Once you realize that the person with dementia is feeling pain, the next step is to track down WHAT is causing the pain and treat accordingly.
Look first at clothing and environment. Is something rubbing? Do the shoes fit properly? Is the seat of chair intact, or is it ripped and something metal is poking the person?
Do a body scan. Do you see any angry red or swollen areas, especially the joints? Look in the mouth. Remove dentures, if the person is wearing them. Any red or white patches in there? Could be a rubbed spot or a yeast infection. Both are painful.
If nothing is obvious, think about the person’s health problems. Someone with long-standing arthritis may be having a flare-up. Is there a specific part of the body that the person is guarding? Could be a fracture or injury. With frailer older adults, especially women, bone fractures can happen without a fall or trauma.
This may involve a trip to the primary care provider’s office to figure out the source of the pain.
Once the source of the pain is identified, the clinician is probably going to recommend pain medication. Older adults, because of changes in body fat composition and metabolism of drugs, may require smaller dosages of pain medication initially.
The available research recommends a stair-step approach. Start with non-narcotic pain relieving medications such as Tylenol, but stair-step upwards if those medications are not effective.
Be careful with combination medications. For example, many “flu and sinus” preparations contain acetaminophen (Tylenol) along with other drugs. Please read the labels or ask a clinician or pharmacist for help.
Ibuprofen and naproxen can be introduced, initially at over-the-counter dosages and then at prescription dosages.
Opiates are appropriate for severe, long-term pain. Addiction is not an issue here. All of the dementias are terminal diseases.
I have found that patches, such as fentanyl patches, that release constant low levels of the medication, are effective.
Short-acting opiates can be used for break-through pain. The dosages of these medications can be stair-stepped upwards until the person with dementia is comfortable.
I have also seen persons with dementia who have severe pain receive non-narcotics, such as antidepressants and seizure medications, in combination with the narcotics, to address certain types of nerve pain.
Non-drug therapies are also helpful and can be used in combination with drug therapies. Massage, moist heat, or cold compresses (depending on location and type of pain) can be helpful.
Sometimes, clinicians shy away from the more powerful narcotic medications because of side effects like constipation or sedation.
Constipation can be addressed through sufficient liquids and high dietary fiber, or psyllium supplements (e.g. Benefiber), or gentle laxatives. Or a combination of all of the above, depending on the choice of narcotics.
Sedation can accompany an increase in dosage but usually resolves in a day or two. If sedation remains a problem, then the dosages of the medications can be pulled back.
Some of this content was published previously in the Alzheimer’s Reading Room. I am a contributing author on that site.
Dr. Rita Jablonski
Rita Jablonski, PhD, CRNP, FAAN, FGSA is a nurse practitioner, researcher, tenured professor, and former family caregiver. Her research and practice involve all aspects of dementia management; she is best known for non-drug strategies to address dementia-related behaviors.