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People with dementia may be unable to verbally express pain and suffer from untreated pain. Use of analgesics in people with dementia has increased during the last decade, in particular opioid analgesics with high potential for adverse effects.This article presents a systematic review of the current evidence for safety and tolerability of analgesic drugs from randomized controlled trials in people with dementia. Relevant trials were identified by a literature search in the EMBASE, MEDLINE, and Cochrane databases from inception to November 2018. The search included the main terms 'dementia' and 'analgesic' or their subterms, and was filtered to limit results to clinical trials.Although pain treatment is increasingly recognized as an important clinical issue in people with advanced dementia, there is currently a lack of evidence to support safety evaluations of commonly used analgesics in this group. To inform treatment decisions and enable care providers to appropriately monitor patients at risk of adverse effects, it is necessary to conduct well-designed clinical trials to investigate the relative efficacy and safety of analgesics in people with dementia, with particular emphasis on harmful effects of long-term opioid use as well as short-term use of nonsteroidal anti-inflammatory drugs.

Wilco P Achterberg,1 Ane Erdal,2 Bettina S Husebo,2 Miriam Kunz,3 Stefan Lautenbacher4 1Department of Public Health and Primary Care, Leiden University Medical Center, RC Leiden, 2300, the Netherlands; 2Department of Global Public Health and Primary Care, University of Bergen, Bergen, 5020, Norway; 3Department of Medical Psychology, University of Augsburg, Augsburg, 86156, Germany; 4Department of Physical Psychology, University of Bamberg, Bamberg, GermanyCorrespondence: Wilco P AchterbergDepartment of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Postzone V0-P, Room V6-76, PO Box 9600, RC Leiden, 2300, the NetherlandsTel +31 71 5268412/8427; + 31 6 23668980Email w.p.achterberg@lumc.nlAbstract: In dementia, neuropathological changes alter the perception and expression of pain. For clinicians and family members, this knowledge gap leads to difficulties in recognizing and assessing chronic pain, which may consequently result in persons with dementia receiving lower levels of pain medication compared to those without cognitive impairment. Although this situation seems to have improved in recent years, considerable geographical variation persists. Over the last decade, opioid use has received global attention as a result of overuse and the risk of addiction, while the literature on older persons with dementia actually suggests undertreatment. This review stresses the importance of reliable assessment and the regular evaluation and monitoring of symptoms in persons with dementia. Based on current evidence, we concluded that chronic pain is still undertreated in dementia.Keywords: pain, dementia, assessment, analgesic treatment

The COVID-19 restrictions affect daily living in Norway, including home-dwelling people with dementia, and researchers conducting clinical trials in dementia care. In this paper, we 1) describe the development of a pandemic cohort (PAN.DEM) incorporated in the LIVE@Home.Path, an ongoing clinical intervention trial on resource utilisation including home-dwelling people with dementia and their caregivers (N = 438 dyads), 2) describe pre-pandemic use of assistive technology and 3) explore the extent to which COVID-19 restrictions increase caregivers interest in innovation in the PAN.DEM cohort (N = 126). Our main finding is that assistive technology is available to 71% pre-pandemic; the vast majority utilise traditional stove guards and safety alarms, only a few operate sensor technology, including GPS, fall detectors or communication aids. In response to COVID-19, 17% show increased interest in technology; being less familiar with operating a telephone and having higher cognitive functioning are both associated with increased interest. We conclude that wearable and sensor technology has not yet been fully implemented among people with dementia in Norway, and few caregivers show increased interest under the restrictions. Clinicaltrials.gov (NCT0404336)

ZusammenfassungDie Altersrevolution verandert die Zusammensetzung unserer Gesellschaft. Immer mehr Menschen erreichen ein sehr hohes Alter und haben damit ein gro ss eres Risiko, Schmerz und Demenz zu entwickeln. Schmerz wird gewohnlich auf verbalem Weg kommuniziert, eine Fahigkeit, die bei Menschen mit Demenz zunehmend verloren geht. In der Folge leiden die Betroffenen unnotigerweise an behandelbarem, aber unerkanntem Schmerz. Die Schmerzerfassung bei Patienten mit Demenz ist eine Herausforderung, wobei die Forschung rasche Fortschritte verzeichnet. Instrumente und Protokolle zur Schmerzerfassung (hauptsachlich Fremdeinschatzungsskalen) wurden in nationale und internationale Leitlinien fur die Schmerzerfassung bei alteren Menschen aufgenommen. Fur eine effektive Schmerzerfassung ist eine interdisziplinare Zusammenarbeit von Pflegekraften, Arzten, Psychologen, Informatikern und Ingenieuren von grundlegender Bedeutung. Auch die Schmerzbehandlung erfolgt bei dieser vulnerablen Patientengruppe bevorzugt interdisziplinar. Nichtmedikamentose Therapieprogramme wurden uberwiegend an jungeren Populationen ohne Demenz untersucht. Viele dieser Ansatze sind jedoch relativ sicher, haben sich als wirksam erwiesen und sollten daher in Schmerztherapieprogrammen an erster Stelle stehen. Paracetamol ist ein relativ sicheres und wirksames Analgetikum der ersten Wahl. In Bezug auf die Anwendung von nichtsteroidalen Antirheumatika, Opioiden und Koanalgetika bei Patienten mit Demenz bestehen dagegen zahlreiche Sicherheitsrisiken. Daher werden regelma ss ige Kontrollen des Schmerzes wie auch der potenziellen Nebenwirkungen empfohlen. Fur eine bessere Orientierung in der Schmerzbehandlung bei Demenz ist weitere Forschung notwendig.

Older adults face the highest risk of COVID-19 morbidity and mortality. We investigated a one-year change in emotions and factors associated with emotional distress immediately after the onset of the pandemic, with emphasis on older age. Methods: The online Norwegian Citizen Panel includes participants drawn randomly from the Norwegian Population Registry. Emotional distress was defined as the sum score of negative (anxious, worried, sad or low, irritated, and lonely) minus positive emotions (engaged, calm and relaxed, happy). Results: Respondents to both surveys (n = 967) reported a one-year increase in emotional distress, mainly driven by elevated anxiety and worrying, but we found no difference in change by age. Multilevel mixed-effects linear regression comparing older age, economy-, and health-related factors showed that persons in their 60s (ß −1.87 (95%CI: −3.71, −0.04)) and 70s/80s (ß: −2.58 (−5.00, −0–17)) had decreased risk of emotional distress relative to persons under 60 years. Female gender (2.81 (1.34, 4.28)), expecting much lower income (5.09 (2.00, 8.17)), uncertainty whether infected with SARS-Cov2 (2.92 (1.21, 4.63)), and high self-rated risk of infection (1.77 (1.01, 2.53)) were associated with high levels of emotional distress. Conclusions: Knowledge of national determinants of distress is crucial to tailor accurate public health interventions in future outbreaks. publishedVersion

Ane Erdal,1 Elisabeth Flo,2 Dag Aarsland,3,4 Geir Selbaek,5–7 Clive Ballard,8 Dagrun D Slettebo,1 Bettina S Husebo1,9 1Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, University of Bergen, Bergen, Norway; 2Department of Clinical Psychology, University of Bergen, Bergen, Norway; 3Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK; 4Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway; 5Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway; 6National Advisory Unit on Aging and Health, Tønsberg, Norway; 7Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway; 8Exeter Medical School, University of Exeter, Exeter, UK; 9Municipality of Bergen, Bergen, Norway Purpose: Buprenorphine transdermal system is increasingly prescribed in people with advanced dementia, but no clinical trial has investigated the safety and factors associated with discontinuation due to adverse events in this population. Patients and methods: One hundred sixty-two people with advanced dementia and significant depression from 47 nursing homes were included and randomized to active analgesic treatment (acetaminophen/buprenorphine) or identical placebo for 13 weeks. In this secondary analysis, the main outcomes were time to and reasons for discontinuation of buprenorphine due to adverse events. Change in daytime activity as measured by actigraphy was a secondary outcome. Results: Of the 44 patients who received active buprenorphine 5 μg/hour, 52.3% (n=23) discontinued treatment due to adverse events compared to 13.3% (6 of 45) in the placebo group (p

Background Pain is associated with depression in nursing home patients with dementia. It is, however, unclear whether pain increases depression. Therefore we evaluated the prospective associations between pain and depressive symptoms in nursing home patients at different stages of cognitive impairment. Methods Two longitudinal studies were combined, including 931 patients (≥ 65 years) from 65 nursing homes. One study assessed patients at admission, with 6-month follow-up (2012–2014). The other study assessed residents with varying lengths of stay, with 4-month follow-up (2014–2015). Patients were assessed with the Mini-Mental State Examination, the Mobilisation-Observation-Behaviour-Intensity-Dementia-2 Pain Scale, and the Cornell Scale for Depression in Dementia. Results At baseline, 343 patients (40% of 858 assessed) had moderate to severe pain, and 347 (38% of 924) had depression. Pain increased the risk of depression (OR 2.35, 95% CI 1.76–3.12). Using mixed model analyses, we found that a 1-point increase in pain was associated with a .48 increase in depression (p

Pain is common in people with dementia, representing a critical aspect of treatment and care. However, there remain considerable gaps in evidence to support pain assessment and treatment.An updated literature search focussing on systematic reviews and randomized controlled trials.There are key areas of consistency around the prevalence, causes and current treatment trends for pain in dementia, the impact of untreated pain and the need for an accurate, fully validated assessment tool.Accurate assessment due to inherent issues in dementia is a critical challenge. There is also a lack of evidence around alternative treatment options.New pain predictors are being identified, including physical function, depression and specific pain types, which should inform assessment methodology.Future research should focus on developing integrated pain management approaches with optimized assessment and evidence-based treatment guidance.