13 - Pain in Dementia - A Hidden Driver of BPSD

Pain is one of the most common and overlooked drivers of behavioral and psychological symptoms of dementia. In this episode of Key Perspectives, we continue our BPSD series as Eric Gordon and Dr. Steve Arze discuss how unrecognized pain often shows up as agitation, vocalization, or resistance to care in patients who cannot reliably communicate their discomfort. We explore why pain is so frequently undertreated in dementia, how the shift away from opioids has shaped current practice, and why sedation should never be confused with true pain relief. Dr. Arze shares a practical, multimodal approach to pain management that focuses on low-dose, multi-class therapy, scheduled rather than PRN analgesics, and time-limited medication trials to avoid long-term, unnecessary prescribing. Together, we discuss how to recognize pain as a behavioral trigger, how to use the PAINAD scale to assess response to treatment, and why addressing pain can reduce inappropriate antipsychotic use. We also walk through thoughtful pharmacologic strategies, including acetaminophen, neuropathic agents, muscle relaxants, NSAIDs, opioids, and topical therapies, along with the importance of deprescribing and setting realistic goals with families. This episode is designed for clinicians caring for patients with dementia in skilled nursing, long-term care, home-based primary care, palliative care, and hospice settings who want to improve quality of life by treating the root cause of behaviors rather than the behaviors themselves.