It was found that more severe pain is associated with less frequent wandering behaviors, but more frequent aggressive and agitated behaviors, after controlling for covariates. Most of the published literature suggested that there is a positive relationship between pain and disruptive behaviors in general [6, 11, 45]. However, the results of this study suggest that the relationship between pain and disruptive behaviors depends on the type of behaviors examined. The direction of the relationship between these variables depends on whether the disruptive behaviors are accompanied by locomotion. Pain is positively correlated with disruptive behaviors that do not involve locomotion (e.g., aggression and agitation), but negatively related to disruptive behaviors that are accompanied by locomotion (e.g., wandering). That is, residents who experience more severe pain are more likely to display aggression and agitation, and less likely to move around.
The finding that pain and aggressive or agitated behaviors are positively linked in NH residents with dementia is consistent with other published reports. Buffum and colleagues  reported that pain was positively related to agitation (r = .50, p = .003) using a bivariate correlation analysis in 33 Veterans Affairs NH residents with dementia. Manfredi and colleagues  demonstrated that opioid treatment for pain reduced agitation in 13 NH residents with dementia who were more than 85 years old (mean change in CMAI score: -6.4, 95% CI [−10.96, -1.8]). Both of these studies have a small sample size. Thus, the results of this study using a large sample from all the nursing home residents with dementia in the state of Florida substantiates and extends the positive relationship between pain and non-locomotive disruptive behaviors from these previous findings.
In contrast, the finding on the relationship between pain and wandering behavior in this study is opposite to the findings presented in the literature review. Kiely and colleagues  used MDS assessment data from 8,982 NH residents, and reported that NH residents who expressed sadness or pain in MDS assessment data were 65% more likely to develop wandering behaviors than their counterparts who did not express sadness or pain (OR = 1.65, p = .02). Our study measured pain more specifically using the MDS-pain severity scale , combining both pain frequency and pain intensity, while Kiely and the colleagues  measured pain by a dichotomized expression of sadness or pain. Sadness is not typically considered an indicator of pain, and its inclusion may have confounded pain and depression or mood disorder.
Several limitations of this study should be noted. First, this study is inherently limited by secondary analysis of federally mandated MDS assessment data, and the effect of clustering within facility is not controlled in this study. The variables and the procedures cannot be controlled. The MDS assessment data may have some variability due to different styles and skills of MDS coordinators in each facility. Second, the role of pain medications is not considered in this study. The highest level of pain could have been managed by pain medications, but it is not possible to discern this in the MDS assessment data. However, similar to our study, most of the literature reported the relationship between highest level of pain and the frequency of behavioral symptoms during the observation period without controlling for pain medications [11, 49]. Third, the amount of variance in disruptive behaviors that is explained by these logistic regression models is small (ranging from 6% to 15%). This suggests that there are other factors that contribute to disruptive behaviors that were not specified in our models. Finally, this study design is descriptive and cross-sectional. As such, this study is not able to examine causal relationships between pain and disruptive behaviors.
Findings from this study can be a foundation for future research. Studies using prospective designs are needed to validate these findings. Also, randomized controlled trials can be used to compare comprehensive pain management and usual pain management with regard to the frequency of disruptive behaviors. This type of study can provide evidence for causal relationships between pain management and disruptive behaviors and support changes in clinical practice. Third, future research would include the longitudinal MDS assessment data to examine trends over time. The longitudinal nature of MDS assessment data, collected every three months or more often, provides an opportunity to describe change over time, and facilitates the use of more powerful statistical analysis techniques to describe both within- and between-person changes.