KS-012049 eCQ 10-4 Newsletter

Early Pain-Specific Advance Care Planning and Directives Urged for Dementia Patients

To ensure that pain care will be pro- vided in ways aligned with their wishes, a pain management plan for older adults with dementia should be discussed and developed early in the disease trajec- tory, while patients retain their decision- making capacity and can be reassured that their values will be honored, according to a forum article published in The Geron- tologist, a journal of the Gerontological Society of America. “Implementing advance care plan- ning (ACP) prior to advanced stages of dementia may assist in developing a person-centered pain management plan and improve pain care for this population throughout the dementia trajectory,” write the authors. Older adults with dementia are particu- larly vulnerable to under-assessment and under-treatment of pain, note the authors. Although dementia is not itself usually a cause of pain, these older patients often have accompanying multiple morbidities or injuries that do cause pain. As patients enter the advanced stages of the disease, it becomes increasingly difficult for caregivers and clinicians to determine the presence of pain, or to know without a written advance directive (AD) how the patient would want it treated. ACP, used as an individualized, practi- cal approach to managing and coordinat- ing pain management for older adults with dementia, involves recurrent con- versations with patients and their families regarding care preferences and should culminate in documentation of an AD. PAIN AND DEMENTIA Studies conducted within the past six years have found that 30% to 68% of older adults with dementia have persistent pain and that the prevalence of pain among these patients increases significantly in the last week of life, the authors explain. Further, research shows that, despite the misconception that older adults with de- mentia are less sensitive to pain, they actu- ally have higher than normal pain intensity ratings, perhaps due to neuropathological

changes in the brain associated with types of the disease, the authors suggest. Adequate pain treatment can help prevent or alleviate some of the deleteri- ous effects of pain, such as decreased immune response, impaired sleep, falls, and compromised mobility, note the authors. “Managing pain adequately can also reduce behavioral and psychological symptoms of dementia,” they write. “In fact, systematic, individualized pain man- agement can significantly lower agitation levels in older adults with dementia,” thus perhaps allowing for reduction in the use of antipsychotic medications. Because of the progressive loss of abil- ity to verbalize their treatment wishes, adults with dementia should be engaged in ACP discussions early in the disease trajectory, urge the authors, adding that the recent change in billing codes for reimbursement for ACP discussions by the Centers for Medicare and Medicaid may help encourage earlier and ongoing conversations. • Goals of care, both overall and specific • Procedures to be avoided or minimized • Risk/benefit assessments for possible proposed treatments • Types of acceptable treatments: nonphar- macological, pharmacological, or none • Treatment routes and frequency The article includes a table with phar- macological and nonpharmacological pain management options as well as a list of sample questions that patients/ proxies can ask their clinicians about pain management. ADDRESSING COMMON CHALLENGES TO ACP IN DEMENTIA “Although older adults with dementia are presumed to have the capacity to make healthcare decisions unless proven otherwise, there is no consensus for de- termining decision-making capacity,” the TOPICS TO DISCUSS FOR AN ADVANCE PAIN-MANAGEMENT CARE PLAN INCLUDE:

authors write in their article. There is also little guidance on holding conversations to determine preferences and needs for geriatric pain management prior to cognitive incapacity, note the authors. Drawing upon research on pain and aging, they offer components of a practical approach to conducting such conversations. APPROACH TO PAIN-SPECIFIC ACP DISCUSSIONS Optimize decision making. • Have a designated healthcare proxy documented and present for decision- making support at each clinical visit. • Introduce conversations about ACP for pain management early in the disease course. Identify goals, values, and preferences. For many older adults with progressive, terminal illness and their families, pain relief and symptom management are the chief goals, the authors note. • Use the patient’s experience of past health events to guide the conversation. • Offer example scenarios in which pain management and palliative care would be called for. Align values with treatment options. • Assess caregivers’capacity to implement a pain management plan. • Provide and discuss a checklist of phar- macological and nonpharmacological options for pain management, and ask the patient and proxy to select the most appealing or acceptable options. Ensure continuity with documentation. “Pain is a common reason why older adults are transferred from nursing homes and skilled nursing facilities to acute care settings,” write the authors. Nevertheless, information about pain assessment and treatment preferences rarely accompanies patients in these transfers. • Ensure that the patient’s pain manage- ment preferences are entered in the Continued on Page 3

Volume 10, Issue 4

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