Protocol Pinpoints Discomfort in Late-Stage Dementia Patients

by Peggy Eastman

CHICAGO--How to assess discomfort and pain in patients with late-stage dementia who cannot communicate their distress in words? This is among the most perplexing problems in long-term care, says Christine R. Kovach, PhD, RN, Associate Professor in the School of Nursing at the University of Wisconsin-Milwaukee. Moreover, there is ample evidence to suggest that discomfort in this patient group is under-recognized and undertreated.

"Because many people with dementia cannot verbalize their discomfort, it is often difficult to determine if a person's troubled state or changed status is due to a physical or affective cause. For these patients, a systematic protocol is needed to help provide more accurate assessments and interventions," Dr. Kovach observed at the recent 10th National Alzheimer's Disease Education conference here. She highlighted the usefulness of the Assessment of Discomfort in Dementia (ADD) protocol in improving comfort and decreasing episodes of discomfort in late-stage patients.

Basic Needs Assessment

In some cases, a demented patient's discomfort can be resolved by simply meeting his or her basic needs, and so a basic needs assessment should be used before the ADD, said Dr. Kovach, adding that a certified nursing assistant who knows the patient's daily activity and behavior patterns may be able to identify and resolve an unmet need immediately by assessing the following:

• Does the resident need his or her eyeglasses or hearing aid?
• Is the hearing aid working?
• Is the patient's discomfort due to toileting or incontinence problems? Hunger? Thirst?
• Is the resident too hot or too cold?
• Does the patient need a position change to relieve pressure points?
• Does the resident need more stimulation? Less stimulation? In the latter case, potentially disturbing environmental stressors should be evaluated. These include:
  • Noise from a television
  • Echoes in bathrooms or other heavily tiled areas
  • Noise from "background" conversations
  • Pounding from pill crushers
  • Ringing telephones or pagers
  • Public address systems
  • Glare from lighting
  • Hard, unpadded chairs or uncomfortable vinyl furniture
  • Wrinkled bed sheets or clothing
  • Garments made of rough or itchy materials
  • Poorly fitting shoes or clothing.

When & How to Use the Protocol

If basic needs have been met and the resident still seems distressed or shows specific symptoms (see box at right), this should trigger the protocol, which Dr. Kovach evaluated as part of a larger educational project to improve pain-management practices at 57 Wisconsin long-term care facilities and found to be effective.

The goals of the ADD protocol are:

• To more accurately assess discomfort in people with dementia who cannot verbally describe their pain
• To more accurately and thoroughly treat physical pain and affective discomfort
• To decrease inappropriate use of prn psychotropic medication
• To provide a guided tool to document the resident's status and response to interventions.

The protocol consists of the following steps:

1. Look for physical causes of discomfort, such as infection, inflammation, acute illness, or manifestations of a chronic illness. Treat them if found.
2. Explore the resident's history for possible sources of potentially painful conditions. For example, does the patient have an old fracture site that could be causing pain, or a history of headaches? Treat these conditions if found.
3. When the physical assessment and history are negative, implement nonpharmacological comfort interventions, including distraction, relaxation, massage, application of heat or cold, change of position, or exercise.
4. When nonpharmacological interventions are ineffective, prescribe and administer a non-narcotic analgesic.

   In the past, psychotropic drugs have often been given when nonpharmacological interventions fail, said Dr. Kovach. But although a psychotropic drug may effectively decrease or halt behavioral symptoms, it is not useful for relieving physical discomfort or pain, she said. If the non-narcotic analgesic is effective, the patient should be put on an appropriate schedule for this medication.

5. When a trial of analgesics is not effective in relieving discomfort (even when a different dose or drug is tried), a consultation should take place, and/or the patient should receive an ordered prn psychotropic drug.

"Using the ADD protocol will likely result in some effective and ineffective outcomes," said Dr. Kovach. "It is important that the effective interventions be incorporated into a systematic plan of care to enhance comfort and decrease episodes of discomfort." She emphasized the importance of thorough documentation--which is part of the protocol--in determining what works and what does not work for each patient. She also cited the importance of trying to find out, if possible, what triggered behavioral symptoms of distress in the first place.

Tips from the Alzheimer's Association

Alzheimer's Association guidelines confirm that a late-stage Alzheimer's patient may have difficult-to-detect discomfort due to such disease manifestations as an inability to use words, difficulty in eating and swallowing, reduced mobility, increasing need for help with personal care, and increased vulnerability to infections and pneumonia.

To decrease discomfort in late-stage dementia, the Alzheimer's Association guidelines recommend the following action steps:

• Thicken mealtime liquids to facilitate swallowing by adding cornstarch or unflavored gelatin to water, juice, milk, broth, and soups
• Eliminate caffeinated beverages, which can act as unwanted diuretics
• Monitor the frequency of bowel movements for possible constipation
• Set a regular toileting schedule
• Prevent limb contractures by carefully and slowly moving arms and legs two to three times a day
• Protect bony areas such as knees and hips with pillows or pads
• Change the patient's position at least every two hours to relieve pressure points
• Be alert for signs of physical illness, such as a pale or flushed skin tone, dry and pale gums, mouth sores, vomiting, or swelling of any body part.

Although more research needs to be done in all areas of care for patients with late-stage dementia, the finding that the ADD protocol is effective "supports the belief that the discomfort experienced by people with late-stage dementia is amenable to treatment," Dr. Kovach concluded.

Medical journalist Peggy Eastman is a Contributing Writer to Caring.

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