Chronic Pain in Dementia: Factors Influencing Analgesic Prescribing Practices of Primary Care Providers

Abstract

Introduction
Effective chronic pain management is crucial for patients with dementia, yet evidence suggests undertreatment in this population. This thesis examines the factors influencing U.S. primary care providers' analgesic prescribing decisions and their contribution to treatment variability.

Methods
A convergent mixed methods design was used across three studies: (1) a retrospective chart review of 344 patients in a U.S. primary care organisation, (2) an online survey of 210 primary care providers with a vignette experiment and open-ended items, and (3) semi-structured interviews with 23 primary care providers.

Results
Analgesic prescribing decisions are influenced by patient, provider, and clinical encounter factors. Dementia status is a critical influential factor, increasing complexity, uncertainty, and perceived risk, leading to more cautious prescribing, though dementia subtype is not significant. Older age and comorbidities complicate treatment decision-making, while pain intensity increases the likelihood of receiving an analgesic. The assessment for presence of pain is a critical factor for the decision to prescribe any analgesic, while assessment of functional status predicts the opioid amount prescribed. Dementia makes accurate pain assessment difficult, leading to under-recognition of pain and undertreatment. Family caregiver involvement and reliability affect prescribing. Training increases willingness to prescribe. Ethical concerns about balancing safety with quality of life in patients with dementia influence prescribing. Providers' belief that dementia patients experience less pain decreases willingness to prescribe. Time constraints, insufficient training and support, and lack of guidelines specific to patients with dementia, impact analgesic prescribing, while an interdisciplinary team approach and peer review support groups may help address some of these challenges.

Conclusion
The thesis provides new evidence on the extent, nature, and complex interplay of the factors that best account for the variation in analgesic prescribing in patients with and without dementia. Further research on dementia and its interactions with other contextual factors is warranted.

Date of Award	10 Dec 2025
Original language	English
Awarding Institution	University of Bath
Supervisor	Abbie Jordan (Supervisor), Janet Bultitude (Supervisor) & Jenny Scott (Supervisor)