Smerte og atferd hos pasienter med demens

Høyskolen i Buskerud Februar 2012  

Forskergruppe

• Bettina Husebø, MD, PhD, UiB, SESAM, SUS

• Clive Ballard, MD, Prof. v/Kings College, London

• Reidun Sandvik, MSc, HiB

• Odd B. Nilsen, statistiker, SUS

• Dag Aarsland, MD, Prof. v/SESAM, SUS og Karolinska, Stockholm

Finansiering og samarbeid

Agitation and other BPSD are common

0

10

20

30

40

50

60

Delusions Hallucination Agitation Depression Anxiety

>20 20-10 <10

Craig D, et al. Am J Geriatric Psychiatry 2005; 13: 460-468

>20: N=11920-10: N=125<10: N=162

AGITATION

Institutionalization Cost

Family burden

Functional impairmentReduced quality of life

Patients Carers

Important consequences

Restraints

Harmful drugs

AGITATION

Structural brain changes Neurochemical changes

Behavioural disturbances: Multi-factorial

Unmet needs

Physical disease

Psychosocial factors

Drugs

Genes

PAIN???

Antipsykotika reduserer livsforventningThe CALM-AD study

At risk (No. of deaths) in subsequent 12 months:

Continue

Placebo

83 (21)

82 (17)

62 (14)

65 (4)

23 (8)

32 (6)

10 (2)

21 (2)

4 (0)

9 (2)

Time since randomisation (months)

Continue

Placebo

Log-rank P=0.0302

04

06

08

01

00

Cu

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lativ

e p

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tag

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f su

rviv

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0 6 12 18 24 30 36 42 48 54

Log rank p=0.02

The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial. www.thelancet.com/neurology. 09 Jan 2009

Ballard et al 2009 Lancet Neurology

Pasienter på sykehjem: kognitiv svikt/ smerte

Pasienter på sykehjem lider av vedvarende, underdiagnostisert og mangelfullt behandlet smerte (AGS-Panel

1998; Weiner 1999; Frampton 2003).

83% av sykehjemspasientene opplever regelmessig smerte som fører til inaktivitet, depresjon og redusert livskvalitet (Ferrell 1995).

Pasienter uten kognitiv svikt får 3 ganger mer analgetika enn pasienter med demens (Cohen-Mansfield 2002).

bettina.husebo@isf.uib.no

Pain and dementia

• Aging associated with pain (muscle skeletal diseases, neuropathic

pain, cancer, vascular disease, fracture)

• Unrecognized and untreated pain due to reduced communicative

skills, memory, and awareness

• More pain and less pain-treatment in dementia (Husebø 2008)

• Pain predicted agitation in dementia (Snow 2009)

• Hypothesis: Pain treatment reduces agitation

Efficacy of treating pain to reduce agitation in residents of nursing homes with dementia: A cluster RCT

• Setting: 18 NHs, 60 NH units (N=352), 5 municipalities in Norway

• Design: Cluster-randomised, 8 week trial + 4-w wash-out period

• Inclusion criteria: 65+ NH resident, dementia, clinically significant

agitation for at least onse week (ie 39+ on CMAI)

• Exclusion: advanced severe medical illness with expected survival < 6

months, severe psychiatric/neurological disorder, severe aggression,

severe renal/liver failure

bettina.husebo@isf.uib.no

Control (n=177) Intervention (n=175)

Age (years) 87 (67-104) 85 (65-101)

Women 131 (74) 132 (75)

Prescribed drugs:

 Antipsychotics 47 (27) 43 (25)

 Anxiolytics, hypnotics 88 (50) 80 (46)

 Anti-dementia 44 (25) 53 (30)

 Opioid analgesics 32 (18) 35 (20)

 Peripheral analgesics 71 (40) 75 (43)

CMAI 51 (39-114) 53 (39-126)

MMSE 8 (0-20) 7 (0-20)

Dementia stage - FAST 6 (4-7) 6 (4-7)

NPI—NH 29 (0-97) 32 (1-101)

MOBID-2 pain scale 3 3.0 (0-10); 98 (60.7) 4.0 (0-10); 103 (63.4)

ADL 8.0 (0-20) 7.00 (0-19)

Groups were similar at baseline

Intervention Group – Individual Pain Treatment*Depending on the ongoing medical treatment, participants allocated to the

treatment protocol started at

Patients with BPSD Basis treatment Study treatment Doses and titration

With/without pain

Without analgesics Paracetamol Max. dose: 3g/d

With pain Paracetamol and/orNSAIDs

Morphine Dolcontin ret. Tab. 5mgx2/d; max. dose:10mgx2/d

With pain, unable to swallow

Paracetamol and/orNSAIDs

Buprenorphin plaster

5ųg/h, change each 7.day; max. dose: 10ųg/h

Neuropathic pain Paracetamol and/or Morphine

Pregabalin Lyrica 75 mgx1/d;max. dose: 300mg/d

Fixed dose regimen throughout the eight week treatment period. In those who were not able to tolerate this treatment, the dosage was either reduced or the participant was withdrawn from the study and treated as clinically appropriate.

*following the recommendations of the American Geriatrics Society (J Am Geriatr Soc 1998;46:635-51)

Assessment of agitation, dementia, pain

Primary outcome measures

Cohen-Mansfield Agitation Inventory – long form (CMAI)

Secondary outcome measures

Mini-Mental State Examination (MMSE)

Functional Assessment Staging (FAST)

Activities of Daily Living (ADL)

Neuropsychiatric Inventory-Nursing Home Version (NPI-NH)

MOBID-2 Pain Scale (MOBID-2)

Repeated measurement ANCOVA (LOCF):p<0.001Average reduction 17%; Treatment effect 7.0 (95% CI 3.7-10.3)

Wash-outTreatment

Results: Reduced agitation during pain-treatment

bettina.husebo@isf.uib.no

bettina.husebo@isf.uib.no

Summary

• Systematic pain treatment was associated with a significant

reduction in agitation and neuropsychiatric symptoms in addition to

reduced pain

• There were very few withdrawals due to sedation, and no reduction

of cognition or ADL, suggesting that reduced agitation was not

secondary to more sedation

Conclusions

• Assessment of pain is crucial in patients with dementia and agitation

• Pain treatment should be considered for these patients, even if

there is no clear evidence of manifest pain

Publications

1. Aarsland D, Husebo B, Ballard C. Authors' reply to McShane and Regnard. BMJ 2011; 343:d5356.

2. Husebo BS, Ballard C, Nilsen OB, Sandvik R. Aarsland D. Effect of individual pain treatment on behavioural disturbances in nursing home patients with moderate and severe dementia: cluster randomised trial. BMJ 2011; 343:d4065 doi: 10.1136/bmj.d4065.

3. Husebo BS, Ballard C, Aarsland D. Efficacy of treating pain in patients with dementia. In: Pain in Older Persons. Newsletter. Int Assoc Stud Pain (IASP) 2011;4:2-3.

4. Sandvik K, Husebo BS. Smerte hos pasienter med demens. Demens&Alderspsykiatri 2012.

5. Sandvik K, Husebo BS. Vitenskap anvendt i praksis: Måler smerte hos personer med demens. Sykepleien 2011; 11:62-64.

6. Husebo BS, Ballard C, Aarsland D. Pain Treatment of Agitation in Patients with Dementia: A Systematic Review. Int J Geriatr Psychiatry 2011; DOI: 10.1002/gps.2649.

In preparation

1. Husebo BS, Ballard C, Aarsland. Pain and agitation in patients with dementia: Are we confident to identify and treat the right items of behavioural disturbances?

2. Husebo BS, Strand LI, Moe-Nilsen R, Ballard C, Aarsland. Internal and external responsiveness of the MOBID-2 Pain Scale used for nursing home patients with moderate to severe dementia.

3. Ballard C, Aarsland D, Husebo B, Corbett A, Malcangio M, Cohen-Mansfield J. Systematic review on analgesia treatment for people with dementia.

4. Fritze F, Ballard C, Aarsland, Husebo BS. Pain and depression in patients with dementia.

Utfordringer og muligheter I

• Informert samtykke (2mnd)

• NH ressurser

– Motivasjon / Mangel av motivasjon

– Kompensasjon for innsats

– Undervisning (3 mnd), Veiledning

– 3 undervisningsdager med diplomer, heder og ære ved avslutning

• http://clinicaltrials.gov/ (registrering i internasjonal database)

• http://www.legemiddelverket.no/ (6 mnd)

Utfordringer og muligheter II

• Review

• Internasjonal prosjekt

• Forskningsassistenter (masterstudenter R. Sandvik, S. Svendson)

• 3x Bachelor (særoppgave for medisinstudenter)

• PhD – data (F. Fritze, SESAM)

bettina.husebo@isf.uib.no

http://www.bbc.co.uk/news/uk-14182472http://www.bbc.co.uk/news/health-14138884

NYHETER

NYHETER

Smertebehandling gir færre atferdsproblemer E Hem Individualisert smertebehandling har effekt på atferdsproblemer hos sykehjemspasienter med moderat og alvorlig demens.

Førsteforfatter Bettina S. Husebø og sisteforfatter Dag Aarsland. Foto privat Agitasjon og aggresjon er hyppige og belastende symptomer hos sykehjemspasienter med demens. Atferdsproblemene behandles ofte med antipsykotika til tross for hyppige bivirkninger og liten eller ingen dokumentert effekt. Pasienter med langkommet demens er ofte ikke i stand til å kommunisere smerte pga. redusert hukommelse, språkbeherskelse og refleksjonsevne. Underdiagnostisert og underbehandlet smerte er forbundet med økende atferdsproblemer.

bettina.husebo@isf.uib.no