Behavioral pain indicators in people with intellectual disabilities: a systematic review

Secondary bruxism: A valid diagnosis or just a coincidental finding of additional masticatory muscle activity? A narrative review of literature

INTRODUCTION

Bruxism is defined as a repetitive masticatory muscle activity that can manifest it upon awakening (awake bruxism-AB) or during sleep (sleep bruxism-SB). Some forms of both, AB and SB can be associated to many other coexistent factors, considered of risk for the initiation and maintenance of the bruxism. Although controversial, the term 'secondary bruxism' has frequently been used to label these cases. The absence of an adequate definition of bruxism, the non-distinction between the circadian manifestations and the report of many different measurement techniques, however, are important factors to be considered when judging the literature findings. The use (and abuse) of drugs, caffeine, nicotine, alcohol and psychoactive substances, the presence of respiratory disorders during sleep, gastroesophageal reflux disorders and movement, neurological and psychiatric disorders are among these factors. The scarcity of controlled studies and the complexity and interactions among all aforementioned factors, unfortunately, does not allow to establish any causality or temporal association with SB and AB. The supposition that variables are related depends on different parameters, not clearly demonstrated in the available studies.

OBJECTIVES

This narrative review aims at providing oral health care professionals with an update on the co-risk factors and disorders possibly associated with bruxism. In addition, the authors discuss the appropriateness of the term 'secondary bruxism' as a valid diagnostic category based on the available evidence.

CONCLUSION

The absence of an adequate definition of bruxism, the non-distinction between the circadian manifestations and the report of many different measurement techniques found in many studies preclude any solid and convincing conclusion on the existence of the 'secondary' bruxism.

Caregiver Perspectives on Pain Sensitivity and Pain Experience in Rett Syndrome

Background

Although delayed or decreased responses to pain are commonly reported among caregivers of individuals with Rett syndrome (RTT), previous studies in relatively small samples have documented that caregivers are concerned about pain, particularly due to gastrointestinal and musculoskeletal conditions.

Aims

The purpose of the current study was to investigate in detail caregivers' perceptions of pain sensitivity, as well as the types, severity, and effect of pain experienced by individuals with RTT in a larger sample than previous studies.

Methods

A total of 51 caregivers (mostly mothers) participated in the study, which involved standardized questionnaires and interviews. The individuals with RTT ranged in age from 2 to 52 years of age, and most (n = 46; 90%) met criteria for classic RTT.

Results

Across the sample, 84% of caregivers reported that they believed that their child was less sensitive to pain compared to her typically developing peers. Despite this perception, 63% of caregivers reported that their child had experienced at least one form of pain in the previous 7 days, and 57% reported their child experienced at least one form of chronic pain. On average, caregivers reported that their child's pain was of moderate severity and interfered with at least one activity of daily living.

Conclusions

The results suggest that pain is a substantial concern among caregivers of individuals with RTT and indicate that additional research is needed to understand the apparent paradox of frequently reported pain experiences despite widespread perceptions of decreased pain sensitivity.

Reliable assessment of pain behaviour in adults with profound intellectual and multiple disabilities: The development of an instruction protocol

BACKGROUND

Persons with profound intellectual and multiple disabilities (PIMD) are vulnerable when it comes to experiencing pain. Reliable assessment of pain-related behaviour in these persons is difficult. Aim To determine how pain items can be reliably scored in adults with PIMD.

METHODS

We developed an instruction protocol for the assessment of pain-related behaviour in four phases. We used videos of 57 adults with PIMD during potentially painful situations. The items were assessed for inter-rater reliability (Cohen's kappa or percentage of agreement).

RESULTS

The developed instruction protocol appeared to be adequate. Twelve items had satisfactory inter-rater reliability (n = 9: .30-1.00; n = 3: 85%-100%).

DISCUSSION

Calibrating and adjustments to the instructions and item set appeared to be crucial to reliably score 12 items in adults with PIMD. Further research should focus on creating an assessment instrument based on these reliably scored items.

Behavioral pain indicators for adults with an intellectual disability: a scoping review protocol

OBJECTIVE

This scoping review aims to identify and map the behavioral pain indicators observed when adults with an intellectual disability experience pain.

INTRODUCTION

Adults with an intellectual disability have more health problems than the general population. The likelihood that this population will experience pain is high, but intellectual disability can obstruct the verbal expression of pain. Adults with an intellectual disability express pain via behavioral pain indicators; however, because no behavioral pain scale exists for this population, observers may misinterpret the pain experienced by adults with an intellectual disability.

INCLUSION CRITERIA

The review will examine literature about behavioral pain indicators for adults with any type of intellectual disability who are suffering from any type of pain in any country or care setting.

METHODS

The review will be conducted according to the JBI recommendations for scoping reviews. A preliminary search focusing on the concepts of intellectual disability and pain measurement was conducted for PubMed and CINAHL in March 2022. Once the protocol is validated, searches will also be carried out in Embase, JBI EBP Database, the Cochrane Database of Systematic Reviews, ProQuest Dissertations and Theses, PsycINFO, Web of Science Core Collection, ERIC, Google Scholar, MedNar, and the websites of relevant professional associations. Titles and abstracts, and then full-text studies, will be selected independently by 2 researchers and assessed against the inclusion criteria. Relevant information will be imported into a data chart. Any behavioral pain indicators identified will be classified into 14 behavioral categories.

REVIEW REGISTRATION NUMBER

Open Science Framework osf.io/8xckf.

Evaluation of children with severe neurological impairment admitted to hospital with pain and irritability

BACKGROUND

Pain is the most common symptom reported by caregivers of children with severe neurological impairment (SNI), a descriptive term for children with disorders affecting the neurological system across multiple domains. In SNI, cognition, communication, and motor skills are impaired and other organ systems are impacted. Pain is difficult to identify and treat in children with SNI because of communication impairment. When a clear cause of pain is not determined, the term "Pain and Irritability of Unknown Origin (PIUO)" is used to describe pain-like behaviours. This study explores the clinical care received by children with SNI admitted to hospital after presenting to the emergency department of a tertiary pediatric hospital with pain or irritability. Findings are compared to the approach suggested in the PIUO pathway, an integrated clinical pathway for identifying and treating underlying causes of pain and irritability in children with complex conditions and limited communication.

METHODS

Retrospective chart review of children (age 0 to 18 years inclusive) with diagnoses compatible with SNI presenting with pain, irritability, and/or unexplained crying that required hospitalization between January 1st, 2019 and December 31st, 2019. Descriptive statistics were used to analyze the clinical care received by children in whom a source of pain was identified or not. In children for whom no cause of pain was identified, investigations completed were compared to the PIUO pathway.

RESULTS

Eight hospital admissions of six unique children were included for data analysis. A cause for pain and irritability was identified and resolved in three patients. In children with PIUO, there were gaps in history taking, physical examination, and investigations that might have allowed a cause of pain and irritability to be found. Pain was assessed using the r-FLACC pain scale and varying medications for pain/irritability were given during each hospital admission.

CONCLUSION

Children with SNI admitted to a tertiary pediatric hospital did not undergo a standardized approach to identifying a cause of pain and irritability. Future efforts should explore the effectiveness of the PIUO pathway, a standardized approach to reducing and resolving pain in children with SNI.

Integrated biopsychosocial pain research in intellectual and developmental disability

This commentary is on the scoping review by Sierra‐Núñez et al. on pages 1085–1095 of this issue.

Computer mediated automatic detection of pain-related behavior: prospect, progress, perils

Pain is often characterized as a fundamentally subjective phenomenon; however, all pain assessment reduces the experience to observables, with strengths and limitations. Most evidence about pain derives from observations of pain-related behavior. There has been considerable progress in articulating the properties of behavioral indices of pain; especially, but not exclusively those based on facial expression. An abundant literature shows that a limited subset of facial actions, with homologs in several non-human species, encode pain intensity across the lifespan. Unfortunately, acquiring such measures remains prohibitively impractical in many settings because it requires trained human observers and is laborious. The advent of the field of affective computing, which applies computer vision and machine learning (CVML) techniques to the recognition of behavior, raised the prospect that advanced technology might overcome some of the constraints limiting behavioral pain assessment in clinical and research settings. Studies have shown that it is indeed possible, through CVML, to develop systems that track facial expressions of pain. There has since been an explosion of research testing models for automated pain assessment. More recently, researchers have explored the feasibility of multimodal measurement of pain-related behaviors. Commercial products that purport to enable automatic, real-time measurement of pain expression have also appeared. Though progress has been made, this field remains in its infancy and there is risk of overpromising on what can be delivered. Insufficient adherence to conventional principles for developing valid measures and drawing appropriate generalizations to identifiable populations could lead to scientifically dubious and clinically risky claims. There is a particular need for the development of databases containing samples from various settings in which pain may or may not occur, meticulously annotated according to standards that would permit sharing, subject to international privacy standards. Researchers and users need to be sensitive to the limitations of the technology (for e.g., the potential reification of biases that are irrelevant to the assessment of pain) and its potentially problematic social implications.

Nurses' Perceived Barriers to and Facilitators of Pain Assessment and Management in Critical Care Patients: A Systematic Review

Aim

This review aims to examine nurses’ perceived barriers to and facilitators of pain assessment and management in adult critical care patients.

Background

Pain is one of the worst memories among critically ill patients. However, pain among those patients is still undertreated due to several barriers that impede effective management. Therefore, addressing the perceived barriers and facilitators to pain assessment management among critical care nurses is crucial.

Methods

A systematic search of pain assessment and management in critical care patient-relevant literature from four databases was done, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

The barriers and facilitators were categorized into four groups: nurse-related, patient-related, physician-related, and system-related. The most frequently reported barriers in this study included nurses’ lack of knowledge regarding the use of pain assessment tools, patients’ inability to communicate, physicians’ prescription of analgesics being independent of pain scores evaluation, and absence of standardized guidelines and protocols for pain evaluation and control. For the facilitators, the most reported ones include ongoing education and professional training related to pain assessment and management, patients’ ability to self-report pain, effective collaboration between physicians and nurses, and productive discussion of patients’ pain scores during nurse-to-nurse handovers.

Conclusion

Various barriers and facilitators to pain assessment and management were identified and examined in this review. However, future research is still needed to further investigate these barriers and facilitators and examine any other potential associated factors among critical care nurses.

Relevance to Clinical Practice

The findings of our study could help hospital managers in developing continuous education and staff development training programs on assessing and managing pain for critical care patients. Also, our findings could be used to develop an evidence-based standard pain management protocol tailored to effectively assess and promptly treat pain in critical care patients.

Automated Assessment of Pain: Prospects, Progress, and a Path Forward

Advances in the understanding and control of pain require methods for measuring its presence, intensity, and other qualities. Shortcomings of the main method for evaluating pain-verbal report-have motivated the pursuit of other measures. Measurement of observable pain-related behaviors, such as facial expressions, has provided an alternative, but has seen limited application because available techniques are burdensome. Computer vision and machine learning techniques have been successfully applied to the assessment of painrelated facial expression, suggesting that automated assessment may be feasible. Further development is necessary before such techniques can have more widespread implementation in pain science and clinical practice. Suggestions are made for the dimensions that need to be addressed to facilitate such developments.

The development of an iPad application for the pain assessment of individuals with developmental disabilities and complex communication needs

Aims: Develop a new pain assessment for youth with communication challenges. The Guard-Putzer Pain Assessment Domains (gPAD) mobile application (app) was designed and tested as a universally accessible way for youth, ages 7-12 years, with a developmental disability (DD) to express their pain experiences through self-report. Methods: A two-phase process developed the design for an app, created an interactive prototype, and tested its face validity and user interface. This work included a comprehensive scoping review of current assessments and pain apps as well as a survey to obtain descriptive data on the clinical practicality of the gPAD to guide the app design. Additionally, 15 therapists reviewed the gPAD assessment. Results: Thirteen respondents (87%) agreed to the statement that they would use the gPAD for this population. School-based practitioners seemed to highlight the most significant needs for the app. Conclusions: Advancement of this app could mainstream the assessment of pain in youth with DD, and other potential populations.

A Randomized Controlled Trial Evaluating a Pain Assessment and Management Program for Respite Workers Supporting Children With Disabilities Part One: Pain-Related Knowledge and Perceptions

This parallel group randomized controlled trial tested effectiveness of the Let's Talk About Pain training on respite workers' (RW) pain-related knowledge and feasibility-confidence-skill ratings using between-group and within-group analyses. Fourteen children's respite organizations were randomized to pain or control training. Participants (nintervention = 66; ncontrol = 92) underwent a 3-3.5 hour training and completed measures at pre-, post-, and 4-6 week follow-up. Intention-to-treat (nintervention = 65; ncontrol = 92) and per-protocol (nintervention = 26-38; ncontrol = 40-57) analyses were conducted. Pain training participants demonstrated significantly higher pain knowledge and feasibility-confidence-skill ratings post-follow-up versus control group and significant increases in knowledge from pre-post. Significant gains were maintained from post-follow-up. Results represent a promising step towards enhancing pain-related care for children with IDD.

Validity of the Rotterdam Elderly Pain Observation Scale for institutionalised cognitively impaired Dutch adults

BACKGROUND

The Rotterdam Elderly Pain Observation Scale (REPOS) has not yet been validated for institutionalised cognitively impaired adults. To fill this gap of knowledge, we tested psychometric properties of the REPOS when used for pain assessment in this population.

METHODS

In this multicentre observational study, residents were filmed during a possibly painful moment and at rest. Healthcare professionals were asked to rate residents' pain by means of a Numeric Rating Scale (NRS)-proxy. Two researchers assessed pain with the REPOS and the Chronic Pain Scale for Non Verbal Adults with Intellectual Disabilities (CPS-NAID) from video-recordings.

RESULTS

In total, 168 observations from 84 residents were assessed. Inter-observer reliability between the two researchers was good, with Cohen's kappa 0.72 [95% confidence interval (CI) 0.64 to 0.79]. Correlation between the REPOS and CPS-NAID for a possibly painful moment was 0.73 (95% CI 0.65 to 0.79). Sensitivity (85%) and specificity (61%) for the detection of pain were calculated with REPOS ≥ 3 and NRS ≥ 4 as a reference value. Item response theory analysis shows that the item grimace displayed perfect discrimination between residents with and without pain.

CONCLUSION

The REPOS is a reliable and valid instrument to assess pain in cognitively impaired individuals.

Probable Pain on the Pain Assessment in Impaired Cognition (PAIC15) Instrument: Assessing Sensitivity and Specificity of Cut-Offs against Three Standards

Observational pain scales can help to identify pain in persons with dementia who may have difficulty expressing pain verbally. The Pain Assessment in Impaired Cognition-15 (PAIC15) covers 15 items that indicate pain, but it is unclear how probable pain is, for each summed score (range 0–45). We aimed to determine sensitivity and specificity of cut-offs for probable pain on the PAIC15 against three standards: (1) self-report when able, (2) the established Pain Assessment in Advanced Dementia (PAINAD) cut-off of 2, and (3) observer’s overall estimate based on a series of systematic observations. We used data of 238 nursing home residents with dementia who were observed by their physician in training or nursing staff in the context of an evidence-based medicine (EBM) training study, with re-assessment after 2 months in 137 residents. The area under the ROC curve was excellent against the PAINAD cut-off (≥0.8) but acceptable or less than acceptable for the other two standards. Across standards and criteria for optimal sensitivity and specificity, PAIC15 scores of 3 and higher represent possible pain for screening in practice, with sensitivity and specificity against self-report in the 0.5 to 0.7 range. While sensitivity for screening in practice may be too low, a cut-off of 4 is reasonable to indicate probable pain in research.

Increased heart rate functions as a signal of acute distress in non-communicating persons with intellectual disability

Intellectual disability (ID) affects approximately 1% of the population. Some patients with severe or profound ID are essentially non-communicating and therefore risk experiencing pain and distress without being able to notify their caregivers, which is a major health issue. This real-world proof of concept study aimed to see if heart rate (HR) monitoring could reveal whether non-communicating persons with ID experience acute pain or distress in their daily lives. We monitored HR in 14 non-communicating participants with ID in their daily environment to see if specific situations were associated with increased HR. We defined increased HR as being > 1 standard deviation above the daily mean and lasting > 5 s. In 11 out of 14 participants, increased HR indicated pain or distress in situations that were not previously suspected to be stressful, e.g. passive stretching of spastic limbs or being transported in patient lifts. Increased HR suggesting joy was detected in three participants (during car rides, movies). In some situations that were previously suspected to be stressful, absence of HR increase suggested absence of pain or distress. We conclude that HR monitoring may identify acute pain and distress in non-communicating persons with ID, allowing for improved health care for this patient group.

Physiological Measures of Acute and Chronic Pain within Different Subject Groups: A Systematic Review

Results

The methods' heart rate variability and electroencephalogram show clear and consistent results as acute pain assessment. Magnetic resonance imaging can measure chronic pain. Ordered by invasiveness and vulnerability, a trend shows that the invasive methods are used more with less vulnerable subjects. Only instruments used for skin conductance and automatic facial recognition have a lower-than-average technological maturity.

Conclusions

Some pain assessment methods show good and consistent results and have high technological maturity; however, using them as pain assessment for persons with ID is uncommon. Since this addition can ameliorate caregiving, more research of assessment methods should occur.

Discovery and validation of biomarkers to aid the development of safe and effective pain therapeutics: challenges and opportunities

Pain medication plays an important role in the treatment of acute and chronic pain conditions, but some drugs, opioids in particular, have been overprescribed or prescribed without adequate safeguards, leading to an alarming rise in medication-related overdose deaths. The NIH Helping to End Addiction Long-term (HEAL) Initiative is a trans-agency effort to provide scientific solutions to stem the opioid crisis. One component of the initiative is to support biomarker discovery and rigorous validation in collaboration with industry leaders to accelerate high-quality clinical research into neurotherapeutics and pain. The use of objective biomarkers and clinical trial end points throughout the drug discovery and development process is crucial to help define pathophysiological subsets of pain, evaluate target engagement of new drugs and predict the analgesic efficacy of new drugs. In 2018, the NIH-led Discovery and Validation of Biomarkers to Develop Non-Addictive Therapeutics for Pain workshop convened scientific leaders from academia, industry, government and patient advocacy groups to discuss progress, challenges, gaps and ideas to facilitate the development of biomarkers and end points for pain. The outcomes of this workshop are outlined in this Consensus Statement.

Prescription of pain medication among older cancer patients with and without an intellectual disability: a national register study

Background

The longevity for people with intellectual disability (ID) has significantly increased in developed countries during the past decades. Consequently, the incidence of cancer is expected to increase in this group. The aim of the present study was to investigate the prescription of pain medication in older cancer patients with intellectual disability (ID) compared to older patients in the general population, surviving or living with a cancer diagnosis.

Methods

This Swedish national registry-based study, included people with ID aged 55 years or older in 2012, and alive at the end of that year (ID cohort, n = 7936). For comparisons, we used a referent cohort, one-to-one matched with the general population by year of birth and sex (gPop cohort, n = 7936). People with at least one diagnosis of cancer during 2002–2012 were identified using the Swedish National Patient Register, resulting in 555 cancer patients with ID and 877 cancer patients from the general population. These two cohorts of cancer patients were compared with respect to prescription of pain medication for the period 2006–2012. Outcome data were aggregated so that each patient was categorized as either having or not having at least one prescription of each investigated drug group during the study period, and relative risks (RRs) for prescription were estimated for prescription in the ID cohort vs the gPop cohort.

Results

Cancer patients with ID were less likely than cancer patients in the gPop cohort to have at least one prescription of COX inhibitors (RR 0.61) and weak opioids (RR 0.63). They were, however, more likely to be prescribed paracetamol (RR 1.16), antidepressants (RR 2.09), anxiolytics (RR 2.84), and “other hypnotics, sedatives, and neuroleptics” (RR 1.39). No statistically significant differences between the two cohorts were found for strong opioids, antiepileptics, tricyclic antidepressants, or hypnotics and sedatives.

Conclusion

In the studied cohort of older people surviving or living with cancer, prescriptions for pain-treatment was less common in patients with ID compared to the general population. These results may suggest that pain is not sufficiently treated among cancer patients with ID, a situation that most likely would compromise the quality of life in this group.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

Identifying pain in children with CHARGE syndrome

Background and aims The objective was to conduct the first investigation to identify the frequency and intensity of pain experiences for individuals with CHARGE syndrome and to review the use of two established non-vocal pain assessments with children with CHARGE, the NCCPC-R (Non-Communicating Children's Pain Checklist-Revised) and the PPP (Pediatrics Pain Profile). Methods Parents of children with CHARGE were enrolled. Participants completed a pain questionnaire and the NCCPC-R and PPP twice, once for a baseline measure and second during a painful experience for their child. Results A moderate negative correlation between the mean intensity of pain and the mean duration of pain among individuals with CHARGE was found, ρ=-0.34. There was a tendency for intensity of pain to increase for sources of pain that were of shorter duration. The NCCPC-R and PPP were found to identify pain when compared to baseline performance (no pain) with a large effect, d=1.3. For the NCCPC-R, the difference between these ratings was significant beyond the 0.05 level, t (40)=8.15, p=0.000, 95% CI [16.93, 28.10]. Similarly, for the PPP, the mean pain ratings were significantly greater than the mean ratings for no pain, with significance beyond the 0.05 level, t (51)=9.59, p=0.000, CI 95% [11.74, 17.96]. Conclusions Evidence exists that children with CHARGE experience pain. While the NCCPC-R and PPP were found to identify pain; future research should consider the development of a pain assessment individualized to pain behaviors present in CHARGE syndrome, given this population's unique expression of pain.

Parents and Physiotherapists Recognition of Non-Verbal Communication of Pain in Individuals with Cerebral Palsy

Pain assessment is difficult in individuals with cerebral palsy (CP). This is of particular relevance in children with communication difficulties, when non-verbal pain behaviors could be essential for appropriate pain recognition. Parents are considered good proxies in the recognition of pain in their children; however, health professionals also need a good understanding of their patients' pain experience. This study aims at analyzing the agreement between parents' and physiotherapists' assessments of verbal and non-verbal pain behaviors in individuals with CP. A written survey about pain characteristics and non-verbal pain expression of 96 persons with CP (45 classified as communicative, and 51 as non-communicative individuals) was performed. Parents and physiotherapists displayed a high agreement in their estimations of the presence of chronic pain, healthcare seeking, pain intensity and pain interference, as well as in non-verbal pain behaviors. Physiotherapists and parents can recognize pain behaviors in individuals with CP regardless of communication disabilities.

Self-Reported Presence and Experience of Pain in Adults with Down Syndrome

Objective

The aim was to examine whether the presence of pain (based on physical conditions and participants' report) and self-reported pain experience in adults with Down syndrome (DS) differ from general population controls.

Design

Cross-sectional study of 224 adults with DS (mean age = 38.1 years, mild-severe intellectual disabilities) and 142 age-matched controls (median age = 40.5 years, mean estimated IQ = 105.7) in the Netherlands.

Methods

File-based medical information was evaluated. Self-reported presence and experience of pain were assessed in rest and after movement during a test session (affect with facial affective scale (FAS: 0.04-0.97), intensity assessed with numeric rating scale (NRS: 0-10).

Results

Compared with controls, more DS participants had physical conditions that may cause pain and/or discomfort ( p  = .004, 50% vs 35%), but fewer DS participants reported pain during the test session ( p  = .003, 58% vs 73%). Of the participants who indicated pain and comprehended self-reporting scales ( n  = 198 FAS, n  = 161 NRS), the DS group reported a higher pain affect and intensity than the controls ( p  < .001, FAS: 0.75-0.85 vs 0.50-0.59, NRS: 6.00-7.94 vs 2.00-3.73).

Conclusions

Not all adults with DS and painful/discomforting physical conditions reported pain. Those who did indicated a higher pain experience than adults from the general population. Research into spontaneous self-report of pain, repeated pain assessment, and acute pain is needed in people with DS for more insight into pain experience and mismatches between self-report and medical information.

Conceptual and operational definitions of the components of the nursing diagnosis Acute Pain (00132)

OBJECTIVE

to develop the operational and conceptual definitions of the defining characteristics and related factors of the nursing diagnosis Acute Pain (00132) for nonverbal critically ill patients.

METHOD

integrative literature review in the databases/libraries: Medical Literature Analysis and Retrieval System Online (MEDLINE via Pubmed), Cochrane Library, The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Latin American & Caribbean Health Sciences Literature (LILACS).

RESULTS

799 results were found in the literature, of which 80 studies were selected for full text reading and 16 were used in the elaboration of definitions for the 17 defining characteristics and three related factors of the nursing diagnosis. The gray literature, ie, thesis, dissertations, books, guidelines and dictionary was also explored to ensure the robustness needed to clarify the topics not covered by the studies.

CONCLUSION

the definitions aim to facilitate the identification of the nursing diagnosis for nonverbal critically ill patients and to support future teaching and research on the nursing diagnosis of Acute Pain (00132).

Pain in Dementia: Use of Observational Pain Assessment Tools by People Who Are Not Health Professionals

Objective

Pain is prevalent among older adults but is often underestimated and undertreated, especially in people with severe dementia who have limited ability to self-report pain. Pain in patients with moderate to severe dementia can be assessed using observational tools. Informal caregivers (relatives of seniors with dementia) are an untapped assessor group who often bear the responsibility of care for their loved ones. Our objective was to evaluate the ability of laypeople to assess pain using observational measures originally developed for use by health care professionals.

Design

We employed a quasi-experimental design and presented videos depicting patients with dementia (portrayed by actors) displaying pain behaviors or during a calm relaxed state (no pain) to long-term care nurses and laypeople. Participants rated the pain behaviors observed in each video by completing two standardized observational measures that had been previously developed for use by long-term care staff.

Results

As expected, both laypeople and nurses were able to effectively differentiate painful from nonpainful situations using the standardized tools. Both groups were also able to discriminate among gradations of pain (i.e., no pain, mild, moderate, severe) and required comparable amounts of time to complete the assessments.

Conclusions

We conclude that, as hypothesized, the instruments under study can be used for the assessment of pain by laypeople. This is the first study to validate these instruments for use by laypeople. The use of these tools by laypeople (under the guidance of health professionals) has the potential of facilitating earlier detection and treatment of pain in older adults with dementia who live in community settings.

Pain underreporting associated with profound intellectual disability in emergency departments

BACKGROUND

Little information is available regarding the visits made by persons with profound intellectual disability (PID) to general hospital emergency departments (ED). This study aims to know whether persons with PID who attend ED are given the same type of diagnoses as people with no such disability.

METHODS

Over a period of 18 months, we gathered data from all non-scheduled visits to an ED by persons with PID to identify the reason for consultation (according to the classification used by the Spanish Society for Emergency Nursing) and the final diagnosis upon discharge. The results were compared with data obtained from a control group of people with no ID who attended an ED for any reason during the same period.

RESULTS

Somatic complaints were the main reason for ED attendance among persons with PID (90% of consultations). These complaints were more often related to the central nervous system than was the case among non-ID patients (16 vs. 4.7%), whereas other kinds of non-central nervous system somatic complaint were less common among persons with PID (74 vs. 91%). A diagnosis implying physical pain was given less often to people with PID than to controls (3 vs. 20%).

CONCLUSIONS

The results suggest that persons with PID are less able to conceptualise and communicate information about their symptoms, especially as regards pain, and that this influences the diagnosis they are given when attending an ED. Professionals working in this environment need to be aware of this possibility so as not to underestimate or overlook such symptoms and the illnesses related to them.

Daily living pain assessment in children with autism: Exploratory study

This study aims to broaden knowledge about pain expression and assessment in daily life situations in children with Autism Spectrum Disorder (ASD). The goals are to provide a description of the responses of the GED-DI, the French version of the NCCPC, and to test the internal structure validity of this scale. Thirty five children with ASD were included in this study (mean age=58months; mean developmental age=32months). The French version of the NCCPC was filled in by parents. Descriptive analysis of responses shows that children with ASD express pain through varied and common behaviours, related to different expressive markers (vocal, facial, activity, etc.). Behaviours more specific to the symptomology and disturbances of ASD are also displayed. A four-factor solution (negative emotional reaction, idiosyncratic expression, hyper-vigilance reaction, pain expression) emerges from an exploratory factor analysis that explains 54.4% of the total variance. Correlation coefficients show good psychometric qualities in terms of internal consistency, factorial validity and discriminant validity. This study provides new data about pain expression in daily life situations and shows that the French version of NCCPC adjusted to ASD children is relevant to assess pain in daily life situations.

A qualitative investigation of recovery after femoral fracture in Rett syndrome

BACKGROUND

Children with severe disability often develop osteoporosis and have an increased risk of fracture. In Rett syndrome, the prevalence of fracture is four times greater than in the general population, and the femur is commonly affected. This study used qualitative methods to investigate the regaining of mobility within 12 months following femoral fracture in Rett syndrome and parent caregiver experiences.

METHODS

Caregivers (n = 14) of cases registered with the Australian Rett Syndrome Database with a daughter with Rett syndrome were recruited if their daughter sustained a femoral fracture between 2009 and 2014. Median (interquartile range) age at fracture was 11 years and 4 months (8 years and 8 months to 22 years and 3 months). Qualitative methods were used to investigate parent/caregiver experiences and their daughter's recovery following fracture. Themes in the interview data were identified with thematic analysis.

RESULTS

Operative management was chosen for those walking independently and non-operative management for most of the remaining. All who walked independently and one of the four who required assistance recovered pre-operative walking skills within 6 months. Themes identified by caregivers related to the complexities of pain recognition, the caregiver emotional journey and later rebuilding of relationships with service providers.

CONCLUSIONS

Those who walked with assistance were vulnerable to loss of this skill. Difficulties in pain recognition increased time to diagnose fracture, and the acute episode was associated with heightened caregiver stress. Service providers can use family-centred practice models to support the strengthening of family functioning following this acute event that is surprisingly common in those with severe disability.

An Exploration of Comfort and Discomfort Amongst Children and Young People with Intellectual Disabilities Who Depend on Postural Management Equipment

BACKGROUND

The natural response to the intrusive bodily sensation is positional change. This study explored how children and young people (CYP) with intellectual disabilities had their comfort needs met when using adaptive positioning equipment.

METHODS

Thirteen qualitative case studies were undertaken. A parent, a teacher/key worker and a therapist for each CYP were interviewed, and daily routines were observed, with selective video recording. Single case and cross case analyses were undertaken.

RESULTS

Attentive caregivers read the behavioural expressions of the CYP and responded reassuringly, safeguarding them from discomforting experiences. Threats to comfort include the restrictive nature of some equipment accessories, positioning errors and procedural stretching.

CONCLUSIONS

The same item of equipment can be both comfortable and uncomfortable. Given the social and interactional world in which the CYP live and learn, it is others who must accept responsibility for ensuring their optimal level of comfort.

Physicians' recognition of death in the foreseeable future in patients with intellectual disabilities

BACKGROUND

Physicians are increasingly confronted with people with intellectual disabilities (ID) who are facing life-threatening diseases. We aimed to explore when and based on which information sources and signals physicians recognised that a patient with ID would die in the foreseeable future. Insights may help in identifying patients in need of palliative care.

METHOD

In this study, 81 physicians for people with ID and 16 general practitioners completed a retrospective survey about their last case of a patient with ID with a non-sudden death.

RESULTS

More than 20% of all physicians foresaw death not until the last week of life. In 30% of all patients, the physician did not discuss the start of the palliative care phase until the last week. The most reported information sources based on which physicians foresaw death were the physicians themselves and professional caregivers. We found 40 different signals that lead to physicians' foreseeing death. These were not only medical signals but also behavioural and physical signals.

CONCLUSIONS

Results indicate that the physicians' ability to foresee death is a result of a process of growing awareness in which multiple signals from different information sources converge. This demands continuous multi-disciplinary communication because people involved have their own unique interactions with the patient and can therefore contribute to a growing and timely awareness of patients' death in the future.