Observation Scales for Pain Assessment in Older Adults With Cognitive Impairments or Communication Difficulties

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

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

Perspectives on approaching pain management in patients with dementia

This paper presents a review of the latest literature and guidance regarding the assessment and management of pain in older adults with dementia. The size and nature of the problem will be presented, in terms of the increasing aging population across the globe and potential for a significant increase in adults with dementia, along with the reduction in younger counterparts who will be available to provide care in the future. We will present the latest recommendations regarding how to assess pain and which tools are recommended for use underpinned by the strongest evidence. Finally, we will present the findings of the latest national (UK) guidelines for the management of pain. Recommendations will be made for future research and clinical practice.

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

Measuring Pain in Aphasia: Validity and Reliability of the PACSLAC-D

BACKGROUND

Post-stroke pain in patients with an inability to communicate is not systematically assessed and therefore not sufficiently treated. This stresses the need to study pain assessment instruments that do not require good communication skills.

AIM

To examine the validity and reliability of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate - Dutch version (PACSLAC-D) in stroke patients with aphasia.

METHOD

Sixty stroke patients (mean age 79.3 years, standard deviation [SD] 8.0), of whom 27 had aphasia were observed during rest, activities of daily living (ADL), and physiotherapy using the Pain Assessment Checklist for Seniors with Limited Ability to Communicate - Dutch version (PACSLAC-D). The observations were repeated after two weeks. To examine convergent validity, correlations between the PACSLAC-D, self-report pain scales, and the clinical judgment of a health care professional (pain present yes/no) were used. To examine discriminative validity, differences in pain were investigated between rest and ADL, in patients who use pain medication and those who do not, and in patients with and without aphasia. Internal consistency and test-retest reliability were assessed to determine reliability.

RESULTS

Convergent validity failed to meet the acceptable threshold during rest but was adequate during ADL and physiotherapy. Discriminative validity was only adequate during ADL. The internal consistency was 0.33 during rest, 0.71 during ADL, and 0.65 during physiotherapy. Test-retest reliability varied from poor during rest (intraclass correlation coefficient [ICC] = 0.07; 95% confidence interval [CI]: -0.40-0.51) to excellent during physiotherapy (ICC = 0.95; 95% CI: 0.83-0.98).

CONCLUSIONS

The PACSLAC-D captures pain in patients with aphasia who are unable to self-report, during ADL and physiotherapy, but may be less accurate during rest.

Multidisciplinary approach, continuous care and opioid management in cancer pain: case series and review of the literature

Underlying cancer pain has heterogenous aetiologies and mechanisms. It requires detailed and comprehensive pain assessment, combined with personalized treatment. A multidisciplinary team is essential to providing the best management of cancer pain at every disease stage, improving the quality of life and outcomes in patients with cancer. This narrative literature review emphasizes the value of providing all patients with multidisciplinary pain management in their preferred care setting. Real-life experiences are also reported to witness the efforts of physicians to properly manage cancer pain. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.

Translation, Cross-Cultural Adaptation, and Validation of the Portuguese Version of the Rotterdam Elderly Pain Observation Scale

<b><i>Introduction:</i></b> This study reports on the translation, cultural adaptation, and validation of a Portuguese version of the Rotterdam Elderly Pain Observation Scale (REPOS), a Dutch scale to assess pain in patients who cannot communicate, with or without dementia. <b><i>Methods:</i></b> This is a multicenter study in pain and neurological units involving Brazil (clinical phase) and the Netherlands (training phase). We performed a retrospective cross-sectional, 2-staged analysis, translating and culturally adapting the REPOS to a Portuguese version (REPOS-P) and evaluating its psychometric properties. Eight health professionals were trained to observe patients with low back pain. REPOS consists of 10 behavioral items scored as present or absent after a 2-min observation. The REPOS score of ≥3 in combination with the Numerical Rating Scale (NRS) of ≥4 indicated pain. The Content Validity Index (CVI) in all items and instructions showed CVI values at their maximum. According to the higher correlation coefficient found between NRS and REPOS-P, it may be suggested that there was an adequate convergent validity. <b><i>Results:</i></b> The REPOS-P was administered to 80 patients with a mean age of 60 years (SD 11.5). Cronbach’s alpha coefficient showed a moderate internal consistency of REPOS-P (α = 0.62), which is compatible with the original study of REPOS. All health professionals reached high levels of interrater agreement within a median of 10 weeks of training, assuring reproducibility. Cohen’s kappa was 0.96 (SD 0.03), and the intraclass correlation coefficient was 0.98 (SD 0.02), showing high reliability of REPOS-P scores between the trainer (researcher) and the trainees (healthcare professionals). The Pearson correlation coefficient was 0.95 (95% confidence interval 0.94–0.97), showing a significant correlation between the total scores of REPOS-P and NRS. <b><i>Conclusion:</i></b> The REPOS-P was a valuable scale for assessing elderly patients with low back pain by different healthcare professionals. Short application time, ease of use, clear instructions, and the brief training required for application were essential characteristics of REPOS-P.

Crying out in pain-A systematic review into the validity of vocalization as an indicator for pain

BACKGROUND

Vocalization is often used to assess pain, sometimes combined with other behaviours such as facial expressions. Contrary to facial expressions, however, for vocalization, there is little evidence available on the association with pain. The aim of this systematic review was to critically analyse the association between vocalization and pain, to explore if vocalizations can be used as a "stand-alone" indicator for pain.

METHODS

The search was performed according to the Prisma Guidelines for systematic reviews and meta-analysis. The following terms were used: "Pain Measurement," "Vocalization" and "Verbalization." The study population included verbal and non-verbal individuals, including older people and children. The search was performed in three different databases: PubMed, Embase and CINAHL. A total of 35 studies were selected for detailed investigation. Quality assessments were made using two grading systems: Grading of Recommendations Assessment Development and Evaluation system and the Newcastle-Ottawa scale.

RESULTS

An association between vocalization and pain was found in most studies, particularly when different types of vocalizations were included in the investigation. Different types of vocalization, but also different types of pain, shape this association. The association is observed within all groups of individuals, although age, amongst others, may have an influence on preferred type of vocalization.

CONCLUSIONS

There is an association between vocalization and pain. However, vocalization as a "stand-alone" indicator for pain indicates only a limited aspect of this multifactorial phenomenon. Using vocalization as an indicator for pain may be more reliable if other pain indicators are also taken into account.

SIGNIFICANCE

Vocalizations are frequently used in pain scales, although not yet thoroughly investigated as a "single indicator" for pain, like, e.g. facial expression. This review confirms the role of vocalizations in pain scales, and stresses that vocalizations might be more reliable if used in combination with other pain indicators.

Psychometric evaluation of the Persian version of the Doloplus-2 (P-Doloplus-2) scale in elderly with dementia

Background/aim

A scale for behavioural pain assessment is useful for the detection and determination of pain in the elderly with dementia. This study aimed to translate and evaluate the psychometric properties of Doloplus-2 in the elderly with dementia in Iran.

Materials and methods

In this methodological study, after translation and evaluating the face and content validity of Doloplus-2, 100 elderly people were selected by the convenience sampling method in Kashan, 2018–2019. Exploratory factor analysis, convergent validity, and known-groups comparison were applied to determine construct validity. Reliability was also assessed through internal consistency, equivalence, and stability methods were used. The ceiling and floor effects were also examined. Data were analyzed using the SPSS-v16 and via Mann-Whitney U test, Cronbach’s alpha, Spearman-Brown, and intraclass correlation coefficient (ICC).

Results

The scale’s content validity index was 0.95%, and the item impact of each item was above 1.5. Factor analysis identified 2 “social- functional” and “conventional subjective-objective” factors in scale that altogether were able to explain 76% of the total variance. The results revealed that P-Doloplus-2 could discriminate between the 2 groups of elderly with and without known chronic painful diseases (P < 0.0001). There was a significant positive correlation between P-Doloplus-2 and PACSLAC-II-IR scores (r = 0.878, P < 0.0001). Cronbach’s alpha, ICC, and standard error of measurement for the scale were 0.950, 0.864, and ± 1.759, respectively. The frequency of minimum and maximum possible score of scale was less than 15%.

Conclusion

The Persian version of Doloplus-2 can be considered as a valid and reliable scale for pain assessment in the elderly with dementia.

Pain assessment and pain treatment for community-dwelling people with dementia: A systematic review and narrative synthesis

OBJECTIVES

To describe the current literature on pain assessment and pain treatment for community-dwelling people with dementia.

METHOD

A comprehensive systematic search of the literature with narrative synthesis was conducted. Eight major bibliographic databases were searched in October 2018. Titles, abstracts, and full-text articles were sequentially screened. Standardised data extraction and quality appraisal exercises were conducted.

RESULTS

Thirty-two studies were included in the review, 11 reporting findings on pain assessment tools or methods and 27 reporting findings on treatments for pain. In regard to pain assessment, a large proportion of people with moderate to severe dementia were unable to complete a self-report pain instrument. Pain was more commonly reported by informal caregivers than the person with dementia themselves. Limited evidence was available for pain-focused behavioural observation assessment. In regard to pain treatment, paracetamol use was more common in community-dwelling people with dementia compared with people without dementia. However, non-steroidal anti-inflammatory drugs (NSAIDs) were used less. For stronger analgesics, community-dwelling people with dementia were more likely to receive strong opioids (eg, fentanyl) than people without dementia.

CONCLUSION

This review identifies a dearth of high-quality studies exploring pain assessment and/or treatment for community-dwelling people with dementia, not least into non-pharmacological interventions. The consequences of this lack of evidence, given the current and projected prevalence of the disease, are very serious and require urgent redress. In the meantime, clinicians should adopt a patient- and caregiver-centred, multi-dimensional, longitudinal approach to pain assessment and pain treatment for this population.

"A tool doesn't add anything". The importance of added value: Use of observational pain tools with patients with advanced dementia approaching the end of life-a qualitative study of physician and nurse experiences and perspectives

BACKGROUND

Observational pain tools (OPTs) are widely recommended in health care policies, clinical guidelines, and recommendations for pain assessment and management. However, it is unclear whether and how these tools are used for patients with advanced dementia approaching the end of life.

AIM

To explore hospice, secondary, and primary care physicians' and nurses' use of OPTs with patients dying with advanced dementia and their perspectives on practice development and training needs.

METHODS

Twenty-three physicians and 24 nurses with experience of caring for people dying with advanced dementia were recruited from primary care surgeries (n = 5), hospitals (n = 6), hospices (n = 4), and nursing homes (n = 10). Semistructured, face-to-face interviews were conducted. Interviews were digitally recorded, transcribed verbatim, and thematic analysis applied to identify core themes.

RESULTS

Three key themes emerged: (1) use of OPTs in this vulnerable patient population, (2) barriers to the use of OPTs and lack of perceived "added value", and (3) perspectives on practice development and training in pain assessment in advanced dementia at end of life. Just over one-quarter of participants (n = 13) routinely used OPTs. Reasons for nonuse included perceived limitations of such tools, difficulties with their use and integration with existing practice, and lack of perceived added value. Most participants strongly emphasised a need for ongoing training and development which facilitated transfer of knowledge and multidisciplinary skills across professions and specialties.

CONCLUSIONS

Health professionals require ongoing support in developing and integrating change to existing pain assessment protocols and approaches. These findings have important implications for health education, practice, and policy.

Which Facial Descriptors Do Care Home Nurses Use to Infer Whether a Person with Dementia Is in Pain?

Objectives

Pain assessment in people with advanced dementia relies strongly on observable pain behaviors, such as facial expressions, body movement, and vocalizations. However, the process of inferring pain in others based on such observations is not well understood. We aimed to investigate which features of facial expressions caregivers rely on when inferring the presence and intensity of pain in people with dementia.

Methods

A questionnaire, including items on 13 facial descriptors, which were extracted from established observational scales for pain in dementia, was sent to 366 nursing homes in Germany. We asked the nurses to observe patients with dementia and then rate their observations using the facial descriptors, as well as to provide an overall pain estimate of the residents' pain. We used regression analyses to identify which facial descriptors nurses use most commonly to infer whether a person with dementia is in pain and to grade the pain's intensity.

Results

Seventy-nine nursing homes participated (22% response rate), and a total of 284 completed observer ratings were returned. The observed individuals suffered from moderate to severe dementia and were observed in everyday care situations. The average pain estimated by the caregivers was slight to moderate. Mainly anatomically based descriptors ("frowning," "narrowed eyes") and indicators of emotional arousal ("looking tense," looking frightened") significantly predicted the overall pain ratings by nurses, explaining approximately 45% of the variance.

Conclusions

Although all presented facial descriptors were used by the nurses, some descriptors were used clearly more frequently than others to infer whether a resident with dementia was in pain. Development of observational pain tools and training in their use should consider the preexisting assumptions that nurses use to infer pain as well as their potential bias.

Dynamic Quantification of Migrainous Thermal Facial Patterns - A Pilot Study

This article documents thermophysiological patterns associated with migraine episodes, where the inner canthi and supraorbital temperatures drop significantly compared to normal conditions. These temperature drops are likely due to vasoconstriction of the ophthalmic arteries under the inner canthi and sympathetic activation of the eccrine glands in the supraorbital region, respectively. The thermal patterns were observed on eight migraine patients and meticulously quantified using advance computational methods, capable of delineating small anatomical structures in thermal imagery and tracking them automatically over time. These methods open the way for monitoring migraine episodes in nonclinical environments, where the patient maintains directional attention, such as his/her computer at home or at work. This development has the potential to significantly expand the operational envelope of migraine studies.

A Technical Note on the PainChek™ System: A Web Portal and Mobile Medical Device for Assessing Pain in People With Dementia

Background: Pain in dementia is predominant particularly in the advanced stages or in those who are unable to verbalize. Uncontrolled pain alters the course of behaviors in patients with dementia making them perturbed, unsettled, and devitalized. Current measures of assessing pain in this population group are inadequate and underutilized in clinical practice because they lack systematic evaluation and innovative design.

Objective: To describe a novel method and system of pain assessment using a combination of technologies: automated facial recognition and analysis (AFRA), smart computing, affective computing, and cloud computing (Internet of Things) for people with advanced dementia.

Methods and Results: Cognification and affective computing were used to conceptualize the system. A computerized clinical system was developed to address the challenging problem of identifying pain in non-verbal patients with dementia. The system is composed of a smart device enabled app (App) linked to a web admin portal (WAP). The App “PainChek™” uses AFRA to identify facial action units indicative of pain presence, and user-fed clinical information to calculate a pain intensity score. The App has various functionalities including: pain assessment, pain monitoring, patient profiling, and data synchronization (into the WAP). The WAP serves as a database that collects the data obtained through the App in the clinical setting. These technologies can assist in addressing the various characteristics of pain (e.g., subjectivity, multidimensionality, and dynamicity). With over 750 paired assessments conducted, the App has been validated in two clinical studies (n = 74, age: 60–98 y), which showed sound psychometric properties: excellent concurrent validity (r = 0.882–0.911), interrater reliability (Kw = 0.74–0.86), internal consistency (α = 0.925–0.950), and excellent test-retest reliability (ICC = 0.904), while it possesses good predictive validity and discriminant validity. Clinimetric data revealed high accuracy (95.0%), sensitivity (96.1%), and specificity (91.4%) as well as excellent clinical utility (0.95).

Conclusions: PainChek™ is a comprehensive and evidence-based pain management system. This novel approach has the potential to transform pain assessment in people who are unable to verbalize because it can be used by clinicians and carers in everyday clinical practice.

Clinimetric properties of the electronic Pain Assessment Tool (ePAT) for aged-care residents with moderate to severe dementia

Purpose

Accurate pain assessment is critical to detect pain and facilitate effective pain management in dementia patients. The electronic Pain Assessment Tool (ePAT) is a point-of-care solution that uses automated facial analysis in conjunction with other clinical indicators to evaluate the presence and intensity of pain in patients with dementia. This study aimed to examine clini-metric properties (clinical utility and predictive validity) of the ePAT in this population group.

Methods

Data were extracted from a prospective validation (observational) study of the ePAT in dementia patients who were ≥65 years of age, living in a facility for ≥3 months, and had Psychogeriatric Assessment Scales - cognitive scores ≥10. The study was conducted in two residential aged-care facilities in Perth, Western Australia, where residents were sampled using purposive convenience strategy. Predictive validity was measured using accuracy statistics (sensitivity, specificity, positive predictive value, and negative predictive value). Positive and negative clinical utility index (CUI) scores were calculated using Mitchell's formula. Calculations were based on comparison with the Abbey Pain Scale, which was used as a criterion reference.

Results

A total of 400 paired pain assessments for 34 residents (mean age 85.5±6.3 years, range 68.0-93.2 years) with moderate-severe dementia (Psychogeriatric Assessment Scales - cognitive score 11-21) were included in the analysis. Of those, 303 episodes were classified as pain by the ePAT based on a cutoff score of 7. Unadjusted prevalence findings were sensitivity 96.1% (95% CI 93.9%-98.3%), specificity 91.4% (95% CI 85.7%-97.1%), accuracy 95.0% (95% CI 92.9%-97.1%), positive predictive value 97.4% (95% CI 95.6%-99.2%), negative predictive value 87.6% (95% CI 81.1%-94.2%), CUI⁺ 0.936 (95% CI 0.911-0.960), CUI^- 0.801 (95% CI 0.748-0.854).

Conclusion

The clinimetric properties demonstrated were excellent, thus supporting the clinical usefulness of the ePAT when identifying pain in patients with moderate-severe dementia.

Pain Assessment in Dementia: Evaluation of a Point-of-Care Technological Solution

Pain is common among people with moderate to severe dementia, but inability of patients to self-report means it often goes undetected and untreated. We developed the electronic Pain Assessment Tool (ePAT) to address this issue. A point-of-care App, it utilizes facial recognition technology to detect facial micro-expressions indicative of pain. ePAT also records the presence of pain-related behaviors under five additional domains (Voice, Movement, Behavior, Activity, and Body). In this observational study, we assessed the psychometric properties of ePAT compared to the Abbey Pain Scale (APS). Forty aged care residents (70% females) over the age of 60 years, with moderate to severe dementia and a history of pain-related condition(s) were recruited into the study. Three hundred and fifty-three paired pain assessments (either at rest or post-movement) were recorded and analyzed. The ePAT demonstrated excellent concurrent validity (r = 0.882, 95% CI: 0.857–0.903) and good discriminant validity. Inter-rater reliability score was good overall (weighted κ= 0.74, 95% CI: 0.68–0.80) while internal consistency was excellent. ePAT has psychometric properties which make it suitable for use in non-communicative patients with dementia. ePAT also has the advantage of automated facial expression assessment which provides objective and reproducible evidence of the presence of pain.

Algoplus® Scale in Older Patients with Dementia: A Reliable Real-World Pain Assessment Tool

Pain is still a neglected clinical issue in elderly people with dementia and/or communicative disorders, with an unacceptable higher rate of under diagnosis and under treatment. Cognitive deficit and emotional and psychological disturbances entangle pain symptoms, affecting patient self-report. So far, observational pain tools do not have fully adequate clinimetric properties and quality requirements for easy-to-use daily rating. Older patients with dementia represent a clinical challenge. The assessment of pain is important for improving clinical outcomes, such as functional status, frailty trajectories, comorbidity, and quality of life. The PAINAID scale appears to be the most accurate pain tool in people with dementia along with the Algoplus® scale, a recently developed tool to rapidly assess acute pain in hospitals settings. The present study aimed to assess the clinimetric properties of the Algoplus®, as compared to PAINAID, for detecting acute pain in a real-world cohort of hospitalized older patients with dementia.

The Rotterdam Elderly Pain Observation Scale (REPOS) is reliable and valid for non-communicative end-of-life patients

BACKGROUND

In palliative care, administration of opioids is often indispensable for pain treatment. Pain assessment may help recognize pain and guide treatment in non-communicative patients. In the Netherlands the Rotterdam Elderly Pain Observation Scale (REPOS) is recommended to this aim, but not yet validated. Therefore the objective of this study was to validate the REPOS in non-communicative or unconscious end-of-life patients.

METHODS

In this observational study, the primary researcher applied the REPOS, while both the researcher and a nurse applied the Numeric Rating Scale (NRS). If possible, the patient in question applied the NRS as well. The NRS scores were compared with the REPOS scores to determine concurrent validity. REPOS scores obtained before and after a pain-reducing intervention were analysed to establish the scale's sensitivity to change.

RESULTS

A total of 183 REPOS observations in 100 patients were analysed. Almost 90% of patients had an advanced malignancy; observations were done a median of 3 days (IQR 1 to 13) before death. Internal consistency of the REPOS was 0.73. The Pearson product moment correlation coefficient ranged from 0.64 to 0.80 between REPOS and NRS scores. REPOS scores declined with median 2 points (IQR 1 to 4) after a pain-reducing intervention (p < 0.001). Optimal sensitivity (0.81) and specificity (0.62) were found at cut-off score 3.

CONCLUSIONS

This study demonstrates that the REPOS has promising psychometric properties for pain assessment in non-communicative end-of-life patients. Its application may be of additional value to relieve suffering, including pain, in palliative care.

Measurement properties, feasibility and clinical utility of the Doloplus-2 pain scale in older adults with cognitive impairment: a systematic review

Background

The Doloplus-2 is a pain assessment scale for assessing pain in older adults with cognitive impairment. It is used in clinical practice and research. However, evidence for its measurement properties, feasibility and clinical utility remain incomplete. This systematic review synthesizes previous research on the measurement properties, feasibility and clinical utility of the scale.

Method

We conducted a systematic search in three databases (CINAHL, Medline and PsycINFO) for studies published in English, French, German, Dutch/Flemish or a Scandinavian language between 1990 and April 2017. We also reviewed the Doloplus-2 homepage and reference lists of included studies to supplement our search. Two reviewers independently reviewed titles and abstracts and performed the quality assessment and data abstraction.

Results

A total of 24 studies were included in this systematic review. The quality of the studies varied, but many lacked sufficient detail about the samples and response rates. The Doloplus-2 has been studied using diverse samples in a variety of settings; most study participants were in long-term care and in people with dementia. Sixteen studies addressed various aspects of the scale’s feasibility and clinical utility, but their results are limited and inconsistent across settings and samples. Support for the scale’s reliability, validity and responsiveness varied widely across the studies. Generally, the reliability coefficients reached acceptable benchmarks, but the evidence for different aspects of the scale’s validity and responsiveness was incomplete.

Conclusion

Additional high-quality studies are warranted to determine in which populations of older adults with cognitive impairment the Doloplus-2 is reliable, valid and feasible. The ability of the Doloplus-2 to meaningfully quantify pain, measure treatment response and improve patient outcomes also needs further investigation.

Trial registration

PROSPERO reg. no.: CRD42016049697 registered 20. Oct. 2016.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0643-9) contains supplementary material, which is available to authorized users.

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.

Pharmacokinetics of Morphine, Morphine-3-Glucuronide and Morphine-6-Glucuronide in Terminally Ill Adult Patients

Background and Objective

Morphine dosing can be challenging in terminally ill adult patients due to the heterogeneous nature of the population and the difficulty of accurately assessing pain during sedation. To determine the pharmacokinetics of morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) in this population, and to find clinically relevant parameters for dose individualisation, we performed a population pharmacokinetic analysis.

Methods

Blood samples were randomly collected from 47 terminally ill patients in both the pre-terminal and terminal phases. Nonlinear mixed-effects modelling (NONMEM) was used to develop a population pharmacokinetic model and perform covariate analysis.

Results

The data were accurately described by a two-compartment model for morphine with two one-compartment models for both its metabolites. Typical morphine clearance was 48 L/h and fell exponentially by more than 10 L/h in the last week before death. Decreased albumin levels and a decreased estimated glomerular filtration rate (eGFR) resulted in lower metabolite clearance. Between-subject variability in clearance was 52 % (morphine), 75 % (M3G) and 79 % (M6G), and changed to 53, 29 and 34 %, respectively, after inclusion of the covariates.

Conclusions

Our results show that morphine clearance decreased up to the time of death, falling by more than 10 L/h (26 %) in the last week before death, and that M3G and M6G accumulated due to decreased renal function. Further studies are warranted to determine whether dose adjustment of morphine is required in terminally ill patients.

Pain assessment tools for older adults with dementia in long-term care facilities: a systematic review

AIM

The aim of this review is to document pain assessment tools used primarily for older adults in long-term care facilities and compare self-report and observer-rated tools.

METHODS

A literature search was conducted in Ovid MEDLINE^®, Embase, Cochrane and PsycINFO. Keywords included 'dementia', 'pain management' and 'managing pain'.

RESULTS

Of 1033 references, 23 articles were selected for inclusion. Six tools were self-rated and 18 tools were administered by an observer. 13 studies evaluated the reliability/validity of their scales; four studies compared different scales against each other.

CONCLUSION

Self-report should be the first-line approach when possible, with observational assessment used as a supplementary tool. Reliable observational tools have been shortened, and shown to maintain high reliability/validity, and positive psychometric properties.

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

Background

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

Aims and objectives

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

Methods

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

Results

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

Limitations

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

Conclusions

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

Funding

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

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

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

The use of facial expressions for pain assessment purposes in dementia: a narrative review

Facial expressions convey reliable nonverbal signals about pain and thus are very useful for assessing pain in patients with limited communicative ability, such as patients with dementia. In this review, we present an overview of the available pain observation tools and how they make use of facial expressions. Utility and reliability of facial expressions to measure pain in dementia are discussed, together with the effect of dementia severity on these facial expressions. Next, we present how behavioral alterations may overlap with facial expressions of pain, and may even influence the extent to which pain is facially expressed. The main focus is on disinhibition, apathy and emotional changes. Finally, an overview of theoretical considerations and practical implications is presented for assessing pain using facial expressions in clinical settings.

Diagnostic imaging to detect and evaluate response to therapy in bone metastases from prostate cancer: current modalities and new horizons

Different therapeutic options for the management of prostate cancer (PC) have been developed, and some are successful in providing crucial improvement in both survival and quality of life, especially in patients with metastatic castration-resistant PC. In this scenario, diverse combinations of radiopharmaceuticals (for targeting bone, cancer cells and receptors) and nuclear medicine modalities (e.g. bone scan, SPECT, SPECT/CT, PET and PET/CT) are now available for imaging bone metastases. Some radiopharmaceuticals are approved, currently available and used in the routine clinical setting, while others are not registered and are still under evaluation, and should therefore be considered experimental. On the other hand, radiologists have other tools, in addition to CT, that can better visualize bone localization and medullary involvement, such as multimodal MRI. In this review, the authors provide an overview of current management of advanced PC and discuss the choice of diagnostic modality for the detection of metastatic skeletal lesions in different phases of the disease. In addition to detection of bone metastases, the evaluation of response to therapy is another critical issue, since it remains one of the most important open questions that a multidisciplinary team faces when optimizing the management of PC. The authors emphasize the role of nuclear modalities that can presently be used in clinical practice, and also look at future perspectives based on relevant clinical data with novel radiopharmaceuticals.

Identifying and Managing Pain in People with Alzheimer's Disease and Other Types of Dementia: A Systematic Review

BACKGROUND AND OBJECTIVE

Pain in patients with Alzheimer's disease is a complex issue; these patients suffer from the common causes of acute and chronic pain, and some also have neuropathic or nociceptive pain. Whatever the mechanism of pain in these patients, their pain will require careful assessment and management, to insure the correct type and level of analgesia is given. The objective of this systematic review was the identification of studies that have investigated the efficacy of different analgesics on pain intensity or pain-related behavior during nursing home stay and at the end of life.

METHODS

A search using pain, pain treatment, and dementia MESH terms and keywords was conducted (October 15, 2015) in MEDLINE, EMBASE, PsychINFO, CINAHL, and Cochrane libraries.

RESULTS

Our search yielded 3138 unique hits, published between 1990 and October 2015. We read titles and abstracts, identified 124 papers for full-text evaluation, and included 12 papers to reflect and synthesize the following questions: (1) Which pain assessment tools for people with dementia are responsive to change in pain intensity scores? (2) Which analgesics are efficacy-tested by controlled trials including people with dementia living in nursing homes, including at the end of life? (3) Which outcome measures have been used to identify pain, pain behavior, and/or treatment efficacy in people with dementia?

CONCLUSION

Despite increased use of analgesics, pain is still prevalent in people with dementia. Validated pain tools are available but not implemented and not fully tested on responsiveness to treatment. Official guidelines for pain assessment and treatment addressing people with dementia living in a nursing home are lacking. The efficacy of analgesic drug use on pain or neuropsychiatric behavior related to dementia has been hardly investigated.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An international road map to improve pain assessment in people with impaired cognition: the development of the Pain Assessment in Impaired Cognition (PAIC) meta-tool

Background

Pain is common in people with dementia, yet identification is challenging. A number of pain assessment tools exist, utilizing observation of pain-related behaviours, vocalizations and facial expressions. Whilst they have been developed robustly, these often lack sufficient evidence of psychometric properties, like reliability, face and construct validity, responsiveness and usability, and are not internationally implemented. The EU-COST initiative “Pain in impaired cognition, especially dementia” aims to combine the expertise of clinicians and researchers to address this important issue by building on previous research in the area, identifying existing pain assessment tools for dementia, and developing consensus for items for a new universal meta-tool for use in research and clinical settings. This paper reports on the initial phase of this collaboration task.

Methods

All existing observational pain behaviour tools were identified and elements categorised using a three-step reduction process. Selection and refinement of items for the draft Pain Assessment in Impaired Cognition (PAIC) meta-tool was achieved through scrutiny of the evidence, consensus of expert opinion, frequency of use and alignment with the American Geriatric Society guidelines. The main aim of this process was to identify key items with potential empirical, rather than theoretical value to take forward for testing.

Results

12 eligible assessment tools were identified, and pain items categorised according to behaviour, facial expression and vocalisation according to the AGS guidelines (Domains 1 – 3). This has been refined to create the PAIC meta-tool for validation and further refinement. A decision was made to create a supporting comprehensive toolkit to support the core assessment tool to provide additional resources for the assessment of overlapping symptoms in dementia, including AGS domains four to six, identification of specific types of pain and assessment of duration and location of pain.

Conclusions

This multidisciplinary, cross-cultural initiative has created a draft meta-tool for capturing pain behaviour to be used across languages and culture, based on the most promising items used in existing tools. The draft PAIC meta-tool will now be taken forward for evaluation according to COSMIN guidelines and the EU-COST protocol in order to exclude invalid items, refine included items and optimise the meta-tool.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-014-0229-5) contains supplementary material, which is available to authorized users.

The importance of pain management in older people with dementia

INTRODUCTION

Pain is common in people with dementia, representing a critical aspect of treatment and care. However, there remain considerable gaps in evidence to support pain assessment and treatment.

SOURCES OF DATA

An updated literature search focussing on systematic reviews and randomized controlled trials.

AREAS OF AGREEMENT

There are key areas of consistency around the prevalence, causes and current treatment trends for pain in dementia, the impact of untreated pain and the need for an accurate, fully validated assessment tool.

AREAS OF CONTROVERSY

Accurate assessment due to inherent issues in dementia is a critical challenge. There is also a lack of evidence around alternative treatment options.

GROWING POINTS

New pain predictors are being identified, including physical function, depression and specific pain types, which should inform assessment methodology.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future research should focus on developing integrated pain management approaches with optimized assessment and evidence-based treatment guidance.

[Scales to evaluate pain in elderly patients suffering from dementia. Help-tools for the physiotherapist, doctor, nurse and occupational therapist]

The purpose of this study was to determine which scales are being used to evaluate pain in old people suffering from dementia. A search strategy was developed to retrieve all articles (randomized controlled trials and clinical trials without randomization) published in MEDLINE, Cochrane Library Plus, PEDro and Dialnet and BMC Geriatrics from January 2000 to January 2012. Exclusion criteria were articles that did not use scales for evaluating pain in elderly patients suffering from dementia, and other type of articles (case studies, reviews...). Finally, 13 studies were included in this review. From the results obtained it appears that more studies are needed to confirm the pain scales used for the elderly suffering from dementia. Observational scales may be useful to evaluate pain in these patients.

A psychometric evaluation of three pain rating scales for people with moderate to severe dementia

Little comparative information exists regarding the reliability and validity of pain rating scales for nurses to assess pain in people with moderate to severe dementia in residential aged care facilities. The objective of this study was to evaluate the relative psychometric merits of the Abbey Pain Scale, the DOLOPLUS-2 Scale, and the Checklist of Nonverbal Pain Indicators Scale, three well-known pain rating scales that have previously been used to assess pain in nonverbal people with dementia. An observational study design was used. Nurses (n = 26) independently rated a cross-section of people with moderate to severe dementia (n = 126) on two occasions. The Abbey Pain Scale and the DOLOPLUS-2 Scale showed good psychometric qualities in terms of reliability and validity, including resistance to the influence of rater characteristics. The Checklist of Nonverbal Pain Indicators Scale also had reasonable results but was not as psychometrically strong as the Abbey Pain Scale and DOLOPLUS-2 Scale. This study has provided comparative evidence for the reliability and validity of three pain rating scales in a single sample. These scales are strong, objective adjuncts in making comprehensive assessments of pain in people who are unable to self-report pain due to moderate to severe dementia, with each having their own strengths and weaknesses. The DOLOPLUS-2 Scale provides more reliable measurement, and the Abbey Pain Scale may be better suited than the other two scales for use by nurse raters who only occasionally use pain rating scales or who have lower level nursing qualifications.

[The pain situation for residents of nursing homes. Results of a study in Münster]

BACKGROUND

Little is known about the phenomenon of pain in German nursing homes. In particular, it is unknown to what extent and severity pain occurs among residents and how their pain can be described.

MATERIAL AND METHODS

A total of 13 nursing homes located in the city of Münster, Germany, were included as part of the health services research project "Action Alliance Pain-free City Münster." Data were collected from 436 residents over 65 years old via self-report or the observational pain tool pain assessment in advanced dementia, german version (PAINAD-G), according to the cognitive status of the residents.

RESULTS

At the time of the interview, the majority of the residents questioned reported suffering from pain at rest and/or during movement. Approximately one quarter of residents complained about moderate to intolerable pain at rest and nearly 45% during movement. Residents encountered pain most often when standing up, sitting, resting in bed and walking and three quarters of residents had suffered from pain for more than 1 year. Many residents experienced pain in several body regions. Among residents assessed solely by the observational pain scale PAINAD-G, signs indicating pain existed in 21% (≥ 6) or 69% (≥ 2), respectively, depending on the cut-off value chosen on the PAINAD-G scale.

CONCLUSION

Pain in nursing homes is a challenge that needs more attention as it has considerable negative consequences for the persons concerned. The extent of pain in the studied facilities indicates an urgent need for action on the part of all professionals caring for residents in nursing homes.

Feasibility and clinical utility of the Japanese version of the Abbey pain scale in Japanese aged care

Active usage of observational pain scales in Japanese aged-care facilities has not been previously described. Therefore, to examine the feasibility and clinical utility of the Abbey Pain Scale-Japanese version (APS-J), this study examined the interrater reliability of the APS-J among a researcher, nurses, and care workers in aged-care facilities in Japan. This study also aimed to obtain nurses' and care workers' opinions on use of the scale. The following data were collected from 88 residents of two aged-care facilities: demographics, Barthel Index, Folstein Mini-Mental Examination (MMSE), 15-item Geriatric Depression Scale (GDS-15), and APS-J for pain. The researchers, nurses, and care workers independently assessed the residents' pain by using the APS-J, and intraclass correlation coefficients (ICC) for interrater reliability and Cronbach alpha for internal consistency were examined. The ICC between researchers and nurses, researchers and care workers, and nurses and care workers were 0.68, 0.74, and 0.76, respectively. Nurses and care workers were invited for focus group interviews to obtain their opinions regarding APS-J use. During these interviews, nurses and care workers stated that the observational points of APS-J subscales were the criteria they normally used to evaluate residents' pain. Several nurses and care workers reported a gap between the estimated pain intensity and APS-J score. Unclear APS-J criteria, difficulties in observing residents, and insufficient practice guidelines were also reported. Our findings indicate that the APS-J has moderate reliability and clinically utility. To facilitate APS-J usage, education and clinical guidelines for pain management may be required for nurses and care workers.

Pain assessment strategies in older patients

The prevalence of pain and pain undertreatment in older persons, along with the many potential detrimental consequences of undertreated pain, pose a substantial burden to the individual, their family, and society. An accurate pain assessment is the foundation for treating pain; yet, thorough pain assessments and regular reassessments are too often neglected. Older adults typically present with multiple pain etiologies, making it all the more imperative that a comprehensive assessment is conducted. Comprehensive assessments should include a detailed investigation of a patient's pain and medical history, a physical examination, and diagnostic testing, if needed. Both the impact of pain and its severity should be established by questioning about the presence of pain and using pain assessment instruments. Tools for pain assessment should be tested in older adult populations to establish reliability, validity, and sensitivity to changes from treatment. Self-report is the gold standard for assessing pain; however, in many clinical circumstances with older adults, the patient's verbal report is unobtainable. Following an unsuccessful attempt at self-report from a nonverbal older adult, the potential causes of pain should be explored. Direct observation can then be used to identify behaviors suggestive of pain, and the patient's response to an analgesic trial can be observed. A pain behavior tool can also provide useful information suggesting the presence of pain.

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

BACKGROUND

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

OBJECTIVES

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

SELECTION CRITERIA

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

SEARCH STRATEGY

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

METHODOLOGICAL QUALITY

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

RESULTS

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

CONCLUSIONS

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

Development of a composite pain measure for persons with advanced dementia: exploratory analyses in self-reporting nursing home residents

CONTEXT

Experts agree that pain assessment in noncommunicative persons requires data from sources that do not rely on self-report, including proxy reports, health history, and observation of pain behaviors. However, there is little empirical evidence to guide clinicians in weighting or combining these sources to best approximate the person's experience.

OBJECTIVES

The aim of this exploratory study was to identify a combination of observer-dependent pain indicators that would be significantly more predictive of self-reported pain intensity than any single indicator. Because self-reported pain is usually viewed as the criterion measure for pain, self-reported usual and worst pains were the dependent variables.

METHODS

The sample consisted of 326 residents (mean age: 83.2 years; 69% female) living in one of 24 nursing homes. Independent variables did not rely on self-report: surrogate reports from certified nursing assistants (CNAs) using the Iowa Pain Thermometer (IPT), Checklist of Nonverbal Pain Indicators (CNPI), Cornell Scale for Depression in Dementia (CSDD), Pittsburgh Agitation Scale (PAS), number of painful diagnoses, and Minimum Data Set (MDS) pain variables.

RESULTS

In univariate analyses, the CNA IPT scores were correlated most highly with self-reported pain. The final multivariate model for self-reported usual pain included CNA IPT, CSDD, PAS, and education; this model accounted for only 14% of the variance. The more extensive of the two final models for worst pain included MDS pain frequency, CSDD, CNA IPT, CNPI, and age (R(2)=0.14).

CONCLUSION

Additional research is needed to develop a predictive pain model for nonverbal persons.

Risk factors associated with opioid medication misuse in community-dwelling older adults with chronic pain

OBJECTIVES

The aim of the study was to identify physical, psychological, and social risk factors associated with opioid medication misuse among community-dwelling older adults with chronic pain.

METHODS

Using a cross-sectional research design, a confidential survey was administered at 11 outpatient clinics affiliated with the Baltimore Veterans Affairs Medical Center and the University of Maryland Medical System. A sample of 163 older adults (response rate 80.7%) with chronic pain and receiving opioid medications provided demographic information and responded to survey items. Severity of pain, alcohol problems, physical disability, depressive symptoms, spirituality, social support, and social network were assessed. Descriptive statistics and exploratory regression analyses were employed to determine factors independently associated with misuse.

RESULTS

Higher levels of pain severity and depressive symptoms, and lower physical disability scores were significantly associated with increased risk of opioid medication misuse. Alcohol problems, spirituality, social support, and social network were not associated with opioid medication misuse.

DISCUSSION

High pain intensity scores may indicate undertreatment of pain or may represent a rationalization to justify opioid medication use. Higher levels of depressive symptoms have been noted in the chronic pain population and may contribute to misuse of opioid medications for psychic effects. Less physically disabled persons are more likely to misuse opioid medications or older person receiving multiple medications may wish to avoid potential adverse drug effects. While there was an association between lower levels of disability and higher risk for opioid medication misuse, a causal relationship could not be determined.

The psychometric qualities of four observational pain tools (OPTs) for the assessment of pain in elderly people with osteoarthritic pain

CONTEXT

Pain in cognitively impaired elderly people (CIEP) often goes unrecognized. Observational pain tools (OPTs) have been designed, but with limited evidence to support their psychometric qualities.

OBJECTIVES

This study compared four OPTs (the Pain Assessment IN Advanced Dementia [PAINAD], Abbey Pain Scale [Abbey PS], Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC], and Discomfort Scale--Dementia of Alzheimer Type [DS-DAT]), two self-report scales, and two proxy-report scales in assessing osteoarthritic (OA) pain among CIEP.

METHODS

Participants (n=124) were divided into two groups: cognitively intact and impaired. They were observed by two raters simultaneously at rest and during a standardized exercise program. Besides reliabilities, the correlation between the OPTs and the self-report/proxy-report scores was evaluated. The OPT scores collected during different activity levels were compared to establish the convergent and discriminant validity. Confirmatory factor analysis was used to evaluate the construct validity.

RESULTS

Similar and accepted patterns of reliability/validity were obtained for all OPTs, in which better levels of psychometric properties were consistently obtained during exercise. However, a single construct (OA pain) appeared only in the PAINAD and Abbey PS after deletion of the "breathing" and "physiological change" indicators, respectively. This showed that OPTs were better used to detect OA pain when pain was triggered by movement (i.e., an exercise program).

CONCLUSION

The PAINAD and Abbey PS appeared to be more reliable and valid for assessing OA pain while using an exercise program among elderly people, regardless of their cognitive ability.

Is pain assessment feasible as a performance indicator for Dutch nursing homes? A cross-sectional approach

Quality of care gains transparency with the help of performance indicators. For Dutch nursing homes, the current set of performance indicators does not include pain. To determine the feasibility of pain assessment as performance indicator, information about pain prevalence and analgesic prescription in one nursing home was collected. Within the time span of 3 days, pain intensity was measured in 91% of the residents (201 out of 221), either with a numeric rating scale, a verbal rating scale, or the Rotterdam Elderly Pain Observation Scale (REPOS). Numerical rating was used for 72%, verbal rating for 3%, and REPOS observation for 25% of the residents. Pain was substantial in 65 residents (32%), who received the following analgesic prescription: World Health Organization (WHO) step 1, 45%; WHO step 3, 12%; and neuroactive agents, 5%. Thirty-eight percent of these residents were in pain and received no analgesics. Residents with substantial pain significantly more often received analgesics (p = .007). Results suggest that pain assessment is feasible in a nursing home and would stimulate staff attention to pain. Further investigation is necessary to find out if a pain algorithm is feasible and will lead to improved pain treatment.