Chronic pain in the elderly with advanced dementia. Are we doing our best for their suffering?

Elderly subjects with advanced dementia are exposed, like any other aging individuals, to a wide range of chronic degenerative and progressive medical conditions that can cause pain and discomfort, both physical and psychological. Pain is defined as a subjective and unpleasant experience, which is generally assessed using verbal self-reporting methods. The inability to report pain verbally - a common occurrence in advanced stages of dementia - is widely recognized as the main confounding factor in identifying these patients' pain. Several previous studies on pain assessment in cognitively impaired elderly subjects systematically eliminated the noncommunicative demented patients, so it is hard to estimate the prevalence of pain in such elderly individuals. The lack of pain assessment methods that do not rely on self-reporting contributes to the underestimation of the prevalence of pain, particularly among institutionalized patients, the majority of whom suffer from some degree of dementia. Assessing chronic pain in these frail elderly would require careful monitoring of any changes in their behavior that might underlie a new source of discomfort rather than an aggravation of their cognitive impairment. Although some currently available tools for pain assessment in non-verbal older adults seem promising, no single tool has yet been sufficiently validated as reliable for widespread adoption in clinical practice. Prior research has documented a significantly lower prescription of analgesic medication in demented patients than in cognitively intact peers, and untreated or under-treated pain can have adverse physical and psychological consequences, so there is an urgent need for appropriate pain assessment methods in elderly patients with advanced dementia, since too many of them continue to suffer needlessly. The purpose of this review was to discuss the main tools developed in the last decade for pain assessment in non-communicative older individuals, highlighting the strengths and weaknesses of each tool, and providing a guide for their use in clinical practice, particularly in geriatric settings.