Pain in patients with dementia: A review of pain assessment and treatment challenges

Pain represents a major treatment challenge in older people with dementia. The majority of healthy older people experience regular pain and around 50% take regular analgesics. Pain is likely to be equally prevalent in people with dementia, yet only a small minority are prescribed regular analgesics. This is a key issue since recent work has provided evidence that untreated pain may be a major contributor to reduced quality of life and increases the likelihood of emergence of behavioural and psychological symptoms such as agitation. Better assessment and treatment of pain may therefore substantially improve outcomes for people with dementia. In this context, we reviewed the literature and summarised the best available evidence regarding the frequency of pain and pain diagnosis in patients with dementia based on pain assessment and treatment recommendations for these individuals. Hardly any randomized, controlled studies of pain treatment efficacy in patients with dementia are available, with the consequence that most pain treatment recommendations are not based on the highest level of evidence

Measuring β\beta in B→D∗+D∗−KsB \to D^{*+}D^{*-}K_s Decays

We consider the possibility of measuring both $\sin (2 \beta)$ and $\cos (2 \beta)$ in the KM unitarity triangle using the process $B^0 \to D^{*+}D^{*-}K_s$. This decay mode has a higher branching fraction (O(1%)) than the mode $B^0 \to D^{*+}D^{*-}$. We use the factorization assumption and heavy hadron chiral perturbation theory to estimate the branching fraction and polarization. The time dependent rate for $B^0(t) \to D^{*+} D^{*-} K_s$ can be used to measure $\sin (2 \beta)$ and $\cos(2 \beta)$ . Furthermore, examination of the $D^{*+} K_s$ mass spectrum may be the best way to experimentally find the broad $1^+$ p-wave $D_s$ meson.Comment: Revtex, 28 pages, 7 figures, title changed, introduction expanded, added references, details of calculations moved to the appendi

Pain management in patients with dementia

There are an estimated 35 million people with dementia across the world, of whom 50% experience regular pain. Despite this, current assessment and treatment of pain in this patient group are inadequate. In addition to the discomfort and distress caused by pain, it is frequently the underlying cause of behavioral symptoms, which can lead to inappropriate treatment with antipsychotic medications. Pain also contributes to further complications in treatment and care. This review explores four key perspectives of pain management in dementia and makes recommendations for practice and research. The first perspective discussed is the considerable uncertainty within the literature on the impact of dementia neuropathology on pain perception and processing in Alzheimer’s disease and other dementias, where white matter lesions and brain atrophy appear to influence the neurobiology of pain. The second perspective considers the assessment of pain in dementia. This is challenging, particularly because of the limited capacity of self-report by these individuals, which means that assessment relies in large part on observational methods. A number of tools are available but the psychometric quality and clinical utility of these are uncertain. The evidence for efficient treatment (the third perspective) with analgesics is also limited, with few statistically well-powered trials. The most promising evidence supports the use of stepped treatment approaches, and indicates the benefit of pain and behavioral interventions on both these important symptoms. The fourth perspective debates further difficulties in pain management due to the lack of sufficient training and education for health care professionals at all levels, where evidence-based guidance is urgently needed. To address the current inadequate management of pain in dementia, a comprehensive approach is needed. This would include an accurate, validated assessment tool that is sensitive to different types of pain and therapeutic effects, supported by better training and support for care staff across all settings

Crying out in pain-A systematic review into the validity of vocalization as an indicator for pain

Background Vocalization is often used to assess pain, sometimes combined with other behaviours such as facial expressions. Contrary to facial expressions, however, for vocalization, there is little evidence available on the association with pain. The aim of this systematic review was to critically analyse the association between vocalization and pain, to explore if vocalizations can be used as a "stand-alone" indicator for pain. Methods The search was performed according to the Prisma Guidelines for systematic reviews and meta-analysis. The following terms were used: "Pain Measurement," "Vocalization" and "Verbalization." The study population included verbal and non-verbal individuals, including older people and children. The search was performed in three different databases: PubMed, Embase and CINAHL. A total of 35 studies were selected for detailed investigation. Quality assessments were made using two grading systems: Grading of Recommendations Assessment Development and Evaluation system and the Newcastle-Ottawa scale. Results An association between vocalization and pain was found in most studies, particularly when different types of vocalizations were included in the investigation. Different types of vocalization, but also different types of pain, shape this association. The association is observed within all groups of individuals, although age, amongst others, may have an influence on preferred type of vocalization. Conclusions There is an association between vocalization and pain. However, vocalization as a "stand-alone" indicator for pain indicates only a limited aspect of this multifactorial phenomenon. Using vocalization as an indicator for pain may be more reliable if other pain indicators are also taken into account. Significance Vocalizations are frequently used in pain scales, although not yet thoroughly investigated as a "single indicator" for pain, like, e.g. facial expression. This review confirms the role of vocalizations in pain scales, and stresses that vocalizations might be more reliable if used in combination with other pain indicators.Public Health and primary careGeriatrics in primary car

Psychometric Properties of the German Version of the Pain Vigilance and Awareness Questionnaire (PVAQ) in Pain-Free Samples and Samples with Acute and Chronic Pain

The way individuals attend to pain is known to have a considerable impact on the experience and chronification of pain. One method to assess the habitual "attention to pain" is the Pain Vigilance and Awareness Questionnaire (PVAQ). With the present study, we aimed to test the psychometric properties of the German version of the PVAQ across pain-free samples and across patients with acute and chronic pain. Two samples of pain-free individuals (student sample (N = 255)/non-student sample (N = 362)) and two clinical pain samples (acute pain patients (N = 105)/chronic pain patients (N = 36)) were included in this cross-sectional evaluation of the German PVAQ. Factor structure was assessed using exploratory and confirmatory factor analyses. Reliability was assessed using internal consistency (Cronbach's alpha). Construct validity was tested by assessing correlations between PVAQ and theoretically related constructs. Exploratory factor analysis (non-student sample) and confirmatory factor analysis (student sample, acute pain patient sample) suggested that a two-factor solution best fitted our data ("attention to pain," "attention to changes in pain"). Internal consistency ranged from acceptable to good in all four samples. As hypothesized, the PVAQ correlated significantly with theoretically related constructs in all four samples, suggesting good construct validity in pain-free individuals and in pain patients. The German PVAQ shows good psychometric properties across samples of pain-free individuals and patients suffering from pain that are comparable to PVAQ versions of other languages. Thus, the German PVAQ seems to be a measure of pain vigilance equally valid as found in other countries

CP Asymmetry In Neutral BB System At Symmetric Colliders

Contrary to the conventional belief, time integrated asymmetry are measurable in selected final states in the neutral $B$ system at symmetric $e^+e^-$ colliders. They occur due to the interplay of weak and strong phases of two different amplitudes in addition to the $B^0 - \bar B^0$ mixing. Observation of these asymmetries would be evidence for direct CP violation in the decay amplitudes.Comment: 10 pages, Revtex; Accepted for publicatin in Phys. Rev. Let

Standard Model Confronting New Results for epsilon'/epsilon

We analyze the CP violating ratio \epe=epsilon'/epsilon in the Standard Model in view of the new KTeV results. We review the present status of the most important non-perturbative parameters B_6, B_8, B_K and of the strange quark mass m_s. We also briefly discuss the issues of final state interactions and renormalization scheme dependence. Updating the values of the CKM parameters, of m_t and Lambda (MSbar) and using Gaussian errors for the experimental input and flat distributions for the theoretical parameters we find \epe substantially below the NA31 and KTeV data: \epe= (7.7^{+6.0}_{-3.5}) 10^{-4} and \epe= (5.2^{+4.6}_{-2.7}) 10^{-4} in the NDR and HV renormalization schemes respectively. A simple scanning of all input parameters gives on the other hand 1.05 10^{-4} < \epe < 28.8 10^{-4} and 0.26 10^{-4} < \epe < 22.0 10^{-4} respectively. Analyzing the dependence on various parameters we find that only for extreme values of B_6, B_8 and m_s and suitable values of CKM parameters and Lambda(MSbar), the ratio \epe can be made consistent with data. We analyze the impact of these data on the lower bounds for Im(V_{td}V_{ts}^*), Br(K_L to pi^0 nu barnu), Br(K_L to pi^0e^+e^-)_{dir} and on tan(beta) in the Two Higgs Doublet Model II.Comment: main latex-file, 4 figures and related latex files, 47 page