Psychometric Evaluation of the MOBID Dementia Pain Scale in U.S. Nursing Homes

Pain in Dementia: An Empirical Test of a Common Assumption

Numerous, and often largely overlapping, observational pain assessment tools have been developed specifically to assess pain in older adults with dementia under the assumption that a specialized approach is necessary to evaluate pain in this population. However, this assumption has never been tested empirically. As an empirical test of this implicit assumption, our goal was to compare existing tools for people living with dementia (with respect to psychometric properties), not only against each other, but also against a tool developed for a different population with cognitive impairments. Videos of older adults with severe dementia recorded in long-term care settings were coded for pain behaviors in the laboratory. Trained coders coded pain behaviors in video segments of older adults with dementia during a quiet baseline condition as well as during a physical examination (designed to identify painful areas), using various observational pain assessment tools. An observational measure of agitation was employed to facilitate the assessment of discriminant validity. Consistent with our expectations, all pain tools (including the tool developed for younger people with cognitive impairments) successfully differentiated between painful and nonpainful states, with large effect sizes. This was the first study to compare tools specifically developed to assess pain in people living with dementia to a tool developed for a different population. Given that all tools under study showed satisfactory psychometric properties when tested on persons with dementia, this study suggests that the assumption that different tools are necessary for different populations with cognitive impairments cannot be taken for granted. PERSPECTIVE: This article challenges an implicitly held assumption that specialized tools are needed to assess pain in different populations with cognitive impairments. Given commonalities in pain expression across populations, further research is needed to determine whether population-specific tools are needed.

Pain trajectories of nursing home residents

BACKGROUND

Understanding changes in nursing home (NH) resident pain over time would provide a more informed perspective, allowing opportunities to alter the course of illness, plan care, and set priorities. Therefore, the purpose of this analysis was to identify and characterize clinically meaningful, dynamic pain trajectories in NH residents.

METHODS

Retrospective longitudinal analysis of NH resident pain scores with a length of stay >100 days (N = 4864). Group-based trajectory modeling was applied to Minimum Data Set 3.0 assessments to identify pain trajectories. Trajectories were then characterized using unadjusted and adjusted cross-sectional associations between residents' demographic and clinical characteristics and their pain trajectory.

RESULTS

We identified four distinct trajectories: (1) consistent pain absence (48.9%), (2) decreasing-increasing pain presence (21.8%), (3) increasing-decreasing pain presence (15.3%), and (4) persistent pain presence (14.0%). Demographics of younger age and living in a rural area were associated with the persistent pain presence trajectory. Clinical variables of obesity and intact cognition were associated with being in the persistent pain presence trajectory. A smaller proportion of residents with moderately or severely impaired cognition were in any of the trajectory groups with pain.

CONCLUSIONS

We identified and characterized four pain trajectories among NH residents, including persistent pain presence which was associated with demographic characteristics (younger, female, rural) and clinical factors (obese, fracture, contracture). Moreover, residents with a diagnosis of Alzheimer's disease or dementia were less likely to be in any of the three trajectories with pain, likely representing the difficulty in evaluating pain in these residents. It is important that NH staff understand, recognize, and respond to the factors associated with the identified pain trajectories to improve mitigation of potentially persistent pain (e.g., hip fracture, contracture) or improve proxy pain assessment skills for residents at risk for under reporting of pain (e.g., Alzheimer's Disease).

Prevalence and Factors Associated with Pain in Nursing Home Residents: A Systematic Review of the Literature

OBJECTIVES

To describe the pain prevalence in nursing home (NH) residents and the factors associated with the experience of pain.

DESIGN

Systematic review of descriptive studies.

SETTING AND PARTICIPANTS

Three electronic databases were searched from 2010 to September 2020 in English. Descriptive studies that examined pain in NH residents, reported pain prevalence, and/or associated factors were included. Studies that focused exclusively on a specific disease or type of care such as cancer or hospice were excluded.

METHODS

Two reviewers independently screened, selected, extracted data, and assessed risk of bias from included studies; narrative synthesis was performed. The review was guided by the Biopsychosocial Model of Chronic Pain for Older Adults.

RESULTS

Twenty-six studies met our inclusion criteria. Overall, the prevalence of current pain ranged from 22.2% to 85.0%, the prevalence of persistent pain ranged from 19.5% to 58.5%, and the prevalence of chronic pain ranged from 55.9% to 58.1%. A variety of pain scales were used reporting higher pain prevalence for those using self-report measures (31.8% to 78.8%) or proxy measures (29.5% to 85.0%) compared with using chart review (22.2% to 29.3%) as the source of pain information. The studies reviewed provide support that certain diseases and clinical conditions are associated with pain. Impairment in activities of daily living (ADL) (12 studies), cognition (9 studies), depression (9 studies), and arthritis (9 studies) are the most widely studied factors, whereas depression, ADL impairment, arthritis, dementia, and cognitive impairment present the strongest association with pain.

CONCLUSION AND IMPLICATIONS

This review highlights the complexities of pain in NH residents and has implications for both clinical practice and future research. Understanding the factors that underlie the experience of pain, such as depression, is useful for clinicians evaluating pain and tailoring management therapies. In addition, the gaps in knowledge uncovered in this review are important areas for future research.

Pain and agitation treatment in severe dementia patients: The need for Italian Mobilization-Observation-Behavior-Intensity-Dementia (I-MOBID2) pain scale translation, adaptation and validation with psychometric testing

The 97% of dementia patients develops fluctuant neuropsychiatric symptoms often related to under-diagnosed and unrelieved pain. Up to 80% severe demented nursing home residents experiences chronic pain due to age-related comorbidities. Patients lacking self-report skills risk not to be appropriately treated for pain. Mobilization-Observation-Behavior-Intensity-Dementia (MOBID2) is the sole pain scale to consider the frequent co-occurrence of musculoskeletal and visceral pain and to unravel concealed pain through active guided movements. Accordingly, the Italian real-world setting can benefit from its translation and validation. This clinical study provides a translated, adapted and validated version of the MOBID2, the Italian I-MOBID2. The translation, adaptation and validation of the scale for non-verbal, severe demented patients was conducted according to current guidelines in a cohort of 11 patients over 65 with mini-mental state examination ≤ 12. The I-MOBID2 proves: good face and scale content validity index (0.89); reliable internal consistency (Cronbach's α = 0.751); good to excellent inter-rater (Intraclass correlation coefficient, and test-retest (ICC = 0.902) reliability. The construct validity is high (Rho = 0.748 p < 0.05 for 11 patients, Spearman rank order correlation of the overall pain intensity score with the maximum item score of I-MOBID2 Part 1; rho=0.895 p < 0.01 for 11 patients, for the overall pain intensity score with the maximum item score of I-MOBID2 Part 2) and a good rate of inter-rater and test-retest agreement was demonstrated by Cohen's K = 0.744. The average execution time is of 5.8 min, thus making I-MOBID2 a useful tool suitable also for future development in community setting with administration by caregivers.

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

PURPOSE

Detecting pain in older people with dementia is challenging. Consequentially, pain is often under-reported and under-treated. There remains uncertainty over what measures should be promoted for use to assess pain in this population. The purpose of this paper is to answer this question.

METHODS

A search of clinical trials registered on the ClinicalTrial.gov and ISRCTN registries was performed to identify outcome measures used to assess pain in people with dementia. Following this, a systematic review of published and unpublished databases was performed to 01 November 2021 to identify papers assessing the psychometric properties of these identified measures. Each paper and measure was assessed against the COSMIN checklist. A best evidence synthesis analysis was performed to assess the level of evidence for each measure.

RESULTS

From 188 clinical trials, nine outcome measures were identified. These included: Abbey Pain Scale, ALGOPLUS, DOLOPLUS-2, Facial Action Coding System, MOBID-2, self-reported pain through the NRS or VAS/thermometer or Philadelphia Geriatric Pain Intensity Scale, PACSLAC/PACSLAC-2, Pain Assessment in Advanced Dementia (PAINAD), and Checklist for non-verbal pain behavior (CNPI). From these, 51 papers (5924 people with dementia) were identified assessing the psychometric properties of these measures. From these, there was strong- and moderate-level evidence to support the use of the facial action coding system, PACSLAC and PACSLAC-II, CNPI, DOLOPLUS-2, ALGOPLUS, MOBID, and MOBID-2 tools for the assessment of pain with people living with dementia.

CONCLUSION

Whilst these reflect measurement tools used in research, further consideration on how these reflect clinical practice should be considered.

PROSPERO REGISTRATION

CRD42021282032.

Evaluation of the Psychometric Properties of PainChek® in UK Aged Care Residents with advanced dementia

BACKGROUND

The aim of this study was to further validate PainChek®, an electronic pain assessment instrument, with a population living with dementia in a UK care home.

METHOD

This study utilised a correlational design to evaluate the psychometric properties of PainChek® when compared to the Abbey Pain Scale (APS). Blinded paired pain assessments were completed at rest and immediately post-movement by a researcher and a nurse. A total of 22 participants with a diagnosis of moderate-to-severe dementia and a painful condition were recruited using opportunity sampling.

RESULTS

Overall, 302 paired assessments were collected for 22 participants. Out of these 179 were conducted during rest and 123 were immediately post-movement. The results demonstrated a positive significant correlation between overall PainChek® pain scores and overall APS pain scores (r = 0.818, N = 302, p < .001, one-tailed), satisfactory internal consistency (α = 0.810), moderate single measure intraclass correlation (ICC = 0.680) and substantial inter-rater agreement (κ = 0.719).

CONCLUSIONS

PainChek® has demonstrated to be a valid and reliable instrument to assess the presence and severity of pain in people with moderate-to-severe dementia living in aged care.

A Paradigm Shift for Movement-based Pain Assessment in Older Adults: Practice, Policy and Regulatory Drivers

BACKGROUND

The profession of nursing has been on the front line of pain assessment and management in older adults for several decades. Self-report has traditionally been the most reliable pain assessment method, and it remains a priority best practice in identifying the presence and intensity of pain. Although advances in technology, biomarkers, and facial cue recognition now complement self-report, it is still important to maximize self-report of pain and to gather understanding of the total pain experience directly from patients. Practices in pain assessment in older adults have evolved over the past 25 years, and current research and quality improvement studies seek not only to detect the presence of pain, but also to determine the best protocol for assessment and most important pain characteristics to assess. Increasing data are now supporting two emerging practices: (1) consistently assessing the impact of pain on function, and (2) measuring pain during movement-based activities rather than at rest.

OBJECTIVE

The purpose of this article is thus to discuss the shifting paradigm for movement-based pain assessment in older adults, as well as the practice, policy, and regulatory drivers that support this practice change.

Pain Patterns and Treatment Among Nursing Home Residents With Moderate-Severe Cognitive Impairment

OBJECTIVES

To examine the frequency and severity of pain and use of pain therapies among long-term care residents with moderate to severe dementia and to explore the factors associated with increased pain severity.

DESIGN

Prospective individual data were collected over 1 to 3 days for each participant.

SETTING

Sixteen long-term care facilities in Alabama, Georgia, Pennsylvania, and New Jersey.

PARTICIPANTS

Residents with moderate to severe cognitive impairment residing in a long-term care facility for at least 7 days were enrolled (N = 205). Residents were 47% female, predominantly white (69%), and 84 years old, on average (SD = 10 years).

MEASUREMENTS

A comprehensive pain assessment protocol was used to evaluate pain severity and characteristics through medical record review, interviews with nursing home staff, physical examinations, as well as pain observation tools (Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale and Pain Intensity Measure for Persons With Dementia). Known correlates were also assessed (agitation, depression, and sleep).

RESULTS

Experts' pain evaluations indicated that residents' usual pain was mild (mean = 1.6/10), and most experienced only intermittent pain (70%). However, 45% of residents experienced moderate to severe worst pain. Of residents, 90% received a pain therapy, with acetaminophen (87%) and opioids (32%) commonly utilized. Only 3% had a nondrug therapy documented in the medical record. The only resident characteristic that was significantly associated with pain severity was receipt of an opioid in the past week.

CONCLUSION

Using a comprehensive pain assessment protocol, we found that most nursing home residents with moderate to severe dementia had mild usual, intermittent pain and the vast majority received at least one pain therapy in the previous week. Although these findings reflect improvements in pain management compared with older studies, there is still room for improvement in that 45% of the sample experienced moderate to severe pain at some point in the previous week. J Am Geriatr Soc 68:794-802, 2020.

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.