Table 2.
Pain medication | Authors, year, nationality, gradea | Population | Method | Outcomes | Findings |
---|---|---|---|---|---|
Paracetamol/acetaminophen | Chibnall et al. [35], 2005, USA, B | 25 NH patients with moderate-to-severe dementia (degenerative 13, AD 4, multi-infarct dementia 4) | Randomized, double-blind, placebo-controlled, crossover trial; 4 weeks placebo, 4 weeks treatment | DCM CMAI; no pain tool |
Patients were more active and spent more time in social surroundings and interacting with others (p < 0.05, η 2 from 0.15 to 0.25); no effect on agitation, emotional well-being or as-needed psychotropic medication |
Buffum et al. [34], 2004, USA, B | 39 NH patients with dementia (AD/VaD) and pain rel. degenerative joint disease; mean MMSE 4.3 and GDS 5.7 | Double-blind, placebo-controlled, crossover 4-week trial investigating scheduled (650 mg × 4/day) vs. as-needed acetaminophen administration | DS-DAT | No differences were found between scheduled or as-needed acetaminophen application; 2600 mg/day acetaminophen is inadequate for NH patients with degenerative joint disease | |
1 % solution of lidocaine, a local anesthetic | Benedetti et al. [40], 2006, I, B | 28 people with AD; mean 74 years; baseline MMSE 22–25, after 1 year 13–20 | Placebo-related analgesic study with open (expected)/hidden (unexpected) paradigm lidocaine gel | NRS–self rating | People with dementia/reduced FAB show reduced placebo effect of analgesic treatment [post hoc Tukey test, q(42) = 13.524, p < 0.001]. Analgesics should be increased to compensate for the loss of placebo effect |
Morphine | Manfredi et al. [36], 2003, USA, B | 47 people with dementia (unknown type) from one NH (1999–2001); mean 86 years; MMSE <20; CMAI ≥40 | All patients received placebo for 4 weeks followed by treatment with oxycodone 20 mg/day or morphine 20 mg/day | CMAI; no pain tool | 25 patients completed the study; no differences in agitation between placebo and opioid phases, though patients ≥85 years old (N = 13) were less agitated (CMAI score −6.4; 95 % confidence interval −10.96 to −1.8). No group differences in sedation; high drop-out rate |
Klapwijk et al. [39], 2014, NL, C | 24 dying patients with most severe dementia (type unknown); two NHs; median age 91 years | Observational study of the last days of life; small sample size; pain instruments not validated for EoL care | PAINAD DS-DAT EOLD-CAD MMSE |
Mean 4.3 observations per patient; all participants received morphine (dosage not available). Low symptom burden but direct effect of morphine was not estimated | |
Vitamin D | Björkman et al. [33], 2008, Finland, B | 202 NH patients with pain and dementia (type unknown); mean 85 ± 7 years; CPS 4.9 ± 1.4, range 1–6 | Randomized, double-blind placebo-controlled 6-month trial with vitamin D supplement in three groups: 0, 400 or 1200 IU cholecalciferol | RAI PAINAD DS-DAT CPS |
38–84 % of the patients were in pain; vitamin D deficiency was not associated to pain or pain behavior; prevalence of painlessness or pain scores not changed after vitamin D treatment |
AD Alzheimer’s disease, CMAI Cohen-Mansfield Agitation Inventory [86], CPS Cognitive Performance Scale, DCM Dementia Care Mapping, DS-DAT Discomfort Scale–Dementia of Alzheimer Type [87], EoL end-of-life, EOLD-CAD End-of-Life in Dementia–Comfort Assessment in Dying [88], FAB Frontal Assessment Battery [89], GDS Global Deterioration Scale [90], I Italy, MMSE Mini-Mental State Examination [95], NH nursing home, NL Netherlands, NRS Numerical Rating Scale, PAINAD Pain Assessment in Advanced Dementia [91], RAI Resident Assessment Instrument, rel related to, VaD vascular dementia
aQuality grade according to the Oxford grading of evidence