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

Pain assessment in the recovery room

The assessment and management of pain in the acute hospital setting is an important issue for practitioners (Layman Young et al 2005). Despite advances in pain management (Fotiadis et al 2004, Powell et al 2004, Wu & Richman 2004) and the use of multimodal analgesic techniques in the theatre/recovery environment (Jin & Chung 2001), for a variety of reasons (Turk & Okifuji 1999, Pasero 2003), patients' reports of pain following surgery suggest that it remains problematic (Rawal 2002, Brown 2004, Coll et al 2004). In the recovery room disorientation, anxiety, fear and nausea may add to and alter patients' perception of pain, making it crucial that recovery room practitioners understand pain and pain assessment. This article outlines and critiques pain assessment tools that may be used to enhance pain management practices in the recovery room.

Summative index: Acute pain management in older adults

One of the challenges in measuring adoption of complex evidence-based practices (EBPs) such as acute pain management is determining what constitutes adherence to an EBP guideline. Traditionally, individual process indicators extrapolated from an EBP guideline are selected as dependent measures of guideline adoption. When using multiple indicators, the challenge is determining the number of indicators that must be met to define adherence to the EBP guideline. The primary goal of the study reported herein was to develop and test a summative index (SI) of guideline adherence for acute pain management of hospitalized older adults. Steps in formulating the initial index are described as well as refinement of this metric. Techniques used included factor analysis, discriminate validity, and split-half reliability. The resulting SI is composed of 18 indicators each scored as 0 (not present) or 1 (present), with a total SI score of 0 to 18.

Improving pain assessment and management for residents with dementia

Pain is a phenomenon experienced by many older adults, with the majority reporting chronic or recurrent pain. Across the breadth of practice care settings, pain is poorly assessed and poorly managed for older patients and for those with dementia, and the pain management provided is typically even more deficient. Consultant pharmacists have the expertise to help other health care professionals do better in assessing and addressing pain in the older adult, especially those with cognitive impairment. The quality of life for elders can be greatly improved by sharing that expertise.

Minimum geriatric screening tools to detect common geriatric problems

BACKGROUND

Health services for the elderly are becoming increasingly important in industrialized nations, and comprehensive geriatric assessment (CGA) is one of the procedures designed to improve the health of this sector of the population. In 2003 a survey among Belgian geriatricians showed that despite the interest of the geriatric teams for comprehensive geriatric assessment, it was not used enough. Considering these results, as a first step, screening tools were proposed for the main geriatric domains (Minimum Geriatric Screening Tools, MGST).

OBJECTIVES

To assess the feasibility of a MGST within the teams of geriatric units and to evaluate the efficacy of a MGST on the detection rate of the geriatric problems of admitted subjects.

DESIGN

Prospective observational survey.

METHODS

The teams were first asked to encode active geriatric problems suspected according to their conventional assessment. Then, in a second phase, a complete MGST was completed by the same team within the first week after admission.

RESULTS

Three hundred and twenty six registrations from 33 centres were available. Mean (+/- SD) number of screened geriatric problems was 1.5 +/- 1.2 without MGST and 4.7 +/- 1.7 (p < 0.0001) using the MGST. Except for the assessment for the risk of falls, the MGST leads to a better screening for the seven other main geriatric domains (functional, continence, cognition, depression, nutrition, pain, social).

CONCLUSIONS

An improvement associated with the use of simple minimal geriatric tools to screen geriatric problems was evident. This approach has additional value for education and quality assurance.

Evaluation of the Iowa pain thermometer and other selected pain intensity scales in younger and older adult cohorts using controlled clinical pain: a preliminary study

OBJECTIVE

To evaluate the sensitivity and utility of the Iowa Pain Thermometer (IPT) and other selected pain intensity scales in younger and older adults using a controlled clinical pain condition.

DESIGN

A quasi-experimental study with 61 younger (age 21-55 years) and 36 older (age 65-87 years) adults experiencing arthritic pain at two rheumatology clinics. Before and after joint injection, patients reported current pain intensity with the following scales: IPT, Numeric Rating Scale (NRS), Verbal Numeric Rating Scale (VNS), Faces Pain Scale (FPS), and Visual Analog Scale (VAS).

RESULTS

The IPT demonstrated the lowest failure rate of all pain intensity scales evaluated. Other scale failure rates were relatively low except for the VNS and the VAS. No significant difference was noted in scale failure by age, gender or education level, but cognitive impairment was significantly related to failure on the VAS and the NRS. All five pain scales were sensitive in detecting changes in pain intensity pre and post joint injection. All correlations between the scales were strong and significant; however, the intercorrelations for the older cohort were weaker. The scale most preferred in both cohorts of patients was the IPT, followed by the FPS.

CONCLUSIONS

Based on sensitivity to change, lower failure rates, higher preference evaluations, and little appreciable affects associated with cognitive impairment, the IPT was judged to be the best choice for assessing pain intensity for both age cohorts and warrants further study.

[The systematic evaluation of instruments designed to assess pain in persons with limited ability to communicate]

Chronic pain is often underdetected and undertreated in long-term care facilities. The use of self-report measures of pain (such as the visual analogue scale) is often problematic for older adults residing in long-term care because of the high prevalence of visual and auditory deficits and severe cognitive impairment. Observational measures of pain have been developed to address this concern. A systematic grid designed to assess the properties of existing observational measures of pain was used for seniors with dementia. The grid focused on the evaluation of content validity (12 items), construct validity (12 items), reliability (13 items) and clinical utility (10 items). Among the 24 instruments that were evaluated, several were deemed to be promising in the assessment of pain among older persons with severe dementia. Nonetheless, additional research is needed before their routine integration in the practices of long-term care settings.

The application of facial expressions to the assessment of orofacial pain in cognitively impaired older adults

BACKGROUND

The anticipated rapid growth in the number of cognitively impaired older adults, declining edentulism and increasing oral health expectations suggest a greater need for comprehensive dental care and effective ways to evaluate orofacial pain in people with compromised mental function and impaired communication skills. The authors conducted a study to evaluate facial expressions as a means of identifying orofacial pain in cognitively impaired and cognitively intact older adults, compared with other available pain assessment tools.

METHODS

The authors conducted a prospective comparative study using three alternative pain measurement tools in a sample of 22 older adults. They divided subjects into cognitively impaired and cognitively intact groups on the basis of their mental status examination scores. The pain measurement methods evaluated were facial expressions quantified by the Facial Actions Coding System (FACS); self-reported pain via the Verbal Descriptor Scale; and physiological response to pain via changes in heart rate. The pain stimuli were local anesthetic injections in subjects who required them for routine dental procedures.

RESULTS

The average FACS scores during anesthetic injections were significantly higher than those during the preinjection period (prebuccal versus buccal, P = .016; prepalatal versus palatal, P = .0002). The differences between preinjection and injection segments were even higher in cognitively impaired patients than in cognitively intact patients. There were no correlations between the three pain measurements (P > .05).

CONCLUSIONS

Changes in facial expression proved to be the most useful measure overall in identifying pain in both cognitively intact and cognitively impaired older patients. This measure appeared to be more sensitive in cognitively impaired patients because they demonstrated fewer facial movements in anticipation of pain stimuli.

Pain management decision making among long-term care physicians and nurses

The purpose of this study is to explore attitudes and beliefs that affect decisions about prescribing and administering pain medications in older adults who live in long-term care (LTC), with a particular emphasis on those with cognitive impairment. At each of the four participating LTC facilities, data were gathered from three separate groups of health care professionals: physicians, registered nurses, and registered practical nurses. Based on grounded theory, a model was developed that highlighted critical decision points for nurses and physicians regarding pain management. The major themes that emerged from the data concerned pain assessment (lack of recognition of pain, uncertainty about the accuracy of pain assessment and diagnosis) and treatment (reluctance to use opioids, working to individualize pain treatments, issues relating to physician trust of the nurse on prescribing patterns). These findings may facilitate the development of innovative approaches to pain management in LTC settings.

Pain perception during the rehabilitation phase following traumatic hip fracture in the elderly is an important prognostic factor and treatment tool

PURPOSE

To evaluate the role of pain perception on admission to geriatric rehabilitation on the functional recovery after rehabilitation treatment in elderly patients with hip fracture and on the length of stay.

METHOD

One hundred and sixty-five community dwelling elderly 65-year-old and over (mean age of 78 years), following recent operated traumatic hip fracture without clinical evidence for another acute medical or surgical condition were assessed regarding age, sex, chronic medical conditions, pre-fracture functional status, type of fracture and of operation, pain perception, and cognitive status. Pain was measured using the Visual Analogue Score (VAS). Functional status was measured using the Functional Independence Measurement (FIM). Activities of Daily Living (ADL) were assessed using the Katz index.

RESULTS

The average VAS score on admission was 7.38 +/- 1.20 and on discharge 3.67 +/- 1.18. Pain on admission inversely correlated to family support, function prior to fracture and cognitive status on admission, and correlated positively with depressed mood. With every increase of one point in VAS on admission above 4 points, the FIM on discharge decreased by 8.77 and the length of stay increased by 4.76 days.

CONCLUSIONS

Pain intensity may add a valuable dimension for the prognostic evaluation of the patients with hip fractures. Inadequate early patient assessment and associated treatment impact on the patients' functional outcome, prolonged duration of rehabilitation treatment, and therefore, in addition to socio-economic effect, increase the cost to the local health care setting.

Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale (MOBID): development and validation of a nurse-administered pain assessment tool for use in dementia

Pain assessment in older persons with severe cognitive impairment (SCI) is a challenge due to reduced self-report capacity and lack of movement-related pain assessment instruments. The purpose of this article was to describe the development of the Mobilization-Observation-Behaviour-Intensity-Dementia Pain Scale (MOBID) and to investigate aspects of reliability and validity. MOBID is a nurse-administered instrument developed for use in patients with SCI, where presence of pain behavior indicators (pain noises, facial expression, and defense) may be observed during standardized active, guided movements, and then inferred to represent pain intensity. Initially, the MOBID contained seven items (observing at rest, mobilization of the hands, arms, legs, turn over in bed, sitting on bedside, and teeth/mouth care). This was tested in 26 nursing home patients with SCI. Their primary caregivers, five registered nurses and six licensed practical nurses (LPNs), rated the patients' pain intensity during regular morning care, and by MOBID, both at bedside and from video uptakes. Three external raters (LPNs), not knowing the patients, also completed the MOBID by rating the videos. Internal consistency of the MOBID indicated high Cronbach's alpha (alpha=0.90) after deleting the items for observation at rest and observation of teeth/mouth care. MOBID disclosed significantly more pain than did pain scorings during regular morning care, and video observation demonstrated higher pain intensity than bedside scoring. Intertester reliability for inferred pain intensity was high to excellent (intraclass correlation coefficient=0.70-0.96), but varied between poor and excellent for pain behavior indicators (kappa=0.05-0.84). These results suggest that registration of pain behavior indicators during active, guided movements, as performed by the MOBID procedure, is useful to disclose reliable and valid pain intensity scores in patients with SCI.

Pain Assessment in Older Adults With Dementia: Using Behavioral Observation Methods in Clinical Practice

Pain assessment in older adults with dementia recently has received considerable attention from both researchers and clinicians as evidenced by a surge of published behavioral observation tools for pain assessment in this vulnerable population. These behavioral observation methods offer a promising strategy to improve pain assessment in older adults who are not able to communicate their pain verbally. However, some concerns exist related to the interpretation and clinical utility of these methods for decision making related to pain management interventions. This article provides an overview of the general state of knowledge on the use of behavioral observation methods in older adults and discusses the use of such methods to guide decision making in clinical settings.

Palliative Care for the Older Adult

The majority of deaths in the United States occur in the geriatric population. These older adults often develop multiple chronic medical problems and endure complicated medical courses with a variety of disease trajectories. Palliative care physicians need to be skilled in addressing the needs of these frail elders with life-limiting illness as they approach the end of life. Although geriatrics and palliative medicine share much in common, including an emphasis on optimizing quality of life and function, geriatric palliative care is distinct in its focus on the geriatric syndromes and on the provision of care in a variety of long-term care settings. Expertise in the diagnosis and management of the geriatric syndromes and in the complexities of long-term care settings is essential to providing high-quality palliative care to the elderly patient. This paper is a practical review of common geriatric syndromes, including dementia, delirium, urinary incontinence, and falls, with an emphasis on how they may be encountered in the palliative care setting. It also highlights important issues regarding the provision of palliative care in different long-term care settings.

Management of noncancer pain in community-dwelling persons with dementia

OBJECTIVES

To explore the pharmacological treatment of noncancer pain in persons with dementia and identify predictors associated with insufficient analgesia.

DESIGN

Cross-sectional analysis of an observational cohort study.

SETTING

Academic outpatient geriatric clinic in Chicago, Illinois.

PARTICIPANTS

A total of 115 dyads, mostly African American, consisting of community-dwelling persons with dementia and their caregivers.

MEASUREMENTS

Patient report of demographics, noncancer pain, function, cognition, and depression. Caregiver report of patient agitation and over-the-counter and prescription medications.

RESULTS

Sixty-two of 115 (54%) patients reported pain "on an average day." The caregivers of more than half of persons with dementia who reported pain "on an average day" did not report analgesic use. The majority of caregivers who reported analgesic use reported that patients took a World Health Organization Class I medication. No patients had been prescribed a Class III (strong opioid) drug. Fifty-three of 115 (46%) patients had potentially insufficient analgesia. In the logistic regression, insufficient analgesia was associated with greater age, Mini-Mental State Examination score of less than 10, and impairment in daily functioning. Insufficient analgesia was 1.07 times as likely (95% confidence interval (CI) = 1.01-1.14) for each additional year of age, 3.0 times as likely (95% CI = 1.05-9.10) if the subject had advanced dementia, and 2.5 times as likely (95% CI = 1.01-6.25) if the patient had any impairment in activities of daily living.

CONCLUSION

In this convenience sample from a geriatric clinic, many persons with dementia and noncancer pain were not receiving pharmacological treatment. Those at greatest risk for insufficient analgesia were older, had moderate to severe dementia, and experienced impairments in activities of daily living.

Delirium in Hospitalized Older Patients With Cancer

PURPOSE/OBJECTIVES

To examine key aspects of delirium in a sample of hospitalized older patients with cancer.

DESIGN

Secondary analysis of data from studies on acute confusion in hospitalized older adults.

SETTING

Tertiary teaching hospital in the southeastern United States.

SAMPLE

76 hospitalized older patients with cancer (mean age = 74.4 years) evenly divided by gender and ethnicity and with multiple cancer diagnoses.

METHODS

Data were collected during three studies of acute confusion in hospitalized older patients. Delirium was measured with the NEECHAM Confusion Scale on admission, daily during hospitalization, and at discharge. Patient characteristics and clinical risk markers were determined at admission.

MAIN RESEARCH VARIABLES

Prevalent and incident delirium, etiologic risk patterns, and patient characteristics.

FINDINGS

Delirium was noted in 43 (57%) patients; 29 (38%) were delirious on admission. Fourteen of 47 (30%) who were not delirious at admission became delirious during hospitalization. Delirium was present in 30 patients (39%) at discharge. Most delirious patients had evidence of multiple (mean = 2.3) etiologic patterns for delirium.

CONCLUSIONS

Delirium was common in this sample of hospitalized older patients with cancer. Patients with delirium were more severely ill, were more functionally impaired, and exhibited more etiologic patterns than nondelirious patients.

IMPLICATIONS FOR NURSING

Nurses caring for older patients with cancer should perform systematic and ongoing assessments of cognitive behavioral performance to detect delirium early. The prevention and management of delirium hinge on the identification and treatment of the multiple risk factors and etiologic mechanisms that underlie delirium. The large number of patients discharged while still delirious has significant implications for posthospital care and recovery.

Observation Scales for Pain Assessment in Older Adults With Cognitive Impairments or Communication Difficulties

BACKGROUND

Several pain observation scales have been developed to accurately assess and manage pain in older adults with severe cognitive impairments, communication difficulties, or both.

OBJECTIVE

To review relevant pain observation scales and the psychometric qualities of these scales.

METHODS

The literature was searched for articles reporting the use of a pain observation scale in an empirical study and describing psychometric properties in older adults with cognitive impairments, communication difficulties, or both.

RESULTS

Thirteen pain observation scales were included. Scales differed in numbers of items, types of categories, and psychometric properties. Facial expression, vocalization, motor behavior, and social behavior or mood are categories present in most of the scales. In terms of reliability and validity, however, most studies are too limited or incomplete to allow definite conclusions to be drawn about usefulness in daily practice.

DISCUSSION

As different methods of evaluating reliability and validity were used, and different aims (e.g., type of pain) were pursued, the available scales cannot be compared easily. Nevertheless, a few are promising, given preliminary results. These should be examined further on psychometric properties and usefulness in different populations because optimal pain assessment is necessary for efficient and effective pain treatment.

An Interdisciplinary Expert Consensus Statement on Assessment of Pain in Older Persons

This paper represents an expert-based consensus statement on pain assessment among older adults. It is intended to provide recommendations that will be useful for both researchers and clinicians. Contributors were identified based on literature prominence and with the aim of achieving a broad representation of disciplines. Recommendations are provided regarding the physical examination and the assessment of pain using self-report and observational methods (suitable for seniors with dementia). In addition, recommendations are provided regarding the assessment of the physical and emotional functioning of older adults experiencing pain. The literature underlying the consensus recommendations is reviewed. Multiple revisions led to final reviews of 2 complete drafts before consensus was reached.

The evaluation of acute pain in individuals with cognitive impairment: A differential effect of the level of impairment

The present study investigated whether the level of cognitive impairment (CI) affects acute pain behavior and how it is manifested. Participants were 159 individuals (mean age 42+/-12), 121 with CI (divided into four groups according to the level of CI: mild, moderate, severe, profound) and 38 with normal cognition (controls). The behavior of the participants before and during acute pain (influenza vaccination) was coded by two raters with the Facial Action Coding System (FACS - scores facial reactions to pain) and the Non-Communicating Children's Pain Checklist (NCCPC-R - scores both facial and general body reactions). Individuals with severe-profound CI exhibited elevated FACS and NCCPC-R values at baseline compared with all other groups (p<0.01). Both FACS and NCCPC-R scores of individuals with mild-moderate CI and controls increased significantly during vaccination (p<0.001). In contrast, individuals with severe-profound CI exhibited high rates of "freezing reaction" (stillness) during vaccination, manifested mainly in the face and therefore resulting in elevation of only NCCPC-R scores but not of FACS's. The results suggest that the level of CI affects baseline as well as pain behavior and it is therefore necessary to choose an appropriate behavioral tool to measure pain in these individuals accordingly. For example, tools based on facial reactions alone might provide the false impression that individuals with severe-profound CI are insensitive to pain (due to freezing).

Evaluation of the Revised Faces Pain Scale, Verbal Descriptor Scale, Numeric Rating Scale, and Iowa Pain Thermometer in Older Minority Adults

The purpose of this study was to determine the reliability and validity of selected pain intensity scales including the Faces Pain Scale Revised (FPS-R), Verbal Descriptor Scale (VDS), Numeric Rating Scale (NRS), and Iowa Pain Thermometer (IPT) with a cognitively impaired minority sample. A descriptive correlational design was used, and a convenience sample of 68 participants, admitted to acute care facilities in the South, with an average Mini Mental Status Exam score of 23 comprised the sample. Thirty-two percent of the participants were males, and 68% were females. The majority (74%) of the sample consisted of African-American participants with the exception that 16% were Hispanic and 10% were Asian. An overwhelming majority of participants were able to use all of the tools. Concurrent validity was supported with correlations ranging from 0.56 to 0.90. The lowest correlations were found between the FPS-R and the other scales, suggesting that the FPS-R may be measuring a broader construct incorporating pain. Test-retest reliability was supported with coefficients ranging from 0.77 to 0.89. In terms of pain scale preference, the Numeric Rating Scale (33%) was the preferred scale in the cognitively intact group and the FPS-R (54%) was the preferred scale in the cognitively impaired group. When race and cognitive status were considered, African-Americans and Hispanics preferred the FPS-R. Severely, moderately, and mildly impaired participants also preferred the FPS-R. The findings of this study support the use of these scales with older cognitively impaired minority adults.

Pain assessment in the nonverbal patient: position statement with clinical practice recommendations

The article presents the position statement and clinical practice recommendations for pain assessment in the nonverbal patient developed by an appointed Task Force and approved by the ASPMN Board of Directors.

Pain in Severe Dementia: Self-Assessment or Observational Scales?

OBJECTIVES

To assess the performance of self-assessment scales in severely demented hospitalized patients and to compare it with observational data.

DESIGN

Prospective clinical study.

SETTING

Geriatrics hospital and a geriatric psychiatry service.

PARTICIPANTS

All patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for dementia, with a Mini-Mental State Examination score less than 11 and a Clinical Dementia Rating score of 3.

MEASUREMENTS

Three self-assessment tools--the verbal, horizontal visual, and faces pain scales--were administered in randomized order. A nursing team independently completed an observational pain rating scale. Main outcomes were comprehension (ability to explain scale use and correctly indicate positions for no pain and extreme pain, on two separate occasions), inter- and intrarater reliability, and comparison of pain intensities measured by the different scales.

RESULTS

Sixty-one percent of 129 severely demented patients (mean age 83.7, 69% women) demonstrated comprehension of at least one scale. Comprehension rates were significantly better for the verbal and the faces pain scales. For patients who demonstrated good comprehension, the inter- and intrarater reliability of the three self-assessment scales was high (intraclass correlation coefficient=0.88-0.98). Correlation between the three self-assessment scales was moderate to strong (Spearman correlation coefficient (r)=0.45-0.94; P<.001). Observational rating correlated at least moderately with self-assessment (r=0.25-0.63), although for patients reporting pain, the observational rating scale underestimated severity compared with all three self-assessment scales.

CONCLUSION

Clinicians should not apply observational scales routinely in severely demented patients, because many are capable of reliably reporting their own pain.

Effects of the Serial Trial Intervention on discomfort and behavior of nursing home residents with dementia

This study tested the effectiveness of the Serial Trial Intervention (STI), an innovative clinical protocol for assessment and management of unmet needs in people with late-stage dementia. A double-blinded randomized experiment was conducted in 14 nursing homes with 114 subjects. The treatment group had significantly less discomfort than the control group at posttesting and more frequently had behavioral symptoms return to baseline. The group of nurses using the STI also showed more persistence in assessing and intervening than control group nurses did. There was a statistically significant difference between the groups in the use of pharmacological, but not nonpharmacological, comfort treatments. Results suggest that the STI is effective and that effective treatment of discomfort is possible for people with late-stage dementia.

Assisting Older Adults With Orthopaedic Outpatient Acute-Pain Management

Management of acute pain by older adults with orthopaedic conditions in their community setting after surgical procedures or injury can be challenging. As older adult orthopaedic outpatients have unique requirements in their pain management, nurses and advanced practice nurses must be cognizant of these needs and intervene when needed to promote a satisfactory recovery. This article will focus on the older adults experiences of orthopaedic pain, barriers to their pain reporting and relief, and acute pain management considerations for the older adult in the home setting.

Documenting the cognitive status of hip fracture patients using the Short Portable Mental Status Questionnaire

AIMS AND OBJECTIVES

The aim of this study was to describe how nurses document their subjective assessment of the patients' cognitive status in the patients' records and to compare this documentation with an assessment made using a validated evaluation instrument in older patients with a hip fracture.

BACKGROUND

There are indications that older people with a hip fracture and impaired cognitive ability do not receive optimal care and that they suffer from a disproportionately high number of complications. Preventing and rapidly detecting confusion is probably an effective strategy for improving care for these patients. To be able to prevent care-related complications and plan for future nursing and medical care, it is necessary to identify patients with impaired cognitive ability.

DESIGN

Clinical trial including 362 patients.

METHODS

The patients' cognitive function was assessed by a research nurse using a validated instrument, the Short Portable Mental Status Questionnaire, and an independent subjective assessment was made by a ward nurse. The agreement between these assessments was analysed.

RESULTS

An assessment of cognitive function by the ward nurse was lacking in 12% of the patients. The assessment made by the nurses did not correspond to the level of orientation according to Short Portable Mental Status Questionnaire in 24% of the patients. In the vast of majority of these cases, the patients were documented as being cognitively alert although they were cognitively impaired according to the Short Portable Mental Status Questionnaire. Among the patients who were cognitively oriented according to the Short Portable Mental Status Questionnaire, the nurses' assessment identified 97% as oriented, but among the patients with impaired cognitive ability according to the Short Portable Mental Status Questionnaire, only 58% were identified as being cognitively impaired by the ward nurses.

CONCLUSIONS

An assessment of cognitive function is still lacking in nursing records for a substantial number of older people with a hip fracture and cognitive dysfunction is frequently underdiagnosed in routine health care.

RELEVANCE TO CLINICAL PRACTICE

Patient care could be improved if the patients' cognitive function was assessed regularly and objectively by means of a validated evaluation instrument.

Mensuração da dor no idoso: uma revisão

A base teórica e prática da mensuração de dor em idosos foi revisada e examinada através de estudos clínicos e revisões bibliográficas. As vantagens e limitações dos instrumentos ordinais mais freqüentemente utilizados foram discutidas em situações nas quais coexistem alterações próprias do envelhecimento, cuja ação na sensação dolorosa ainda não está bem esclarecida. Os fatores que interferem no processo de avaliação da experiência dolorosa, levando à subestimação e controle inadequados da dor em indivíduos idosos, foram apontados.

Institutionalizing effective pain management practices: practice change programs to improve the quality of pain management in small health care organizations

The Resource Center of the American Alliance of Cancer Pain Initiatives provided templates, faculty, and ongoing consultation to assist seven state pain initiatives to implement programs to improve pain management practices. A total of 113 health care organizations participated. Each organization committed to support a team of two to three staff through a 10-month pain quality improvement process, which included a site visit, two educational conferences, pre- and postprogram analyses of the organizational structures in place to support pain assessment and management, quality improvement work plan development, and patient survey data collection. Postprogram results showed statistically significant increases in the presence of structural elements that are critical to effective pain management, as well as statistically significant, though modest, decreases in the percentage of patients who reported pain of any severity, and specifically moderate to severe pain, in the previous 24 hours. The largest changes occurred in long-term care facilities. Nevertheless, the percentage of patients in moderate to severe pain remained unacceptably high.

Introduction of a pain scale for palliative care patients with cognitive impairment

AIM

To describe the development and introduction of a pain scale for patients with cognitive impairment who are admitted to homes for older people and nursing homes in the region of northwest Flanders in Belgium.

DESIGN

A questionnaire comparing the Abbey and Pain Assessment in Advanced Dementia (PAINAD) scales was distributed in 17 homes; 185 care providers participated, evaluating 157 patients.

FINDINGS

Approximately half of the care providers evaluated both scales as being good measures of pain and easy to use. Of the different items scored in both scales, care providers agreed upon three indicators as being most valuable to use for measuring pain: facial expression; vocalization; and body language.

CONCLUSION

The findings were not conclusive for the introduction of either Abbey or PAINAD. Based on the results, a simplified pain observation scale consisting of three items was developed. It has been introduced in the homes of the region and is being tested currently.

Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review

To improve assessment and management of pain in nonverbal older adults with dementia, an effective means of recognizing and evaluating pain in this vulnerable population is needed. The purpose of this review is to critically evaluate the existing tools used for pain assessment in this population to provide recommendations to clinicians. Ten pain assessment tools based on observation of behavioral indicators for use with nonverbal older adults with dementia were evaluated according to criteria and indicators in five areas: conceptualization, subjects, administration, reliability, and validity. Results indicate that although a number of tools demonstrate potential, existing tools are still in the early stages of development and testing. Currently, there is no standardized tool based on nonverbal behavioral pain indicators in English that may be recommended for broad adoption in clinical practice.

Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools

Background

Pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40–80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia.

Methods

This systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales.

Results

Twenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales (DOLOPLUS2; ECPA; ECS; Observational Pain Behavior Tool; CNPI; PACSLAC; PAINAD; PADE; RaPID; Abbey Pain Scale; NOPPAIN; Pain assessment scale for use with cognitively impaired adults) were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities.

Conclusion

Based on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility.

Effect of acetaminophen on behavior, well-being, and psychotropic medication use in nursing home residents with moderate-to-severe dementia

OBJECTIVES

To evaluate the effect of regularly scheduled administration of analgesic medication on behavior, emotional well-being, and use of as-needed psychotropic medications in nursing home residents with moderate-to-severe dementia.

DESIGN

Randomized, double-blind, placebo-controlled, crossover trial.

SETTING

Nursing-home based.

PARTICIPANTS

Twenty-five nursing home residents with moderate-to-severe dementia.

INTERVENTION

Participants received 4 weeks of acetaminophen (3,000 mg/d) and 4 weeks of placebo.

MEASUREMENTS

Behavior and emotional well-being were assessed using Dementia Care Mapping, an observational method that quantifies time spent in behaviors across 26 domains (e.g., social interaction, unattended distress) and assesses emotional state while behaviors are being observed. Agitation was measured using the Cohen-Mansfield Agitation Inventory. As-needed psychotropic medication use was aggregated from medication logs.

RESULTS

Participants spent more time in social interaction, engaged with media, talking to themselves, engaged in work-like activity, and experiencing unattended distress when they received acetaminophen than they did when they received placebo. Participants also spent less time in their rooms, less time removed from the nursing home unit, and less time performing personal care activities when they received acetaminophen. There were no effects on agitation, emotional well-being, or as-needed psychotropic medication use.

CONCLUSION

Untreated pain inhibits activity in nursing home residents with moderate-to-severe dementia. Pain treatment in this group may facilitate engagement with the environment.

Measuring pain intensity in nursing home residents

Assessing pain intensity in nursing home residents remains a challenge. As part of a multifaceted intervention study to improve pain practices in nursing homes, quarterly pain assessments were conducted in 12 Colorado nursing homes. Residents who reported pain or discomfort of any kind in the past 24 hours were asked to choose one of three pain intensity scales to quantify their current and highest level of pain intensity. They were also observed for pain behaviors using Feldt's Checklist of Nonverbal Pain Indicators. Residents preferred the Verbal Descriptor Scale almost 2:1 over the 11-point Verbal Numeric Rating Scale and the Faces Pain Scale. Sex and ethnicity were associated with differences in scale preference. More than one-half of residents reporting pain had an observable pain indicator. There was a monotonic relationship between reported pain intensity and number of observed pain indicators. To improve pain assessment and management in nursing homes, residents should be given a choice of pain intensity scales and observed for possible pain behaviors.

The State of Chronic Pain Education in Geriatric Medicine Fellowship Training Programs: Results of a National Survey

A survey of U.S. geriatric medicine fellowship training programs was performed to assess the status of teaching about chronic pain evaluation and management and identify opportunities for improvement. After an initial e-mail query, 43 of 96 programs agreed to participate. A self-administered questionnaire, with items adapted from a 2002 consensus panel statement, was mailed to their 171 fellows-in-training and 43 fellowship directors. Thirty-two programs (33% of nationwide sample) including 79 fellows (30% of nationwide sample) and 25 directors (26% of nationwide sample) returned surveys; 21 institutions returned both faculty and fellow surveys. Overall, directors endorsed the 19 items identified by the consensus panel as essential components of fellowship training, but fellows identified deficiencies, both before and during fellowship training. Specific areas of undereducation included comprehensive musculoskeletal assessment, neuropathic pain evaluation, indications for low back pain imaging, the role of multidisciplinary pain clinics and nonpharmacological modalities, the effect of physical and psychosocial comorbidities in formulating treatment goals, and the effect of aging on analgesic metabolism and prescription. Both groups were generally positive about fellows' abilities to implement pain-related clinical skills. Discrepancies existed between fellowship directors' ratings of importance of teaching individual items and the degree to which teaching was actually done, as well as faculty versus fellow assessments of whether some of the 19 items were taught. Primary care training programs (e.g., internal medicine, family medicine, geriatric medicine) should pay more systematic attention to educating trainees about chronic pain to optimize patient care, decrease suffering, and diminish healthcare expenditures.

Using quality improvement to address pain management practices in nursing homes

The objective of this study was to test whether a quality improvement intervention can improve pain management in nursing homes. Experts in quality improvement and clinical pain management provided nursing home staff leaders with feedback on pain quality indicator data, education in pain management, and technical assistance to apply the Plan-Do-Study-Act model of quality improvement. Trained abstractors completed structured chart audits at baseline and five months to capture quality indicator data related to pain assessment and treatment. Residents in pain who underwent pain assessments increased from 8% to 29% (P < 0.001). Residents receiving non-pharmacological pain treatments increased from 31% to 42% (P = 0.010), but pain medication use did not change. Among residents with daily moderate or excruciating pain, complete pain assessment was associated with increased probability of pain medication use. Quality improvement is a promising method to improve pain management in nursing homes.

End of life in nursing homes: connections between structure, process, and outcomes

PURPOSE

This study was a prospective, in-depth exploration of the experience of dying in two nursing homes from the perspective of residents, staff, and family members.

DESIGN AND METHODS

A qualitative, case study design was used. Formal and informal interviews, participant observation, and document review were the primary data collection methods. A total of 56 declining residents were followed until death or for 6 months, whichever occurred first.

RESULTS

The intimate linkages between structure, process, and outcome were evident in both nursing homes. The two homes had contrasting institutional philosophies, reflected in staffing and environment (structure) and processes of care. Processes included different patterns of planning, communication, and decision making. Most importantly, outcomes (residents' satisfaction with care and quality of life while approaching death) were substantively different.

IMPLICATIONS

Institutional philosophy and leadership permeate all aspects of care. A compliance- centered, deficiency-free approach to assessing quality of care is not sufficient to address the needs of declining residents. A client-centered philosophy that embraces "caring for dying people," combined with integrated care planning, contributes to improved resident outcomes.

Palliative Care NURSING EDUCATION: OPPORTUNITIES FOR GERONTOLOGICAL NURSES

Approximately 80% of Americans who die each year are 65 or older. Increasingly, gerontological nurses are asked to deliver high quality end-of-life care. Studies, however, have identified deficiencies in the delivery of care to older adults who are dying-particularly those who die in nursing homes. Enhancing nursing education and training in end-of-life care is one strategy proposed as a remedy for inadequate care for nursing home residents who are dying. This article reviews the current status of end-of-life nursing home care, describes the philosophy and components of quality palliative care, and provides information about opportunities and resources for educating gerontological nurses in end-of-life care.

Feasibility and Reliability of Four Pain Self-Assessment Scales and Correlation With an Observational Rating Scale in Hospitalized Elderly Demented Patients

BACKGROUND

Acute and chronic pain is common in hospitalized demented elderly people, yet there are limited data about the performance of pain assessment tools in this population. The aim of this study was to evaluate the feasibility and reliability of four pain self-assessment scales in this population and compare their performance to an observational pain rating scale.

METHODS

Our prospective clinical study was conducted in an acute-care and intermediate-care geriatric hospital on 160 consecutive inpatient referrals to the dementia consultation who met Diagnostic and Statistical Manual of Mental Disorders-IV criteria for dementia. Exclusion criteria were delirium, terminal care, and severe sensory impairment. Four unidimensional self-assessment tools--the verbal, horizontal visual, vertical visual, and faces pain scales--were administered in randomized order to mild, moderate, and severely demented patients. An observational pain rating scale was independently completed by the nursing team.

RESULTS

Only 12% of the 160 patients (mean age 85 years, 71% women) understood no scale. Respectively, 97%, 90%, and 40% of patients with mild, moderate, and severe dementia understood at least one scale (p <.05). There was a nonsignificant trend toward poorer comprehension of the faces scale. Test-retest reliability was high for all four self-assessment scales, and the correlation between these scales was very strong (Spearman's r(s) = 0.81-0.95; p <.001). Observational rating correlated moderately with self-assessment and tended to underestimate pain intensity (r(s) = 0.31-0.40; p <.05).

CONCLUSIONS

Self-assessment pain scales can be used reliably in the vast majority of older hospitalized patients with mild to moderate dementia and in nearly half of those with severe dementia. Observational pain rating scales correlate only moderately with self-assessment and should be reserved for those few patients who have demonstrated that they cannot complete a self-assessment.

Describing Use of Nursing Interventions for Three Groups of Patients

PURPOSE

To describe the nursing interventions used most frequently during an acute hospital stay for three patient groups.

METHODS

Analysis of nursing interventions documented by use of the Nursing Interventions Classification (NIC) contained in an electronic clinical database obtained from 33 general inpatient units in one large health care facility from July 1, 1998, to June 30, 2002. The numbers of hospitalizations for each sample in the analyses were: 1,435 in the heart failure group, 567 in the hip fracture procedures group, and 11,756 in the fall prevention group.

FINDINGS

The mean number of interventions done at least once during a single hospitalization ranged from 18 to 22 for the three samples. For the total number of patient hospitalizations for each group, the number of interventions ranged from 94 for the hip fracture procedures sample to 182 for the fall prevention sample. Seven interventions were done twice or more a day in at least 20% of the sample in all three groups. Patterns of interventions during the first 6 days of care differed by intervention and sample, indicating that nursing care was individualized.

CONCLUSIONS

The results indicate the types of information that can result from analysis of actual clinical nursing data documented with standardized language (Nursing Interventions Classification) in a nursing information system. The knowledge of nursing interventions used in clinical practice has major implications for staff development and nursing education. The information is also useful in making staffing decisions for different types of patient populations.

Psychometric Evaluation of Selected Pain Intensity Scales for Use with Cognitively Impaired and Cognitively Intact Older Adults

The purpose of this study was to determine the reliability and validity of selected pain intensity scales such as the Faces Pain Scale (FPS), the Verbal Descriptor Scale (VDS), the Numeric Rating Scale (NRS), and the Iowa Pain Thermometer (IPT) to assess pain in cognitively impaired older adults. A descriptive correlational design was used, and a convenience sample of 66 volunteers age 60 and older residing in assisted living facilities in the South was recruited for this study. The sample included 22 (33%) men and 44 (67%) women, with a mean age of 76. Ninety-eight percent (65) of the sample comprised Caucasian participants, with the exception of 1 African-American man. Seventy percent (47) completed high school and/or college. The mean Mini Mental State Exam (MMSE) score was 16, with a range of 1 to 29. Eighty-five percent scored 24 or lower, indicating some degree of cognitive impairment. The remaining 15% were cognitively intact. All but one participant could use each scale to rate their pain. Concurrent validity of the VDS, NRS, and IPT was supported with Spearman rank correlation coefficients ranging from .78 to .86 in the cognitively impaired group. The FPS, however, demonstrated weak correlations with other scales when used with the impaired group, ranging from .48 to .53. In the cognitively intact group, strong correlations ranging from .96 to .97 were found among all of the scales. Test-retest reliability at a 2-week interval was acceptable in the cognitively intact group (Spearman rank correlations ranged from .67 to .85) and unacceptable for most scales in the cognitively impaired group (correlations ranged from .26 to .67). When asked about scale preference, both the cognitively impaired and the intact groups preferred the IPT and the VDS. This study revealed that cognitive impairment did not inhibit participants' ability to use a variety of pain intensity scales, but the stability issue must be considered.