Loriann Hom, MPH
Medical Student
Touro University of California
Monterey Park, California, United States
Henry Dinh, MS
Medical Student
Touro University California College of Osteopathic Medicine
San Jose, California, United States
Kyaw Lin, DO
Assistant Professor
Touro University
Concord, California, United States
CASE 1: A 98 year old female with a past medical history of Alzheimer's presented to the hospital for a left femur fracture caused by a fall. She was a poor historian and required Tagalog translation services during hospitalization. Physiatrist’s physical examination was unremarkable, but the patient was scheduled opioids every 6 hours.
CASE 2: A 94 year old female with a past medical history of Alzheimer's, overactive bladder, and insomnia was admitted to the hospital for lethargy and coughing. Her complications developed into a urinary tract infection and metabolic encephalopathy. Patient endorsed no pain. However, her family was concerned she was undermedicated for pain control.
Discussions:
Self-reported pain scales were ineffective for both patients because they could not state their pain levels due to their cognitive impairment at baseline. This prevented proper assessment for pain medication and control. Physiatrists can utilize the Pain Assessment in Advanced Dementia (PAINAD) scale to standardize pain level and effectively manage their patients’ care. Proper pain management for patients with Alzheimer's disease becomes more difficult because self-report pain scales are no longer reliable (1). With the language barrier component, pain assessment can be further misconstrued. The usage of the PAINAD scale is promising because it has shown to discriminate between painful and non-painful events in the elderly with dementia (2).
Conclusions: Physiatrists routinely treat patients with difficult pain cases where a comprehensive assessment is required to determine their long-term treatment plans. The PAINAD scale is an invaluable tool to mediate the overuse or underuse of pain medication in the elderly with dementia. PAINAD demonstrated a 92% sensitivity rate in United Kingdom patients with dementia (3). There is minimal training required to carry out the PAINAD scale and it is easy to compute the scoring for breathing, vocalization, facial expression, body language, and consolability (4).
