Cues for the identification of pain in nursing home residents

Are nurse`s needs assessment methods robust enough to recognise palliative care needs in people with dementia? A scoping review

BACKGROUND

People with dementia are most at risk of experiencing serious health related suffering, if they do not have a palliative care approach introduced early enough in the illness. It can be challenging for nurses to assess experienced needs of people, who are thought no longer able to self-report such as people with dementia. Assessment help to understand the care the patient and their family need promptly. It is unknown how nurses recognise holistic palliative care needs in people with dementia during routine care.

METHODS

Scoping review where EMBASE, MEDLINE, CINAHL, PsycInfo databases, and references were searched with an advanced search strategy, which was built on three concepts (nurses, dementia, and nursing assessment) using corresponding Medical Subject Headings. Data were charted in a piloted extraction form, based on the assessment domains within the nursing process followed by summarise and synthesise results narratively.

RESULTS

37 out of 2,028 qualitative and quantitative articles published between 2000 and 2021, and relating to 2600 + nurses, were identified. Pain was sole focus of assessment in 29 articles, leaving 8 articles to describe assessment of additional needs (e.g., discomfort). Nurses working in a nursing home assess pain and other needs by observing the persons with dementia behaviour during routine care. Nurses in the acute care setting are more likely to assess symptoms with standard assessment tools at admission and evaluate symptoms by observational methods. Across settings, about one third of pain assessments are supported by person-centred pain assessment tools. Assessments were mostly triggered when the person with dementia vocalised discomfort or a change in usual behaviour was observed. Nurses rely on family members and colleagues to gain more information about needs experienced by people with dementia.

CONCLUSION

There is a scarcity of evidence about techniques and methods used by nurses to assess needs other than pain experienced by people with dementia. A holistic, person-centred screening tool to aid real-time observations at the bedside and used in conversations with health care professionals and families/friends, may improve need recognition other than pain, to ensure holistic needs could then be addressed timely to improve care in people with dementia.

Differences in Staff-Assessed Pain Behaviors among Newly Admitted Nursing Home Residents by Level of Cognitive Impairment

OBJECTIVE

Pain is common among nursing home residents with cognitive impairment and dementia. Pain is often underdiagnosed and undertreated, which may lead to adverse health outcomes. Nonverbal behaviors are valid indicators of pain, but the extent to which these behavioral expressions vary across levels of cognitive impairment is unknown. This study sought to examine differences in the prevalence of pain behaviors among nursing home residents with varying levels of cognitive impairment.

METHODS

The Minimum Data Set, version 3.0, was used to identify newly admitted nursing home residents with staff-assessed pain (2010-2016, n = 1,036,806). Staff-assessed pain behaviors included nonverbal sounds, vocal complaints, facial expressions, and protective body movements or postures over a 5-day look-back period for residents unable or unwilling to self-report pain. The Cognitive Function Scale was used to categorize residents as having no/mild, moderate, or severe cognitive impairment. Modified Poisson models provided adjusted prevalence ratios (aPR) and 95% CIs.

RESULTS

Compared to residents with no/mild cognitive impairments (any pain: 48.1%), residents with moderate cognitive impairment (any pain: 42.4%; aPR: 0.94 [95% CI 0.93-0.95]) and severe cognitive impairment (any pain: 38.4%; aPR: 0.86 [95% CI 0.85-0.88]) were less likely to have any pain behavior documented. Vocal pain behaviors were common (43.5% in residents with no/mild cognitive impairment), but less so in those with severe cognitive impairment (20.1%). Documentation of facial expressions and nonverbal pain behaviors was more frequent for residents with moderate and severe cognitive impairment than those with no/mild cognitive impairment.

CONCLUSIONS

The prevalence of behaviors indicative of pain differs by level of cognitive impairment. Pain evaluation and management plays an important role in treatment and care outcomes. Future work should examine how practitioners' perceptions of pain behaviors influence their ratings of pain intensity and treatment choices.

Development and Testing of the Pain Assessment Tool in Cognitively Impaired Elders (PATCIE): Nonverbal Pain Behaviors in African American and Caucasian Nursing Home Residents with Dementia

BACKGROUND

People with dementia experience a decline in language skills required to self-report pain; researchers thus recommend the use of nonverbal behaviors to assess pain. Although multiple instruments exist for assessing nonverbal pain behaviors, psychometric data are lacking for African American nursing home residents with dementia.

AIMS AND DESIGN

The purpose of this methodological study was to describe the development and testing of the Pain Assessment Tool in Cognitively Impaired Elders (PATCIE) in African American and Caucasian nursing home residents with dementia.

SETTINGS/PARTICIPANTS

The convenience sample included 56 African American and 69 Caucasian residents with dementia in multiple nursing homes from three states. The research staff completed the pain assessments when the nursing home staff transferred the residents.

RESULTS/CONCLUSIONS

Initially, 15 nonverbal pain behaviors were evaluated. Based on the alpha scores and additional literature review, the 15 nonverbal pain behaviors were expanded to 28 behaviors. The PATCIE had a Cronbach's alpha of .73 during movement. Construct validity for the pain behaviors was demonstrated because higher scores were noted during movement, and scores before movement were significantly higher than those obtained after movement. For movement over time, there was a significant difference in the PATCIE score, regardless of ethnicity or time (p < .0001). There were no significant differences found between ethnic groups, either overall or in change over time between movements or between the categories of cognitive function. African Americans were more likely to display frowning, and Caucasians to display irritability. The PATCIE demonstrates preliminary reliability and validity in assessing pain in African American and Caucasian nursing home residents with dementia.

Body movements as pain indicators in older people with cognitive impairment: A systematic review

BACKGROUND AND OBJECTIVE

Pain assessment tools for cognitively impaired older people, unable to self-report pain, are commonly founded upon observation of pain behaviour, such as facial expressions, vocalizations and body movements. The scientific basis for claiming that body movements may indicate pain has not formerly been investigated in a systematic review. The objective was to explore research evidence for body movements being pain indicators in older people with cognitive impairment.

DATA BASES AND DATA TREATMENT

MEDLINE, EMBASE, CINAHL, PsycINFO and the Cochrane Library were searched systematically. Two researchers independently identified and consented on studies to be included. PRISMA statement for reporting systematic reviews was followed. Mixed Methods Appraisal Tool was used for critical evaluation of study quality.

RESULTS

A total of 2,096 records from the literature searches were identified, and 17 quantitative and eight qualitative studies were included in the review, the studies mainly related to older people with dementia. Quality scores ranged from 50% to 100%. We combined 62 items of body movements into 13 similar or synonymous items, and criteria for evidence were defined. Strong evidence was found for restlessness (agitation), rubbing, guarding, rigidity and physical aggression as the behaviours frequently responded (increased or decreased) to pain provoking activities, painful procedures and/or pain medication.

CONCLUSIONS

Among 13 categories of body movements, we found five with strong and five with moderate evidence of validity. As few items were typically included in many studies reflecting criterion validity, all should be included in future studies of patients with different characteristics, location and duration of pain.

SIGNIFICANCE

Pain assessment tools for older people with cognitive impairment or dementia should include valid pain behaviour items. Our review shows strong scientific evidence for the following body movements indicating pain: restlessness (agitation), rubbing, guarding, rigidity and physical aggression.

Pain Assessment in Impaired Cognition (PAIC): content validity of the Dutch version of a new and universal tool to measure pain in dementia

Objectives

Detection and measurement of pain in persons with dementia by using observational pain measurement tools is essential. However, the evidence for the psychometric properties of existing observational tools remains limited. Therefore, a new meta-tool has been developed: Pain Assessment in Impaired Cognition (PAIC), as a collaborative EU action. The aim is to describe the translation procedure and content validity of the Dutch version of the PAIC.

Methods

Translation of the PAIC into Dutch followed the forward-backward approach of the Guidelines for Establishing Cultural Equivalence of Instruments. A questionnaire survey was administered to clinical nursing home experts (20 physicians and 20 nurses) to determine whether the PAIC items are indicative of pain and whether items are specific for pain or for other disorders (anxiety disorder, delirium, dementia, or depression). To quantify content validity, mean scores per item were calculated.

Results

Eleven items were indicative of pain, for example, “frowning,” “freezing,” and “groaning.” Fifteen items were considered to be pain-specific, for example, “frowning,” “curling up,” and “complaining.” There were discrepancies between the notion of pain characteristics according to nurses and physicians, especially in the facial expressions domain.

Discussion

Within the body movement domain, PAIC items correspond well with the clinical experience of the physicians and nurses. However, items in the facial expressions and vocalizations domains need further study with respect to item reduction. Also, differences were revealed in the notion of pain characteristics between physicians and nurses, suggesting the need for more interdisciplinary education on pain in dementia.

Towards improved decision support in the assessment and management of pain for people with dementia in hospital: a systematic meta-review and observational study

Background

Pain and dementia are common in older people, and impaired cognitive abilities make it difficult for them to communicate their pain. Pain, if poorly managed, impairs health and well-being. Accurate pain assessment in this vulnerable group is challenging for hospital staff, but essential for appropriate management. Robust methods for identifying, assessing and managing pain are needed.

Aims and objectives

Two studies were undertaken to inform the development of a decision support tool to aid hospital staff in the recognition, assessment and management of pain. The first was a meta-review of systematic reviews of observational pain assessment instruments with three objectives: (1) to identify the tools available to assess pain in adults with dementia; (2) to identify in which settings they were used and with what patient populations; and (3) to assess their reliability, validity and clinical utility. The second was a multisite observational study in hospitals with four objectives: (1) to identify information currently used by clinicians when detecting and managing pain in patients with dementia; (2) to explore existing processes for detecting and managing pain in these patients; (3) to identify the role (actual/potential) of carers in this process; and (4) to explore the organisational context in which health professionals operate. Findings also informed development of health economics data collection forms to evaluate the implementation of a new decision support intervention in hospitals.

Methods

For the meta-review of systematic reviews, 12 databases were searched. Reviews of observational pain assessment instruments that provided psychometric data were included. Papers were quality assessed and data combined using narrative synthesis. The observational study used an ethnographic approach in 11 wards in four UK hospitals. This included non-participant observation of 31 patients, audits of patient records, semistructured interviews with 52 staff and four carers, informal conversations with staff and carers and analysis of ward documents and policies. Thematic analysis of the data was undertaken by the project team.

Results

Data from eight systematic reviews including 28 tools were included in the meta-review. Most tools showed moderate to good reliability, but information about validity, feasibility and clinical utility was scarce. The observational study showed complex ward cultures and routines, with variations in time spent with patients, communication patterns and management practices. Carer involvement was rare. No pain decision support tools were observed in practice. Information about pain was elicited in different ways, at different times, by different health-care staff and recorded in separate documents. Individual staff made sense of patients’ pain by creating their own ‘overall picture’ from available information.

Limitations

Grey literature and non-English-language papers were excluded from the meta-review. Sample sizes in the observational study were smaller than planned owing to poor documentation of patients’ dementia diagnoses, gatekeeping by staff and difficulties in gaining consent/assent. Many patients had no or geographically distant carers, or a spouse who was too unwell and/or reluctant to participate.

Conclusions

No single observational pain scale was clearly superior to any other. The traditional linear concept of pain being assessed, treated and reassessed by single individuals did not ‘fit’ with clinical reality. A new approach enabling effective communication among patients, carers and staff, centralised recording of pain-related information, and an extended range of pain management interventions is proposed [Pain And Dementia Decision Support (PADDS)]. This was not tested with users, but a follow-on study aims to codesign PADDS with carers and clinicians, then introduce education on staff/patient/carer communications and use of PADDS within a structured implementation plan. PADDS will need to be tested in differing ward contexts.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Normalizing suffering: A meta-synthesis of experiences of and perspectives on pain and pain management in nursing homes

Older people who live in nursing homes commonly suffer from pain. Therefore, relieving suffering among older people that stems from pain demands knowledge improvement through an integration of international knowledge. This study aimed to integrate current international findings and strengthen the understanding of older people's experiences of and perspectives on pain and pain management in nursing homes. A meta-synthesis study using Noblit and Hare's interpretative meta-ethnography approach was conducted. Empirical research papers from journals were collected from various databases. The search process and appraisal determined six articles for inclusion. Two studies were conducted in the US and one each in Iceland, Norway, the UK, and Australia. The older people's experiences of pain as well as perspectives on pain management from all involved (older people, their family members, and healthcare staff) were integrated into a theoretical model using three themes of "identity of pain," "recognition of pain," and "response to pain." The metaphor of "normalizing suffering" was devised to illustrate the meaning of pain experiences and pain management in nursing homes. Society's common attitude that pain is unavoidable and therefore acceptable in old age in society-among older people themselves as well as those who are responsible for reporting, acknowledging, and relieving pain-must change. The article emphasizes that pain as a primary source of suffering can be relieved, provided that older people are encouraged to report their pain. In addition, healthcare staff require sufficient training to take a person-centered approach towards assessment and management of pain that considers all elements of pain.

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

Pain is a common symptom for long-term care residents, particularly those in need of palliative care. However, pain assessment in residents who have communication limitations is challenging. A study was conducted with the aim of developing a pain assessment tool that could feasibly be used by direct care providers in long-term care with minimal training yet demonstrating strong psychometric properties. The study used both qualitative and quantitative methods to develop and test the Pain Assessment in the Communicatively Impaired (PACI) tool. Part I of this paper reports on the development phase; a forthcoming second part will report on the testing phase. The overall results of this study support the psychometric properties and feasibility of the PACI tool, offering preliminary support for its use in clinical practice.

Ethnic Differences in Nonverbal Pain Behaviors Observed in Older Adults with Dementia

Research supports using nonverbal pain behaviors to identify pain in persons with dementia. It is unknown whether variations exist among ethnic groups in the expression of nonverbal pain behaviors in this special population. The purpose of this descriptive study was to examine ethnic differences in the presentation and intensity of nonverbal pain behaviors among African American, Caucasian, and Hispanic older adults with dementia when screened for pain by certified nursing assistants. Six certified nursing assistants were trained to review and score 28 video recordings of subjects with dementia for nonverbal pain behaviors using the Non-Communicative Patient's Pain Assessment Instrument. Chi-square was used to examine differences among ethnic groups with regard to the display of nonverbal pain behaviors, and ANOVA was used to evaluate differences in the intensity of overall pain across ethnic groups. Of the 168 assessments, pain words (28%), pain noises (29.8%), and pain faces (28%) were observed most often as indicators of pain. Rubbing, bracing, and restlessness were rarely noted. Chi-square analysis revealed ethnic differences in the expression of pain words (χ(2) = 19.167, p < .001). No significant differences were noted across ethnic groups with regards to overall pain intensity. These findings are the first to examine ethnic differences in nonverbal pain behaviors for older adults with dementia. However, future work should examine assessment tendencies of providers in a larger, more diverse sample.

Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools

BACKGROUND

There is evidence of under-detection and poor management of pain in patients with dementia, in both long-term and acute care. Accurate assessment of pain in people with dementia is challenging and pain assessment tools have received considerable attention over the years, with an increasing number of tools made available. Systematic reviews on the evidence of their validity and utility mostly compare different sets of tools. This review of systematic reviews analyses and summarises evidence concerning the psychometric properties and clinical utility of pain assessment tools in adults with dementia or cognitive impairment.

METHODS

We searched for systematic reviews of pain assessment tools providing evidence of reliability, validity and clinical utility. Two reviewers independently assessed each review and extracted data from them, with a third reviewer mediating when consensus was not reached. Analysis of the data was carried out collaboratively. The reviews were synthesised using a narrative synthesis approach.

RESULTS

We retrieved 441 potentially eligible reviews, 23 met the criteria for inclusion and 8 provided data for extraction. Each review evaluated between 8 and 13 tools, in aggregate providing evidence on a total of 28 tools. The quality of the reviews varied and the reporting often lacked sufficient methodological detail for quality assessment. The 28 tools appear to have been studied in a variety of settings and with varied types of patients. The reviews identified several methodological limitations across the original studies. The lack of a 'gold standard' significantly hinders the evaluation of tools' validity. Most importantly, the samples were small providing limited evidence for use of any of the tools across settings or populations.

CONCLUSIONS

There are a considerable number of pain assessment tools available for use with the elderly cognitive impaired population. However there is limited evidence about their reliability, validity and clinical utility. On the basis of this review no one tool can be recommended given the existing evidence.

Preferred Thinking Style, Symptom Recognition, and Response by Nursing Students During Simulation

A better understanding of the relationships between symptom recognition, nursing response, and preferred thinking style is needed to improve nursing education practices. Final semester nursing students ( N = 29) completed a high fidelity patient simulation (HFPS) scenario; recognized symptoms (i.e., dyspnea) and responses (i.e., apply oxygen) were recorded, and compared with students’ preferred thinking style using the Rational-Experiential Inventory–40. Relationships between concepts were explored. Significant relationships were noted between preference for Rational thinking styles and symptom recognition ( p < .05). Preferred thinking style was not related to numbers of therapeutic responses. Thirty percent of students delayed application of oxygen until directed to do so by members of the health care team. Students having a stronger preference for rational thinking demonstrate greater accuracy in cue recognition. More nursing research is needed to explore the cognitive processing during simulation .

Exploring nursing assistants' roles in the process of pain management for cognitively impaired nursing home residents: a qualitative study

AIM

To explore nursing assistants' roles during the actual process of pain management (assessment, reporting, implementation of pain-relieving interventions and re-assessment) for cognitively impaired home residents with pain.

BACKGROUND

Nursing assistants provide most of the direct care to residents and represent the major taskforce in nursing homes. They may develop specialized knowledge of residents' pain experience that enables them to play both a pivotal role in pain assessment and possibly a supporting role in pain treatment. Currently, there is a lack of research into nursing assistants' functions in pain management.

DESIGN

This is a descriptive, exploratory qualitative study.

METHODS

Forty-nine nursing assistants were recruited from 12 nursing homes, 12 of them participating in semi-structured individual interviews and 37 in 8 semi-structured focus groups. All interviews were carried out from May to September 2010. Data collected via both data collection methods were transcribed verbatim and analysed by content analysis.

RESULTS

Nursing assistants were found to play four roles in the pain management process: (1) pain assessor; (2) reporter; (3) subordinate implementing prescribed medications; and (4) instigator implementing non-pharmacological interventions.

CONCLUSIONS

This study highlights the importance of nursing assistants in successful pain assessment and identifies their possible supporting roles in other aspects of pain management. However, nursing assistants' scope of practice resulted in their functions in pain management being continually undervalued by other healthcare professionals. Continuous in-service training, the use of a standardized pain management protocol and strategies for building coherent work teams in nursing homes are suggested to improve this situation.

A study of longitudinal data examining concomitance of pain and cognition in an elderly long-term care population

Purpose

To examine if a concomitant relationship exists between cognition and pain in an elderly population residing in long-term care.

Background/significance

Prior research has found that cognitive load mediates interpretation of a stimulus. In the presence of decreased cognitive capacity as with dementia, the relationship between cognition and increasing pain is unknown in the elderly.

Patients and methods

Longitudinal cohort design. Data collected from the Minimum Data Set-Resident Assessment Instrument (MDS-RAI) from the 2001–2003 annual assessments of nursing home residents. A covariance model was used to evaluate the relationship between cognition and pain at three intervals.

Results

The sample included 56,494 subjects from nursing homes across the United States, with an average age of 83 ± 8.2 years. Analysis of variance scores (ANOVAs) indicated a significant effect (P < 0.01) for pain and cognition, with protected t test revealing scores decreasing significantly with these two measures. Relative stability was found for pain and cognition over time. Greater stability was found in the cognitive measure than the pain measure. Cross-legged effects observed between cognition and pain measures were inconsistent. A concomitant relationship was not found between cognition and pain. Even though the relationship was significant at the 0.01 level, the correlations were low (r ≤ 0.08), indicating a weak association between cognition and pain.

Conclusion

Understanding the concomitance of pain and cognition aids in defining additional frameworks to extend models to include secondary needs, contextual factors, and resident outcomes. Cognitive decline, as with organic brain diseases, is progressive. Pain is a symptom that can be treated and reduced to improve resident quality of life. However, cognition can be used to determine the most appropriate method to assess pain in the elderly, thereby improving accuracy of pain detection in this population.

The psychometric properties, feasibility and utility of behavioural-observation methods in pain assessment of cognitively impaired elderly people in acute and long-term care: A systematic review

BACKGROUND

The key factor to improving pain management for cognitively impaired elderly patients is accurate pain assessment. Behavioural-observation methods are required for individuals who cannot communicate their pain verbally. A thorough understanding of the key components of behavioural pain assessment and the use of valid and reliable behavioural pain assessment tools would enhance the assessment of pain in this vulnerable population.

OBJECTIVES

To identify the key components involved in behavioural pain assessment in cognitively impaired elderly people and to analyse the reported psychometric properties, feasibility and utility of behavioural pain assessment tools.

SELECTION CRITERIA

Studies using descriptive, correlation and comparative designs were included.Cognitively impaired elderly people older than 65 years in aged care, acute care or nursing home settings were included.Components measured in behavioural pain assessment; psychometric properties, feasibility and utility of behavioural pain assessment tools used to assess pain in cognitively impaired elderly people in acute or long-term care settings.Identification of behavioural criteria for assessment of pain and investigation of any aspect of the psychometric properties of behavioural pain assessment tools.

SEARCH STRATEGY

An initial limited search of MEDLINE and CINAHL to find published studies between 1990 to 2010 in the English Language was undertaken, following an analysis of the text words contained in the title and abstract. A second search using all identified keywords and index terms was undertaken and extended to a further seven relevant databases. Thirdly, the reference lists of all identified reports and articles were searched for additional studies.

METHODOLOGICAL QUALITY

Studies selected for retrieval were assessed for inclusion by two independent reviewers for methodological validity using the Critical Appraisal Tool for Psychometric Studies adapted from Fallon, Westaway, and Moloney1.

DATA EXTRACTION

Quantitative data were extracted from included studies using the Data Extraction Tool for Psychometric Studies adapted from Fallon, Westaway, and Mahoney1.

DATA SYNTHESIS

As statistical pooling was not possible, evidence in relation to psychometric properties, was analysed and presented in narrative summary.

RESULTS

Twenty three studies were included in the review. No tool has been found suitable for use across both acute and long-term care settings. Nevertheless, three tools show the most promising outcomes and potential for use.

CONCLUSIONS

Although behavioural measures may inform healthcare providers on the presence of pain in an individual, they do not provide information about the aetiology of pain. Hence, pain assessment should not depend solely on behavioural observation conducted using standardised behavioural pain assessment tools, but regarded as an essential component of a multifaceted approach to pain assessment. Clinicians may select tools which show promising qualities and pilot them in their respective clinical settings and populations. In particular, the MPS, the PACSLAC and the PAINAD are recommended for potential use in the cognitively impaired elderly in acute and long-term care settings.Several tools show promise for use in acute or long-term care settings. These tools require tool revisions to strengthen their psychometric properties. Instead of developing new tools, modification of existing tools and conducting further psychometric evaluations on them can provide more evidence of their psychometric properties.

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

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

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.