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Mark Your
Calendars!! ACT's Annual Meeting is October 13th, 2001 on Lake
Norman. Scheduled speakers are listed below:
Meeting
Agenda
1:30 Corporate Status
Report
Erinn Moore, MBA
ACT President
Staff & Customer
Relations
Linda Evans, EdD
ACT Professional Relations Specialist
Regulatory Compliance
Status
Sara Schneidmiller, PhD
ACT Risk Management Director
2:30
Break
2:35 Treatment of
Psychosis in the Elderly
Steven Sevush, MD
3:45 Break
4:00 Quality Indicators
and Depression in the Nursing Home
Paul Switzer, MD
5:30
Break
5:40 Round Table
Discussion:
Coordinating Psychiatric and Psychological Services
Jeffrey Crawford, PhD
ACT Psychologist
Pain and Cognitive Impairment
Ouch!!! Pain - invisible to all but the
person experiencing it. Try to describe pain - the words often elude
even the most verbally adept individuals. Under ordinary
circumstances, the "gold standard" for pain assessment is the
patient's verbal report. Numerical rating scales (i.e. "On a scale
of 0 to 10, how much does it hurt?") or verbal self-reporting ("How
much have you been bothered by pain?" or even, "Where do you hurt?")
are often ineffective in assessing pain in individuals with
cognitive impairment due to dementia or stroke. Anomia (difficulty
in word retrieval) and confusion about their own body parts can
result in inability to accurately report pain. Failure to adequate
assess pain in these individuals has led to and perpetuated myths
about pain in the elderly.
Myth #1: Patients with dementia complain needlessly
about pain much of the time.
Studies suggest that 45 to 80% of long term care
patients endure varying levels of pain. In a survey of pain
management in a long term care facility, Marva Hoogland found that
all but 5 of 78 residents had at least one chronic pain-inducing
diagnosis, with most having two or more (average: 2.4). Researchers
at the Washington University School of Medicine (Porter, et al,
1996) found that people with dementia are less likely to report pain
than other elderly patients.
Myth #2: Aging and dementia dull the perception of
pain so that patients don't need as much medication to relieve it.
While the pain threshold has been shown to increase
with age by some studies, others have shown that this may be true
only with cutaneous pain. Research has suggested that the elderly
have lower tolerance for deep pain. Recognition of pain, however,
may be blunted for elderly patients with dementia. In a comparison
of responses of cognitively normal and demented patients during and
after venipuncture, Porter, et al found that while patients with
dementia reported relatively low anxiety and pain, they did show an
increase in heart rate that stayed high in response to the needle
stick. Individuals with dementia used twice as many facial actions
during the preparation period and were five times more expressive
than cognitively intact individuals during the venipuncture.
Marzinki, 1991, reported diverse responses to pain in Alzheimers
patient that were atypical of conventional pain behaviors.
Nonverbal Indicators of Pain
Hurley et al (1992) developed an objective scale for
assessing discomfort in non-verbal, cognitively impaired patients.
Nine behavioral indicators for discomfort were identified:
Noisy breathing
Negative vocalization
Absence of a look of contentment
Looking sad
Looking frightened
Frowning
Absence of relaxed body posture
Looking tense
Fidgeting behavior
K. S. Feld (2000) developed the following checklist
for pain behaviors:
Nonverbal vocalizations such as sighs, gasps, moans, cries
Facial grimacing or wincing, clenched teeth, furrowed brow,
tightened lips, or narrowed eyes
Bracing behavior characterized by clutching or holding an affected
area during movement
Restlessness characterized by constant or intermittent shifting of
position, rocking, or inability to keep still
Massaging the affected area
Vocal complaints such as "ouch", "that hurts", or "stop"
Consequences of Undiagnosed Pain "The
potential for unrelieved and unrecognized pain is greater in
patients who cannot verbally express their discomfort" (Fink, 2001).
In a comparison of cognitively impaired vs. cognitively intact long
term care residents with arthritis, Hoogland found use of prn pain
medication to be 74% less in residents with dementia. Undiagnosed
pain can lead to not only to unnecessary suffering, but can result
in serious consequences in the management of patients with dementia.
Pain itself causes confusion and the incidence of delirium has found
to decrease when pain is treated adequately (Brummel-Smith).
Patients who cannot verbally express their pain often respond to
pain through irritability and combative behaviors. Pain related
combative behaviors are often observed during personal care tasks.
Thus, failure to adequately recognize and treat pain can result in
increased use of anti-psychotic medications to combat delirium and
manage difficult behaviors.
References:
Duke, D. Elderly with Dementia have Trouble Reporting Pain.
http://news-info.wustl.edu/feature/1997/Jan97-Dementia.html .
Fink, R. Assessing pain in nonverbal patients. Provider, Aug. 2001,
51-55.
Hoogland, M. Survey of Pain Management in a Long-Term Care Setting.
http://coninfo.nursing.uiowa.edu/
Sites/AdultPain/Surveys/LTCsur.htm .
Porter, F.L. et al. Dementia and response to pain in the elderly.
Pain, 1996; 68:413-421.
Rojas-Burke, J. Pain experts try to break the barrier of dementia.
Oregon Live: 9/13/99.
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Research News
Combating Post-Stroke Depression
(Health Media, Ltd. 8/23/01).
In our last newsletter, research was reported that demonstrated
positive effects of antidepressant medication treatment upon
post-stroke intellectual recovery (Robinson, et al, 2000). Recent
research has shown that the effects of antidepressant medication
treatment for stroke victims can improve physical as well as
cognitive and emotional functioning. A team of Italian researchers (Gainotti,
2001) evaluated the effects of post-stroke depression on stroke
rehabilitation and whether antidepressant therapy could
counterbalance any negative effects of depression upon functional
recovery. Findings indicated that motor recovery was greater among
the depressed stroke patients who received treatment (fluoxetine)
for their depression than those for whom depression was left
untreated.
Gainotti. Journal of Neurology, Neurosurgery, and Psychiatry, 2001.
Robinson, R.G., et. al. Stroke. 2000; 31:1482-1486
Physical Activity and Cognitive
Decline in Elderly Women. The cognitive performance of
community-dwelling 65-year-old women was assessed on the MMSE with
follow-up 6-8 years later. Physical activity was measured by
self-reported blocks walked per week and total calories expended per
week in recreation, blocks walked, and stairs climbed. Results
indicated women with a greater physical activity level at baseline
were less likely to experience cognitive decline during the 6-8
years of follow-up. This association was not explained by
differences in baseline function or health status, suggesting the
hypothesis that physical activity prevents cognitive decline in
older community-dwelling women.
Yaffe, K., Barnes, D., Nevitt, M., Lui, L., & Covinsky, K. Archives
of Internal Medicine, 2001; 161:1703-1708.
Dementia Patients Aware of Losing
Grasp Most Likely to Lose Emotional Control
People with dementia who are still aware enough to realize they are
losing their ability to function are the patients in nursing homes
who may be most likely to have dramatic emotional breakdowns and to
lash out physically or verbally. Nursing home patients who are in
the middle of their decline are five times as likely to become
intensely distressed than patients either in early or late stages of
dementia. According to Dr. Watson of the Rochester School of
Nursing, "These patients may still be conscious of their cognitive
losses, but they are losing their ability to cope or compensate for
them, resulting in extreme emotional distress." One event that was
found to trigger the most episodes of acute distress was that of
needing help with personal hygiene, particularly care that seems
intrusive. More than half of catastrophic reactions occurred during
care activities, with the most likely time of day being around the
dinner hour.
Watson, R.N. European Union Geriatric Medicine Society, Aug. 30,
2001.
Employee
Anniversaries
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Employee |
Hired |
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John P. Rucker |
10/06/1997 |
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Aneel N. Patel |
10/24/1997 |
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James M Cox |
09/19/1998 |
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Linda D Allen |
08/03/1999 |
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Rebecca L Moody |
08/09/1999 |
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Susan C Pollard |
09/05/2000 |
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Evans J Mandes |
10/23/2000 |
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Elizabeth B Harrell |
10/30/2000 |
Employee Birthdays
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Employee |
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Birthday |
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Leslie B. Heller |
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13-Sep |
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Leslie M McNamara |
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18-Sep |
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Rebecca L Moody |
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28-Sep |
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Alice M Caldwell |
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14-Oct |
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Smeeta A.L.
Souza-Roy |
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20-Oct |
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Thomas C Goodwin |
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26-Oct |
Welcome New
Employees!
Stephen
Shechtman, EdD
Lise
Osvold , PhD
Paul
Bramblett, PhD
Nancy
Costello, PhD
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