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Rapid response to:


Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial

BMJ 2011; 343 doi: (Published 17 July 2011) Cite this as: BMJ 2011;343:d4065

Rapid Response:

Rather than analgesia focus on "Bowels, Bladder, Beverage and Bottom"

I would concur with several responses to the paper by Husebo and
colleagues (1) and share the concerns with a blanket "trial of analgesia"
in patients with agitation and advanced cognitive impairment:

(1) As other authors have highlighted, many of the tools which use
non-verbal indicators for pain assessment in patients with cognitive
impairment are in fact measures of distress, of which pain may be one of
many causes.

(2) A "trial of analgesia" in such patients may indeed reduce the
measured "distress" simply through sedation, as would also be seen with an
antipsychotic. Oramorph 10mg given to a frail cachetic elderly patients
with advanced dementia is highly likely to reduce observable "distress"
through sedation regardless of whether the patient does in fact have pain
or not.

(3) When the patient is felt to be in pain the next step in
assessment process should be to evaluate why. Clearly this may be
difficult in a patient with cognitive impairment but there should never be
a clinical step straight from recognition of pain to analgesia without
consideration as to why the patient has pain in the first place. Some
causes of pain would not need analgesia: pain from urinary retention
requires a urinary catheter, pain from severe constipation requires bowel
care (and certainly not opioid based analgesics), pain from mal-position
in the bed requires careful repositioning of the patient.

I would suggest that the use of complex tools which simply measure
non-verbal indicators of distress and then "trigger" administration of
analgesia misses a fundamental clinical step: a basic overall assessment
of the patient. Whilst incredibly simple (and logical) it is all too often

Healthcare workers, at whatever level, should always check the four
B's. In many cases completion of a distress scoring tool or administration
of analgesia will then no longer be required. The importance of a basic
clinical assessment of the patient should never be overlooked.

Bowels: when did the patient last open their bowels?

Bladder: when did the patient last pass urine, is there a palpable

Beverage: is the patient hungry of thirsty? Has anybody offered the
patient food/water?

Bottom: a visual survey from top to bottom for obvious precipitants
of distress/agitation e.g. leg twisted around side of bed

1. 1. Husebo BS, Ballard C, Sandvik R, Nilsen OB, Arsland D. Efficacy
of treating pain to reduce behavioural disturbances in residents of
nursing homes with dementia: cluster randomised clinical trial. BMJ, 2011;
343: 193.

Competing interests: No competing interests

08 September 2011
Dylan G Harris
Consultant in Palliative Medicine
Cwm Taf Local Healthboard and Hospice of the Valleys