Screen Dementia Patients for Pain at Every Visit

Dementia patients should be screened for pain at every clinical encounter, and other visits should address safety risks, behavioral problems, functionality, and advance care planning, according to updated American Academy of Neurology (AAN) and American Psychiatric Association (APA) metrics.

While the newest version of the Dementia Management Quality Measurement Set is similar to the one issued in 2015, its improvements demonstrate how care metrics are reinforced by current literature, wrote Susan Schultz, MD, of the University of South Florida in Tampa, and co-authors, in a paper published simultaneously in Neurology and the American Journal of Psychiatry.

An expert panel of neurologists and psychiatrists found that recent research supports the 2015 measurements without any marked changes in their content, Schultz said.

To prepare the update, the panelists reviewed 63 dementia papers published after 2015 and clinical practice data in the AAN's Axon Registry. "As a result, we refined the language and added key phrases that are likely used in clinical practice as examples to aid clinicians in identifying patients who are appropriate to have the quality measures applied to their care," Schultz told MedPage Today.

The metrics are designed to help physicians improve care for dementia patients and care partners, noted panelist Amy Sanders, MD, MS, of the Hartford Healthcare Medical Group in Connecticut, in an AAN podcast.

"This is a measurement set. It is not a guideline, nor is it a clinical practice parameter," she said. "This is a to-do list, basically, of how to take good care of patients with dementia."

The measures encompass nine areas:

• Disclosing diagnoses to patients and caregivers

• Supporting caregivers

• Assessing functional status

• Behavioral and psychiatric screening

• Safety risk screening

• Screening for driving risk

• Discussing advance care planning

• Screening for pain

• Discussing drug treatments or lifestyle changes, if appropriate

Some measurements may seem more problematic than others, Sanders noted. Many doctors don't want to address driving because it's "a huge threat to a patient's independence," she said. Several factors can influence driving impairment and a composite assessment like the Clinical Dementia Rating scale may be helpful, the panel recommended. "It's not the physician's job to determine whether or not the patient is safe to drive," Sanders added. "Their job is to determine whether the patient is at risk."

Likewise, advance care planning discussions can be uncomfortable. "This is probably the single most difficult measure in the measurement set," Sanders said. "It's really hard to have these kinds of conversations with patients and their care partners. It takes a lot of time. It takes a lot of skill. But it is so important because the risk, if this is not done, is that a patient with advanced dementia will wind up being hospitalized over and over again, and may get an unnecessary feeding tube or may be unnecessarily intubated," she continued. Without palliative care counseling, they may die in pain instead of "comfortably, with dignity, surrounded by their loved ones," she added.

The measurement set specifies that pain symptoms should be screened for at every clinical encounter. Pain management can be "complicated, because now it's in the whole context of the opioid crisis," Sanders said. "But patients with dementia often cannot verbalize their needs. If it seems that pain is keeping a patient awake at night or is causing them to be agitated and irritable and to act out in some manner, attending to that pain can make a huge difference."

Clinicians can use these metrics in a number of ways. Sanders, a practicing neurologist, puts the list of measurements on her template for patients with dementia and checks off ones she completed that day. With the exception of assessing pain, not every measure needs to be done at every clinical visit, she pointed out. "That's not the goal of the measurement set. I recommend trying to do a couple of measures at every visit."

These quality measures cover care for dementia patients only, not people with mild cognitive impairment, panel members emphasized. The AAN released a separate set of metrics for managing patients with mild cognitive impairment last September.

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