAIDs can promote the risks of having cognitive impairment and may lead to degradation
of functional independence of the patients (Łojko et al., 2015).

10PAIN IN DEMENTIA PATIENTS
Bibliography
Hendriks, S. A., Smalbrugge, M., Hertogh, C. M., & van der Steen, J. T. (2014). Dying with
dementia: symptoms, treatment, and quality of life in the last week of life. Journal of
pain and symptom management, 47(4), 710-720.
Husebo, B. S., Ostelo, R. W. J. G., & Strand, L. I. (2014). The MOBID‐2 pain scale:
Reliability and responsiveness to pain in patients with dementia. European journal of
pain, 18(10), 1419-1430.
Jensen-Dahm, C., Werner, M. U., Dahl, J. B., Jensen, T. S., Ballegaard, M., Hejl, A. M., &
Waldemar, G. (2014). Quantitative sensory testing and pain tolerance in patients with
mild to moderate Alzheimer disease compared to healthy control
subjects. PAIN®, 155(8), 1439-1445.
Łojko, D., Wegner, A., Czajkowska, A., Jaracz, K., Górna, K., Pniewska, J., ... & Suwalska,
A. (2015). Factors contributing to cognitive deficits in elderly residents of rural
areas. Eur Rev Med Pharmacol Sci, 19(14), 2590-2596
Neumann-Podczaska, A., Nowak, T., Suwalska, A., Łojko, D., Krzymińska-Siemaszko, R.,
Kozak-Szkopek, E., & Wieczorowska-Tobis, K. (2016). Analgesic use among nursing
homes residents, with and without dementia, in Poland. Clinical interventions in
aging, 11, 335. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4807940/)
Whitlock, E. L., Diaz-Ramirez, L. G., Glymour, M. M., Boscardin, W. J., Covinsky, K. E., &
Smith, A. K. (2017). Association between persistent pain and memory decline and
dementia in a longitudinal cohort of elders. JAMA internal medicine, 177(8), 1146-
1153.