Dementia and Pain Control

  1. I work in a LTC facility, and we have this one patient who is always complaining of lower back pain, she has a history of dementia, and her doctor does confirm that she did have back pain before the dementia set in. When she was in charge of her own medication at home before she came to my place she would just pop pills like crazy, surprised she doesn't have any kidney issues. She is taking the maximum dose of hydro/Apap she can get, to reach the 4000 mg of APAP/24 hours.
    The problem I have is she is always asking for back pain medication, something to relieve her back pain, she could just have taken two vicodin, walked two steps and turn around and ask for two more pills, when she is reminded that she just took some, she doesn't remember and/or wants to take more medication. I feel so bad for her because its a constant thing, she never has any relief from her back pain that I know of. Her dr says its just a psychological thing and that she probably doesn't have any pain, but how is he to know, right?
    Is pain in a dementia patient what the patient says it is, or is it really a psychological issue that her brain just makes her ask over and over for medication? And are there any suggestions on how to get her relief or her mind set on something else other than back pain, redirection really doesn't work.

    TIA
    Nikki
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  2. 7 Comments

  3. by   nicolel1182
    nobody?
  4. by   1Tulip
    There is nothing unusual about old people having chronic back pain. I think it's safe to assume that she is, in fact, in pain. She has a couple of things going on, only one of which is directly attributable to dementia.

    1. She is habituated to relief seeking. That is different than "drug seeking". Chronic pain pts are not looking for a high. But they can get into a panic if they feel like their source of relief (their accustomed pain med) is running out or for other reasons being withheld.

    2. She's developed physiological tolerance to the narcotic. One or two 7.5 mg hydrocodone for her may be like pissing in the wind, they probably do next to nothing for her.

    3. And, finally, she has no short term memory so, of course, she has forgotten that you gave her the med, because a) she can't remember anything and b) she's still in pain.

    Suggestions:

    She should not be on a short acting pain med. This promotes physiological tolerance and psychological dependence. The patients with chroinc pain, who are trying to make do on drugs with a 2 hr. half-life are forever on a roller coaster of pain, and never get comfortable. The American Pain Society has information on the proper use of drugs like Oxycontin and fentenyl patches.

    And, I don't work with the demented as a rule. And I don't know if what I'm suggesting is ethically OK. But I wonder if you couldn't do the following...

    First: Assure yourself that you're doing everything possible to give her extended relief from pain. Get the MD (if possible) to put her on regularly scheduled (NOT prn) pain med, a long acting one. Then address the cognitive and psychological issues. She is afraid she cannot get access to her source of relief. Could you use a placebo to make her feel like her medicine is there whenever she needs it? I don't see it as unethical, since she does, in fact, have the regularly scheduled, long-acting narcotic in her system.

    Oh, and btw: You are correct to worry about acetomenophen. She shouldn't be taking that volume of Vicodan. Bad drug for her all around.
    Last edit by 1Tulip on Jan 6, '06
  5. by   southern_rn_brat
    We have been very successful treating chronic pain in our facility with small doses of oxycontin bid or methadone qday with something for breakthru pain.

    While it's true she could just be dependent on her pain meds, she could also not be getting adequate pain control even on her hydrocodone.

    Do any of yall use lidoderm patches? Those seem to help alot too.
  6. by   txspadequeenRN
    I work with dementia patient exclusivly and run into this frequently. It is very common for older people to have back pain just because of osteoporosis , being up all day (like many geri patients are) or whatever... if she has pain... she had pain. Now saying that she needs to be diverted from the vicodin and given something else. Lidocaine patches work wonderful for lower back pain. I have several patients that I put one on and leave for 12 hours (removing at bedtime) and it works. Now what I have found is that it works best for pain in a localized place and not all over general back pain. When I use the lidocaine patch I also will back it up with something else like Ultram. Dementia patients that are in pain also benifit from a dose of ativan because of their short term memory loss they become very anxious and cannot remember they have either taken medication or have medication avaiaible to them. Anxiety makes pain very hard to control and takes several doses to get it under control. Ativan will reduce the anxiety and allow the pain medication to work at it's best. If you have a doc that believes the patient is drug seeking or it is all a pysch issue he will never give a order for fent patch oxycodone or methadone. You may also be able to get an order for vicoprophen (vicoden and ibuprophen combo) . I would presonally start with ultram and ativan just from what I have read and if that dont work for your patient ,document the effects so you can have some back up this patient does have pain and you should be able to move up the pain control ladder from there.

    I meant for this to be posted under the op's post. sorry



    Quote from southern_rn_brat
    We have been very successful treating chronic pain in our facility with small doses of oxycontin bid or methadone qday with something for breakthru pain.

    While it's true she could just be dependent on her pain meds, she could also not be getting adequate pain control even on her hydrocodone.

    Do any of yall use lidoderm patches? Those seem to help alot too.
  7. by   txspadequeenRN
    Oh and I wanted to say that it is great that your are concerned about your patients pain problem many nurses wouldnt even question a doctors thoughts about drug seeking. I personaly am all over it if I have a patient in pain. You are being a great advocate for your patient!!!!
  8. by   Angels'
    nicloel1182, 1 Tulip, southern rn brat, tsxpadequeen921

    I am so happy and relieved that there are actively caring people to help the dementia patients.

    Cheers Cheers Cheers

    A returning student,
    Angels’
  9. by   nicolel1182
    Thank you so much for the replies!!!! I will call her Dr monday and ask about the patches or something more long term

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