Pain in Cognitively Impaired Older Persons

Pain and the Montreal Cognitive Assessment (MoCA) in Aging

OBJECTIVE

The present study aimed to determine whether specific cognitive domains part of the Montreal Cognitive Assessment (MoCA) are significantly lower in community-dwelling older adults with chronic pain compared with older adults without pain and whether these domains would be associated with self-reported pain, disability, and somatosensory function.

DESIGN

Secondary data analysis, cross-sectional.

SETTING

University of Florida.

SUBJECTS

Individuals over 60 years old enrolled in the Neuromodulatory Examination of Pain and mobility Across the Lifespan (NEPAL) study were included if they completed the MoCA and other study measures (n = 62). Most participants reported pain on most days during the past three months (63%).

METHODS

Subjects underwent a health assessment (HAS) and a quantitative sensory testing (QST) session. Health/medical history, cognitive function and self-reported pain measures were administered during the HAS. Mechanical and thermal detection, and thermal pain thresholds were assessed during the QST session.

RESULTS

Older adults with chronic pain had lower MoCA scores compared with controls on domains of executive function, attention, memory, and language (P < 0.05). The attention and language domains survived adjustments for age, sex, education, depression, and pain duration (P < 0.05). Attention was significantly associated with all pain characteristics including pain intensity and disability, while executive function was associated with mechanical detection (P < 0.05).

CONCLUSION

Our results support previous findings that individuals with chronic pain tend to show poorer cognitive functioning compared with pain-free controls in domains of attention and executive function. Our findings also extend these findings to community-dwelling older adults, who are already most vulnerable to age-related cognitive declines.

The impact of relocation stress on cognitively impaired and cognitively unimpaired long-term care residents

Objectives: The current aims were to explore the effects of relocation stress on depression and anxiety in long-term care residents and to investigate the moderating effect of cognitive status.Methods: The study used existing data from nursing home and congregate apartment residents. Self-reported measures of relocation stress, cognitive status, depression, and anxiety were examined. Exploratory analyses examined group differences in depression and anxiety within the full sample (n = 568) and the sample of first-year residents (n = 347). Main analyses were conducted in a subsample of 107 first-year residents who completed the measure of relocation stress.Results: Residents who had moved in the past year reported more anxiety but not depression than longer-term residents. Relocation stress significantly predicted depression but not anxiety in the subsample of first-year residents. There was no significant effect of cognitive status or the interaction of cognitive status and relocation stress on depression and anxiety.Conclusion: Findings suggest that cognitively impaired older adults are no more vulnerable to the negative effects of relocation stress than cognitively unimpaired older adults. Relocation stress should be regarded as a risk factor for depression in long-term care residents, regardless of cognitive status, in the first year after relocation.

Rocking chair therapy for dementia patients: Its effect on psychosocial well-being and balance

The use of platform style rocking chairs to improve psychological well-being and balance of nursing home residents with dementia was studied. Despite significant cognitive impairment, most medically stable unrestrained residents accepted the chairs and learned to actively rock. During the six week program, residents were able to rock an average of 101 minutes per day. Using a cross-over design (n=25), there were improvements in depression/anxiety and reductions in PRN pain medication significantly related to amount of rocking. Those who liked rocking and wanted to continue it at the end of the study also demonstrated significant improvements in balance as measured by center of gravity.

Pain Management in Elderly Patients

In elderly patients, persistent pain negatively impacts quality of life. An interdisciplinary approach to pain management and emphasis on quality improvement will help to achieve better therapeutic outcomes. Managing pain in the geriatric population is challenging because of age-related changes in pain perception, cognition, pharmacokinetics, and drug effects. Improvement and maintenance of physical and emotional function is the goal. Pharmacotherapy should be initiated conservatively and titrated to effective doses with minimal adverse effects. Milder pain should be treated with non-opioid analgesics with a progression toward opioids and/or adjuvant medications as the pain intensifies. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and adjuvant medications represent most of the analgesic agents used in pain management. Knowing the underlying mechanism of pain will help guide pharmacologic therapy. The patient should be monitored initially, with every dose change, and periodically to assess efficacy and severity of adverse effects.

An action-based approach to improving pain management in long-term care

PURPOSE

The study purposes were twofold: (1) to explore barriers to pain management and those associated with implementing a pain management program in long-term care (LTC); and (2) to develop an interprofessional approach to improve pain management in LTC.

METHODS

A case study approach included both qualitative and quantitative components. We collected data at two LTC sites using seven focus groups for the licensed nurses, unregulated care providers and physicians, and 10 interviews with other health care provider groups, administration, and residents. We reviewed documents and administered a short survey to study participants to assess perceptions of barriers to pain management.

RESULTS

The findings revealed barriers to effective LTC pain management at the resident/family, health care provider, and system levels. We then developed a six-tiered model with proposed interventions to address these barriers.

CONCLUSIONS

This model can guide the development of innovative approaches to improving pain management in LTC settings.

Pain in older people with frailty

In this review we identified cohort and cross-sectional studies that assessed pain in community-dwelling older people (>65 years) reliably characterized as frail. Secondly, we considered biologically plausible mechanisms that may alter pain perception, or contribute to, or exacerbate pain in an older person with frailty. Thirdly, we considered specific implications of pain management for this group of people. From the limited data from the seven included studies, it would appear that the presence of pain is higher in older people with frailty compared with people characterized as pre-frail or not frail. Thus older people reporting pain are more likely to be frail. However, a lack of prospective data precludes inferences about the direction of the relationship: that is whether pain or frailty is the antecedent. Further research is needed to understand the direction of the relationship, and to identify appropriate pain management strategies for older people with frailty.

Pain experience of adults with intellectual disabilities--caregiver reports

BACKGROUND

Pain is a problem for individuals with intellectual and developmental disability (IDD), secondary to their impairments, due to invasive medical procedures that these individuals undergo on a regular basis. Current literature indicates pain as a common experience for children with IDD, yet no such reports have been made in regard to adults with IDD.

PURPOSES

This study aimed (1) to re-establish the reliability of caregivers as proxy observers; (2) to evaluate the pain experience of adults with IDD by caregivers' proxy report; and (3) to assess the sensitivity of the Non-Communicating Adult Pain Checklist (NCAPC) as a pain scale for chronic pain (CP) in individuals with IDD.

METHOD

Frothy-three caregivers, working for more than 3 years with adults with IDD, performed pain assessments of 187 individuals living in a residential facility. Two caregivers evaluated whether each resident suffers from pain and assessed the intensity, causes and duration of pain experience. Furthermore, 52/187 residents [26 with CP and 26 pain free (PF) based on medical record and caregiver reports] were evaluated by an additional seven caregivers using the NCAPC in order to establish the reliability of caregivers as proxy observers.

RESULTS

According to caregivers' report, 48% of adults with IDD suffer from pain at a mean level of 6/10, with more than 10% suffering from high levels of pain on a constant basis. Inter-rater agreement was found mostly high with intraclass correlation values ranging between 0.73 and 0.93. Using the NCAPC, we were able to identify CP and PF individuals with a significant score difference (P = 0.003).

CONCLUSIONS

The results support the use of the NCAPC as a scale to evaluate CP in adults with IDD. The findings reiterate the reliability of caregivers as proxy observers and the importance of involving them in identifying pain behaviours of their protégées. Our findings reiterate the need for an immediate action for appropriate pain management protocols for adult with IDD.

The Verbal Rating Scale Is Reliable for Assessment of Postoperative Pain in Hip Fracture Patients

Background. Hip fracture patients represent a challenge to pain rating due to the high prevalence of cognitive impairment. Methods. Patients prospectively rated pain on the VRS. Furthermore, patients described the changes in pain after raising their leg, with one of five descriptors. Agreement between paired measures on the VRS at rest and by passive straight leg raise with a one-minute interval between ratings at rest and three-minute interval for straight leg raise was expressed by kappa coefficients. Reliability of this assessment of pain using the VRS was compared to the validity of assessing possible change in pain from the selected descriptors. Cognitive status was quantified by the short Orientation-Memory-Concentration Test. Results. 110 patients were included. Paired scores with maximum disagreement of one scale point reached 97% at rest and 95% at straight leg raise. Linear weighted kappa coefficients ranged from 0.68 (95% CI = 0.59–0.77) at leg raise to 0.75 (95% CI = 0.65–0.85) at rest. Unweighted kappa coefficients of agreement in recalled pain compared to agreement of paired VRS scores ranged from 0.57 (95% CI = 0.49–0.65) to 0.36 (95% CI = 0.31–0.41). Interpretation. The VRS is reliable for assessment of pain after hip fracture. The validity of intermittent questioning about possible change in pain intensity is poor.

Making the investment count: revision of the Minimum Data Set for nursing homes, MDS 3.0

BACKGROUND

The Minimum Data Set (MDS) is a potentially powerful tool for implementing standardized assessment in nursing homes (NHs). Its content has implications for residents, families, providers, researchers, and policymakers, all of whom have expressed concerns about the reliability, validity, and relevance of MDS 2.0. Some argue that because MDS 2.0 fails to include items that rely on direct resident interview, it fails to obtain critical information and effectively disenfranchises many residents from the assessment process.

PURPOSE

Design a major revision of the MDS, MDS 3.0, and evaluate whether the revision improves reliability, validity, resident input, clinical utility, and decreases collection burden.

DESIGN AND METHODS

In the form design phase, we gathered information from a wide range of experts, synthesized existing literature, worked with a national consortium of VA researchers to revise and test eight sections, pilot tested a draft MDS 3.0 and revised the draft based on results from the pilot. In the national validation and evaluation phase, we tested MDS 3.0 in 71 community NHs and 19 VHA NHs, regionally distributed throughout the United States. The sample was selected based on scheduled MDS 2.0 assessments. Comatose residents were excluded. A total 3822 residents of community NHs in eight states were included. The evaluation was designed to test and analyze inter-rater agreement (reliability) between research nurses and between facility staff and research nurses, validity of key sections, response rates for interview items, anonymous feedback on changes from participating nurses, and time to complete the MDS assessment.

RESULTS

The reliability for research nurse to research nurse and for research nurse to facility staff was good or excellent for most items. Response rates for the resident interview sections were high: 90% for cognitive, 86% for mood, 85% for preferences, and 87% for pain. Staff survey responses showed increased satisfaction with clinical relevance, validity and clarity compared with MDS 2.0. The test version of the MDS 3.0 took 45% less time for facilities to complete.

IMPLICATIONS

Improving the reliability, accuracy, and usefulness of the MDS has profound implications for NH care and public policy. Enhanced accuracy supports the primary legislative intent that MDS be a tool to improve clinical assessment and supports the credibility of programs that rely on MDS.

Pain and its Association with Disability in Institutional Long-Term Care in Four Nordic Countries

On a utilisé des données transversales (n = 6 487) de quatre pays nordiques (le Danemark, la Finlande, l'Islande et la Suède) pour établir la prévalence de la douleur quotidienne et de ses effets sur l'invalidité en milieu institutionnel de soins de longue durée. Chaque pensionnaire des établissements examinés a été évalué au moyen de la version 1.0 du Minimum Data Set. L'échantillonnage était représentatif des soins de longue durée donnés en institution à Copenhagen et Reykjavik. De plus, on a utilisé des données recueillies à Stockholm et Helsinki pour tirer des renseignements importants sur les pensionnaires de ces capitales. Les résultats indiquent qu'entre 22 et 24 pour cent des pensionnaires éprouvent des douleurs quotidiennes observables, ce qui est encore plus évident chez les sujets les plus invalides. S'ajoutant à l'invalidité et au sexe féminin, les maladies ou états associés à la douleur étaient un pronostic de maladie terminale, d'ostéoporose, de pneumonie, d'arthrite, de dépression, d'anémie, d'acrosyndrome, de cancer et de défaillance cardiaque. Le lien entre la douleur et la déficience intellectuelle grave était inexistant. Les résultats indiquent clairement que la douleur quotidienne est intimement liée à l'invalidité, celle-ci agissant sur les maladies sous-jacentes pour constituer la cause et l'effet de la douleur. On peut done voir un cercle vicieux entre la douleur et l'invalidité.

Correspondence of verbal descriptor and numeric rating scales for pain intensity: an item response theory calibration

BACKGROUND

Assessing pain intensity in older adults is critical and challenging. There is debate about the most effective way to ask older adults to describe their pain severity, and clinicians vary in their preferred approaches, making comparison of pain intensity scores across settings difficult.

METHODS

A total of 3,676 residents from 71 community nursing homes across eight states were asked about pain presence. The 1,960 residents who reported pain within the past 5 days (53% of total, 70% female; age: M = 77.9, SD = 12.4) were included in analyses. Those who reported pain were also asked to provide a rating of pain intensity using either a verbal descriptor scale (VDS; mild, moderate, severe, and very severe and horrible), a numeric rating scale (NRS; 0 = no pain to 10 = worst pain imaginable), or both. We used item response theory (IRT) methods to identify the correspondence between the VDS and the NRS response options by estimating item parameters for these and five additional pain items.

RESULTS

The sample reported moderate amounts of pain on average. Examination of the IRT location parameters for the pain intensity items indicated the following approximate correspondence: VDS mild approximately NRS 1-4, VDS moderate approximately NRS 5-7, VDS severe approximately NRS 8-9, and VDS very severe, horrible approximately NRS 10.

CONCLUSION

This IRT calibration provides a crosswalk between the two response scales so that either can be used in practice depending on the preference of the clinician and respondent.

Pain assessment in the elderly

Admissions to hospital for patients aged over 65 years are three times higher than for younger patients for all medical and surgical wards. Older people are often excluded from trials on pain assessment and treatment because of cognitive or sensory impairments. Professionals tend to underestimate pain needs, under-prescribe and under-medicate in general and in older people in particular. Where studies have included older people, the benefit of treatment is similar regardless of age. The first step in managing acute pain is through its assessment. Although pain is a subjective experience, pain rating scales are valid and reliable when used appropriately. Older people demonstrate some differences in reporting pain that may be attributable to a range of factors including biology, culture, religion, ethnicity, cognitive impairment, organisation or social context. Attitudinal barriers are also relevant because these include a persistent belief that older people experience less pain than other age groups. Not surprisingly, older people themselves might believe that pain is something to be endured, strong analgesics lead to addiction, complaining about pain is a sign of personal weakness and pain is an inevitable part of aging. Undertreatment of pain can lead to the development of chronic pain syndromes that can prove difficult to treat and adversely affect long-term quality of life. Effective treatment is paramount because of the increased morbidity and mortality associated with undertreated pain.

Pain management: an adolescent scoliosis patient

Recovery units can be busy environments not often conducive to reflective practice. Reflection is, however, an important aspect of high quality care. Using Gibbs model of reflection (see Figure 1), applied to the experience of caring for a 15 year old patient who had undergone surgery to correct a scoliosis deformity, this article illustrates how a deeper understanding of holistic pain management and assessment can be achieved and high standards of care maintained through careful reflective practice.

Portraits of caregivers of end-stage dementia patients receiving hospice care

The purpose of this study was to investigate how caregivers respond to the end stages of dementia with the assistance from hospice. Data were collected from 27 family caregivers over the course of 10 months, with each caregiver being interviewed up to 4 times during the time that the patient received hospice care. Chart review data were also collected. Four distinct caregiver portraits emerged: (a) disengaged; (b) questioning; (c) all-consumed; and (d) reconciled. Caregivers in each portrait differed in how they responded to the impending death of the care recipient, the disease progression, and hospice care. Recognizing the differences in the ways that caregivers respond to the final stages of the disease will assist hospice and other providers in best meeting the needs of the caregivers.

Pain in patients living in Norwegian nursing homes

The aims of this study were to describe the pain and use of pain medication in nursing home patients and examine which variables that were associated with pain. Inpatients (n = 307) older than 64 years from nursing homes were included. Pain was measured with a 4-point verbal rating scale in the self-reported group (SRG) and Doloplus-2 in the proxy-rated group (PRG). The mean age was 86 years (SD, 7), and more than two-thirds were female. A total of 128 (60%) patients were able to self-report their pain. Approximately 50% of the SRG reported 'pain now', and of these, nearly 50% reported moderate or severe pain intensity. Better cognitive function was associated with higher pain and receiving more potent pain medication in the SRG. The pain prevalence in the PRG was higher than in the SRG (67.5% vs 51%), but no variable was associated with proxy-rated pain. Nearly 30% in the SRG and 40% in the PRG did not receive pain medication in spite of pain. Pain is still a huge problem in the nursing homes, and more research is needed on pain management in nursing home residents.

Detection and management of pre-existing cognitive impairment and associated behavioral symptoms in the Intensive Care Unit

Recent increase in both the elderly population and associated incidence of dementia are of critical importance to patient care in ICUs in the United States. Identification of pre-existing cognitive impairment, such as mild cognitive impairment and dementia, could prevent delirium and associated morbidity and mortality in the ICU. Additionally, noncognitive behavioral symptoms, such as depression, psychosis, agitation, and catastrophic reactions, are common in patients with pre-existing cognitive impairment. Detection and management of noncognitive behavioral symptoms associated with MRI and dementia in ICU leads to improved delivery of life-saving critical care.

Disparities in pain management between cognitively intact and cognitively impaired nursing home residents

This study tests the association between residents' cognitive impairment and nursing homes' pain management practices. We used chart abstraction to collect data on 551 adults in six North Carolina nursing homes. From the standard data collected in the Minimum Data Set, 24% of residents experienced pain in the preceding week. Reports of pain decreased as cognitive abilities declined: nurses completing the Minimum Data Set reported pain prevalence of 34%, 31%, 24%, and 10%, respectively, for residents with no, mild, moderate, and severe cognitive impairment (P<0.001), demonstrating a "dose-response"-type result. Eighty percent of cognitively intact residents received pain medications, compared to 56% of residents with severe impairment (P<0.001). Cognitively impaired residents had fewer orders for scheduled pain medications than did their less cognitively impaired peers. Yet the presence of diagnoses likely to cause pain did not vary based on residents' cognitive status. We conclude that pain is underrecognized in nursing home residents with cognitive impairment and that cognitively impaired residents often have orders for "as needed" analgesics when scheduled medications would be more appropriate.

Symptom Experience of Dying Long-Term Care Residents

OBJECTIVES

To describe the end-of-life symptoms of nursing home (NH) and residential care/assisted living (RC/AL) residents, compare staff and family symptom ratings, and compare how staff assess pain and dyspnea for cognitively impaired and cognitively intact residents.

DESIGN

After-death interviews.

SETTING

Stratified random sample of 230 long-term care facilities in four states.

PARTICIPANTS

Staff (n=674) and family (n=446) caregivers for dying residents.

MEASUREMENTS

Interview items measured frequency and severity of physical symptoms, effectiveness of treatment, recommendations to improve care, and staff report of assessment.

RESULTS

Decedents' median age was 85, 89% were white, and 77% were cognitively impaired. In their last month of life, 47% had pain, 48% dyspnea, 90% problems with cleanliness, and 72% symptoms affecting intake. Problems with cleanliness, intake, and overall symptom burden were worse for decedents in NHs than for those in RC/AL. Treatment for pain and dyspnea was rated very effective for only half of decedents. For a subset of residents with both staff and family interviews (n=331), overall ratings of care were similar, although agreement in paired analyses was modest (kappa=-0.043-0.425). Staff relied on nonverbal expressions to assess dyspnea but not pain. Both groups of caregivers recommended improved application of treatment and increased staffing to improve care.

CONCLUSION

In NHs and RC/AL, dying residents have high rates of physical symptoms and need for more-effective palliation of symptoms near the end of life.

The facial expression of pain in patients with dementia

The facial expression of pain has emerged as an important pain indicator in demented patients, who have difficulties in providing self-report ratings. In a few clinical studies an increase of facial responses to pain was observed in demented patients compared to healthy controls. However, it had to be shown that this increase can be verified when using experimental methods, which also allows for testing whether the facial responses in demented patients are still typical for pain. We investigated facial responses in 42 demented patients and 54 aged-matched healthy controls to mechanically induced pain of various intensities. The face of the subject was videotaped during pressure stimulation and was later analysed using the Facial Action Coding System. Besides facial responses we also assessed self-report ratings. Comparable to previous findings, we found that facial responses to noxious stimulation were significantly increased in demented patients compared to healthy controls. This increase was mainly due to an increase of pain-indicative facial responses in demented patients. Moreover, facial responses were closely related to the intensity of stimulation, especially in demented patients. Regarding self-report ratings, we found no significant group differences; however, the capacity to provide these self-report ratings was diminished in demented patients. The preserved pain typicalness of facial responses to noxious stimulation suggests that pain is reflected as validly in the facial responses of demented patients as it is in healthy individuals. Therefore, the facial expression of pain has the potential to serve as an alternative pain assessment tool in demented patients, even in patients who are verbally compromised.

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

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

Mehrdimensionale Schmerzmessung bei Demenzpatienten

BACKGROUND

It is well known that patients with dementia complain less about pain and receive fewer analgesics than other patients. The question arises of whether disorders associated with dementia change the processing of pain.

METHODS

A total of 20 patients with dementia and 40 patients with mild cognitive impairment (MCI) as well as 40 healthy control subjects were investigated for their subjective (category scale), facial (FACS) and motor (R-III reflex) pain responses to mechanical and electrical stimuli.

RESULTS

Patients with dementia did not rate the intensity of the stimuli differently; however, they were less frequently capable of providing ratings. At equal levels of stimulus intensity, demented patients showed stronger facial responses. The R-III reflex thresholds were lowered in demented patients. MCI patients appeared only slightly changed.

CONCLUSIONS

Our findings suggest that the processing of acute noxious stimuli is intensified in patients with dementia. Against the background of a reduced prescription of analgesics, an under-treatment of pain in patients with dementia might be the consequence.

Prevalence of Pain in Nursing Home Residents With Different Cognitive and Communicative Abilities

OBJECTIVES

To determine the prevalence of pain and its impact among nursing homes residents with different cognitive and communication abilities.

DESIGN

Cross-sectional study.

SETTING

Three nursing homes in Singapore.

PARTICIPANTS

Residents aged 65 years and above, without a recent change in their cognitive status.

MEASUREMENTS

Self-reports were obtained whenever possible. Pain severity was measured with the Pain Assessment in Advanced Dementia scale (categorized version) among the uncommunicative. Residents were also assessed with the short-form version of the Geriatric Depression Scale, the Cornell Scale for Depression in Dementia, the state portion of the Spielberger State-Trait Anxiety Inventory, and the Human Activities Profile.

RESULTS

Pain prevalence did not differ between the communicative resident with normal cognition (48.7%), mildly impaired cognition (46.5%), or severely impaired cognition (42.9%). However, the latter 2 groups reported more acute pain than those with normal cognition (7.9% to 14.1% vs. 2.5%). Those with impaired cognition reported constant pain more often, reported fewer total sites of pain, and had more frequent and more severe pain. Regardless of cognitive status, 73.3% to 100% of residents had significant scores on depression or anxiety measures when they reported pain-related mood disturbance. Pain-related reduction in activity was associated with a lower Human Activities Profile score. Sixteen of 36 uncommunicative residents had pain on the Pain Assessment in Advanced Dementia and at least 12 of them had significant mood disturbance.

CONCLUSIONS

Cognitive status does not affect pain prevalence; however, it affects the chronicity and characteristics of reported pain. Self-report of pain-related mood involvement is associated with significant mood scores.

The Discomfort Behavior Scale: a measure of discomfort in the cognitively impaired based on the Minimum Data Set 2.0

Because persons with cognitive impairment often cannot self-report pain, it is imperative to develop instruments that use observable indicators. The purpose of this study was to develop and test the psychometric properties of the Discomfort Behavior Scale (DBS), which is comprised of 17 items from the Minimum Data Set (MDS). MDS data from 29,120 cognitively impaired nursing home residents were used for psychometric testing. Factor analyses of the DBS indicated that it reflects a single discomfort dimension. The items are tau equivalent, allowing unity weighting and simple summation to create scale scores, and the internal consistency was good. The DBS has potential to be useful in studies of efforts to improve pain management in cognitively impaired residents of nursing homes.

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

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

Behavioral Manifestations of Pain in the Demented Elderly

In long-term care settings, behavioral disturbances are exhibited more often by those residents with some level of cognitive impairment. The extent to which pain influences dysfunctional behaviors, and the extent to which pain manifests itself as dysfunctional behaviors, has not been empirically studied. The purpose of our study was to investigate the relationship between pain and behavioral disturbances among long-term care residents suffering from varying levels of dementia. A cross-sectional study of 277 long-term care residents aged 60 and older was conducted to (1) determine the influence of pain on the number, intensity, frequency, and duration of dysfunctional behaviors; (2) investigate the differences between residents with varying levels of dementia who were suffering from acute pain in the intensity, frequency, and duration of 19 behavioral categories; and (3) investigate the differences between residents with varying levels of dementia who were suffering from chronic pain in the intensity, frequency, and duration of 19 behavioral categories. Results suggest that pain influenced behavioral disturbances among those with severe dementia more often than those with moderate or mild dementia, and residents with chronic pain who have severe dementia exhibit significantly more dysfunctional behaviors than those with earlier-stage dementia. These findings support the utility of comprehensive behavioral analysis involving clinical ratings of intensity, frequency, and duration of dysfunctional behaviors, with the assessment of the resident's level of dementia. Moreover, our results imply that pain and other forms of physical suffering must be adequately treated in order to reduce behavioral disturbances and improve quality of life.

The Bathing Of Older Adults with Dementia

Older adults who need assistance with bathing often find the activity to be both physically and emotionally demanding, as do their caregivers. Research has identified several contributing factors, including pain; fatigue and weakness; confusion; anxiety resulting from being naked in front of strangers, being afraid of falling, and being in a noisy or unfamiliar place; and discomfort from cold or drafty bathing areas or harsh water sprays. The authors of this article make the case for the elimination of forced bathing. Research supports this change in philosophy and practice, whereby bathing is not a task to be performed but rather a human interaction. Inexpensive, practical, and evidence-based alternatives are discussed.

The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment

BACKGROUND

Difficulty with pain assessment in individuals who cannot self-report their pain poses a significant barrier to effective pain management. However, available assessment tools lack consistent reliability as pain measures in children with cognitive impairment (CI). This study evaluated the validity and reliability of the revised and individualized Face Legs Activity Cry and Consolability (FLACC) behavioral pain assessment tool in children with CI.

METHODS

Children with CI scheduled for elective surgery were studied. The FLACC was revised to include specific descriptors and parent-identified, unique behaviors for individual children. The child's ability to self-report pain was evaluated. Postoperatively, two nurses scored pain using the revised FLACC scale before and after analgesic administration, and, children self-reported a pain score, if able. Observations were videotaped and later viewed by experienced nurses blinded to analgesic administration.

RESULTS

Eighty observations were recorded in 52 children aged 4-19 years. Twenty-one parents added individualized pain behaviors to the revised FLACC. Interrater reliability was supported by excellent intraclass correlation coefficients (ICC, ranging from 0.76 to 0.90) and adequate kappa statistics (0.44-0.57). Criterion validity was supported by the correlations between FLACC, parent, and child scores (rho = 0.65-0.87; P < 0.001). Construct validity was demonstrated by the decrease in FLACC scores following analgesic administration (6.1 +/- 2.6 vs 1.9 +/- 2.7; P < 0.001).

CONCLUSIONS

Findings support the reliability and validity of the FLACC as a measure of pain in children with CI.

Nursing Home Resident Barriers to Effective Pain Management: Why Nursing Home Residents May Not Seek Pain Medication

OBJECTIVES

Multiple barriers to effective pain management are present in the nursing home setting. The purpose of this analysis was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior.

DESIGN

Every 3 months, a 20% sample of residents in 12 nursing homes was administered a short pain interview, then observed for pain indicators. Medical records were reviewed at the same time for documentation about pain and its treatment. All residents were asked if they had pain (or a similar word) now or in the past 24 hours. They were also asked if they had pain but did not request pain medication. If affirmative, the resident was asked to provide up to three reasons for not requesting medication.

SETTING

The study was conducted in 12 Colorado nursing homes, located in both urban and rural settings.

PARTICIPANTS

A total of 2033 nursing home residents completed pain interviews and/or were observed for pain indicators by trained research assistants. These interviews took place before, during, and after implementation of an intervention to improve pain practices.

MEASUREMENTS

A cognitive organizing structure was used to categorize resident responses into a coherent classification. Individual responses were assigned by team members to the appropriate category using a consensus process. The final classification scheme consisted of 10 categories of reasons why residents do not request pain medication.

RESULTS

More than one-half of residents (59.5%) reporting pain in the past 24 hours did not request medication for that pain. Subjects in pain were most likely to state medication concerns or stoicism as the reasons for not requesting pain medication. Concerns about staff reactions to a request or perceptions that the staff was too busy were also mentioned frequently by the residents. Subgroup analyses suggested that residents in pain but not requesting pain medication were significantly more likely to be in rural rather than urban nursing homes (67.9% vs. 52.9%, P < or = .01), and white as compared to nonwhite ethnicity (60.6% vs. 52.1%, P < or = .05). They also tended to be older on average (80.4 +/- 12.1 years vs. 77.9 +/- 12.7 years, P < or = .01) than residents who did request pain medication. Finally, residents in pain but not requesting pain medication were significantly more likely to report having both continuous (c) and intermittent (i) pain (71.8% [c + i] vs. 61% [c] or 56.5% [i], P < or = 0.01).

CONCLUSION

Interventions to reduce pain in nursing home residents need to be responsive to the concerns of the residents. It must be acknowledged that resident preferences and beliefs may lead to declined pain interventions regardless of the staff's motivation to make the resident more comfortable. Staff nurses also need to make a more concerted effort to systematically assess pain and offer pain medication to residents rather than rely on resident requests.

Using an osteoarthritis-specific pain measure in elders with cognitive impairment: a pilot study

AIM AND BACKGROUND

The Western Ontario and McMaster Osteoarthritis Index pain scale has not been used with cognitively impaired elders to measure their knee or hip pain. This study therefore examined the usefulness of the Western Ontario and McMaster Osteoarthritis Index pain scale for measuring pain in this population.

METHOD

Fourteen cognitively impaired elders with osteoarthritis of the knee or hip participated in the study. Elders' pain was assessed with the Western Ontario and McMaster Osteoarthritis Index pain scale, the Verbal Descriptor Scale and the Present Pain Intensity Scale, twice 5 minutes apart. Proxy report of pain was provided by the nursing staff.

RESULTS

The correlations among the Western Ontario and McMaster Osteoarthritis Index pain scale, Verbal Descriptor Scale and Present Pain Intensity were between 0.77 and 1.00 (P < 0.01). All pain measures showed high test-retest reliability (r = 0.98-1.00, P < 0.01). Staff's pain ratings using the Western Ontario and McMaster Osteoarthritis Index pain scale were strongly correlated with elders' pain ratings using any pain measure (r = 0.68-0.80, P < 0.05 or P < 0.01). However, staff's pain ratings using either the Verbal Descriptor Scale or Present Pain Intensity had no association with elders' pain ratings (r = -0.07 to -0.30, P = NS).

CONCLUSION

The study confirmed that the Western Ontario and McMaster Osteoarthritis Index pain scale is as valid and reliable as the Verbal Descriptor Scale and Present Pain Intensity for elders with moderate and mild cognitive impairment. When used by staff, the Western Ontario and McMaster Osteoarthritis Index pain scale provides a better pain assessment for cognitively impaired elders than the Verbal Descriptor Scale or Present Pain Intensity.

Obtaining Self-Report Data From Cognitively Impaired Elders: Methodological Issues and Clinical Implications for Nursing Home Pain Assessment

PURPOSE

We developed and evaluated an explicit procedure for obtaining self-report pain data from nursing home residents across a broad range of cognitive status, and we evaluated the consistency, stability, and concurrent validity of resident responses.

DESIGN AND METHODS

Using a modification of the Geriatric Pain Measure (GPM-M2), we interviewed 61 residents from two nursing homes (Mini-Mental State Examination score, M = 15 +/- 7) once a week for 4 consecutive weeks. We collected additional data by means of chart review, cognitive status assessments, and surveys of certified nursing assistants. We used descriptive and correlational analyses to address our primary aims.

RESULTS

Eighty-nine percent of residents completed all four scheduled interviews. Cognitive status was not significantly correlated with number of nonresponses and prompts for yes-no questions, but it was significantly correlated with nonresponses and prompts for Likert-scale questions (r = -.48, p <.001 and r = -.59, p <.001, respectively). Completion time for the 17-item pain measure (M = 13 min) was not predicted by cognitive status. Residents' scores on the GPM-M2 were significantly correlated with number of chronic pain-associated diagnoses, r =.37, p <.01, and internal consistency was excellent, alpha = 0.87 - 0.91. Residents' GPM-M2 scores were stable over time, r =.74-.80, p <.0001, for all comparisons.

IMPLICATIONS

Using explicit protocols and reporting procedural data allows researchers and clinicians to better understand and apply results of self-report studies with cognitively impaired elders. Results suggest that many nursing home residents can provide consistent and reliable self-report pain data, given appropriate time and assistance.

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

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

Nursing home resident barriers to effective pain management: why nursing home residents may not seek pain medication

OBJECTIVES

Multiple barriers to effective pain management are present in the nursing home setting. The purpose of this analysis was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior.

DESIGN

Every 3 months, a 20% sample of residents in 12 nursing homes was administered a short pain interview, then observed for pain indicators. Medical records were reviewed at the same time for documentation about pain and its treatment. All residents were asked if they had pain (or a similar word) now or in the past 24 hours. They were also asked if they had pain but did not request pain medication. If affirmative, the resident was asked to provide up to three reasons for not requesting medication.

SETTING

The study was conducted in 12 Colorado nursing homes, located in both urban and rural settings.

PARTICIPANTS

A total of 2033 nursing home residents completed pain interviews and/or were observed for pain indicators by trained research assistants. These interviews took place before, during, and after implementation of an intervention to improve pain practices.

MEASUREMENTS

A cognitive organizing structure was used to categorize resident responses into a coherent classification. Individual responses were assigned by team members to the appropriate category using a consensus process. The final classification scheme consisted of 10 categories of reasons why residents do not request pain medication.

RESULTS

More than one-half of residents (59.5%) reporting pain in the past 24 hours did not request medication for that pain. Subjects in pain were most likely to state medication concerns or stoicism as the reasons for not requesting pain medication. Concerns about staff reactions to a request or perceptions that the staff was too busy were also mentioned frequently by the residents. Subgroup analyses suggested that residents in pain but not requesting pain medication were significantly more likely to be in rural rather than urban nursing homes (67.9% vs. 52.9%, P < or = .01), and white as compared to nonwhite ethnicity (60.6% vs. 52.1%, P < or = .05). They also tended to be older on average (80.4 +/- 12.1 years vs. 77.9 +/- 12.7 years, P < or = .01) than residents who did request pain medication. Finally, residents in pain but not requesting pain medication were significantly more likely to report having both continuous (c) and intermittent (i) pain (71.8% [c + i] vs. 61% [c] or 56.5% [i], P < or = 0.01).

CONCLUSION

Interventions to reduce pain in nursing home residents need to be responsive to the concerns of the residents. It must be acknowledged that resident preferences and beliefs may lead to declined pain interventions regardless of the staff's motivation to make the resident more comfortable. Staff nurses also need to make a more concerted effort to systematically assess pain and offer pain medication to residents rather than rely on resident requests.

Osteoarthritic knee or hip pain: possible indicators in elderly adults with cognitive impairment

Many elderly individuals with cognitive impairment (CI) suffer from chronic pain resulting from osteoarthritis (OA). They have diminished ability to communicate their pain to health care providers, and when pain is undetected, it may be untreated. A method of detecting chronic OA pain in elderly individuals with Cl and measuring treatment outcomes is thus urgently needed. This article examines indicators of chronic OA pain in cognitively intact elderly individuals that could be used to identify pain in elderly individuals with Cl. The review suggests that patients with severe knee or hip OA pain tend to show specific motor patterns, disturbances of gait patterns, and reduction of activity level. Therefore, these behaviors could serve as alternatives to verbal report of chronic pain in elderly individuals with Cl and knee or hip OA.

Assessing Pain as a FIFTH VITAL SIGN IN LONG-TERM CARE FACILITIES: Recommendations from the Field

In long-term care facilities, pain management is complex because dementia, delirium, and other reasons for residents' altered communication ability are a significant barrier to pain assessment. The purpose of this study was to explore the status of implementation of pain as a fifth vital sign in a sample of long-term care facilities. A three-round Delphi survey was used to obtain consensus from personnel in 60 long-term care facilities in NY State. Findings are presented in terms of recommendations related to pain criteria, assessment methods, frequency of pain assessment, responsibility for pain assessment, monitoring strategies, education, documentation, and pain management education. The results of this study highlight many important considerations in the treatment of pain as a fifth vital sign in long-term care facilities. Evidence-based practice will be facilitated by further research related to underexplored aspects of pain assessment and management, and further attention to care delivery systems that support continued knowledge acquisition and the implementation of best practices.

[Deficiencies in treating pain of elderly people suffering from a severe cognitive impairment]

The objective of this study was to verify if the provision of care aimed at reducing pain was identical between elderly people suffering from a server cognitive distortion and other elderly people. The sample, taken from a two-tiered survey, was composed of 352 elderly people living in 34 retirement homes or other similar establishments housing the elderly. We categorised the residents into 2 groups: Group I was comprised of those who had a complete loss of physical autonomy, and Group II contained all of the others. Within these two groups, we compared four types of medicine of which the prescription was given at the request of the patient following a complaint, and four types of medicine prescribed as a result of the analysis of biological tests and screening and not as a result of a complaint from the patient. The results showed that the elderly people having a severe cognitive impairment received significantly less medication aimed at reducing pain than the other elderly people. This difference is not recognised when the medication is prescribed as a result of a need noted due to a biological check-up and analysis.

Cues for the identification of pain in nursing home residents

The aim of this section of a larger study was to identify the range of cues from which pain was inferred for a sample of residents with various levels of cognitive impairment in 15 UK nursing homes. Sixty-five nursing home staff and 36 informal carers of the 113 residents were interviewed. There was extensive use of body movements, facial expressions, and verbal and vocal cues and a considerable degree of interpretation of cues was used. There was little difference between the types of cue used by formal and informal carers, although informal carers tended to identify more of all types. There were differences in cues identified according to level of cognitive impairment, in particular, the interpretation of body movements. A simple model of the interaction between cognitive deficit, cue type and level of cue interpretation was proposed.

Treatment of chronic pain in persons with dementia: an overview

The purpose of this review is to identify the common causes of nonmalignant chronic pain in people with dementia, discuss methods for determining the level of pain in patients who are nonverbal, and evaluate pharmacologic treatment for nonmalignant chronic pain.

Veränderung des Schmerzerlebens bei Alzheimer-Patienten

Zusammenfassung: Klinische Studien, die nahe legen, dass Alzheimer-Patienten im Vergleich zur Altersgruppe deutlich seltener über Schmerzen berichten und deutlich weniger Analgetika verschrieben bekommen, haben die Frage aufgeworfen, inwieweit die Alzheimer-Erkrankung zu Veränderungen im Schmerzerleben führt. Um diese Frage zu beantworten, sind experimentelle Studien unabdingbar, da nur sie erlauben, Veränderungen des Schmerzsystems selbst zu erfassen. Die bisherigen experimentellen Befunde weisen darauf hin, dass die Schmerztoleranzschwelle deutlich erhöht und die vegetative Schmerzreaktion teilweise erheblich vermindert ist. Die Schmerzschwelle und schmerzkorrelierten Hirnpotenziale zeigten sich hingegen weitestgehend unverändert. Dies spräche eher für eine Abschwächung der Schmerzreagibilität bei Alzheimer-Demenz. Als mögliche Erklärungen hierfür diskutieren wir altersbedingte Veränderungen des Schmerzerlebens und neuroanatomische Veränderungen im Rahmen der Alzheimer-Erkrankung. Erste Ergebnisse einer eigenen Studie mit alternativer Methodik (mimische Schmerzreaktion, nozifensiver RIII-Reflex, u. a.) lassen im Gegensatz zu früheren Annahmen auch an die Möglichkeit einer erhöhten Schmerzreagibilität denken. Auch die beeinträchtigte Fähigkeit der Demenzpatienten zur verbalen Schmerzkommunikation und die Notwendigkeit alternativer, nonverbaler Messmethoden sind Thema der vorliegenden Übersichtsarbeit

Ameliorating Pain in Nursing Homes: A Collaborative Quality-Improvement Project

OBJECTIVES

To evaluate a multifaceted intervention to improve pain-management processes of care and outcomes in nursing homes.

DESIGN

Quasi-experimental, pretest/posttest.

SETTING

Nursing homes in Rhode Island.

PARTICIPANTS

Twenty-one facilities.

INTERVENTION

This project used a multifaceted collaborative intervention involving audit and feedback of pain management, education, training, coaching using rapid-cycle quality-improvement techniques, and inter-nursing home collaboration.

MEASUREMENTS

Pain-management processes of care and outcomes, measured using chart review and the Minimum Data Set.

RESULTS

Of 21 facilities, 17 completed the project. Postintervention, nursing homes increased the use of appropriate pain assessments (3.9% vs 43.8%, P<.001), pain intensity scales (15.6% vs 73.9%, P<.001), and nonpharmacological treatments (40.5% vs 81.9%, P<.001). Prescriptions of World Health Organization Step II or Step III pain medications for residents with daily moderate or severe pain showed trends towards improvement (40.8% vs 50.6%, P=.057), but prescription of any pain medication (93.3% vs 94.6%, P=.710), change in pain medication (29.0% vs 30.1%, P=.386), and prescription of pain medications on a regularly scheduled basis (67.9% vs 69.5%, P=.370) did not. There was a 41.1% reduction in prevalence of pain (12.2% vs 7.2%, P=.032) between the pre- and postintervention time periods in the nursing homes that completed the project, whereas all the other facilities in Rhode Island (n=72) had only a 12.1% reduction (12.7% vs 11.2%, P=.286) during the same period.

CONCLUSION

A multifaceted intervention improved pain-management process and outcome measures in nursing homes.

A comparison of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment

The aim of the study was to compare five different pain assessment scales for use with people with different levels of cognitive impairment who resided in nursing homes. The verbal rating scale, horizontal numeric rating scale, Faces pictorial scale, color analogue scale and mechanical visual analogue scale were presented in random order to 113 residents. Cognitive impairment was assessed using the Mini-Mental State Examination. The use of the verbal rating scale was the most successful with this group, completed by 80.5% overall, and 36% of those with severe cognitive impairment. Repeated explanation improved completion rates for all the scales. Consistency between scores on the five scales was good for those with none to moderate cognitive impairment and poor for those severely impaired. This study showed no difference in pain scores according to cognitive status.