title: Association of pain with behavioral and psychiatric symptoms among nursing home residents with cognitive impairment: results from the SHELTER study.
abstract: The etiology of behavioral and psychiatric symptoms is generally considered to be multifactorial, and these symptoms often indicate a need for care or assistance, which may include the presence of uncontrolled pain. The aim of this cross-sectional study was to assess the association of pain with behavioral and psychiatric symptoms in a population of nursing home (NH) residents with cognitive impairment in Europe. Data are from the SHELTER project, which contains information on NH residents in 8 countries. Pain was defined as any type of physical pain or discomfort in any part of the body in the 3 days before the assessment. The mean age of 2822 cognitively impaired residents entering the study was 84.1 (standard deviation 9.1)years, and 2110 (74.8%) were women. Of the total sample, 538 residents (19.1%) presented with pain. After adjusting for potential confounders, pain was significantly and positively associated with socially inappropriate behavior (odds ratio [OR] 1.37; 95% confidence interval [CI] 1.04-1.80), resistance to care (OR 1.41; 95% CI 1.08-1.83), abnormal thought process (OR 1.48; 95% CI 1.16-1.90), and delusions (OR 1.48; 95% CI 1.07-2.03). A borderline inverse association was observed with wandering (OR 0.74; 95% CI 0.55-1.00). In conclusion, this cross-sectional study provides evidence from a large sample of frail elderly showing an association between pain and behavioral and psychiatric symptoms. Treatment models that put together assessment and treatment of pain and evaluate their effect on behavioral and psychiatric symptoms are needed.
authors.affiliation: Centro Medicina dell'Invecchiamento, Università Cattolica Sacro Cuore, Dipartimento di Scienze Gerontologiche, Geriatriche e Fisiatriche, Largo F. Vito 1, 00168 Rome, Italy AGAPLESION Bethesda Clinic, Competence Center of Geriatrics and Aging Research, University of Ulm, Zollernring 26, D-89073 Ulm, Germany EMGO Institute for Health and Care Research, Department of Nursing Home Medicine, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands Ageing and Services Unit, National Institute for Health and Welfare, P.O. Box 30, FI-00271 Helsinki, Finland.
authors.forename: Matteo
authors.initials: M
authors.lastname: Tosato
authors.forename: Albert
authors.initials: A
authors.lastname: Lukas
authors.forename: Henriette G
authors.initials: HG
authors.lastname: van der Roest
authors.forename: Paola
authors.initials: P
authors.lastname: Danese
authors.forename: Manuela
authors.initials: M
authors.lastname: Antocicco
authors.forename: Harriet
authors.initials: H
authors.lastname: Finne-Soveri
authors.forename: Thorsten
authors.initials: T
authors.lastname: Nikolaus
authors.forename: Francesco
authors.initials: F
authors.lastname: Landi
authors.forename: Roberto
authors.initials: R
authors.lastname: Bernabei
authors.forename: Graziano
authors.initials: G
authors.lastname: Onder
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D059350:Chronic Pain / Q000453:epidemiology* / Q000523:psychology; D003072:Cognition Disorders / Q000453:epidemiology* / Q000523:psychology; D015897:Comorbidity / Q000639:trends; D003430:Cross-Sectional Studies; D003704:Dementia / Q000453:epidemiology* / Q000523:psychology; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology*; D019964:Mood Disorders / Q000453:epidemiology*; D009735:Nursing Homes
references.citation: Achterberg WP, Gambassi G, Finne-Soveri H, Liperoti R, Noro A, Frijters DH, Cherubini A, Dell’aquila G, Ribbe MW. Pain in European long-term care facilities: cross-national study in Finland, Italy and The Netherlands. Pain. 2010;148:70-74.
references.citation: Benoit M, Arbus C, Blanchard F, Camus V, Cerase V, Clement JP, Fremont P, Guerin O, Hazif Thomas C, Jeanblanc F, Lafont C, Moreaud O, Pedra M, Poncet M, Richard Harston S, Rigaud AS, Sotto Martin ME, Touchon J, Vellas B, Fitten LJ, Robert PH. Professional consensus on the treatment of agitation, aggressive behaviour, oppositional behaviour and psychotic disturbances in dementia. J Nutr Health Aging. 2006;10:410-415.
references.citation: Bergh I, Steen G, Waern M, Johansson B, Oden A, Sjostrom B, Steen B. Pain and its relation to cognitive function and depressive symptoms: a Swedish population study of 70-year-old men and women. J Pain Symptom Manage. 2003;26:903-912.
references.citation: Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop R, Lipsitz L, Steel K, Mor V. Management of pain in elderly cancer patients. JAMA. 1998;279:237-249.
references.citation: Bernabei R, Landi F, Onder G, Liperoti R, Gambassi G. Second and third generation assessment instruments: the birth of standardization in geriatric care. J Gerontol A Biol Sci Med Sci. 2008;63:308-313.
references.citation: Black BS, Finucane T, Baker A, Loreck D, Blass D, Fogarty L, Phillips H, Hovanec L, Steele C, Rabins PV. Health problems and correlates of pain in nursing home residents with advanced dementia. Alzheimer Dis Assoc Disord. 2006;20:283-290.
references.citation: Chan DC, Kasper JD, Black BS, Rabins PV. Prevalence and correlates of behavioral and psychiatric symptoms in community-dwelling elders with dementia or mild cognitive impairment: the Memory and Medical Care Study. Int J Geriatr Psychiatry. 2003;18:174-182.
references.citation: Cipher DJ, Clifford PA. Dementia, pain, depression, behavioral disturbances, and ADLs: toward a comprehensive conceptualization of quality of life in long-term care. Int J Geriatr Psychiatry. 2004;19:741-748.
references.citation: Hurt C, Bhattacharyya S, Burns A, Camus V, Liperoti R, Marriott A, Nobili F, Robert P, Tsolaki M, Vellas B, Verhey F, Byrne EJ. Patient and caregiver perspectives of quality of life in dementia. An investigation of the relationship to behavioural and psychological symptoms in dementia. Dement Geriatr Cogn Disord. 2008;26:138-146.
references.citation: Husebo BS, Ballard C, Aarsland D. Pain treatment of agitation in patients with dementia: a systematic review. Int J Geriatr Psychiatry. 2011;26:1012-1018.
references.citation: Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ. 2011;343:d4065.
references.citation: Ishii S, Streim JE, Saliba D. Potentially reversible resident factors associated with rejection of care behaviors. J Am Geriatr Soc. 2010;58:1693-1700.
references.citation: Kunik ME, Snow AL, Davila JA, Steele AB, Balasubramanyam V, Doody RS, Schulz PE, Kalavar JS, Morgan RO. Causes of aggressive behavior in patients with dementia. J Clin Psychiatry. 2010;71:1145-1152.
references.citation: Landi F, Sgadari A, Zuccala G, Pahor M, Carbonin P, Bernabei R. A brief training program on resident assessment instrument improves motivation of nursing home staff. J Nutr Health Aging. 1999;3:24-28.
references.citation: Landi F, Tua E, Onder G, Carrara B, Sgadari A, Rinaldi C, Gambassi G, Lattanzio F, Bernabei R., SILVERNET-HC Study Group of Bergamo. Minimum data set for home care: a valid instrument to assess frail older people living in the community. Med Care. 2000;38:1184-1190.
references.citation: Lyketsos CG, Lopez O, Jones B, Fitzpatrick AL, Breitner J, DeKosky S. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study. JAMA. 2002;288:1475-1483.
references.citation: Maxwell CJ, Dalby DM, Slater M, Patten SB, Hogan DB, Eliasziw M, Hirdes JP. The prevalence and management of current daily pain among older home care clients. Pain. 2008;138:208-216.
references.citation: Morris JN, Fries BE, Mehr DR, Hawes C, Phillips C, Mor V, Lipsitz LA. The MDS Cognitive Performance Scale. J Gerontol. 1994;49:174-182.
references.citation: Morris JN, Fries BE, Morris SA. Scaling ADL’s within the MDS. J Gerontol. 1999;4:M546-M553.
references.citation: Onder G, Cesari M, Russo A, Zamboni V, Bernabei R, Landi F. Association between daily pain and physical function among old–old adults living in the community: results from the ilSIRENTE study. Pain. 2006;121:53-59.
references.citation: Onder G, Finne-Soveri H, Soldato M, Liperoti R, Lattanzio F, Bernabei R, Landi F. Distress of caregivers of older adults receiving home care in European countries: results from the AgeD in HOme Care Study. Am J Geriatr Psychiatry. 2009;17:899-906.
references.citation: Onder G, Landi F, Gambassi G, Liperoti R, Soldato M, Catananti C, Finne-Soveri H, Katona C, Carpenter I, Bernabei R. Association between pain and depression among older adults in Europe: results from the Aged in Home Care (AdHOC) Project: a cross-sectional study. J Clin Psychiatry. 2005;66:982-988.
references.citation: Parmalee PA, Smith BD, Katz IR. Pain complaints and cognitive status among elderly institution residents. J Am Geriatr Soc. 1993;41:517-522.
references.citation: Porter FL, Malhotra KM, Wolf CM, Morris JC, Miller JP, Smith MC. Dementia and response to pain in the elderly. Pain. 1996;68:413-421.
references.citation: Sengstaken EA, King SA. The problem of pain and its detection among geriatric nursing home residents. J Am Geriatr Soc. 1993;41:541-544.
references.citation: Seitz D, Purandare N, Conn D. Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review. Int Psychogeriatr. 2010;22:1025-1039.
references.citation: Sengupta M, Bercovitz A, Harris-Kojetin LD. Prevalence and management of pain, by race and dementia among nursing home residents: United States, 2004. NCHS Data Brief. 2010;30:1-8.
references.citation: Shega JW, Paice JA, Rockwood K, Dale W. Is the presence of mild to moderate cognitive impairment associated with self-report of non-cancer pain? A cross-sectional analysis of a large population-based study. J Pain Symptom Manage. 2010;39:734-742.
references.citation: Snow AL, Shuster JL Jr. Assessment and treatment of persistent pain in persons with cognitive and communicative impairment. J Clin Psychol. 2006;62:1379-1387.
references.citation: Soldato M, Liperoti R, Landi F, Finne-Sovery H, Carpenter I, Fialova D, Bernabei R, Onder G. Non malignant daily pain and risk of disability among older adults in home care in Europe. Pain. 2007;129:304-310.
references.citation: Won A, Lapane K, Gambassi G, Bernabei R, Mor V, Lipsitz LA. Correlates and management of nonmalignant pain in the nursing home. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology. J Am Geriatr Soc. 1999;47:936-942.