Annotated Abstracts of Journal Articles
2015, 2nd Quarter
Annotations by Elie Isenberg-Grzeda, MD and
Sean Heffernan, MD
Sampson EL, White N, Lord K, et al
ANNOTATION (Isenberg-Grzeda & Heffernan)
The Finding: Among patients with dementia admitted to an acute care hospital, pain occurred at some point during admission in up to a third of the sample. About half of those experiencing pain did so on an ongoing basis throughout admission, and 12% were not prescribed analgesics. Pain was associated with behavioral and psychiatric symptoms.
Strength and Weaknesses: The authors developed an important research question based on gaps in the literature, and created a well-designed study employing sound methodology. An important confounder in this population, delirium, was accounted for.
Relevance: Pain—and untreated pain—has been well described in dementia populations living in nursing homes and the community, but little has been reported on this among dementia patients admitted to acute care hospitals. Pain in dementia patients is associated with behavioral and psychiatric symptoms, which may be part of the reason that these patients come to the attention of PM/C-L psychiatrists in the general hospital. This study is the first step in providing hard evidence to what many PM/C-L psychiatrists know anecdotally, and it highlights important gaps in the literature on treating pain in this patient population.
Pain is underdetected and undertreated in people with dementia. We aimed to investigate the prevalence of pain in people with dementia admitted to general hospitals and explore the association between pain and behavioural and psychiatric symptoms of dementia (BPSD). We conducted a longitudinal cohort study of 230 people, aged above 70, with dementia and unplanned medical admissions to 2 UK hospitals. Participants were assessed at baseline and every 4 days for self-reported pain (yes/no question and FACES scale) and observed pain (Pain Assessment in Advanced Dementia scale [PAINAD]) at movement and at rest, for agitation (Cohen-Mansfield Agitating Inventory [CMAI]) and BPSD (Behavioural Pathology in Alzheimer Disease Scale [BEHAVE-AD]). On admission, 27% of participants self-reported pain rising to 39% on at least 1 occasion during admission. Half of them were able to complete the FACES scale, this proportion decreasing with more severe dementia. Using the PAINAD, 19% had pain at rest and 57% had pain on movement on at least 1 occasion (in 16%, this was persistent throughout the admission). In controlled analyses, pain was not associated with CMAI scores but was strongly associated with total BEHAVE-AD scores, both when pain was assessed on movement (β = 0.20, 95% confidence interval [CI] = 0.07-0.32, P = 0.002) and at rest (β = 0.41, 95% CI = 0.14-0.69, P = 0.003). The association was the strongest for aggression and anxiety. Pain was common in people with dementia admitted to the acute hospital and associated with BPSD. Improved pain management may reduce distressing behaviours and improve the quality of hospital care for people with dementia.
ANNOTATION (Isenberg-Grzeda & Heffernan)
The Finding: This large, retrospective study aimed to add to the literature on the complex relationship between opiate use, pain, and depression. The authors reported high rates of depression among patients with chronic pain, and found that while many developed depression prior to starting opiates, many more developed depression after having started opiates. Pain patients with depression tended to report higher medication side-effects, pain severity, and comorbid psychiatric illness.
Strength and Weaknesses: The authors used a self-reported measure of opiate usage to circumvent the problem of false-positives that can occur when studying prescribing data. This study was not able to establish causality, which is its major limiting factor. The authors may have overemphasized the distinction between the clinical characteristics of patients who developed depression after starting opiates compared to those who developed depression prior to starting opiates.
Relevance: PM/C-L psychiatrists working with patients receiving opiates for non-cancer chronic pain should be aware that depression may follow the onset of opiate use. In addition to evaluating pain patients for comorbid depression prior to and following opiates initiation, PM/C-L psychiatrists should emphasize improving self-efficacy in pain management.
Background and Aims: Pharmaceutical opioid prescription rates are increasing globally, however knowledge of their long-term effects on mental health, in particular depression remains limited. This study aimed to identify factors associated with the onset of depression post-opioid use that differ to factors associated with depression post-pain.
Method: Participants (N=1418) were a national sample prescribed opioids for chronic non-cancer pain. Age at onset of depression, pain and commencement of opioid medications were collected via structured interview.
Results: Six in 10 (61%) reported lifetime depression; of those, almost half developed depression after pain and after they started opioid medications (48%). Variables associated with post-opioid depression included lower pain self-efficacy and poorer social support, younger onset of opioid use, and difficulties and concerns with opioid medications.
Conclusions: The findings highlight the importance of monitoring for the emergence of mood dysfunction, particularly for those starting opioids for pain at a younger age, and consideration of psychological treatments that address self-efficacy that appears to be associated with post-opioid depression.