The tragedy of dementia: clinically assessing pain in the confused nonverbal elderly

Treatment of chronic pain in persons with dementia: an overview

The purpose of this review is to identify the common causes of nonmalignant chronic pain in people with dementia, discuss methods for determining the level of pain in patients who are nonverbal, and evaluate pharmacologic treatment for nonmalignant chronic pain.

Veränderung des Schmerzerlebens bei Alzheimer-Patienten

Zusammenfassung: Klinische Studien, die nahe legen, dass Alzheimer-Patienten im Vergleich zur Altersgruppe deutlich seltener über Schmerzen berichten und deutlich weniger Analgetika verschrieben bekommen, haben die Frage aufgeworfen, inwieweit die Alzheimer-Erkrankung zu Veränderungen im Schmerzerleben führt. Um diese Frage zu beantworten, sind experimentelle Studien unabdingbar, da nur sie erlauben, Veränderungen des Schmerzsystems selbst zu erfassen. Die bisherigen experimentellen Befunde weisen darauf hin, dass die Schmerztoleranzschwelle deutlich erhöht und die vegetative Schmerzreaktion teilweise erheblich vermindert ist. Die Schmerzschwelle und schmerzkorrelierten Hirnpotenziale zeigten sich hingegen weitestgehend unverändert. Dies spräche eher für eine Abschwächung der Schmerzreagibilität bei Alzheimer-Demenz. Als mögliche Erklärungen hierfür diskutieren wir altersbedingte Veränderungen des Schmerzerlebens und neuroanatomische Veränderungen im Rahmen der Alzheimer-Erkrankung. Erste Ergebnisse einer eigenen Studie mit alternativer Methodik (mimische Schmerzreaktion, nozifensiver RIII-Reflex, u. a.) lassen im Gegensatz zu früheren Annahmen auch an die Möglichkeit einer erhöhten Schmerzreagibilität denken. Auch die beeinträchtigte Fähigkeit der Demenzpatienten zur verbalen Schmerzkommunikation und die Notwendigkeit alternativer, nonverbaler Messmethoden sind Thema der vorliegenden Übersichtsarbeit

The problem of pain management among persons with dementia, personhood, and the ontology of relationships

While pain is common among seniors, it is not adequately treated or managed. In particular, pain in seniors with dementia is often undertreated and undermanaged. Although the undertreatment of pain among persons with cognitive impairments represents a serious ethical concern for pain clinicians, most writers in the area explain the undertreatment of pain by focusing on issues related to liability, fears of addiction to opioids, and erroneous beliefs that pain is a normal part of the ageing process. We argue that the philosophical notion of personhood must also be given careful attention when considering the problem of pain undermanagement. In this paper, we consider the undertreatment of pain among seniors with dementia, while focusing on the ontology of relationships and on existential philosophy. Moreover, we outline a series of recommendations to help minimize the probability of pain undertreatment in this population and to encourage considerations relating to personhood when treating people with dementia.

Elder Care Supportive Interventions Protocol: Reducing Discomfort in Confused, Hospitalized Older Adults

This study tested the Elder Care Supportive Interventions Protocol (ECSIP), which are nursing and family support interventions designed to reduce discomfort and the associated consequences of delirium, impaired physical function, and need for post-hospital care in hospitalized older adults experiencing confusion from delirium or dementia. All adults older than age 74 or older than age 64 if from a nursing home who were admitted to the medical and surgical units of a tertiary care hospital were screened for a diagnosis of dementia, dependence on functional activities, or delirium. The ECSIP includes interventions to prevent and control discomfort, and to promote environmental organization and familiarity. Outcome measures administered within 48 to 72 hours of admission and again within 24 hours prior to discharge included the modified Discomfort Screen--Dementia Alzheimer's Type, NEECHAM Confusion Scale, and Katz Index of Activities of Daily Living. Patients problems with delirium and impaired physical function improved over hospitalization but were still pronounced at discharge. With the exception of reduced discomfort, there were no significant treatment effects for patients, which is attributed, in part, to inadequate implementation of the ECSIP protocol by nursing staff.

Pain Treatment and Quality of Life

The purpose of this study was to identify implications for the care of nursing home residents based on exploration of the relationship of depression to pain, cognitive impairment, and communication impairment in this population. A descriptive, cross-sectional, post-hoc design was used. Methods of statistical analysis included bivariate correlation coefficient calculation, stepwise multiple regression, and analysis of variance. A complex triad of cognitive impairment, pain, and depression was identified. The strength of the relationship between depression and cognitive impairment increases as cognitive impairment increases and in the presence of pain. This relationship is strongest among residents with severe cognitive impairment, severe communication impairment, and advanced age. Nurses may be able to relieve symptoms of depression in nursing home residents by using strategies based on knowledge of the resident's cognitive, communication, and pain status. Treating pain may lead to improved cognitive performance in residents who are depressed or reduced depression in residents who are cognitively impaired. The most elderly adults and adults with severe communication impairment may benefit most from these interventions.

Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC)

The purpose of this study, conducted in three phases, was to develop a clinically useful observational tool (i.e., the Pain Assessment Checklist for Seniors With Limited Ability to Communicate [PACSLAC]) to assess pain in seniors with severe dementia. In Phase 1, professional caregivers of seniors with severe dementia were interviewed in order to generate a list of pain-related behaviors that are characteristic of care recipients living in long-term-care facilities. Based on a systematic examination of interview transcripts by experienced researchers and an independent coder, a behavioral checklist (i.e., the initial version of the PACSLAC) was developed. The checklist items were organized into conceptually based subscales (e.g., facial expressions, activity/body movement). Phase 2 focused on an assessment of the internal consistency of the checklist (alpha =.92). Following an item analysis, the subscales of the PACSLAC (Social/Personality/Mood Indicators, Facial Expressions, Activity/Body Movement, and Physiological Indicators/Eating/Sleeping Changes/Vocal Behaviors) were found to be internally consistent. Phase 3 focused on a preliminary validation of the PACSLAC. Analyses suggest that the PACSLAC discriminated among pain events (during which there was a clear and recognizable cause for the patients' pain), events during which patients were experiencing nonpainful distress, and situations during which patients were calm.

Pharmacological treatments for persistent non-malignant pain in older persons

Persistent non-malignant pain is common, often neglected and under-treated among older persons. Some older adults do not complain because they consider chronic pain to be a characteristic of normal aging. Physicians have concerns regarding adverse effects of pharmacological treatment. The model of the World Health Organization for treatment of cancer pain is generally accepted and also recommended for persistent non-cancer pain. Furthermore, non-pharmacological treatment should complement drug treatment whenever possible. An initial assessment and possible treatment of underlying causes of pain are pertinent. Modern pharmacological pain management is based on non-opioid and opioid analgesics. NSAIDs are among the most widely prescribed class of drugs in the world. The new cyclo-oxygenase-2 inhibitors such as celecoxib and rofecoxib offer an alternative for the treatment of mild-to-moderate pain in patients with a history of gastric ulcers or bleeding. Paracetamol (acetaminophen) is being used widely for the management of mild pain across all age groups as it has moderate adverse effects at therapeutic dosages. For moderate pain, a combination of non-opioid analgesics and opioid analgesics with moderate pain relief properties (e.g. oxycodone, codeine, tramadol and tilidine/naloxone) is recommended. For severe pain, a combination of non-opioid analgesics and opioid analgesics with strong pain relief properties (e.g. morphine, codeine) is recommended. The least toxic means of achieving systemic pain relief should be used. For continuous pain, sustained-release analgesic preparations are recommended. Drugs should be given on a fixed time schedule, and possible adverse effects and interactions should be carefully monitored. Adjuvant drugs, such as antidepressants or anticonvulsants, can be very effective especially in the treatment of certain types of pain, such as in diabetic neuropathy. Effective pain management should result in decreased pain, increased function and improvement in mood and sleep.

Chronic pain in elderly nursing home residents: the need for nursing leadership

The incidence of chronic pain amongst elderly people in nursing homes is very high, making pain in this population a serious problem for aged care facilities. Research studies reveal a pattern of poor pain management in this setting despite the high incidence of pain suggesting that the management of pain in nursing homes is limited in scope and only partially effective. What is not fully appreciated by health professionals is the impact pain has on the lives of elderly people who live in nursing homes. In the study reported here a phenomenological method was used involving several in depth interviews with elderly people over a period of 9 months. Field notes of observations were also recorded as the participants went about their everyday lives in the nursing home. The discussion focuses on some of the themes drawn from the study with an emphasis on a key theme 'being constantly pained'. The findings of the study highlight what it is like to experience pain and how this impacts on everyday lives of elderly people. The paper concludes with some suggestions for health professional for improving care in this area.

Assessment of pain in the cognitively impaired older adult in long-term care

This study's objectives were twofold: to identify pain assessment methods used by caregivers of cognitively impaired older adults in long-term care, and to identify medications ordered and administered to them. Over 60% of RNs, with fewer LPNs and CNAs, used formal pain assessment tools. Patient records identified that 77.5% of cognitively impaired patients had a regularly ordered pain medication and 91% had a PRN pain medication order. Thirty percent of patients received at least one PRN medication in a 1-week period. No one diagnosis was significantly associated with a greater tendency for PRN pain medications to be administered, with cancer a possible exception. Eighty-two percent of cognitively impaired patients had a PRN order for acetaminophen. Using minimum data set (MDS) criteria, this study found that patients with greater communication impairments received fewer pain medications.

A comparison of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment

The aim of the study was to compare five different pain assessment scales for use with people with different levels of cognitive impairment who resided in nursing homes. The verbal rating scale, horizontal numeric rating scale, Faces pictorial scale, color analogue scale and mechanical visual analogue scale were presented in random order to 113 residents. Cognitive impairment was assessed using the Mini-Mental State Examination. The use of the verbal rating scale was the most successful with this group, completed by 80.5% overall, and 36% of those with severe cognitive impairment. Repeated explanation improved completion rates for all the scales. Consistency between scores on the five scales was good for those with none to moderate cognitive impairment and poor for those severely impaired. This study showed no difference in pain scores according to cognitive status.

Gerontology Coursework in Undergraduate Nursing Programs in the United States: A Regional Study

Because of the changing demographics, it is increasingly necessary for nurses to acquire competence in gerontology. In this article, the authors present the findings of a study investigating the extent to which undergraduate nursing programs in the United States include gerontology. Fifty-six undergraduate nursing programs in the United States were examined. In this study, course content and program curricula were examined to assess the extent to which programs include gerontological content, either integrated into other courses, or as required, stand-alone courses. The sample was randomly chosen from the Northeast, South, West and Midwest regions. All programs were accredited. More than 85% of programs evaluated did not require coursework in gerontology. The authors suggest that nurses are not being educated adequately to care for older adults.

James M. Humber and Robert F. Almeder (Eds.). Biomedical Ethics Reviews: Care of the Aged. Totowa, NJ: Humana Press, 2003

L'ouvrage collectif Care of the Aged fait partie de l'excellente série Biomedical Ethics Reviews publiée par Humana Press. Cet ouvrage contient huit articles analysant, sous divers angles, le rôle de l'éthique dans la prise en charge des personnes âgées. La toile de fond de l'ouvrage est que, d'ici 2050, les personnes âgées représenteront 20 % de la population mondiale et que la plupart résideront en Occident, ce phénomène s'expliquant par la baisse des taux de natalité et le remarquable allongement de la durée de vie. Il est donc impératif que le système de santé en général, et les soignants qui s'occupent de personnes âgées en particulier, comprennent bien comment prendre en charge cette cohorte. Ces huit articles explorent un large éventail de questions allant des obligations naturelles de la société à la participation de personnes âgées dans la recherche non-thérapeutique. L'ouvrage permettra au lecteur de mieux mesurer la complexité des questions liées à l'augmentation constante du nombre des personnes âgées. Les auteurs de Care of the Aged examinent la perception et la prise en charge des aînés à partir de disciplines très diverses, telles que la philosophie, la médecine, le travail social et le droit. Ils opposent à l'âgisme des arguments percutants et inspirants, et proposent au lecteur des moyens théoriques et pratiques d'améliorer la qualité de vie des personnes âgées.

The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia

The need for a specialized clinical regimen for patients with dementia who require palliative care has only recently been recognized. Structured approaches to palliative care are not well developed. The recognition and treatment of pain is an important part of this management risk. However, pain is consistently underdiagnosed and undertreated in this population. A factor contributing to this has been a lack of appropriate tools to help recognize and document pain. This study sought to develop and validate an easy-to-use pain scale for use in residential aged care homes. The tool was developed with residents with end- or late-stage dementia who were unable to articulate their needs, identified by the registered nurses who knew them. Results showed that following pain-relief intervention the average pain score recorded using the scale fell by more than half. A paired Student's t-test showed the reduction to be highly significant (P<0.001). Validity and internal reliability, assessed by calculating Gamma and Cronbach's alpha, were found to be satisfactory. Qualitative evidence gathered from users of the scale indicated that it was considered a useful clinical device that could be completed within one minute. Further analysis of the use of the scale in clinical settings, testing of inter-rater reliability and examination of the limitations found in this study will commence early in 2004.

Testing a theory of chronic pain

BACKGROUND

Chronic pain is highly prevalent among older people with arthritis, with depression as its major outcome. The psychopathological process of chronic pain and its outcomes in older people with arthritis have not been the subject of extensive research. The purpose of this study was to test a middle-range theory of chronic pain derived from the Roy Adaptation Model, a nursing theory whose validity has not been tested in the context of chronic pain.

METHODS

The study used a convenience sample of 71 older people with arthritis. Two subscales of the Arthritis Impact Measurement Scales were used to measure pain and physical disability. Social support was measured by Part II of the Personal Resource Questionnaire, and the Elderly Daily Stress scale was used to measure daily stress. Participants also completed the 10-item Center for Epidemiological Studies of Depression scale. Univariate analysis, correlation, and path analysis were used to analyse the data.

RESULTS

Overall, the data supported the hypothesized model in which pain, disability, social support, age, and gender are predictors of daily stress and daily stress further predicts depression. The direct effects of chronic pain, disability, and social support accounted for 37% of the variance of daily stress, which in turn predicted 35% of the variance of depression. Age and gender had no influence on daily stress. The chi-square index suggested a fit between the data and the model, and therefore the current model is temporarily accepted. Other fit indices also showed a good fit of the model to the data. To simplify the model, a revised version was developed.

CONCLUSIONS

This study validated a middle-range theory to explain the effects of chronic pain in older people with arthritis and highlights the importance of chronic pain in the development of depression.

Pain assessment in critical care: what have we learnt from research

Despite an ongoing acknowledgement in the literature that pain is a significant problem within the critical care environment, this issue has not been adequately addressed by critical care nurses. This paper examines strategies for changing pain management practices in critical care, including reviewing documentation practices, the utilisation of guidelines and algorithms to augment clinical decision making, and increasing educational opportunities available to critical care nurses. It is recommended that pain assessment be given a higher priority within the clinical context, particularly as inadequate pain assessment and management has been linked to increased morbidity and mortality within critical care. Importantly, critical care nurses need to not only be aware of research-based pain management practices, but also lead the way in implementation and continuous evaluation as a measure of decreasing patient pain in the future.

Do nurses exercise power in basic care situations?

Power is a matter of authority and control. It can be wielded either consciously or unconsciously, and it can be either overt or latent. Using a structured questionnaire, this study set out to describe nurses' opinions about the exercise of power in basic care situations in both acute and long-term care. The questionnaire was organized into four categories in which items concerned: power in obligatory daily activities; power in activities necessitated by obligatory activities; power in voluntary activities; and power in activities that take into account the patient's characteristics. The samples consisted of 228 nurses from five medical and surgical wards of district hospitals, and 233 nurses from five geriatric units of a community health centre and from one nursing home in Finland. The final response rate was 65% (acute care 76%; long-term care 55%). Data analysis was based on statistical methods. The results showed that, in the nurses' own opinion, negative power is exercised only in certain situations and in the patient's best interest, when for instance there are concerns that something may happen to the patient.

The association between knee temperature and pain in elders with osteoarthritis of the knee: a pilot study

BACKGROUND

Osteoarthritis is a highly prevalent, disabling condition that causes significant pain and suffering among older adults. Cognitively impaired elders are as susceptible to osteoarthritis as their peers. However, since they have diminished ability to communicate their pain, an alternative method to detect osteoarthritis pain in cognitively impaired elders is urgently needed. Because the late stages of osteoarthritis involve joint inflammation with a mild increase in local temperature, skin surface temperature might reasonably be expected to serve as a proxy measure of osteoarthritis pain. If knee surface temperature could be shown to predict pain in cognitively intact elders, it could be used as a proxy measure of pain for cognitively impaired elders.

AIM

To test this, the study reported here assessed the relationship between knee surface temperature and pain in cognitively intact elders with osteoarthritis of the knee.

METHODS

We recruited 12 cognitively intact elders with documented osteoarthritis of the knee who lived in retirement apartments. Elders' pain and knee temperature were measured three times on three separate occasions. Osteoarthritis pain of the knee was measured using the Knee Pain Scale and the Western Ontario and McMaster Osteoarthritis Index pain subscale. A YSI Model 4000 Dual Channel Display Telethermometer was used to measure knee temperature.

RESULTS

We found no significant associations between knee temperature and any of the pain measures used, with one exception. However, body mass index, amount of pain medication used and activity level observed during the interview were significantly related to elders' pain.

CONCLUSION

Knee temperature does not appear to predict knee pain in elders with osteoarthritis of the knee. Body mass index, use of pain medication and activity level are better predictors of this.

Family members' perceptions of pain and distress related to analgesics and psychotropic drugs, and quality of care of elderly nursing home residents

The aims of the present study were: (1) to describe family members' perceptions of nursing homes residents' pain and distress in relation to analgesics and psychotropic drugs; and (2) to compare whether background variables, dementia, help/support, prescribing of analgesics and psychotropic drugs, and quality of care vary between subgroups of residents. Two hundred and thirty-two family members of elderly people in 10 Swedish nursing homes participated in the study. The participants responded to a questionnaire including background variables, pain and distress variables, and the Quality from the Patient's Perspective (QPP) questionnaire. Data on drug prescribing was obtained from the medical records. The head nurse on each ward noted whether or not the resident had a documented or known diagnosis of dementia. The results showed that a high frequency of elderly nursing home residents were estimated as having physical pain and worry. A large number of the residents were prescribed psychotropic drugs. In addition, some of the residents with moderate or severe physical pain were not prescribed any analgesics. The residents were divided into three subgroups based on scores of physical discomfort, physical pain and worry. Subgroup comparisons differed with regard to sex, help/support, drugs and quality of care. Staff have a responsibility to assess the residents' pain and distress since this will form a basis for better pain and distress management. Other suggestions for improving quality of care are the provision of better information to the family members and the residents, meaningful occupation, less task-oriented care, and care that involves residents.

Difficulties in identifying distress and its causes in people with severe communication problems

In 1999 a palliative care team was established for adults with severe learning disabilities at Northgate Hospital in the North East of England. It was given NHS Beacon status in 2001 and now provides specialist advice to patients with learning disabilities who have a life-limiting or life-threatening illness through cancer, dementia or other conditions. This partnership between learning disability and palliative care teams has produced new views of the issues faced by this group of people. Through its work with caring for such patients, one of the key issues which has arisen is identifying distress and its causes.

Disease-specific pain measures for osteoarthritis of the knee or hip

Many elders suffer from chronic pain resulting from osteoarthritis (OA) of the knee or hip. This review identifies useful pain measures for assessing OA. Several disease-specific pain measures are discussed: Arthritis Impact Measurement Scales pain subscale, Western Ontario and McMaster University OA Index pain subscale, pain subscales of the Index of Severity for OA of the Hip or of the Knee, and Knee Pain Scale. Generic pain measures, the verbal descriptor scale, and the 21-point box scale, also are discussed. Because knee/hip OA is characterized by pain that is activated during or aggravated by certain activities, disease-specific pain scales that measure pain associated with these various activities are more effective than a generic pain scale.

Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale

OBJECTIVES

To develop a clinically relevant and easy to use pain assessment tool for individuals with advanced dementia that has adequate psychometric properties.

DESIGN

Instrument development study using expert clinicians and behavioral observation methods. Measurement of sensitivity of the instrument to detect the effects of analgesic medications in a quality improvement activity.

SETTING

Inpatient dementia special care units in a Veterans Administration Medical Center.

PARTICIPANTS

Nineteen residents with advanced dementia who were aphasic or lacked the ability to report their degree of pain and six professional staff members. Additionally, data from medical records of 25 residents who were receiving pain medications as required (PRN) were collected.

MEASUREMENTS

Based on the literature review, related assessment tools and consultation with expert clinicians, a five-item observational tool with a range of 0 to 10 was developed. The tool, Pain Assessment in Advanced Dementia (PAINAD), was compared with the Discomfort Scale and two visual analog scales (discomfort and pain) by trained raters/expert clinicians in the development study, and used for detection of analgesic efficacy in a quality improvement activity.

RESULTS

Adequate levels of interrater reliability were achieved between dyads of the principal investigator with each clinical research rater and between two raters. PAINAD had satisfactory reliability by internal consistency with a one factor solution. PAINADthe Discomfort Scale-Dementia of Alzheimer Type (DS-DAT) were significantly correlated, providing evidence of construct validity. PAINAD detected statistically significant difference between scores obtained before and after receiving a pain medication.

CONCLUSIONS

The PAINAD is a simple, valid, and reliable instrument for measurement of pain in noncommunicative patients. Since the patient population used for its development and testing was limited to a relatively small number of males, further research is needed before it can be universally recommended.

Pain assessment in patients with possible vascular dementia

PREVIOUS studies comparing Alzheimer's disease (AD) patients with the normal elderly suggest that AD patients experience less pain. In the present study, pain reporting in 20 patients with possible vascular dementia (VaD) was compared to 20 nondemented elderly who had comparable pain conditions. It was hypothesized that, due to de-afferentiation, the possible VaD patients would experience more pain than the cognitively intact elderly. Pain assessment was conducted using three visual analogue scales, (1) the Coloured Analogue Scale (CAS) for Pain Intensity, (2) the CAS for Pain Affect, and (3) the Faces Pain Scale (FPS); a verbal pain questionnaire, Number of Words Chosen--Affective (NWC-A) of the McGill Pain Questionnaire; and an observation scale, the Checklist of Nonverbal Pain Indicators (CNPI). Results showed a significant increase in the scores on the CAS for Pain Affect and the FPS in the demented patients compared to the control group. There was a tendency for an increase in scores on the CNPI in the VaD group. These results suggest that patients with possible VaD suffer more pain than healthy elderly without cognitive impairment.

Feasibility of using quadriceps-strengthening exercise to improve pain and sleep in a severely demented elder with osteoarthritis - a case report

BACKGROUND: Osteoarthritis (OA) of the knee, which is prevalent among older adults in nursing homes, causes significant pain and suffering, including disturbance of nocturnal sleep. One nonpharmacologic treatment option is quadriceps-strengthening exercise, however, the feasibility of such a treatment for reducing pain from OA in severely demented elders has not been studied. This report describes our test of the feasibility of such an exercise program, together with its effects on pain and sleep, in a severely demented nursing home resident. CASE PRESENTATION: The subject was an elderly man with severe cognitive impairment (Mini-Mental Status Exam score 4) and knee OA (Kellgren-Lawrence radiographic grade 4). He was enrolled in a 5-week, 10-session standardized progressive-resistance training program to strengthen the quadriceps, and completed all sessions. Pain was assessed with the Western Ontario and MacMaster OA Index (WOMAC) pain subscale, and sleep was assessed by actigraphy.The patient was able to perform the exercises, with a revision to the protocol. However, the WOMAC OA pain subscale proved inadequate for measuring pain in a patient with low cognitive functioning, and therefore the effects on pain were inconclusive. Although his sleep improved after the intervention, the influence of his medications and the amount of daytime sleep on his nighttime sleep need to be considered. CONCLUSIONS: A quadriceps-strengthening exercise program for treating OA of the knee is feasible in severely demented elders, although a better outcome measure is needed for pain.

Older adults with hip fractures. Treatment of pain following hospitalization

This study examined pain experiences and treatment for older adults in long-term care or rehabilitation settings 3 week after surgical repair of a hip fracture. Pain report and pain treatment for cognitively intact residents were compared with cognitively impaired residents. Two thirds of all participants reported pain. Most rated pain as slight or mild in severity. Pain report was similar for cognitively impaired and intact participants. Pain was reported as severe or worse by 17% of the residents. Nursing care plans documented comfort as a goal for fewer than half the participants. Almost 40% (n = 23) of the participants were receiving no pain medication 3 weeks postoperatively, five of these rated their pain as moderate or severe. Pain documentation, including effective non-pharmacological treatments, needs to be improved for cognitively impaired and intact older adults who are recovering from hip fracture surgery.

The last 48 hours of life in long-term care: a focused chart audit

OBJECTIVES

As a component of palliative care educational program development, the faculty at the University of Ottawa Institute of Palliative Care wished to assess end-of-life care for patients in long-term care (LTC) settings to develop an educational strategy for physicians.

DESIGN

A chart audit, focusing on the last 48 hours of life of residents dying in LTC facilities.

SETTING

Five LTC facilities in a city in Canada.

PARTICIPANTS

Residents who died in the LTC facilities in a 12-month period. Those who died suddenly (i.e., with no palliation period) or in a hospital were excluded.

MEASUREMENTS

Symptoms highlighted in the literature as commonly found in the terminally ill and the matching treatments were recorded on an audit form created by the authors. Included were pain, dyspnea, noisy breathing, delirium, dysphagia, fever, and myoclonus.

RESULTS

One hundred eighty-five charts were reviewed. A large number of patients were cognitively impaired. Cancer was the final diagnosis in 14% of cases. Respiratory symptoms were the most prevalent symptom, with dyspnea being first and noisy breathing third. Pain was second, with a prevalence similar to that found in studies of cancer patients. Dyspnea was not treated in 23% of the patients with this symptom; opioids were used in only 27% of cases with dyspnea. Ninety-nine percent of patients who experienced pain were treated for it. Less than one-third of patients with noisy breathing were treated. Delirium was not treated in 38% of the cases, and no anti-dopaminergic medications were administered. Nurses were primarily responsible for documenting end-of-life issues, supporting the families of the dying residents, and communicating with other team members.

CONCLUSION

The focused chart audit identified the high prevalence of cognitive impairment in the patient population, which complicates symptom management. Respiratory symptoms predominated in the last 48 hours of life. This symptom profile differs from that of cancer patients, who, according to the literature, have more pain and less respiratory trouble. Management of symptoms was variable. Nurses played a crucial role in the care of dying residents through their documentation and communication of end-of-life issues. Appropriate palliative care education can provide knowledge and skills to all health-care professionals, including physicians, and assist them in the control of symptoms and improvement of quality of life for patients dying in LTC facilities.

Nursing staff members' perceptions of pain indicators in persons with severe dementia

OBJECTIVES

The aims of this study were to (1) identify behaviors that occur in noncommunicative nursing home residents that are perceived by nurses to be indicators of pain, (2) determine factors affecting the differentiation of pain behaviors from similar behaviors due to other causes, and (3) assess nurses' perceptions of the prevalence and importance of specific indicators of pain as well as barriers to the detection of pain in this population.

SETTING AND PATIENTS

Seventy-two staff members of three nursing homes were interviewed and surveyed about specific behaviors associated with pain. Focus groups were conducted with staff to validate pain indicators and investigate perceptions of their own ability to identify pain.

RESULTS

Nursing staff members agreed on a core group of behaviors that they perceive as pain indicators in elderly persons suffering from dementia. These indicators include specific physical repetitive movements, vocal repetitive behaviors, physical signs of pain, and changes in behavior from the norm for that person. The nursing staff members' level of familiarity with the residents was reported to have a significant effect on staff members' ability to identify and differentiate pain behaviors from other behaviors of impaired residents. Barriers to the detection of pain pertain to staff issues, resident behaviors, and resident-staff relationships.

CONCLUSIONS

The study of pain among the noncommunicative elderly and, in particular, the development of a tool that can be used to assess their pain may greatly improve the quality of life of the estimated 20% to 35% of nursing home residents who cannot adequately express their needs.

Pain assessment and management in cognitively impaired nursing home residents: association of certified nursing assistant pain report, Minimum Data Set pain report, and analgesic medication use

OBJECTIVES

The primary purpose of this preliminary study was to investigate the associations between certified nursing assistant (CNA) report of pain, Minimum Data Set (MDS) report of pain, and analgesic medication use in cognitively impaired nursing home residents.

DESIGN

Correlational study.

SETTING

Three nursing homes in the greater Birmingham, Alabama area.

PARTICIPANTS

Fifty-seven cognitively impaired nursing home residents with a mean Mini-Mental State Examination (MMSE) score of 11.1.

MEASUREMENTS

Pain was assessed using a three-item proxy pain questionnaire (PPQ), developed by the researchers and administered to the residents' primary CNA. MDS and analgesic medication data corresponding with the time of PPQ data collection were gathered from medical records. Cognitive status was measured with the MMSE.

RESULTS

The PPQ elicited substantially higher estimates of pain prevalence than the MDS (48% versus 20%), and the PPQ and the MDS were not well correlated (pain frequency: r=.19, P=.18; pain intensity: r=.22, P=.11). The PPQ was also more strongly associated with analgesic medication use than the MDS. Cognitive status was significantly associated with pain report on the PPQ but not on the MDS. Test-retest reliability coefficients for the three items of the PPQ were excellent, ranging from.84 to.87 (P </=.01).

CONCLUSIONS

The CNA-generated PPQ was a more sensitive measure of pain than the MDS for this sample. Although the MDS represents an important step toward systematic and standardized assessment of pain, more emphasis should be placed on multimodal assessment, including CNAs' perceptions and observations about pain experienced by cognitively impaired nursing home residents.

Assessment and measurement of pain in older adults

Although the empiric base is still limited when providing clear directions for pain assessment and management in older adults, it is possible to identify recommendations for guiding practice based on consensus and a developing scientific base to support best practice activities. A brief overview of the epidemiology and consequences of pain is offered, followed by a summary of issues and approaches relevant to pain assessment in older adults. Cohort-specific recommendations for comprehensive pain assessment and measurement based on current evidence are then addressed, including strategies for assessment of pain in cognitively impaired older adults.

Pain measurement in the elderly: a review

Measurement of pain in the elderly is an issue that has received limited attention. The purpose of this review was to analyze and synthesize research findings from 1975 to 1999 that are related to pain measurement in the elderly. Based on best-evidence synthesis criteria, the review led to the selection of 15 studies. These studies used a descriptive and quantitative analytic approach and were not based on a theoretical framework. Comparison of selected pain measurement tools was incorporated in 40% of the included studies. Substantial gaps in knowledge were identified; namely, these included determining the reliability and validity of selected tools for the institutionalized or community-dwelling elder; modifying instruments to overcome barriers such as communication issues, cultural diversity, or cognitive dysfunction; and expanding the scope of pain measurement to other dimensions of the pain experience.

Recognising pain in older adults living in sheltered accommodation: the views of nurses and older adults

Sixty-six randomly selected older adults and their contact nurses participated in interviews based on standardised assessments of pain and open-ended questions focusing how pain was expressed and recognised. The sample included older adults with normal as well as cognitively impaired function. Seventy-nine percent of older adults with normal cognition were often in pain. Contact nurses assessed pain in 57% of cognitively impaired older adults. The content in the statements showed that pain recognition was a communicative interactive process based on verbal and non-verbal expressions. The process comprised attempts to understand the cause and intention of the expression and to verify the presence of pain. Changes in mood, facial expressions and physiological responses were described less often by older adults than by their nurses. Contact nurses of cognitively impaired older adults judged immobility as the source of pain, that it was possible to see when the person was in pain and that pain was expressed by paralinguistic and body language more often than contact nurses of cognitively healthy older adults. Characteristics of nurses and older adults could facilitate or hinder pain recognition. The findings indicate a need for reflective discussions in the staff group focusing on how to perform systematic assessments of verbal and non-verbal expressions and of hindrances and facilitators for recognising pain in older adults.

Pain in nursing home residents: management strategies

Pain is prevalent and undertreated in nursing home residents, despite the existing wide array of effective pharmacological and nonpharmacological treatment modalities. In order to improve the quality of life of these vulnerable individuals, practitioners require education about the correct approach to assessment and management. Assessment should be comprehensive, taking into account the basic underlying pathology (e.g. osteoarthritis, osteoporosis, peripheral neuropathy, fibromyalgia, cancer) as well as other contributory pathology (e.g. muscle spasm, myofascial pain) and modifying comorbidities (e.g. depression, anxiety, fear, sleep disturbance). Pharmacological management should be guided by a stepped-care approach, modelled after that recommended by the World Health Organization for treatment of cancer pain. Nonopioid and opioid analgesics are the cornerstone of pharmacological pain management. Tricyclic antidepressants and anticonvulsants can be very effective for the treatment of certain types of neuropathic pain. In addition to treating the pain per se, attention should be given to prevention of disease progression and exacerbation, as maintaining function is of prime importance. Nursing home residents with severe dementia challenge the practitioner's pain assessment skills; an empirical approach to treatment may sometimes be warranted. The success of treatment should be measured by improvement in pain intensity as well as physical, psychosocial and cognitive function. Effective pain management may impact any or all of these functional domains and, therefore, substantially improve the nursing home resident's quality of life.

Recognizing pain in the institutionalized elder with dementia

Of the approximately 2 million elders residing in nursing homes, experts estimate that 49% to 83% are experiencing pain. Elders in nursing homes have a high incidence of cognitive impairment, possibly as high as 50%. The verbalization of pain can be difficult for those with cognitive impairment, and elders with dementia may be undertreated and unknowingly allowed to suffer. This article summarizes what is known about pain assessment in the cognitively impaired elderly who reside in nursing homes. Clinical practice implications were derived from this summary. Until accurate ways of assessing pain are discovered, nurses must be educated to the prevalence of pain in cognitively impaired elders and the subtle ways in which it might be detected. Nursing practice is about eliminating suffering. Relieving suffering in those most vulnerable and unable to express their needs is critical.

A pilot study of the relationship between discomfort and agitation in patients with dementia

People with dementia often have painful conditions that go unnoticed because of their communication problems. Signs of pain in this population may include agitation and observable behaviors associated with discomfort. Agitation, discomfort, and severity of dementia were evaluated in 33 Veterans Affairs nursing home patients using the Cohen-Mansfield Agitation Inventory, the Discomfort Scale, and the Global Deterioration Scale, respectively. Findings revealed statistically significant positive relationships between agitation and severity of dementia (r = 0.34, P = 0.01), discomfort and severity of dementia (r = 0.44, P = 0.01), and agitation and discomfort (r = 0.50, P = 0.003). In a multiple regression analysis, agitation was significantly associated with discomfort (R(2) =.14, P = 0.02) after controlling for dementia severity. These preliminary findings suggest that discomfort may be a source of agitation.

Assessment and understanding of pain in patients with dementia

The literature on pain in dementia patients is reviewed. A summary of methods for assessment of pain in demented elderly persons and an examination of studies that used such methods are included. In addition, literature theorizing a decrease in affective pain in this population is discussed; management of pain in such patients is not discussed extensively. Research reveals 3 major findings: (a) a moderate decrease in pain occurs in cognitively impaired elderly persons, (b) communicative dementia patients' reports of pain tend to be as valid as those of cognitively intact patients, and (c) assessment scales developed thus far for noncommunicative patients require improvement in accuracy and facility. Many questions about pain in dementia patients remain, and the continued development of valid pain assessment techniques is a necessity.

Ethical implications of pain management in a nursing home: a discussion

Pain is the most frequently communicated complaint among elderly people. Discussion of the ethics of pain management in nursing home residents has not appeared in the literature. The purpose of this article is to present an ethically-based pain management action plan for elderly nursing home residents. Nurses empowered with the latest information and cognizant and comfortable with their own views about pain are likely to effectuate a positive patient outcome. Further research will add to the current knowledge base while laying the groundwork for new interventions.

Nurses' perceptions of pain assessment and treatment in the cognitively impaired elderly. It's not a guessing game

The purpose of the study was to describe nurses' perceptions regarding the assessment and treatment of pain in patients with late-stage dementia. Thirty nurses from six long-term care facilities were interviewed using a semistructured format for this qualitative study. Initial results were presented to a second group for validation and refinement of findings. The most commonly cited behaviors used to indicate discomfort were facial grimacing, restless body movement, change in behavior, moaning, and tense muscles. Psychotropic drugs were perceived to be commonly misused because behavior changes were seen as a psychiatric problem rather than a representation of the patient's unmet need. Nurses had positive feelings about using both narcotics and nonnarcotic analgesics with this population but believed both types of analgesics were underused. The most common concerns regarding the administration of narcotic analgesics to this population were falls, sedation, and constipation.

The checklist of nonverbal pain indicators (CNPI)

This article critiques the literature on existing pain assessment instruments for cognitively impaired elders and reports findings of pilot testing of the Checklist of Nonverbal Pain Indicators. This instrument was designed to measure pain behaviors in cognitively impaired elders. Instrument testing was conducted on a population of elderly patients with hip fractures. Interrater reliability showed 93% agreement on the dichotomous checklist items. Behaviors occurred more frequently during movement in this population. Of the six pain-related behaviors in the instrument, facial grimaces/winces occurred in 44% of the patients tested. Observed pain behaviors were positively correlated with self-report of pain. No differences between observed pain behaviors in cognitively intact versus cognitively impaired older adults with hip fractures were noted. Limitations of the instrument and recommendations for tool use are discussed.

Comparison of pain assessment instruments in cognitively intact and cognitively impaired nursing home residents

This study was conducted to determine which pain severity and location instruments were most useful in the nursing home setting. Pain severity and location were assessed monthly for 1 year in 37 participants enrolled in a restorative rehabilitation program. Pain location was determined by the residents' indications on a diagram, a doll, and their body. Pain severity was determined by resident response to verbal, visual analog, faces, and word scales. Cognitively impaired residents had greater difficulty using all instruments. The McGill Word Scale was used most to determine pain severity. Pointing to themselves most frequently determined pain location among residents. New strategies are needed for pain assessment in the elderly, especially the cognitively impaired elderly, and a combination of instruments to assess pain in the latter group may be necessary.

Assessment and management of cancer pain in the cognitively impaired elderly

Cancer pain in the cognitively impaired elderly is a challenging problem for clinicians. Nursing and medical literature on the subject is sparse because the problem has not been adequately studied. This article presents strategies for assessment and management when the older adult has cancer and cognitive impairment. Traditional, pharmacologic, and alternative therapies are reviewed. Common etiologies for pain and confusion also are presented.

Assessing the pain of people with cognitive impairment

This review presents evidence of the undertreatment of pain for people with cognitive impairment and explores reasons for this, emphasizing inadequate detection due to lack of suitable pain assessment protocols. Implications for practice and suggestions for further research are made.

Pain in nursing home residents: an exploration of prevalence, staff perspectives, and practical aspects of measurement

OBJECTIVE

To help rectify the underdiagnosis of chronic pain in frail nursing home residents by developing a new feasible pain self-report instrument, the structured pain interview; to use this new tool to estimate pain prevalence and staff's knowledge of residents' pain in two nursing homes; and to compare the performance differences of the structured pain interview and the commonly used 0-10 scale.

DESIGN

Cross-sectional survey.

SETTING

One 120-bed VA-affiliated and one 125-bed university-affiliated, community-based nursing home in Durham, North Carolina.

PATIENTS

One hundred fifty-eight chronic care nursing home residents without aphasia, acute illness, persistent vegetative status, or severe hearing impairment and 3 1 nursing home nurses.

OUTCOME MEASURES

Pain prevalence according to resident self-report and nurse report; stability of response to the structured pain interview and 0-10 scale over 1 month; agreement between residents and nurses on the structured pain interview and 0-10 scale.

RESULTS

Fifty-eight percent of the VA and 45% of the community nursing home residents reported pain. Forty-two percent at the VA and 20% at the community home were unable to respond to the 0-10 scale, compared with 7.5% and 14% using the structured pain interview. Stability of response to the structured pain interview at 1 month was 0.56 at the VA (nurse-resident agreement 0.38) and 0.72 in the community (nurse-resident agreement 0.07), which was very comparable to the 0-10 scale.

CONCLUSIONS

We have developed a highly feasible tool for examining pain prevalence in nursing homes. This tool uncovered considerable miscommunication regarding pain between residents and staff. Improvement in pain communication between nursing home residents and staff is needed, so that more effective pain treatment programs can be developed for this vulnerable population.

Patient problems, needs, and nursing diagnoses in Swedish nursing home records

PURPOSE

To describe the main problems, needs, risks, and nursing diagnoses and to examine the descriptions of some common and serious patient problems in nursing home records.

METHODS

A retrospective audit of a stratified, random sample (N = 12O) of patient records from eight nursing homes in six Swedish municipalities.

FINDINGS

Results showed major deficiencies in nursing documentation in the patient records. Only one record contained a comprehensive description of one patient problem that corresponded to the requirements of Swedish laws and regulations. No record was found that contained a systematic and comprehensive assessment of any of the selected problems based on established criteria or the use of an assessment instrument.

CONCLUSIONS

Nursing documentation in patient records does not reflect the use of systematic assessment and research-based instruments for determining patient care needs. Nurses need skills in assessment in the care of the elderly to be able to set priorities in care and deliver adequate care.

Caregiver distress. Related to disruptive behaviors on special care units versus traditional long-term care units

The link between staff stress and exposure to disruptive behaviors is an important issue in long-term care settings. This study compared the perceptions of two groups of formal caregivers (staff) regarding their distress from the behaviors of residents in their care. Staff on special care units for dementia were less distressed with disruptive behaviors than comparable staff on traditional units, although they reported higher exposure to these behaviors. These results were related to different perceptions of intent to harm and expectations of physical aggression as "part of the job." Implications for nursing include education and support for staff to enhance the quality of life for residents and staff on units where disruptive behaviors occur.

Alzheimer patients report less pain intensity and pain affect than non-demented elderly

Pain assessment for patients with Alzheimer's disease (AD) is generally aimed at quantifying pain, i.e., the intensity and locations of pain. Based on the extensive neuropathology in limbic brain areas with this disorder, we hypothesized that, compared to control patients, AD patients would report an additional loss of qualitative aspects of pain, i.e., pain affect. This hypothesis was tested by administering specific parts of three pain questionnaires and comparing the use of analgesics in 19 AD patients with that of 18 elderly patients without dementia who were matched for the presence of painful conditions. Results reveal that AD patients, compared to controls, experience less intense pain and less pain affect. In contrast, the number of AD patients using analgesics did not differ from the number of controls. These findings suggest that pain assessment for patients with AD should be focused on both quantitative and qualitative aspects of pain.

Examining pain in aggressive cognitively impaired older adults

Few studies have explored the phenomenon of pain in people with severe cognitive impairment. Pain assessment, which depends primarily on people's ability to describe dimensions of pain, becomes problematic when clients' cognitive impairment is so severe they cannot respond to pain assessment tools. The purpose of this study was to describe the phenomenon of pain for a subgroup of aggressive cognitively impaired nursing home residents who were enrolled in a larger study of aggressive behavior. To determine if pain was a possible factor influencing aggression, information was sought from five sources: family members, nursing assistant (NA) caregivers, medical record listings of pain-related diagnoses, use of analgesics, and observations of aggressive behaviors. Families reported pain in 44% of subjects, while NAs reported pain in 66% of subjects. Seventy-six percent of subjects had one or more pain-causing diagnoses. Sixty-four percent of subjects whose family members thought they may have pain were being treated with analgesics, compared to 44% of subjects whose NA reported they may be experiencing pain. Aggression scores were significantly higher in subjects who had two or more pain-related diagnoses and in subjects with arthritis. Nurses who are aware of a history of pain, reports of pain by families and caregivers, presence of pain-related medical diagnoses, and who realize pain may be a trigger for aggressive behavior may be more likely to recognize pain in cognitively impaired older adults. Better pain assessment should lead to improved treatment of pain in this population.

Predictors of pain self-report in nursing home residents

The purpose of this study was to examine the influence of cognitive function and other biopsychosocial factors on test-retest agreement, four-week variability, and intensity of self-reported pain using the verbal 0 to 10 scale and a pain thermometer in 115 nursing home residents over four weeks. Pain was assessed twice on three days during week 1, and once each during weeks 2, 3 and 4. A forward stepwise regression procedure was used to examine the influence of biopsychosocial parameters (age, race, gender, educational status, marital status, comorbidity, cognitive function, depression, social support, physical function and self-rated health) on pain intensity, test-retest agreement and variability. There was a quadratic association between cognitive function and test-retest agreement with the 0-10 scale; residents with Folstein scores of 22-26 were more likely to show disagreement (50% of 34) than residents with scores < 22 or > 26 (7% of 71). Higher Folstein scores were also associated with greater pain intensity for both pain scales (p < 0.001). Baseline pain intensity was significantly related to pain variability (0-10 scale only). The clinician should be cognizant of these relationships when interpreting verbalizations of pain in long-term care facilities.

Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture

OBJECTIVE

To compare the experience of pain and treatment of pain in cognitively impaired and cognitively intact older adults after surgical repair of a hip fracture.

DESIGN

Prospective comparative survey design.

PARTICIPANTS

A convenience sample of 88 hip fracture patients (53 cognitively impaired, 35 cognitively intact) from three Midwestern urban hospital orthopedic units was interviewed between days 2 and 5 postoperatively. Subjects whose Folstein Mini-Mental State Exam (MMSE) score was less than or equal to 23 were categorized as impaired.

RESULTS

Pain report and intensity did not differ significantly between the two groups. One-third of the subjects in both groups rated pain as severe or worse. Cognitively impaired subjects scored significantly higher on the Checklist of Nonverbal Pain Indicators observed with movement (CNPI-m) than did cognitively intact subjects. Cognitively impaired subjects received significantly less opioid analgesics than cognitively intact subjects in the first and second 48 hours postoperatively. Both groups received less than 25% of the mean prescribed amount of opioid analgesics. Age, MMSE, and CNPI-m score accounted for 27% of the variance in the amount of opioid analgesic administered in the first 48 hours postoperatively.

CONCLUSIONS

Pain is treated poorly in older postoperative patients. Cognitive impairment and age strongly influence the amount of analgesic nurses administer to older patients after surgical repair of hip fracture. Provision for patient comfort is a fundamental ethical obligation of healthcare providers. Clinicians need to pursue this goal more aggressively, especially for cognitively impaired, postoperative older adults.