Identifying & Treating Pain in Patients with Dementia - Long Term

Are you in pain? Identifying & Treating Pain in Patients with Dementia

Gregory [email protected]

Disclosure

• I have been paid from time to time to speak from:▫ Purdue Pharma▫ Janzen▫ Pfizer▫ Valeant

• None of this presentation was funded

Objectives

• Ways of identifying pain with someone who cannot verbally express their pain

• Use of alternate treatment options

Common Problems (Especially in residential or nursing homes)

• Tendency to normalize pain. ▫ i.e. We become older so aching/soreness is seen as

an everyday discomfort

• One of the most common symptoms for people with dementia experience is pain that is poorly diagnosed/undertreated

http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf

http://www.scie.org.uk/publications/dementia/endoflife/pain.asp

Common Problems • Pain is an individual experience that different

people feel in different ways• People with dementia are less likely to report

pain through normal auditory communication. As dementia progresses:▫ Speech ability may decline poor

communication▫ Inability to understand questions▫ Need prompting to take pain meds


Common problems• People with advanced dementia this is a

common symptom• People with dementia experience pain just like

everyone else• Pain is often poorly recognised/undertreated

not difficult to treat• Some people think that people with dementia do

not experience pain or that their memory is so poor that they forget the experience


Common Problems

• National UK statistics pain is under-treated and under-recognized in older people▫ 65 years old 50% reported pain/discomfort▫ 75 years + 56% men, 65% women▫ Institutionalized people, 45 – 83% reported at

least one current pain problem

http://www.bgs.org.uk/Publications/Clinical%20Guidelines/pain%20concise%20guidelines%20WEB.pdf

Common Problems• Myth:▫ Stronger analgesics (opioids) must be avoided as

they can add to confusion and make the dementia worse

• Opioid medications can cause confusion if given too high of a starting dose or one titrates the dose too fast

• The greater amount of pain someone is in, generally the higher the dose they can tolerate without a lot of side effects

http://web.missouri.edu/proste/tool/cog/AJN-Pain-Assess-108.7.2008.pdf

Do pain killers confusion in people with dementia?• 181 participants, long-term stay, patients:▫ Severe dementia did not experience less pain

intensity▫ Severely demented patients receiving opioids

demonstrated higher pain intensity than non-demented patients

▫ Patients with mixed dementia receiving opioids had more pain then mentally healthy controls & they received less pain treatment

http://www.mendeley.com/catalog/suffers-most-dementia-pain-nursing-home-patients-cross-sectional-study/

Common causes of pain in people with dementia• Sitting/lying down in one position with

uncomfortable/tight clothes/shoes can lead to pressure sores

• Weight loss associated with dementia ill-fitting dentures & sore gums

• People with teeth decay/abscesses improper cleaning


Common causes of pain in people with dementia• Osteoarthritis• Pressure sores• Skin tears• Leg ulcer dressings• Stiffening of joints• Changing wound dressings

• Muscle rigidity• Constipation• Urinary tract infections• Movement pain▫ i.e. helping someone turn in

bed, get dressed/undressed


Consequences of not treating pain

• Unnecessary suffering/distress• Inadequate Tx pain ▫ Problematic behaviours▫ Inappropriate Rxs of sedatives/tranquilisers

• Pain functional ability, worsen memory or delay recovery after surgery

• Interfere with sleep depression/social withdrawal


“To leave a person in avoidable pain and suffering should be regarded as a serious

breach of fundamental human rights [and] can be regarded not only as unethical, but also as

negligence.”

-Margaret Somerville

Proceedings of the 7th World Congress on Pain, 1994

What is pain?“Unpleasant sensory and emotional experience

associated with actual or potential tissue damage”

“Pain is what the person says hurts. No other person can experience the pain, know what it feels like or how it really affects the person physically &

emotionally”

International Association for the Study of Pain 1994

International Association of Hospice and Palliative Care

Striking the Right Balance

Treat Pain

Treat Psychosocial Issues

MinimizeAdverse Effects

Detecting someone in pain

• Dementia DOES NOT alter the fundamental experience of pain

• Social/cultural factors should be considered▫ Use interpreters if person doesn’t speak English as

their 1st language▫ Relatives/close care givers may notice subtle

changes


Observational Changes Associated with Pain

• Autonomic changes▫ Pallor, sweating, tachypnea, altered breathing

patterns, tachycardia, hypertension• Facial expressions▫ Grimacing, wincing, frowning, rapid blinking,

brow raising/lowering, cheek raising, eyelid tightening, nose wrinkling, lip corner pulling, chin raising, lip puckering

• Mental status change▫ Confusion, crying, distress, irritability


Observational Changes Associated with Pain• Body movements▫ Altered gait, pacing, rocking, hand wringing,

repetitive movements, increased tone, guarding, bracing

• Verbalisations/vocalisations▫ Aggression, withdrawal, resisting

• Changes in activity patterns▫ Wandering, altered sleep, altered rest patterns


Ways of expressing pain

• Behavioural changes▫ Fidgeting, restlessness, repetitive behaviours,

pacing or wandering▫ May become tense or on edge when physical care

is about to be given pushing away of care givers or angry if they cannot verbally express pain that will be experienced


Ways of expressing pain• Mood changes▫ Depression & withdrawal

• Facial expressions▫ Frowning, sad, grimacing, tense, frightened

• Body language▫ Guarding, bracing, rubbing or holding the painful

part of the body• Speech▫ Shouting out repeatedly, screaming, crying or

groaning


Ways of expressing pain• Signs on physical examination▫ Pressure sores, tears in the skin, arthritis or

deformities in the joints▫ Changes blood pressure, pulse rate, sweating,

pallor, noisy or laboured breathing▫ Food refusal/loss of appetite▫ Changes in mobility or walking gait▫ Constipation, retention of urine distended

abdomen


How to communicate with Someone who can’t speak• Someone who can no longer speak in

words/sentences still DO communicate• Ability to communicate in one-syllable words

such as “Yes” or “No”▫ Exceptions: Final stage dementia Suffered a stroke or similar condition that may have

affected their speech circuitry

http://www.dementiacareaustralia.com/index.php

How to communicate with Someone who can’t speak• “Yes” or “No” answer can be given:▫ Saying the words out loud▫ Shaking or nodding of head▫ Using facial expressions Looking up & making eye contact; smiling or looking

down for a “Yes” Looking straight into space or giving no reaction at

all for a “No”


How to communicate with Someone who can’t speak• Research shows words are not our only means

of communicating a message▫ Words: makes up 7%▫ Tone of voice: makes up 38% and▫ Body language: which makes up 55%

• 93% of our communication is non-verbal• Word/sentence through our tone of voice & look

on our face completely opposite meaning


How to communicate with Someone who can’t speak• Be a good listener▫ Help someone who can’t put words or sentences

together make sense of what is going on inside his/her mind & to express it

• Ask yourself:▫ What is the person attempting to communicate?▫ What is the need that is not fulfilled?


How to communicate with Someone who can’t speak

• Intuition▫ Use your intuition as a guide to help you guess at

what the person is attempting to communicate▫ Intuition is our ability to take information &

process it in relation to what we have learned previously/experienced

▫ Gives us our initial response to a question▫ Is incredibly fast as we use both of our

hemispheres in our brain


How to communicate with Someone who can’t speak• Intuition▫ Once we have guessed what the person is

attempting to communicate we need to acknowledge the need or feeling that is being expressed check this “guessed” need or feeling of the person

▫ People with dementia do know how they feel & what their needs are but simply express them differently


Diagnosing Pain• Use simple “yes/no” questions when asking person

about their pain do not overload the person by asking repeated questions or the person may become agitated/distressed

• Try other words:▫ “ache” and “hurt”, “Is it sore?”▫ “Does it hurt a lot?” or “How much?” may not be

helpful as the person may not be able to describe how bad the pain is or how often it occurs

• Ask the person directly provide information on their pain


Diagnosing pain

• Non-verbal communication▫ Ask to point to affected part▫ Use of pictures

• Caregivers need to work hard to understand a person’s verbal/non-verbal signs of being in pain

Diagnosing pain

• Pain not obvious thorough physical examination by doctor/nurse taking cues from patient’s facial expression/posture

• Referring to another health provider:▫ Occupational therapist/physiotherapist may be

helpful with musculoskeletal problems▫ Nurse for care of ulcers/pressure areas


Treating pain in dementia• Assessment▫ Done on regular/systemic basis to minimize pain

• Acknowledging person is in pain▫ Reassure person and act on information given▫ Explain what you are doing to help them even

though you don’t think they understand you• Treat cause▫ Pressure cushions/mattresses, repositioning,

relieve of constipation, loosen clothing, regular dental check ups


Treating pain in dementia

• Comfort▫ Heat/ice packs for joint problems▫ Massage for tension/muscle spasms▫ Immobilising/splinting limbs may discomfort

associated with chronic fractures/arthritis


Brief Pain Inventory – BPIMeasure

Adapted from Cleeland CS and Ryan KM, 1994

Abbey Pain Scale

• For measurement of pain in people with dementia who cannot verbalize

• Australian Pain Society recommends that this scale is to be used as a movement-based assessment▫ Observe & record while resident is being moved i.e. during pressure area care, while showering, etc.

Abbey Pain Scale

• Pain scale is part of an overall pain management plan

• Pain management requires ongoing assessment • Scale does not differentiate between distress &

pain measure effectiveness of pain-relieving interventions is essential

Abbey Pain Scale• Complete the scale immediately following

procedure & record results in resident’s notes• Include:▫ Time of completion of scale & score▫ Staff member’s signature & action (if any) taken in

response to results of assessment i.e. pain medication or other therapies

• 2nd evaluation done 1 hour after any intervention taken in response to 1st assessment to see if Tx effective

Abbey Pain Scale

• Score on pain scale is the same or worse, undertake a comprehensive assessment and monitor closely over 24 hour period including any interventions undertaken

• No improvement notify practitioner

1 Australian Pain Society(2005) Residential Aged Care Pain Management Guidelines, August. http://www.apsoc.org.au 1 Gibson, S., Scherer ,S and Goucke , R (2004) Final Report Australian Pain Society and the Australian Pain Relief Association Pain Management Guidelines for Residential Care: Stage 1Preliminary field-testing and preparations for implementation. November

Abbey Pain Scale1. Vocalization:▫ Whimpering, groaning, cryingAbsent 0 Mild 1 Moderate 2 Severe 3

2. Facial Expression: ▫ Looking tense, frowning, grimacing, looking frightenedAbsent 0 Mild 1 Moderate 2 Severe 3

3. Change in body language:▫ Fidgeting, rocking, guarding part of body, withdrawn Absent 0 Mild 1 Moderate 2 Severe 3

http://prc.coh.org/PainNOA/Abbey_Tool.pdf

Abbey Pain Scale4. Behavioural change: ▫ confusion, refusing to eat, alteration in usual patterns

Absent 0 Mild 1 Moderate 2 Severe 35. Physiological change: ▫ Temperature, pulse/blood pressure outside normal limits,

perspiring, flushing or pallorAbsent 0 Mild 1 Moderate 2 Severe 3

6. Physical changes: ▫ Skin tears, pressure areas, arthritis, contractures,

previous injuriesAbsent 0 Mild 1 Moderate Severe 3

http://prc.coh.org/PainNOA/Abbey_Tool.pdf

Abbey Pain Scale

• Add scores 1 6

• Check box which matches type of pain

0 – 2 3 – 7 8 – 13 14 +

No pain Mild Moderate Severe

Chronic Acute Acute on chronic

Abbey Pain Scale

• Conceptual blurring between acute and chronic pain with no discussion on distinguishing characteristics of pain types

• Physiological indicators is not supported in the literature on chronic pain

• Validity testing is based on nurse judgement of pain severity and is not substantiated in the literature

http://prc.coh.org/PainNOA/ABBEY_B.pdf

Pain Assessment in Advanced Dementia (PAINAD) ScaleItems 0 1 2 Score

Breathingindependent of vocalization

Normal Occasional labouredbreathing. Short period of hyperventilation

Noisy laboured breathing. Long period of hyperventalation. Cheyne-Stokes respirations

Negative vocalization

None Occasional moan or groan.Low level speech with negative or disapproving quality.

Repeated troubled calling out. Loud moaning or groaning. Crying

Facial expression

Smiling or inexpressive

Sad. Frightened. Frown Facial grimacing

Body language Relaxed Tense. Distressed pacing. Fidgeting.

Rigid. Fists clenched. Kneespulled up. Pulling or pushing away. Striking out.

Consolability No need to console

Distracted or reassured by voice or touch.

Unable to console, distract or reassure.

Total

http://www.healthcare.uiowa.edu/igec/tools/pain/PAINAD.pdf

PAINAD Scale

• Total score ranges from 0 – 10 points

Score Rating

1 – 3 Mild pain

4 – 6 Moderate pain

7 – 10 Severe pain

http://www.healthcare.uiowa.edu/igec/tools/pain/PAINAD.pdf

NON-OPIOID

ASAAcetaminophen

NSAID+/- adjuvant

OPIOID FOR MILD TO MODERATE PAIN

CodeineOxycodoneTramadol

Tapentadol

+/- non-opioid+/- adjuvant

OPIOID FOR MODERATE TO SEVERE PAIN

OxycodoneHydromorphone

Morphine-------------------------------------------

FentanylMethadone

+/- non-opioid+/- adjuvant

WHO Analgesic Ladder

Pain 1 - 3

Pain 4 - 6

Pain 7 - 10

Approaches to reducing pain

• Timely warnings▫ Warn resident before a potentially painful

movement/action▫ Allow resident to prepare for movement/action▫ Wait for resident to provide permission (if able)

before performing task

Talerico KA, et al. Alzheimer’s Care Quarterly 2006;7(3):163-74


• Movement in bed▫ Don’t pull on arms when rolling/moving. Grasp

shoulders/hips using a “log-roll” technique to keep body in proper alignment

▫ Draw sheets to roll patient from side to side rather pulling or pushing on various parts of the body


Approaches to reducing pain• Transferring▫ Insufficient body strength raise the head of the bed

and help resident onto his/her side before bringing to a sitting position

▫ Don’t pull on the resident’s neck when moving/transferring

▫ Allow resident time at the edge of the bed to get his/her bearings before completing transfer

▫ Raise electric beds high enough that legs are bent at the knee at a slightly more than 90° to assist in coming to standing position

▫ Brace painful knees during transfersTalerico KA, et al. Alzheimer’s Care Quarterly 2006;7(3):163-74


• Seating and positioning▫ Get an individualized wheelchair assessment from

physical or occupational therapist▫ Ensure foot rests are fitted to resident▫ Pad areas of wheelchair that cause pressure▫ Adjust tilt-in-space wheelchair Q1-2H to relieve

pressure & change position


Treating pain

• Simple pain killers▫ Acetaminophen/NSAID mild to moderate pain▫ Acetaminophen dose 3 – 4 grams/day ▫ NSAID 26% of people Tx require anti-ulcer Rx

• Chronic pain Tx regular dosing to prevent pain from occurring▫ Long-acting medications tend to give better

coverage


Treating Pain• Stronger painkillers▫ Opioids useful moderate to severe pain ▫ SE’s constipation & confusion but this should

not stop them from being prescribed• Consider stopping some medical treatments ▫ Some Txs may make little contribution to person’s

health but can cause pain & QOL painful blood tests Invasive physical investigations


Opioids• Opioids should be started at a lower dose (25-

50%) of a younger person due to pharmacokinetics/pharmacodynamic changes

• Opioids in elderly people▫ Meperidinemetabolite can cause

neuroexcitation, nervousness & seizures▫ Tramadol caution with SSRI medications▫ Codeine great variability in it’s effectiveness. Up

to 30% of the population are poor metabolizers of codeine

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546472/

Equipotent Doses of OpioidsOpioid Oral Dose IM/IV/SC Dose

Morphine 10mg 3-5mgCodeine 100mg 50-60mgFentanyl - 0.25mg

Hydromorphone 2mg 1mgOxycodone 5mg 2-3mgMethadone 1-10mg -Meperidine 150mg 35-40mgTapentadol 25mg -Tramadol 50mg -

Transdermal ConversionDaily PO

morphine doseBuprenorphine patch

strengthFentanyl patch

strengthBreakthrough PO

morphine dose12mg daily 5ug/hr - 2mg hourly PRN24mg daily 10ug/hr - 4mg hourly PRN

30 – 59mg daily 12ug/hr 5 – 7.5mg hourly PRN

60 – 90mg daily 25ug/hr 10 – 15mg hourly PRN

Alternate Routes• Development of alternate method(s) of drug

administration allows to manage specific problem(s) or an alternate way of introducing systemic medication

• Look at the following alternate routes:▫ Transmucosal Sublingual & intranasal

▫ Topical

Transmuccosal:Anatomic & Physiologic Factors Factors

• Buccal mucosa is crisscrossed by a large network of blood and lymphatic vessels.

• Drugs administered by this route are quickly absorbed into the systemic circulation rapid onset

• Avoidance of gastric proteases, hepatic 1st-bypass and intestinal metabolism

Care Beyond Cure 4th Edition

Transmuccosal:Limiting Factors and Disadvantages• Taste of formulation may be unpalatable• Ideal volume < 0.5ml; if more than 1-2 ml is

administered, then some of the solution will be swallowed

• Excessive salivation may lead too rapid dissolution & absorption of drugs unstable at gastric pH

• Route may be compromised if integrity of mucosa altered (mucositis)


Transmucosal:Required Conditions & Method of Administration

• Unsweetened concentrated solutions ideal▫ Keeps volume < 0.5ml▫ Reduces chance of nausea▫ Sweetened solutions saliva production

• Patient’s mouth is dry, place a few drops of water under the tongue to hydrate & help dissolve medication

• Try not to swallow/chew for about 10 minutes (if possible) to allow complete absorption


Transmucosal Treatment of Pain• Absorption after 10 minutes▫ Fentanyl 51%▫ Hydromorphone 25%▫ Morphine 22%

• Fentanyl S/L Incident pain▫ Onset 5 -10 minutes▫ Peak effect 15 – 30 minutes▫ Duration of analgesia 30 – 40 minutes▫ NB* Patient needs to be instructed not to swallow

doseCare Beyond Cure 4th Edition

Medical Care of the Dying 4th Edition

Intranasal:General Principles• Most intranasal (IN) use is off label• Nasal cavity easily accessible, rich vascular

plexus permits topically administered drugs to achieve rapid blood levels while avoiding intravenous catheters

• Most effective when distributing drug solutions as a mist rather than large droplets which may aggregate & run off instead of being absorbed

Therapeutic Intranasal Drug Delivery http://intranasal.net/Overview/default.htm

Intranasal:General Principles• Emerging as a promising method of delivering

medications directly into blood stream due to easy access to a vascular bed

• Method of delivery can eliminate the need for intravenous catheters while still achieving rapid, effective blood levels of the medication administered


Intranasal:Advantages1. Rich vascular plexus of the nasal cavity

provides a direct route into the blood stream for medications that easily cross mucous membranes

2. Avoids GI destruction & hepatic 1st – bypass allowing more drug to be cost-effectively, rapidly and predictably bioavialable than if given PO


Intranasal:Advantages3. IN medications absorption rates and plasma

concentrations are comparable to IV administration and typically are better than SC or IM routes

4. Easy, convenient and safe to use. Essentially painless and does not require a sterile technique & is immediately & readily available for all patients


IntranasalAdvantages5. Nasal mucosa is near the brain, cerebral spinal

fluid drug concentrations can exceed plasma concentrations. IN administration may rapidly achieve therapeutic brain & CNS drug concentrations

IN medication delivery is simply another option or method to deliver medication


Intranasal:Limiting Factors & Disadvantages• Limited medications that can be delivered • Many medications are not adequately

concentrated to achieve ideal dosing volumes• Mucosal health impacts absorption▫ Bloody nose or large volumes of mucous

production will wash medication contact with mucosa

▫ Destroyed mucosa will have blood flow absorption i.e. topical use of vasoconstrictors


Intranasal:Required Conditions & Method of Administration• Ideal volume per nostril is 0.25 – 0.3ml▫ Some clinicians use as much as 1ml per nostril &

accept runoff and drug loss at this higher volume• The larger the nasal mucosa surface area that is

covered, the more medication that can be absorbed

• Ideal drug dose is divided in ½ and each nostril receive the ½ dose


Intranasal:Required Conditions & Method of Administration• Significant difference in drug distribution is

observed with drops, nebulizer, atomized pump, pressurized aerosol, etc.

• Multiple studies show atomized pump is the best nasal delivery system as it gives a constant dose & very good mucosal distribution▫ Ideal particle size 10 – 20µm are deposited on

nasal mucosa and not inhaled


Intranasal: Dosing• Doses are usually less than PO meds but higher

than IV • Therapeutic effect is achieved in 3-5 minutes &

peaking at 10-15 minutes▫ Dose larger than 1ml split dose & deliver @ 10-15

minute intervals• Due to delayed rising of drug levels, respiratory

depression will rarely happen ▫ Exception sufentanil due to high potency


Intranasal: MAD Device(Mucosal Atomizing Device)

Use a luer lock syringeWorks in any positionSemipermeable soft plus absorbs runoffDead space 0.09ml Wolfe Tory Medical

Intranasal Drugs & Dosing

Drugs used and dosing go to:Therapeutic Intranasal Drug Delivery:

Needleless treatment options for medical problemshttp://intranasal.net/Home/default.htm

Reasons for Topical Route• Oral route not desirable• More localized action ▫ Transdermal us can provide up to 30 fold higher

drug concentration than PO• Most sites produce in systemic blood levels

and chance of drug interactions• Avoids the GI tract and hepatic first-pass

metabolism

Topical Treatment of Neuropathic Pain – IJPC Vol 12 No 3

Reasons for Topical Route

• Can reduce systemic side effects as different sites have different systemic absorption▫ Apply to knee about 5% systemic absorption▫ Apply to thigh, mid-section & upper arms about

20% systemic absorption Oxybutynin 10% Transdermal: 100mg applies OD ≈

PO 5mg IR tablets - TID▫ Apply to inner wrist or behind ear systemic

levels similar to SC levels

• Possible irritation at application site• Drying of the skin with transdermal products• Variations in the stratum corneum barrier

variable absorption▫ May need to add penetration enhancers

• Need to concentrate dosage form to accommodate therapeutic response

• Rate of absorption may vary

Heir, Gary DMD, et al. IJPC 2004; 8:337-343

Topical Route: Drawbacks

Transdermal• Greg’s 5 R’s▫ Right volume Need to saturate area 1ml to knee

▫ Right concentration▫ Right penetration depth Can add penetration enhancer like DMSO 2.5 – 20%

to allow drug(s) to reach site of action▫ Right length of time to rub product into area▫ Right combination

Site Permeability

• Generalized rank order of site permeabilities:▫ genitals > head/neck > trunk > arm > leg▫ Preterm infant > term infant > young adult

> elderly

Klein & collegues,. Transdermal Clonidine Therapy in Elderly Mild Hypertensives; Hypertension Suppl 1985:3;581-584

□ Ketamine __5% __10% __15%(requires a triplicate Rx with this Rx)

□ Gabapentin __6% __8% __10%□ Clonidine __0.1% __0.2%□ Lidocaine __2% __ 5% __ 7.5%□ Tetracaine __ 2% __ 5% __ 7.5%□ Loperamide __5% __10%□ Morphine __ 0.5% __ 1% __ 2%□ Ketoprofen __5% __10% __20%□ Diclofenac __2% __4% __5%□ Carbamazepine __2% __5%□ Baclofen __2% __5%□ Amitriptyline __2% __5%□ Guaifenesin __5% __10%

DMSO ____ 5% ____ 10% ____ 20% Other: ____ %

Transdermal• Shingles▫ Ketamine 10-15%, morphine 1-5%, gabapentin

6-10%, tetracaine 2-5% in Lipoderm®• Lower back pain▫ Diclofenac 8%, DMSO 5%, baclofen 2-5%,

tetracaine 2-5% in Lipoderm®• Joint pain▫ Diclofenac 10%, DMSO 20%, tetracaine 5% ▫ Ketorolac 8%, DMSO 20%, tetracaine 5%

Both in Lipoderm®

ABHR Topical Gel

• Lorazepam 2mg/diphenhydramine 50mg/ haloperidol 2mg/metoclopramide 40mg/ml

• Lorazepam 4mg/diphenhyramine 100mg/ haloperidol 4mg/metoclopramide 80mg/ml▫ Applied 0.25-0.5ml QID PRN ▫ To inner part of wrist

Rectal FissuresNifedipine ____ 0.2% ____0.3% ____ 0.5%

ONLY USE 1 OF THESE 3Diltiazem ____ 2%

Nitroglycerin ____ 0.1% ____ 0.2% ____0.4% ____0.6%

Lidocaine ____ 1% ____ 2%

Hydrocortisone ____ 1% ____ 2%

Other: _____ %

All products will be in Vaseline as a base unless otherwise specified

Other base:

Mitte: ________ gm

Sig: Apply to the affected area 2 to 3 times daily and after a bowel movement

OR: ________________________________________________________________

Refill: ____________

Documents

Identifying & Treating Pain in Patients with Dementia - Long Term