Institut de Neurociències (INc) - UAB Barcelona

More reliable pain diagnosis tools needed in people with dementia

More reliable pain diagnosis tools needed in people with dementia

A study with the participation of Dr. Lydia Giménez-Llort and Aida Muntsant concludes that a better pain assessment in patients with severe cognitive impairment is possible, using more reliable tools and spending more time with patients, developing standardized guidelines and specific training for professionals. Read the article

17/12/2020

In cognitive impairment, especially in dementia, alterations in cognitive and emotional brain areas, together with verbal difficulties, make pain assessment and management a challenge for healthcare professionals. Available tools, based on questionnaires and scales for patients to answer, lose utility, whereas a professional observation of some key aspects of their behaviour, such as facial expressions, movements or vocalizations, become essential clues. Better diagnosis of pain in these patients requires, among other factors, faster and easier-to-use observation tools, specific training, and more time spent with each patient.

This has been shown in a study carried out by researchers from the Univesitat Autònoma de Barcelona (UAB) and the University of Zaragoza (UNIZAR) published in Frontiers in Neurology, which has explored the opinion of more than one hundred health professionals on the assessment of pain in people with dementia in Spain and how to improve these diagnoses. The work is the result of two surveys conducted in 2015 and 2017 among medical and nursing staff, physiotherapists and psychologists, in hospitals, nursing homes and day centers, in 16 different autonomous communities.

“In both surveys, we detected concern among professionals on the lack of reliable measuring instruments, guidelines and training on pain assessment for people with dementia, offered by public administrations, as well as the scarce amount of training offered in non-verbal diagnosis tools used with dementia patients. This is aggravated when the disease progresses, as in most cases there are neuropsychiatric symptoms, and the capability to speak is not only compromised but may become non-existent", says Dr. Lydia Giménez- Llort.

This study was part of a multidisciplinary research funded by the European Union to set down common criteria and validate optimized observational tools for pain assessment based on already existing ones. The research, carried out between 2001 and 2018, was led by Stephan Lautenbacher, a German psychologist, and Wilco Achterberg, a Dutch geriatrician, and included 16 countries.

"Data obtained in Spain are in line with what we observed in most countries, and show that all EU health professionals are facing the same challenges", said Patricia Schofield, of Abertay University and Sheffield Hallam University, who coordinated the field study in the United Kingdom, the Netherlands, Germany, Denmark, Belgium, Switzerland and Austria, and whose findings are now being compared to those of Spain in the paper published now. "The study also reflects that facial expression of the patients’ pain, considered one of the key elements of non-verbal communication in observational tools, is also the most valued feature by Spanish professionals, while in Central Europe body movements seem more important for professionals”, adds the researcher, for whom this difference would be due to cultural issues.

Improving pain assessment for a more accurate treatment

Spanish researchers consider it key to improve the assessment of pain in dementia patients, which make up around 40% to 80% of people in nursing homes, so that they can receive more accurate treatments.

"In some cases, the presence of pain aggravates the manifestation of behavioural disorders, such as agitation, which are treated with antipsychotic drugs. If the pain is underdiagnosed, it is more likely to be undertreated and the pharmacological management of the disease is not optimized”, adds María Luisa Bernal, professor of pharmacology at UNIZAR and the Aragonese Institute of Health (IIS Aragón).

A new observational tool

From the results obtained by these international studies, a new measurement scale wasdeveloped at European level in 2018. It includes the assessment items that professionals consider most useful, and is already available for use. The PAIC 15 (Pain Assessment Impairment Cognition) scale contains a total of 15 behaviour descriptors, distributed in groups of facial expressions, body movements, and vocalizations, including frowning and narrowing of eyes, restlessness, alertness, moaning or yelling.

Among the list of actions to be implemented, the development of manuals with standardized guidelines and recommendations is included, as well as training actions, so that pain in patients with dementia can no longer be underestimated.

"Efforts to establish more viable instruments and policies, along with education to improve the diagnosis and treatment of pain in these patients are key goals for the countries that have participated in this EU initiative", said Antoni Bulbena, head of the Department of Psychiatry and Forensic Medicine at the UAB, who also participated in the study.

Original article: Giménez-Llort, L et al. Pain in Older Adults With Dementia: A Survey in Spain. Front. Neurol. (2020) https://doi.org/10.3389/fneur.2020.592366



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Social isolation increases anxiety and asymmetry in brain atrophy in Alzheimer’s disease

Social isolation increases anxiety and asymmetry in brain atrophy in Alzheimer’s disease

A study coordinted by Dr Lydia Giménez allows estimating, from the viewpoint of translational neuroscience, the effects of isolation in the current pandemic scenarios in elderly patients with dementia. The findings also may serve as a guide to the rethinking of vital conditions after the Covid-19 crisis. The study was published in Frontiers in Psychiatry, in a special number devoted to coronavirus. 

The researchers analysed the effects of isolation in male mice models suffering from advanced stages of Alzheimer’s disease through a series of behavioural tests, which could be compared to several areas found in elderly residence homes. They compared these results with mice models of Alzheimer’s that were not isolated, and with other healthy animal models undergoing a normal ageing process. The study was conducted with male mice because these are more affected by Covid-19 and are also the ones to show more deterioration of the neuro-immuno-endocrine system and worse survival conditions when suffering dementia. 

The main findings demonstrate that isolation exacerbates hyperactivity up to twice as normal in mice with Alzheimer’s disease, and also causes the appearance of strange behaviours. This increase was demonstrated consistently in the gross motor skills, related to the movement of arms, legs, feet or the entire body. However, it also affected fine motor skills, small movements made by hands, wrists, fingers, toes, lips and tongue. The isolated animals showed emotional patterns comparable to anxiety and changes in their stress management strategies. 

“The results are concerning, given that anxiety is one of the main neuropsychiatric symptoms associated with dementia, which produces a large burden on the caregiver and, in some cases, makes clinical management a challenge”, points out Aida Muntsant, first autor of the research, which is included as part of her PhD thesis. 

Effects of isolation on memory 

Researchers also analysed the effects of isolation on other neuropathological variables, and obtained different results. “Although the characteristic variables of the disorder, like taupathy, were not modified, some others such as asymmetric hippocampal atrophy increased with isolation. This dysfunction was recently described in human patients with dementia and modelled here for the first time with animal models of Alzheimer’s disease. The finding is important, given that asymmetry has been linked to greater vulnerability to stress factors”, states Lydia Giménez-Llort. 

The study also confirmed that the mice suffering from Alzheimer’s disease lost body and renal mass, effects which also have been observed in Covid-19 patients, although the loss was greater with those in isolation. The loss in spleen mass, an important organ of the peripheral immune system, was only observed in isolated animals. 

Rethinking isolation among the elderly 

“Thinking of what the post-Covid-19 era will be like for the elderly implies a great deal of effort in redesigning all conditions of life, interventions in care and rehabilitation, and the management of forced solitude as part of new physical distancing measures. Therefore, it is necessary and urgent to estimate the impact these measures will have on the more vulnerable elderly population, such as those suffering from dementia”, the researchers point out. 

The study also highlights the need for personalised interventions adapted to the heterogeneous and complex clinical profile of people with dementia, and to consider how all of this affects the obligations of caregivers, whether they be professionals or members of the patient’s family. 

The results of the study form part of Aida Muntsant’s PhD thesis and are a product of the research led by Lydia Giménez-Llort, under the framework of the project ArrestAD H2020 Fet-OPEN-1-2016-2017-737390, led by Dulce Papy of the Paris-Est Créteil University, UPEC. 

The H2020 project QSPainRelief awarded by the European Commission

The H2020 project QSPainRelief awarded by the European Commission

The QSPainRelief project "Effective combinational treatment of chronic pain in individual patients by an innovative quantitative systems pharmacology pain relief approach", which includes the participation of Dr. Jesús Giraldo’s team (Institute for Neurosciences and Biostatistics Unit of the School of Medicine), has been funded from the European Commission.

This  project will attempt to solve a crucial problem since about 20% of Europeans suffer from chronic pain and current therapies are not effective in many cases. Around 60% of patients do not reach enough relief from traditional painkillers, which in turn can lead to several adverse effects.

The QSPainRelief project addresses the problem of chronic pain by identifying new drug combinations that are expected to increase analgesic efficacy while reducing side effects. To do this, quantitative systems pharmacology and computational modeling will be used. The best combinations will be validated in animal models and clinical studies.

The QSPainRelief project will receive more than € 6 million in funding for 5 years through the H2020 program. The project is a collaboration between 9 research institutions from 6 different countries, including the UAB, starting January 1, 2020.

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