The purpose of this study is to test an intervention focused on the treatment of chronic pain for institutionalized older adults with dementia, with the intention of also reducing protective behavioral symptoms, such as aggression. A secondary purpose is to understand the mechanism that underlies the relationships among morning care, observed pain, and protective behavioral symptoms, both in the absence and presence of the proposed intervention. Older persons are at special risk for unidentified and under treated pain, often receiving significantly less analgesic medications than their cognitively intact peers. In addition, protective behavioral symptoms are exhibited by as many as 90 percent of persons with dementia. Although researchers and clinicians have hypothesized an association between pain and protective behavioral symptoms, little research has explored this relationship. This quasi-experimental study will use a 3-group repeated measures design with an untreated control group, to evaluate the effects of an individualized pain treatment intervention on nursing home residents with dementia. A purposive sample of 30 residents who are moderately to severely cognitively impaired, have at least one potentially painful chronic musculoskeletal condition, and exhibit protective behavioral symptoms (resistiveness to care, verbal and/or physical aggression) will be selected from 3 nursing homes (n=10 per facility). The Comfort And Responsiveness Enhancement (CARE) intervention, implemented by an advanced practice nurse consists of two components: 1) an analgesic drug component and 2) a psychosocial component. The two treatment components will be introduced in opposite sequence in intervention facilities, and during the final phase each participant will be exposed to the additive CARE intervention, which is expected to be associated with the best outcomes for participants. Outcomes of interest include self- report of pain, observed pain, protective behavioral symptoms, analgesic drug use, and psychosocial intervention use. Analysis of the effects of the intervention will use ANOVA if possible, or the corresponding nonparametric analytic technique (Wilcoxon signed rank sum tests). Content analysis of field notes kept throughout the intervention will be used to modify the intervention and evaluate the feasibility of testing it in a larger randomized clinical trial.
