A Psychophysical Investigation of the Facial Action Coding System as an Index of Pain Variability among Older Adults with and without Alzheimer's Disease

Development and evaluation of the Pain Assessment in the Communicatively Impaired (PACI) tool: part II

Pain is a common symptom for long-term care residents, particularly those in need of palliative care. However, pain assessment in residents who have communication limitations is challenging. A study was conducted with the aim of developing a pain assessment tool that could feasibly be used by direct care providers in long-term care with minimal training yet demonstrating strong psychometric properties. The study used both qualitative and quantitative methods to develop and test the Pain Assessment in the Communicatively Impaired (PACI) tool. Part I of this paper reported on the development phase; this second part reports on the test results. The validity and reliability results of the PACI tool were acceptable, and the convergent validity was moderately strong. A moderate level of interobserver agreement was evident, with kappas ranging from 0.46 to 0.63 for the individual items and a kappa score of 0.59 for the total tool score. The overall results of this study support the psychometric properties and feasibility of the PACI tool, offering preliminary support for its use in clinical practice.

Automated Facial Action Coding System for dynamic analysis of facial expressions in neuropsychiatric disorders

Facial expression is widely used to evaluate emotional impairment in neuropsychiatric disorders. Ekman and Friesen's Facial Action Coding System (FACS) encodes movements of individual facial muscles from distinct momentary changes in facial appearance. Unlike facial expression ratings based on categorization of expressions into prototypical emotions (happiness, sadness, anger, fear, disgust, etc.), FACS can encode ambiguous and subtle expressions, and therefore is potentially more suitable for analyzing the small differences in facial affect. However, FACS rating requires extensive training, and is time consuming and subjective thus prone to bias. To overcome these limitations, we developed an automated FACS based on advanced computer science technology. The system automatically tracks faces in a video, extracts geometric and texture features, and produces temporal profiles of each facial muscle movement. These profiles are quantified to compute frequencies of single and combined Action Units (AUs) in videos, and they can facilitate a statistical study of large populations in disorders known to impact facial expression. We derived quantitative measures of flat and inappropriate facial affect automatically from temporal AU profiles. Applicability of the automated FACS was illustrated in a pilot study, by applying it to data of videos from eight schizophrenia patients and controls. We created temporal AU profiles that provided rich information on the dynamics of facial muscle movements for each subject. The quantitative measures of flatness and inappropriateness showed clear differences between patients and the controls, highlighting their potential in automatic and objective quantification of symptom severity.

Validation of an acute pain-behavior scale for older persons with inability to communicate verbally: Algoplus

To compensate for poor acute pain detection in elderly inpatients with inability to communicate verbally (ICV), the Doloplus Collective team devised the 5-item Algoplus behavior-assessment scale specifically aimed at quickly detecting acute pain in these individuals. Algoplus was developed in three successive phases, including expert opinions, caregivers interviews, patient video recordings and statistical procedures. Among the 1500 recorded primary pain behaviors, 48 were selected and clustered into a 5-item scale. This version was validated based on 349 old inpatients (204 with acute pain and 145 without) from different care settings and hospitals. Comparators were objective acute pain clinical situations, experts' clinical judgment on acute pain presence, and self-rating scales (Visual Analog Scale, Numeric Rating Scale and Verbal Descriptor Scale) for a communicative subsample (n=134). Algoplus showed good discriminant validity with adequate internal consistency (Kuder-Richardson-20, 0.712), excellent interrater reliability (intraclass coefficient, 0.812) and high sensitivity to change during specific pain situations and after starting pain management. Excellent correlations were observed between Algoplus and experts' clinical judgment, acute pain clinical situations or each comparator self-rating-pain score. For patients with acute pain conditions, a score ⩾2 out of 5 on the Algoplus scale was retained as the threshold for the presence of acute pain in elderly ICV inpatients, with 87% sensitivity and 80% specificity. In addition, the very brief rating time of ∼1min is particularly relevant in acute-care settings, where repetitive pain-monitoring is required.

Practice guidelines for assessing pain in older persons with dementia residing in long-term care facilities

PURPOSE

Frail patients with dementia most frequently present with musculoskeletal pain and mobility concerns; therefore, physiotherapy interventions for this population are likely to be of great benefit. However, physiotherapists who work with older adults with dementia confront a considerable challenge: the communication impairments that characterize dementia make it difficult to assess pain and determine its source. For an effective physiotherapy programme to be implemented, valid pain assessment is necessary. This paper is intended to provide practice guidelines for pain assessment among older persons with dementia.

SUMMARY OF KEY POINTS

Over the last several years, there has been tremendous research progress in this area. While more research is needed, several promising assessment methodologies are available. These methodologies most often involve the use of observational checklists to record specific pain behaviours.

RECOMMENDATIONS

We encourage the ongoing and regular evidence-based pain assessment of older persons with dementia, using standardized procedures. Without regular and systematic assessment, pain problems will often go undetected in this population. Given the need for systematic pain assessment and intervention for long-term care populations with mobility concerns and muculoskeletal pain problems, we call for increased involvement of physical therapists in long-term care facilities.

A modified version of the non-communicating children pain checklist-revised, adapted to adults with intellectual and developmental disabilities: sensitivity to pain and internal consistency

Despite enhanced interest in manifestations of pain in adults with intellectual and developmental disabilities (IDD), the characteristics of pain behavior in this group have seldom been examined. The aim of the present study was to provide a sensitive pain behavior scale for adults with IDD. The participants, 228 adults (mean age, 38.7 years) with different levels of IDD, were videotaped before and during an influenza vaccination and scored using the Non-Communicating Children's Pain Checklist-Revised (NCCPC-R). Observed pain behaviors not captured by the NCCPC-R, was also registered. Sensitivity to pain of all 27 items was examined by Signed Rank test, internal consistency by Cronbach's alpha, and sensitivity to change of the total scale by Standardized Response Mean (SRM). Thirteen items were excluded from the original NCCPC-R scale; 4 new items were added, making a modified scale of 18 items. This scale, named the Non-Communicating Adults Pain Checklist-Revised (NCAPC), was rescored and examined for psychometric properties in a random sample (N = 89). Sensitivity to pain of all items (P < .05) and high internal consistency (alpha = 0.773) were demonstrated. Large sensitivity to pain at all levels of IDD was shown (SRM, 1.20 to 2.07). Better psychometric properties were demonstrated for NCAPC than NCCPC-R in the target population.

PERSPECTIVE

This article presents initial psychometric properties of a new measure, the NCAPC, evaluating pain behavior in adults with IDD. This measure could help clinicians to better capture pain expressions in this population and contribute to better pain management for this group of patients.