Pain in Cognitively Impaired Nursing Home Patients
How do you know if a resident with dementia is in pain? For many nursing home patients, cognitive issues make it hard to speak up—and their pain often goes untreated. Missed signs can lead to unnecessary suffering. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Katherine Reab to talk about how pain should be recognized and managed in residents with cognitive impairment.
Reab:
When you move them because you need to, or they’ll get bed sores, they slap, hit, fight, grimace. They’ll fist their hands because they’re in cane. They’re not in the same universe you are living in, so you have to bridge that gap. Complacency is probably the single biggest reason for failure to diagnose pain.
Intro
Schenk:
Hey, out there. Welcome back to the Nursing Home Abuse Podcast. My name is Rob. I’ll be your host for this episode. Today we are talking about detecting pain in long-term care residents, particularly those, with dementia, Alzheimer’s that are cognitively impaired. Like how do we know what are they doing to tell us that they’re in pain?
Schenk:
And what do we do about it? We’re not having that conversation alone. We had the fantastic Katherine Reab to walk us through this process.
After a 20 year career as a computer engineer, Katherine Reab transitioned into nursing and discovered a passion for trauma care. Today she serves as a forensic nurse analyst and legal nurse consultant with Integrity Legal Nurse Consulting where she helps attorneys analyze medical records and uncover critical case details with a, with broad experience from bedside nursing to leadership.
She brings sharp investigative skills and clinical insight to support attorneys in medical negligence, personal injury and criminal defense cases. And we’re so glad to be talking with her today. Catherine, welcome to the show.
Reab:
Thank you for having me.
Why is it difficult to recognize pain in patients with cognitive impairment?
Schenk:
So the first question is the obvious question and, why is it for nursing homes? Why is it difficult to recognize pain symptoms and those with dementia or cognitive impairment?
Reab:
This is actually a broad question that covers many different topics from complacency of the nursing staff. Poor training, extremely poor staffing. Completely, sorry. Not understanding. The tech guy cannot understand the actual process of the non-communicative patient, whether they have dementia or their unconscious. They have had trauma. Like that. So understanding that is really critical. Most nurses don’t and or they don’t care to, which goes to complacency.
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What are some signs that a non-verbal resident might be in pain?
Schenk:
So when you have somebody that’s non-communicative, okay, at least verbally what are the signs that you’re looking for to know whether or not that person may or may not be in pain?
Reab:
So there’s a wide variety of signs we look for. Now it depends on the disease process that we’re assessing.
So for instance, dementia patients, they’re extremely difficult to assess if you’re complacent about their behavior, you go in and go, that’s just Eddie. He gets all cranky, blah, blah, blah. He doesn’t have any injuries. He doesn’t have any bed sores. He has no sign of injury. Why in the world would he be in pain?
We know now that dementia, 50 to 80% of dementia patients have or will have significant pain even without injury because the areas of the brain that involve pain receptors are also affected by the dementia process. And what we end up with is when your brain works normal, it ends up. The pain receptors which tell ’em they’re in pain, whether there’s natural injury, and then you basically have inflammation of those nerve receptors and they’re in exquisite pain even though there’s not an injury.
New findings on the impact of preventive health measures in elderly populations help clarify outcomes of early pain intervention in cognitively impaired patients.
And that pain still needs to be treated so. You have to not be complacent. We have many tools that nurses are trained on CNAs are trained on in order to assess that kind of pain in the nonverbal patient. So if you see a patient who is, for instance, they don’t wanna roll off of one side. That happens all the time.
So it can’t be painful. You can’t do that. You can’t be that complacent. You have to go, okay, why do they wanna be on that side all the time? Maybe 25 years ago they had a hip replacement. It’s starting to fail. They can’t tell you their occurs. All you know is when you move them because you need to, or they’ll get bed sores, they slap, hit, fight grimace, they’ll fist their hands because they’re in pain.
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So you can’t just say, oh, they’re noncompliant, which is typically what we see happen. So someone with dementia can’t be compliant because they’re not in the same universe you are living in. You have to bridge that gap and complacency is probably the single biggest reason for failure to diagnose pain.
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How can nursing home staff improve pain assessment in dementia patients?
Schenk:
That’s so interesting because it’s in my mind, I feel like we’re not, we, I’m not a nurse and I would never, nurses do the Lord’s work, but I feel like we’re only looking at least in the notes that I see, we’re only looking at facial grimacing. But there’s so much more, as you mentioned, there’s behavior.
There’s oh, why are we, why are we getting mad at doing this or this? It’s not just, where the person’s eyes are. Squinched up.
Reab:
Oh yeah. The problem with dementia, specifically Alzheimer’s, the further you go into the disease process, the more mask-like their face becomes, and so those normal signs start going away.
They’re a response anymore where they’re very minimal responses, which you really have to look for. So you can’t look at just one thing to determine pain. For instance, the p and a scale, it assesses multiple things because there’s multiple reasons for the pain. And when you are in, you include neuro.
Inflammation on top of that. Most of the time they go, eh, Betty’s just being cranky today. And maybe she is, but did you assess it? Here’s where we get to the next problem. Nursing homes are for profit. For the majority of them, their patients are a commodity. They make money to make money. That’s the hard business truth about it.
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That means they staff to the absolute minimum, legally required amount of staff. So the reality is when I look at records and nurses say, yeah, I did my assessment. It basically only says assessment is done. It’s really? So tell me what you did. They don’t document it. More than likely their assessment was they popped their head in the door and went, okay, because they don’t have time.
So it’s almost wholly falling on the shoulders of the CNE to do those moment to moment, day-to-day observations, because they’re the one actually delivering the lion’s share of care. They’re not trained to do it.
Practical guidance for assessing nonverbal pain in dementia patients can be found on the impact of preventive health measures in elderly populations.
Are there tools or methods that help detect pain in memory care residents?
Schenk:
You mentioned a pain scale. Like what, is there a particular pain assessment that’s more common than others or maybe perhaps better than others?
Reab:
Pain aid is found to be 80 to 90% effective and it’s P-A-I-N-A-D. And it’s a multi-step assessment that you go through. It includes facial, grimacing, auditory noise, what kind of noise, but we go a step further and we assess breathing. So when you hurt, you breathe fast, right?
Schenk:
Right.
Reab:
Okay. You can breathe and hold your breath.
When somebody, so I’m going, okay, my patient hurts. They can’t tell me where, so you gently don’t wanna move this leg for me. Let me gently start to manipulate the leg while I listen and look at their face. And I hear the, and the breathing stops, oh, I’ve got a pain set.
Okay. That something hurts here. Now let’s dig deeper into that assessment. And unfortunately, for most patients in many nursing homes, they’re just muscled into position and it’s oh, she’s being cranky. Dementia patients are very mentally and emotionally difficult for nursing to deal with.
It’s hard. Become complacent. Oh, I’ve seen this a hundred times. In the first hundred, the person is dying and you missed it. So you can never get complacent like that. And unfortunately, we’re humans and it happens.
If you’re unsure where to file a complaint, see our breakdown of Where to Report Nursing Home Abuse in Georgia.
Schenk:
So if you’re walking up to a typical. Residents that has dementia, that’s not on, that doesn’t, it’s not a care plan for pain. Okay? How often are we doing the pain aid assessment ever? Or is it every shift?
Reab:
Every shift. And the difference is my experience predominantly is in trauma, we’re doing things very fast. We don’t get to know our patients per se. Okay? In a nursing home, a long-term care environment, you do get to know that patient intimately, and you should be able to spot from the doorway a change of behavior.
This is normal for her. Slapping that’s not normal for her. Okay? Let’s look at what’s going on. Instead of going, she’s just being noncompliant again. Can we give her some Ativan? And I see that.
Get a visual guide to pressure injury progression in our post on Bed Sore Stages with Pictures.
So stop. She’s not just like that. Let’s find out why she’s being like that. And even if that isn’t pain controlled or pain caused. Let’s find out how we can redirect that behavior. Let’s find out what we can do to support that patient through that behavior. It’s very complex working for dementia or with dementia patients, and it requires a really sound understanding of the neurology of it, the brain functions of it, because the brain will tell the patient they’re in pain.
Understand potential claims in cases of delayed treatment with our article: My Loved One Died of Sepsis at a Nursing Home—Do I Have a Claim?
How can families advocate for better pain management in nursing homes?
Schenk:
What are some advice if you had a family that had a loved one with dementia in a nursing home, what would, what advice would you have them in term? What advice would you give them in terms of pain management?
Reab:
So there’s an expectation that at least 80% of all dementia patients will suffer pain at one point in time or the other, either from old injuries, good old, or Bones Creek.
You are less mobile, so you start becoming stiff and tight and painful because of that. So you want to look at the nursing home and going, what are you doing with restorative nursing? IE massages, warm packs, cold packs, things that don’t require medication to do to make that patient more comfortable.
For a broad overview of long-term care approaches, check out Understanding Dementia Care in Nursing Homes.
And then going on, especially if you have a patient who is violent or you know is acting out in those fashions. A lot of times we just medicate for the violence. You just medicate them down because they’re dangerous and they are, they’re dangerous to the staff. They’re dangerous to other patients because they have no filters left and.
But you have to now re go in and say, why are they being violent? So if it was my family member, I’ve just been notified they were in an altercation or something, I would be, what is your pain assessment? Can I see it? Show me you did it. Don’t tell me you did it. Show me you did it. It’s a form. You fill it out.
Residents in Cobb County can consult a Mableton Nursing Home Abuse Lawyer for local legal representation.
You either fill it out on the computer or you fill it out by hand depending on how sophisticated your facility is. Now let’s talk about what we can do, and you need to involve the physician in this conversation or nurse practitioner who’s doing this type of care. You need to get their social work people involved.
You need to get the head of nursing involved, and you need to get the physician or medical provider. In all of you talking on the same page for how these assessments are gonna be done now it is within our perve as a nurse to do it whenever we want. We don’t have to be ordered to do it. Maybe that you need your physician to order them to do it.
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Q shift every shift. You look at what medications they’re already on, you have that reviewed and make sure it’s not polypharmacy, which is contributing to their confusion in anger. This is a very complex subject and I wish it was as easy as hear everybody please fill this form out once a shift, but it’s not, and so as, and.
My mother-in-law just passed away from Alzheimer’s. Sorry. So as somebody who’s been involved in that, getting the team, ’cause we do medicine in a team approach. The head of nursing or the director of nursing or the charge nurse for that, you get in the physician or the physician’s assistant or the nurse practitioner, their social worker, which is.
Learn how resident rights intersect with cognitive impairments in Dementia Care and Residents’ Rights (Ep 127).
That’s their patient advocate. That’s the one who’s advocating for the patient and make sure they’re advocating for your patient or for your mom or your dad or whoever, and get everybody on the same page and educate yourself. And that’s a really tough thing for people who aren’t in my industry. And it really is, there’s some wonderful resources for families, caregivers of people who have dementia or Alzheimer’s.
There are different kinds of dementia, okay? Alzheimer’s is just one. And go to those support and learn how to advocate for yourself. That’s probably the most difficult part for caregivers.
Discover real-world strategies for supporting memory care residents in Episode 72: Caring for Nursing Home Residents with Dementia.
Schenk:
Very well said, Catherine. Very much appreciate you coming on the show and sharing your knowledge with us today.
Reab:
You are most welcome, sir. Anything I can answer, let me know.
Schenk:
Folks, I hope that you found this episode educational. If you have an idea for someone that you would like for me to talk to, please let me know. If you have an idea for a topic that you would like for me to talk about, let me know that as well.
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