Pain and behavioral subgroups among nursing home patients with worsening cognition: A latent transition analysis

Background Prevalence estimates of pain in nursing home patients with dementia range from 40% ‐ 60% however pain among those who have difficulty with self‐report such as those with dementia is often missed. Pain scales may miss some key indicators of pain such as aggressive behavior (physical and verbal) and rejection of care, particularly among those who have cognitive difficulties. The purpose of this study was to utilize measurements of staff‐assessed pain, agitated and reactive behavior, functional status, and symptoms of depression to uncover non‐traditional pain subgroups. Method The Minimum Data Set 3.0 contains information on the health and functional status of every nursing home resident in Medicare/Medicaid certified nursing homes in the United States. Only patients who had staff assessed pain at admittance, 3 months, and 6 months, and thus were unable to self‐report pain, were included in the analysis (n = 26,816). Latent class analysis was used first to classify subgroups of pain, depression, functional status, and behavioral symptoms and then latent transition analysis was used to measure if and how patients moved between these subgroups at 3 and 6 months given if their cognition (measured by the Cognitive Performance Scale) got worse or had no change/got better. Result The latent class analysis revealed 5 classes: behavioral plus depression, functional, physical, behavioral, and low classes. At all time‐points the functional class was the most prevalent (∼28%) and the behavioral plus severe depression was the least prevalent (∼8%). Among those with worsening cognition, pain manifesting as behavioral symptoms in addition to depression remained largely unchanged in the first three months but partially transitioned to a subgroup characterized by physical dependence or remained the same by 6 months. Among the same group, pain manifesting as behavioral symptoms without depression largely stayed the same from admittance to month 3 with some movement to the behavioral plus depression and physical subgroups and largely stayed in the behavioral class by month 6. Conclusion This may indicate that pain manifesting as behavioral symptoms is not being properly treated among those with worsening cognitive function.