23rd Annual Pain Medicine Meeting 2024

Balancing Opioid Use with the PAINAD Scale

Henry Dinh MS1, Loriann Hom MPH2, Kyaw Lin DO3

Touro University, Vallejo, CA, USA1 2

Sutter Health, Palo Alto, , CA,USA3

Introduction

The widespread abuse and overuse of opioids can be further complicated when treating patients with cognitive impairments such as Alzheimer’s disease1.
These patients have limitations in accurately perceiving their pain and expressing their pain level to their physician.
Therefore, it can become hazardous when there is no clear indication for opioids or when the use of opioids does not adequately address the patient’s pain.

Patient Case #1

94-year-old female with a past medical history of Alzheimer's disease, overactive bladder, and insomnia. She was admitted to the hospital for lethargy and coughing.
Her complications led to a urinary tract infection and metabolic encephalopathy. She continued to endorse no pain.
However, her family was concerned she was undermedicated for pain because of her altered mental status.

Patient Case #2

98-year-old female with a past medical history of Alzheimer's disease 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.
There was concern that she was overmedicated with tramadol due to her inability to communicate her pain level effectively.

Results

Self-reported pain scales were ineffective for both patients due to their Alzheimer’s disease.

There was inconclusive assessment for opioid administration to manage their pain.
The Pain Assessment in Advanced Dementia (PAINAD) scale was implemented by the care team for both patients to successfully standardize their pain level and management.

PAINAD Scale

Discussion

Opioid management for patients with Alzheimer’s disease becomes difficult because self-report pain scales are not reliable2.
With a language barrier, pain assessment can be further misconstrued as seen in case #2.
Patients with cognitive impairment are not required to communicate and articulate their pain with the PAINAD scale3.
The PAINAD scale has been demonstrated to differentiate between painful and non-painful events in the elderly with dementia3.
The scale has been adopted by the United Kingdom and had a 92% sensitivity rate4.

Conclusion

The PAINAD scale can be an invaluable tool to mediate the misuse of opioids and to standardize the discontinuation of opioids in the elderly with dementia.
The scoring system accounts for the patient’s breathing rate, vocalization, facial expression, body language, and consolability – making it easy to train other healthcare professionals5.

References

Manchikanti, L., Fellows, B., Ailinani, H., & Pampati, V. (2010). Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain physician, 13(5), 401.
Malara, A., De Biase, G. A., Bettarini, F., Ceravolo, F., Di Cello, S., Garo, M., Praino, F., Settembrini, V., Sgrò, G., Spadea, F., & Rispoli, V. (2016). Pain assessment in elderly with behavioral and psychological symptoms of dementia. Journal of Alzheimer’s Disease, 50(4), 1217–1225. https://doi.org/10.3233/jad-150808
Dunford, E., West, E., & Sampson, E. L. (2022). Psychometric evaluation of the Pain Assessment in Advanced Dementia scale in an acute general hospital setting. International Journal of Geriatric Psychiatry, 37(12). https://doi.org/10.1002/gps.5830
Jordan, A., Hughes, J., Pakresi, M., Hepburn, S., & O’Brien, J. T. (2011). The utility of PAINAD in assessing pain in a UK population with severe dementia. International Journal of Geriatric Psychiatry, 26(2), 118–126. https://doi.org/10.1002/gps.2489
Teh, H. L., Tan, I. J., Lim, H. T., Ho, Y. Y., Ng, C. C., Ali, R. M., Ling, J. N., Lim, W. C., Pang, G. H. M., Chua, H. H., Norizan, F., Ibrahim, N., Goh, C. E., Chai, G. W., Suppamutharwyam, M., Ang, M., Musa, D., Chan, S. C., Obet, N., . . . Zam, U. a. a. U. M. (2023). Multi-Center Validation of Pain Assessment in Advanced Dementia (PAINAD) scale in Malaysia. Psych, 5(3), 792–801. https://doi.org/10.3390/psych5030052

BALANCING OPIOID USE WITH THE PAINAD SCALE