Many people with dementia experience pain, but often find it difficult to communicate this to their carers and the pain is therefore manifested as agitation instead.

A randomised controlled trial published in the British Medical Journal looks at a systematic approach to the treatment of pain, to see if it can reduce agitation in people with moderate to severe dementia living in nursing homes in Norway.  The cluster design investigated 60 single independent nursing home units in 18 nursing homes.

It compared daily treatment of pain for 8 weeks according to a stepwise analgesic protocol (paracetamol, morphine, buprenorphine transdermal patch, or pregabalin) with usual treatment. In the intervention group, 69% of patients received only paracetamol at a maximum dose of 3 g/day.

• Agitation was statistically and clinically significantly reduced in the intervention group compared with control group
• After 8 weeks there was an average difference of −7.0 (95% confidence interval [CI] −3.7 to −10.3) in scores for agitation (Cohen-Mansfield agitation inventory) between the treatment group (p < 0.001)
• Treatment of pain was also significantly beneficial for the overall severity of neuropsychiatric symptoms and pain, but the groups did not differ significantly for activities of daily living or cognition

The authors concluded:

A systematic approach to the management of pain significantly reduced agitation in residents of nursing homes with moderate to severe dementia. Effective management of pain can play an important part in the treatment of agitation and could reduce the number of unnecessary prescriptions for psychotropic drugs in this population.

This study claims to be the first adequately powered parallel group randomised controlled trial of pain management for the treatment of agitation in people with moderate to severe dementia. An accompanying editorial in the BMJ says that the results compare favourably to the equivocal results of treatment for agitation using antipsychotics, acetylcholinesterase inhibitors, and memantine.

The existing NICE guidance on dementia provides no specific recommendations for treating agitation in dementia with analgesic regimens, but the more recently published Alzheimer’s Society best practice guide (endorsed by the Department of Health) does include advice on how to treat behavioural and psychological symptoms (such as agitation and depression) with the aim of preventing inappropriate prescriptions of antipsychotics.

This new RCT adds more evidence to the discussion, but the lack of proper blinding means that these results should be used with caution.

Husebo BS, et al. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ 2011; 343:d4065

Dementia (CG42) Supporting people with dementia and their carers in health and social care. NICE, March 2011.

Optimising treatment and care for behavioural and psychological symptoms of dementia: A best practice guide. Alzheimer’s Society, July 2011.