PPM Editorial Board Discusses Mental Deterioration in Pain Patients

Editor’s Note:
We recently surveyed our Editorial Board members and asked them how a pain practitioner can effectively manage a pain patient who is experiencing mental deterioration. What is your view on this topic? Let us know; send comments to ppmeditorial@verticalhealth.com.

First, Check Patient’s Medications
C. Norman Shealy, MD, PhD
Fair Grove, Maryland
Obviously, the first issue is to check on the various drugs the patient is taking—that is, by far, the most likely cause. In the rare situation where there are no narcotic or mood-altering drugs, then checking vitamin B12, high-sensitivity C-reactive protein, and homocysteine levels would be essential. If those are normal, then an MRI of the brain would be necessary.

Safe Environment Key for Appropriate Treatment
Jennifer Schneider, MD, PhD
Tucson, Arizona
Dementia is only one of several diagnoses in which the patient cannot be relied upon to take their medications safely and reliably. We pain practitioners also occasionally encounter pain patients who are active drug addicts or who have a coexisting psychiatric disorder (eg, bipolar illness or schizophrenia), as well as patients of any age who are mentally retarded. The solution in all these cases is to create a safe environment that will allow the patient to continue receiving appropriate medication treatment for their chronic pain. In most cases, this means finding another reliable person—a relative or friend, for example—to dispense the medication. If the problem is chemical dependency, it will also be necessary to refer the patient for addiction treatment, obtain frequent urine drug screens, do pill counts, etc.

Examine the Root Cause
Mark A. Young, MD, MBA, FACPE
Baltimore, Maryland
I think it’s always very important to establish the root cause of the mental deterioration. In other words, one of the first things that’s critically important is establishing whether any of the mental deterioration is due to existing treatments. Opioids, or other medications that can cause deterioration, are well known to affect things like concentration, language, and affect. If the patient is not on any medications that would be causing the mental deterioration, I think the practitioner would be obligated to do a mental status evaluation to try and figure out whether the mental deterioration is due to some organic process like something affecting the liver, or is related to something with the brain like Alzheimer’s disease.

Cognitive decline in people over the age of 60 years is frequently associated with organic illness or evolving neurodegenerative conditions. If someone over the age of 60 years suddenly develops issues with concentration, language, or function, you really need to be concerned there isn’t something organic going on. You can dismiss mental deterioration as being psychological, but it could be an organic process like a brain tumor, electrolytes, or medication related. The obligation is always on the practitioner to never dismiss something as being totally psychological or psychiatric in nature without fully investigating underlying medical conditions.

First published on: March 31, 2012