Psychometric properties of pain measurements for people living with dementia: a COSMIN systematic review

Quality of life, pain and use of analgesic, anxiolytic and antidepressant medication, in people living in care homes

BACKGROUND

People living in care homes often have problems with pain, anxiety and depression. Whether being on analgesia, anxiolytics or antidepressants has any bearing on pain severity and quality of life (QoL) in this population, requires further investigation.

OBJECTIVES

(i) to examine the relationship between pain, anxiety and depression and medication use in care home residents and (ii) to compare those on medications to treat pain, anxiety and depression, and those who were not, and associations with pain severity and overall QoL.

METHODS

This was a secondary analysis of a randomised controlled trial testing a falls prevention intervention in care homes. We recorded pain, anxiety and depression, QoL measurements and prescribed medication use.

RESULTS

In 1589 participants, the mean age was 84.7 years (±9.3 SD), 32.2% were male and 67.3% had a diagnosis of dementia. 54.3% and 53.2% of participants had some level of pain and anxiety or depression respectively, regardless of prescribed medication use. There was a direct association between pain severity and being on any analgesia, opioid analgesia, and antidepressants, but no associations between pain severity and use of paracetamol and anxiolytics. QoL was best for residents with no pain and not on any analgesia, anxiolytics or antidepressants and worst for those with moderate-extreme pain and taking at least two of these classes of medications.

CONCLUSION

Many care home residents live with pain, anxiety and depression. Addressing residents' pain may also increase their quality of life, but using medication alone to reach this goal may be inadequate.

Pain in non-communicative older adults beyond dementia: a narrative review

Aging is associated with an increased risk of developing pain, especially in the presence of concurrent chronic clinical conditions. Similarly, multimorbidity can affect the perception and ability of older adults to appropriately respond to and communicate pain, and there is a clinical heterogeneity in the processing of painful sensations in different neurological conditions. The present narrative review is aimed at assessing the prevalent diseases associated with poor communication and pain in older adults, together with the available diagnostic instruments for the clinical assessment of pain in such a vulnerable population. Dementia was the most described pathology identified in the current literature associated with poor communication in older adults affected by pain, along with Parkinson's disease and stroke. Notably, a common pattern of pain behaviors in these neurological disorders also emerged, indicating potential similarities in the clinical presentation and appropriate diagnostic workout. At the same time, there are many differences in the way patients express their pain according to their main neurological pathology. In addition to this, although a plethora of observation-based tools for pain in patients with dementia have been developed, there is no gold standard, and the clinical utility of such measurements is still largely unaddressed. Meanwhile, there is substantially no standardized observation-based tool for pain in non-communicative patients with Parkinson's disease, and only a few for stroke. Overall, the present narrative review provides an update on the prevalent diseases beyond dementia associated with a communicative disability and a painful condition in older adults.

Physiological Biomarkers for Assessment of Pain during Routine Blood Tests for Older Adults with Dementia in Long-Term Residential Care

OBJECTIVE

Evaluating pain in individuals with dementia can be difficult when verbal communication is limited. Vocalization has emerged as a potential avenue for assessments of pain in nonverbal populations. This study aimed to evaluate if physiological assessments of vocalization were correlated with observational assessments of pain during routine blood tests for persons with dementia.

DESIGN

A cross-sectional descriptive study.

SETTING AND PARTICIPANTS

Sixty older adults (aged ≥65 years old) with dementia requiring routine finger puncture and peripheral venipuncture for routine blood tests were recruited by purposive sampling from 3 long-term care facilities in Taiwan.

METHODS

Observational assessments were conducted with the Pain Assessment in Advanced Dementia (PAINAD) instrument; physiological biomarkers of vocalization were assessed with a noninvasive sensing device and microphone (NISDM). Assessments were conducted simultaneously in one session during situations of increasing pain levels: at rest, making a sound, finger puncture, and peripheral venipuncture. PAINAD scores were compared with signal recording measures from the NISDM. Analysis of variance and Pearson correlation coefficient assessed correlations between observational and physiological measures.

RESULTS

Most participants were female (63.3%); mean age was 81.27 years (SD = 9.69); Clinical Dementia Rating was 2.23 ± 0.70; and Mini-Mental State Examination was 7.07 ± 6.95. Signal recording measures using the NISDM during finger puncture and venipuncture were significantly greater compared with measures at rest and making sound, indicating higher signal levels were associated with pain. PAINAD scores were significantly correlated with physiological measures for vocalization variables of sound amplitude (r = 0.49, P < .001), shimmer (r = 0.63, P < .001), and inhalation-to-exhalation amplitude ratio (r = 0.48, P < .001).

CONCLUSIONS AND IMPLICATIONS

Elevated vocalizations detected with the NISDM were correlated with increased pain scores on the PAINAD instrument. Physiological measures of pain using novel vocalization biomarkers have the potential to enhance the quality of care for individuals with dementia and limited communication abilities.

Pain prevalence and pain relief in end-of-life care - a national registry study

BACKGROUND

Despite pain control being a top priority in end-of-life care, pain continues to be a troublesome symptom and comprehensive data on pain prevalence and pain relief in patients with different diagnoses are scarce.

METHODS

The Swedish Register of Palliative Care (SRPC) was used to retrieve data from 2011 to 2022 about pain during the last week of life. Data were collected regarding occurrence of pain, whether pain was relieved and occurrence of severe pain, to examine if pain differed between patients with cancer, heart failure, chronic obstructive pulmonary disease (COPD) and dementia. Binary logistic regression models adjusted for sex and age were used.

RESULTS

A total of 315 000 patients were included in the study. Pain during the last week of life was more commonly seen in cancer (81%) than in dementia (69%), heart failure (68%) or COPD (57%), also when controlled for age and sex, p < 0.001. Severe forms of pain were registered in 35% in patients with cancer, and in 17-21% in non-cancer patients. Complete pain relief (regardless of pain intensity) was achieved in 73-87% of those who experienced pain, depending on diagnosis. The proportion of patients with complete or partial pain relief was 99.8% for the whole group.

CONCLUSIONS

The occurrence of pain, including severe pain, was less common in patients with heart failure, COPD or dementia, compared to patients with cancer. Compared with cancer, pain was more often fully relieved for patients with dementia, but less often in heart failure and COPD. As severe pain was seen in about a third of the cancer patients, the study still underlines the need for better pain management in the imminently dying.

TRIAL REGISTRATION

No trial registration was made as all patients were deceased and all data were retrieved from The Swedish Register of Palliative Care database.

The Difficulties of Managing Pain in People Living with Frailty: The Potential for Digital Phenotyping

Pain and frailty are closely linked. Chronic pain is a risk factor for frailty, and frailty is a risk factor for pain. People living with frailty also commonly have cognitive impairment, which can make assessment of pain and monitoring of pain management even more difficult. Pain may be sub-optimally treated in people living with frailty, people living with cognitive impairment and those with both these factors. Reasons for sub-optimal treatment in these groups are pharmacological (increased drug side effects, drug-drug interactions, polypharmacy), non-pharmacological (erroneous beliefs about pain, ageism, bidirectional communication challenges), logistical (difficulty in accessing primary care practitioners and unaffordable cost of drugs), and, particularly in cognitive impairment, related to communication difficulties. Thorough assessment and characterisation of pain, related sensations, and their functional, emotional, and behavioural consequences ("phenotyping") may help to enhance the assessment of pain, particularly in people with frailty and cognitive impairment, as this may help to identify who is most likely to respond to certain types of treatment. This paper discusses the potential role of "digital phenotyping" in the assessment and management of pain in people with frailty. Digital phenotyping is concerned with observable characteristics in digital form, such as those obtained from sensing-capable devices, and may provide novel and more informative data than existing clinical approaches regarding how pain manifests and how treatment strategies affect it. The processing of extensive digital and usual data may require powerful algorithms, but processing these data could lead to a better understanding of who is most likely to benefit from specific and targeted treatments.

Pain management education needs for nurses caring for older adults undergoing total knee replacement

INTRODUCTION

Effective postoperative pain management is necessary to improve the outcomes of older adults undergoing total knee replacement (TKR). Discovering what registered nurses (RNs) need to know about pain management may be beneficial to improving the quality of care.

AIM

The study aimed to identify the information needed to develop pain management education for RNs caring for older adults undergoing TKR.

METHODS

A qualitative descriptive design was used in this study. Three focus groups were conducted with 22 staff RNs with experience caring for older adults undergoing TKR at a supra-tertiary care hospital in Bangkok, Thailand; one focus group was conducted with five members of the hospital's nursing pain management committee. Data were analyzed using content analysis.

RESULTS

Two themes relevant to pain assessment education were pain assessment and pain management. Subthemes of pain assessment included challenges in cognitively impaired older adults, inadequate knowledge and misconceptions, and re-assessing pain. Three subthemes of pain management were created, including knowledge of pain medication, new trends in pharmacological pain management and devices, and non-pharmacological pain management using cold compression.

CONCLUSIONS

RNs require current information about pain management to provide effective postoperative care for older adults undergoing TKR. The findings may be used in pain management education to update RNs' knowledge of pain management.

Effect of need-based care on behavioural and psychological symptoms in residents with dementia and formal caregivers' distress in nursing homes: a three-arm cluster randomized controlled trial

PURPOSE

To evaluate to what extent the standardized concept of need-based care on Behavioural and Psychological Symptoms of Dementia (BPSD), and formal caregiver distress, is superior when compared to spending more time or standard care with residents with BPSD.

METHODS

A longitudinal cluster randomized controlled study in 23 nursing homes in Belgium with 3 parallel groups was set up. A total of 481 residents with dementia participated. Formal caregivers in the need-based care group treated residents who displayed agitated or aggressive behaviour with a non-pharmacological intervention, tailored to unmet needs, twice a week with re-evaluation every 8 weeks. In the time group, formal caregivers spent 'extra time'. In the standard care group, it was 'care as usual'. Outcomes were measured at four different time points with the Doloplus-2 (to assess pain behaviour), Cohen-Mansfield Agitation Inventory (CMAI) for agitation, the Neuropsychiatric Inventory (NPI-NH) for BPSD and formal caregivers' distress.

RESULTS

Need-based interventions had a significant effect on residents' levels of pain behaviour. In the need-based care group, scores on overall BPSD (agitation and aggression, depression, euphoria, irritability, sleep and night-time behaviour) improved significantly from baseline when compared to other timepoints. No significant different interactions over time were found between all three groups for categorized versions of NPI scores (ever versus never).

CONCLUSION

Need-based care reduced the level of BPSD in residents with dementia as well as formal caregivers' distress. The study supports the importance of tailored non-pharmacological interventions in the residential care for people with dementia.

TRIAL REGISTRY

Trial registration number B300201942084 (18/11/2019).

Pain Management in the Postoperative Period for People With Dementia: An Integrative Review

Objective

With the increased global prevalence of older people with dementia, more will present for surgery over the coming decades. Therefore, the objective of this study was to synthesize the existing research about how pain in managed for people with dementia in the postoperative period and discuss the implications for clinical practice.

Methods

For this integrative review, the Cumulative Index to Nursing and Allied Health literature, Medline/Pubmed, ProQuest, ERIC, and Health Source Nursing were searched to identify original empirical research published between 2000 and 2021. Tasks were divided between reviewers to ensure independent study selection, data extraction, and risk of bias assessment.

Results

Eleven articles were eligible. The evidence is incompletely developed therefore the review focused on pain assessment, the types and amount of pain relief, that people with dementia receive less analgesia than people without dementia and the challenges for effective pain management. Most studies were surgery for hip fracture so there is scope to look at outcomes for other types of surgery. Analgesia was administered but it was noted that even over a 20-year period, people with dementia received less than cognitively intact people. Pain management could have a stronger evidence-base with more psychometric development of pain assessment tools. Challenges are due to the impaired ability of the person with dementia to communicate pain and that clinicians have difficulty understanding pain behavior in people with dementia.

Conclusion

Adequate pain management for people with dementia in the postoperative period is important for a faster and better recovery.

The Abbey Pain Scale: not sufficiently valid or reliable for assessing pain in patients with advanced cancer

BACKGROUND

Patients with advanced cancer can be unable to verbalize their pain. The Abbey Pain Scale (APS), an observational tool, is used to assess pain in this setting, but has never been psychometrically tested for people with cancer. The aim of this study was to assess the validity, reliability, and the responsiveness of the APS to opioids for patients with advanced cancer in a palliative oncology care setting.

MATERIAL AND METHODS

Patients with advanced cancer and poor performance status, drowsiness, unconsciousness, or delirium, were assessed for pain using a Swedish translation of the APS (APS-SE) and, if possible, the Numeric Rating Scale (NRS). The assessments using APS were conducted simultaneously, but independently, by the same raters on two separate occasions, approximately one hour apart. Criterion validity was assessed by comparing the APS and NRS values using Cohen's kappa (κ). Inter-rater reliability was determined using the intraclass correlation coefficient (ICC), internal consistency using Cronbach's α, and responsiveness to opioids using the Wilcoxon signed-rank test.

RESULTS

Seventy-two patients were included, of whom n = 45 could rate their pain using the NRS. The APS did not detect any of the n = 22 cases of moderate or severe pain self-reported using the NRS. The APS at first assessment had a κ of 0.08 (CI: -0.06 to 0.22) for criterion validity, an ICC of 0.64 (CI: 0.43-0.78) for inter-rater reliability, and a Cronbach's α of 0.01 for internal consistency. The responsiveness to opioids was z = -2.53 (p = 0.01).

CONCLUSION

The APS was responsive to opioids but displayed insufficient validity and reliability and did not detect moderate or severe pain as indicated by the NRS. The study showed a very limited clinical use of the APS in patients with advanced cancer.

Chronic pain interference assessment tools for children and adults who are unable to self-report: A systematic review of psychometric properties

AIM

To identify and evaluate psychometric properties of assessment tools for assessing pain interference in children, adolescents, and adults with chronic pain and the inability to self-report.

METHOD

The protocol was registered with PROSPERO (CRD42022310102). A search was run in MEDLINE, Embase, and PsycInfo (29th March 2022) to identify articles reporting psychometric properties of pain interference assessment tools for children, adolescents, and adults with chronic pain and the inability to objectively self-report pain. Retrieved studies were reviewed by two authors (MGS, LCF) and study quality was assessed using COSMIN.

RESULTS

Psychometric properties of 10 pain interference tools were assessed from 33 studies. The Paediatric Pain Profile (PPP) had low-quality evidence for content validity and internal consistency with children and adolescents who are unable to self-report. No tools for adults had evidence for content validity and internal consistency. No tool had evidence for all nine psychometric properties.

INTERPRETATION

The PPP is recommended for pain interference assessment in children and adolescents with chronic pain and the inability to self-report. Few tools are available for adults. Three tools for children (Patient-Reported Outcome Measurement Information System Pediatric Proxy Pain Interference Scale; Bath Adolescent Pain Questionnaire for Parents; modified Brief Pain Inventory-Proxy [mBPI]) and three tools for adults (Doloplus-2; Patient-Reported Outcome Measurement Information System Pain Interference Scale-proxy; Brief Pain Inventory-proxy) are promising but require further investigation.

Pain management for people with dementia: a cross-setting systematic review and meta-ethnography

Background

Pain management for people with dementia is challenging. There is limited understanding on the experiences of pain management from people with dementia, but also from those who support them. This study synthesised the qualitative evidence to explore the perspectives of people with dementia, their family, friends, carers and healthcare professionals to pain management.

Methods

A systematic literature review was undertaken of published and unpublished literature databases (to 01 November 2021). All qualitative research studies reporting the perspectives of people with dementia, their family, friends, carers and healthcare professionals to managing pain were included. Eligible studies were appraised using the Critical Appraisal Skills Programme (CASP) qualitative appraisal tool. A meta-ethnography analysis approach was adopted, with findings assessed against the GRADE-CERQual framework.

Results

Of the 3994 citations screened, 33 studies were eligible. Seven themes were identified from the data. There was moderate evidence from six studies indicating inequity of pain management for people with dementia. There was moderate evidence from 22 studies regarding anxieties on cascading pain information. There was moderate evidence from nine studies that familiarisation of the person with pain, their preferences, routines and behaviours were key factors to better pain management. Consistently, carers and healthcare professionals had a low opinion of the management of pain for people with dementia, with tensions over the 'best' treatment options to offer. This was associated with poor training and understanding on how pain 'should' be managed.

Conclusion

The findings highlight the challenges faced by people with dementia and pain, and those who support them. Improvements in education for people who support these individuals would be valuable across health and social care pathways. Supporting family members and relatives on pain experiences and treatment options could improve awareness to improve quality of life for people with dementia and pain and those who support them.