Pain treatment can reduce agitation in people with dementia

Thirty five million people worldwide have dementia, and this number is expected to increase to 115 million by 2050. Agitation and aggression are common in people with dementia, in particular those with moderate to severe dementia living in nursing homes, where the cross sectional prevalence of these symptoms exceeds 50%.

Agitation is associated with increased distress to residents and a burden to family and professional caregivers and is one of the most challenging symptoms for clinical management. Antipsychotics are often used as first line drug treatment for agitation and aggression, with 40-60% of residents with dementia in nursing homes prescribed such treatment. In the United Kingdom alone, a report for the Department of Health estimated that 180 000 people with dementia were being prescribed antipsychotics, causing 1620 excess strokes and 1800 deaths a year. These figures emphasise the importance of finding safe and effective ways to reduce agitation and aggression in people with dementia.

Many people with dementia have painful conditions, and it has been proposed that pain in patients with impaired language and abstract thinking may manifest as agitation.

So effective treatment of undiagnosed pain may contribute to the overall prevention and management of agitation.

In a new study published in the BMJ Researchers investigated whether a systematic approach to the treatment of pain can reduce agitation in people with moderate to severe dementia living in nursing homes.

The Study included 60 clusters (single independent nursing home units) in 18 nursing homes within five municipalities of western Norway. The participants  of the study where 352 residents with moderate to severe dementia and clinically significant behavioural disturbances randomised to a stepwise protocol for the treatment of pain for eight weeks with additional follow-up four weeks after the end of treatment (33 clusters; n=175) or to usual treatment (control, 27 clusters; n=177).

Participants in the intervention group received individual daily treatment of pain for eight weeks according to the stepwise protocol, with paracetamol (acetaminophen),morphine, buprenorphine transdermal patch, or pregabaline while the control group received usual treatment and care.

The study results showed that agitation was significantly reduced in the intervention group compared with control group after eight weeks : the average reduction in scores for agitation was 17% . Treatment of pain was also significantly beneficial for the overall severity of neuropsychiatric symptoms, but the groups did not differ significantly for activities of daily living or cognition.

The authors concluded that a systematic approach to the management of pain significantly reduced agitation in residents of nursing homes with moderate to severe dementia. Effective management of pain can play an important part in the treatment of agitation and could reduce the number of unnecessary prescriptions for psychotropic drugs in this population

Trial registration ClinicalTrials.gov NCT01021696 and Norwegian Medicines Agency EudraCTnr 2008-007490-20.

BMJ 2011;343:d4065 doi: 10.1136/bmj.d4065