Rose was 86 years old when she required surgery. The procedure itself was straightforward, but Rose had Alzheimer’s disease. The hospital was right to send her to our skilled nursing facility hours after surgery, knowing we were best equipped to care for her, given her significant cognitive impairment.

The doctor at the SNF denied the possibility of Rose being in pain, stating “Alzheimer’s disease acts like a buffer to pain”; he instead attributed the change in her behavior to her dementia.

“Rose’s rocking back and forth and moaning was a manifestation of her brain disease,” he shared.

Wait, what? Scientific evidence does NOT support the idea that people with dementia do not feel pain. They may express pain differently, but they DO feel it. This blog’s title and story should incite your rage as the memory of this experience reignites mine.

Please, someone tell me why we are still challenged with identifying and treating pain in the elderly, particularly those with dementia. How can we simultaneously make great strides in reducing the use of psychotropics in skilled nursing facilities and yet not tackle a probable reason for their misuse in this population – to treat symptoms that are best treated with an analgesic?

Pain in the demented population is often expressed by verbal/physical aggression, sleep disturbances, anxiety and weight loss, or by a mere change of their typical behavioral symptoms. What might seem like “an improvement” can be withdrawal because of pain. Pain and discomfort can present as behavioral and psychological symptoms of dementia.

We studied how often people with dementia were assessed as being pain free, and how that compared to people without significant dementia. We examined 2.5 million MDS assessments from 2016. For our study, dementia was considered “significant” if the Brief Interview for Mental Status (BIMS) was 8 or less or the Cognitive Performance Scale was equal to 3. The table below illustrates that in both cases more than 75% of this population was assessed as being without pain.

We went on to study whether residents with dementia and no pain also had daily behavioral symptoms such as physical/verbal actions directed towards others and self (potential BPSD). These findings also point to an opportunity to identify pain.

From this analysis, it became clear that cognition and pain are not assessed by the same clinician on the MDS. How could we know that? The prevalence of residents with a completed cognitive performance scale (CPS) (n=195,536) indicates they could not be interviewed for the BIMS. Yet 77,647 (40%), could self-report their pain using either the Verbal Descriptor Scale or Numeric Rating Scale. These scales are the only accepted pain measurement tools that should be used for MDS 3.0.

A final comment: You could make a valid argument that your facility does an exceptional job managing pain in all residents, including those with dementia. I would believe you, honor you, and hold your commitment to compassionate care in highest esteem. There is no “but” statement that follows (I know you expected one). You are a very positive outlier and are cherished. Now we need to compel our peers to commit to your same level of excellence.

No pain or low pain should be treated as a paradoxical finding. In most instances, it indicates the lack of assessment or proper care, particularly in this population. A “non-PRN” trial of a proper analgesic might be warranted.

We have made such important strides in improving the quality of care in U.S. SNFs and this is reflected by our outcomes. Let’s add one more accomplishment.

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.