Validity of pain behaviors in persons with mild to moderate cognitive impairment

Differences in the Association of Neighborhood Environment With Physical Frailty Between Urban and Rural Older Adults: The Korean Frailty and Aging Cohort Study (KFACS)

OBJECTIVE

We examined the difference in the relationship between perceived neighborhood environments and physical frailty between urban and rural older adults.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Urban and rural community in South Korea; a total of 2593 community-dwelling older adults aged 70-84 years (mean age: 76.0 years, 51.0% women) in the Korean Frailty and Aging Cohort Study (KFACS).

METHODS

The neighborhood environment was assessed using the 17-item Environmental Module of the International Physical Activity Questionnaire (IPAQ-E). The IPAQ-E had 7 environmental factors (residential density, access to destinations, neighborhood infrastructure, neighborhood safety, social environment, aesthetic qualities, and street connectivity). Physical frailty was defined using the Fried frailty criteria with modified cutoffs.

RESULTS

The number of participants residing in urban and rural areas was 1902 and 691, respectively. The prevalence of frailty was 5.3% and 12.0% in urban and rural areas, respectively. In urban areas, frailty was associated with the total IPAQ-E score (β = -0.007, P = .009) after adjusting for confounding factors. There was no association in the rural areas (β = -0.003, P = .535). In urban older adults, logistic regression showed that absence of destination [odds ratio (OR) 2.58, 95% confidence interval (CI) 1.36-4.90] and no crime safety at night (OR 2.00, 95% CI 1.12-3.57) were associated with a higher risk of frailty. In rural older adults, poor access to recreational facilities (OR 2.17, 95% CI 1.07-4.40) and no aesthetics (OR 2.49, 95% CI 1.22-5.10) were associated with frailty.

CONCLUSIONS AND IMPLICATIONS

Our study indicated that the presence of destination and crime safety at night was significantly associated with physical frailty among older adults living in urban areas, whereas aesthetics and recreational facilities were significantly associated with physical frailty in rural older adults.

How to Teach Medical Students About Pain and Dementia: E-Learning, Experiential Learning, or Both?

OBJECTIVE

Pain management in persons with mild to moderate dementia poses unique challenges because of altered pain modulation and the tendency of some individuals to perseverate. We aimed to test the impact of an e-learning module about pain in communicative people with dementia on third-year medical students who had or had not completed an experiential geriatrics course.

DESIGN

Analysis of pre- to postlearning changes and comparison of the same across the student group.

SETTING

University of Pittsburgh School of Medicine and Saint Louis University School of Medicine.

SUBJECTS

One hundred four University of Pittsburgh and 57 Saint Louis University medical students.

METHODS

University of Pittsburgh students were randomized to view either the pain and dementia module or a control module on pain during a five-day geriatrics course. Saint Louis University students were asked to complete either of the two modules without the context of a geriatrics course. A 10-item multiple choice knowledge test and three-item attitudes and confidence questionnaires were administered before viewing the module and up to seven days later.

RESULTS

Knowledge increase was significantly greater among students who viewed the dementia module while participating in the geriatrics course than among students who viewed the module without engaging in the course (P < 0.001). The modules did not improve attitudes in any group, while student confidence improved in all groups.

CONCLUSIONS

Medical students exposed to e-learning or experiential learning demonstrated improved confidence in evaluating and managing pain in patients with dementia. Those exposed to both educational methods also significantly improved their knowledge.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

AIMS AND DESIGN

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

SETTINGS/PARTICIPANTS

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

RESULTS/CONCLUSIONS

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

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

BACKGROUND AND OBJECTIVE

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

DATA BASES AND DATA TREATMENT

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

RESULTS

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

CONCLUSIONS

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

SIGNIFICANCE

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

Patients with limited communication in end-of-life situations: Initial psychometric properties of a discomfort observation scale

This work presents an observational scale which takes into account different observable indicators of discomfort of patients in end-of-life situations with difficulties in communicating due to cognitive impairment, fatigue or sedation and provides details of its validation. In all, 71 adults participated. Model fit was adequate (χ²(27) = 43.28, p = .024, comparative fit index = .975, root mean square error of approximation = .092 and confidence interval 90% (.033-.140)). Alpha coefficient was .70 and composite reliability index was .90. Our study provides data regarding the properties of a discomfort assessment scale. Such a scale is needed and could be very useful for the evaluation of such patients and thus to attend to their needs.

Frail elderly with and without cognitive impairment at the end of life: Their emotional state and the wellbeing of their family caregivers

PURPOSE OF THE STUDY

(1) To identify the main predictors of the emotional state of the frail elderly at the end-of-life and that of their primary family caregivers, taking into consideration the presence/absence of significant cognitive impairment in the patient and (2) to analyse the relationship between the emotional state of the patient and that of their primary family caregiver.

METHODS

Our study is cross-sectional. 85 frail elderly patients at the end-of-life and their primary family caregivers participated. Information on the following aspects was collected: (1) From the patients: Socio-demographics, Functional independence, and Cognitive and Emotional state; (2) From the caregivers: Socio-demographics, Emotional state and Overburden (according to Zarit Scale). Descriptive, correlational and linear regression analyses were computed using SPSS.

RESULTS

The models that best predict the observed variance in the emotional state of patients (with or without significant cognitive impairment) include the same variables: functional independence of the patient and caregiver's overburden. Similarly, the models that best predict the observed variance in the emotional state of family caregivers include: cognitive state of the patient and caregiver's overburden.

IMPLICATIONS

The overburden of the family caregiver stands out as a key factor in the reduction of the emotional distress of frail elder patients -whether or not they present significant cognitive impairment- and that of their family caregivers. Our results suggest that reducing overburden of the family caregiver may also reduce the emotional distress of the patient and that of their family caregiver.

Low back pain in older adults: risk factors, management options and future directions

Low back pain (LBP) is one of the major disabling health conditions among older adults aged 60 years or older. While most causes of LBP among older adults are non-specific and self-limiting, seniors are prone to develop certain LBP pathologies and/or chronic LBP given their age-related physical and psychosocial changes. Unfortunately, no review has previously summarized/discussed various factors that may affect the effective LBP management among older adults. Accordingly, the objectives of the current narrative review were to comprehensively summarize common causes and risk factors (modifiable and non-modifiable) of developing severe/chronic LBP in older adults, to highlight specific issues in assessing and treating seniors with LBP, and to discuss future research directions. Existing evidence suggests that prevalence rates of severe and chronic LBP increase with older age. As compared to working-age adults, older adults are more likely to develop certain LBP pathologies (e.g., osteoporotic vertebral fractures, tumors, spinal infection, and lumbar spinal stenosis). Importantly, various age-related physical, psychological, and mental changes (e.g., spinal degeneration, comorbidities, physical inactivity, age-related changes in central pain processing, and dementia), as well as multiple risk factors (e.g., genetic, gender, and ethnicity), may affect the prognosis and management of LBP in older adults. Collectively, by understanding the impacts of various factors on the assessment and treatment of older adults with LBP, both clinicians and researchers can work toward the direction of more cost-effective and personalized LBP management for older people.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part XI: Dementia

OBJECTIVE : To present the 11th in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributions to pain and disability in older adults with CLBP. This article focuses on dementia.

METHODS

A modified Delphi technique was used to develop an algorithm for an approach to treatment for older adults living with CLBP and dementia. A panel of content experts on pain and cognition in older adults developed the algorithm through an iterative process. Though developed using resources available within Veterans Health Administration (VHA) facilities, the algorithm is applicable across all health care settings. A case taken from the clinical practice of one of the contributors demonstrates application of the algorithm.

RESULTS

We present an evidence-based algorithm and biopsychosocial rationale to guide providers evaluating CLBP in older adults who may have dementia. The algorithm considers both subtle and overt signs of dementia, dementia screening tools to use in practice, referrals to appropriate providers for a complete a workup for dementia, and clinical considerations for persons with dementia who report pain and/or exhibit pain behaviors. A case of an older adult with CLBP and dementia is presented that highlights how an approach that considers the impact of dementia on verbal and nonverbal pain behaviors may lead to more appropriate and successful pain management.

CONCLUSIONS

Comprehensive pain evaluation for older adults in general and for those with CLBP in particular requires both a medical and a biopsychosocial approach that includes assessment of cognitive function. A positive screen for dementia may help explain why reported pain severity does not improve with usual or standard-of-care pain management interventions. Pain reporting in a person with dementia does not always necessitate pain treatment. Pain reporting in a person with dementia who also displays signs of pain-associated suffering requires concerted pain management efforts targeted to improving function while avoiding harm in these vulnerable patients.Key Words. Dementia; Chronic Pain; Low Back Pain; Lumbar; Primary Care.

Tools to Assess Pain or Lack of Comfort in Dementia: A Content Analysis

CONTEXT

There is need for tools to help detect pain or lack of comfort in persons unable to communicate. However, pain and (dis)comfort tools have not been compared, and it is unclear to what extent they discriminate between pain and other possible sources of discomfort, or even if items differ.

OBJECTIVES

To map and compare items in tools that assess pain and the broader notion of discomfort or comfort in people with severe dementia or at the end of life.

METHODS

Using qualitative content analysis with six classifications, we categorized each item of four thoroughly tested observational pain tools (Pain Assessment in Advanced Dementia [PAINAD], Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC], Doloplus-2, and draft Pain Assessment in Impaired Cognition [PAIC]), and four discomfort tools (including distress, comfort, and quality of life in severe dementia or at the end of life; Discomfort Scale-Dementia Alzheimer Type [DS-DAT], Disability Distress Assessment Tool [DisDAT], End-of-Life in Dementia-Comfort Assessment in Dying with Dementia [EOLD-CAD], and Quality of Life in Late-Stage Dementia [QUALID] scale). We calculated median proportions to compare distributions of categories of pain and discomfort tools.

RESULTS

We found that, despite variable content across tools, items from pain and discomfort tools overlapped considerably. For example, positive elements such as smiling and spiritual items were more often included in discomfort tools but were not unique to these. Pain tools comprised more "mostly descriptive" (median 0.63 vs. 0.44) and fewer "highly subjective" items (0.06 vs. 0.18); some used time inconsistently, mixing present and past observations.

CONCLUSION

This analysis may inform a more rigorous theoretical underpinning and (re)development of pain and discomfort tools and calls for empirical testing of a broad item pool for sensitivity and specificity in detecting and discriminating pain from other sources of discomfort.

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

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

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

People with intellectual disabilities (IDs) have a higher risk of painful medical conditions. Partly because of the impaired ability to communicate about it, pain is often undertreated. To strengthen pain assessment in this population, we conducted a systematic review to identify behavioral pain indicators in people with IDs by using Embase, PubMed, PsycINFO, CINAHL, and Cochrane. Inclusion criteria were 1) scientific papers; 2) published in the last 20 years, that is, 1992 to 2012; 3) written in English, 4) using human subjects, 5) intellectual disabilities, 6) pain, 7) behavior, and 8) an association between observable behavior and pain experience. From 527 publications, 27 studies were included. Pain was acute in 14 studies, chronic in 2 studies, both acute and chronic in 2 studies, and unspecified in 9 studies. Methodological quality was assessed with the Mixed Methods Appraisal Tool. Of the 14 categories with behavioral pain indicators, motor activity, facial activity, social-emotional indicators, and nonverbal vocal expression were the most frequently reported. Most of the behavioral pain indicators are reported in more than 1 study and form a possible clinical relevant set of indicators for pain in people with IDs. Determination of a behavioral pattern specific for pain, however, remains a challenge for future research.

PERSPECTIVE

This review focuses on categories of behavior indicators related to pain in people with IDs. The quality of evidence is critically discussed per category. This set of indicators could potentially help clinicians to recognize pain in this population, especially when unique individual pain responses are also identified.

Using the Folstein Mini Mental State Exam (MMSE) to explore methodological issues in cognitive aging research

Cognitive scales are used frequently in geriatric research and practice. These instruments are constructed with underlying assumptions that are a part of their validation process. A common measurement scale used in older adults is the Folstein Mini Mental State Exam (MMSE). The MMSE was designed to screen for cognitive impairment and is used often in geriatric research. This paper has three aims. Aim one was to explore four potential threats to validity in the use of the MMSE: (1) administering the exam without meeting the underlying assumptions, (2) not reporting that the underlying assumptions were assessed prior to test administration, (3) use of variable and inconsistent cut-off scores for the determination of presence of cognitive impairment, and (4) failure to adjust the scores based on the demographic characteristics of the tested subject. Aim two was to conduct a literature search to determine if the assumptions of (1) education level assessment, (2) sensory assessment, and (3) language fluency were being met and clearly reported in published research using the MMSE. Aim three was to provide recommendations to minimalize threats to validity in research studies that use cognitive scales, such as the MMSE. We found inconsistencies in published work in reporting whether or not subjects meet the assumptions that underlie a reliable and valid MMSE score. These inconsistencies can pose threats to the reliability of exam results. Fourteen of the 50 studies reviewed reported inclusion of all three of these assumptions. Inconsistencies in reporting the inclusion of the underlying assumptions for a reliable score could mean that subjects were not appropriate to be tested by use of the MMSE or that an appropriate test administration of the MMSE was not clearly reported. Thus, the research literature could have threats to both validity and reliability based on misuse of or improper reported use of the MMSE. Six recommendations are provided to minimalize these threats in future research.

Behavioral cues to expand a pain model of the cognitively impaired elderly in long-term care

BACKGROUND

The purpose of this study was to determine the relationship between hypothesized pain behaviors in the elderly and a measurement model of pain derived from the Minimum Data Set-Resident Assessment Instrument (MDS-RAI) 2.0 items.

METHODS

This work included a longitudinal cohort recruited from Medicare-certified longterm care facilities across the United States. MDS data were collected from 52,996 residents (mean age 83.7 years). Structural equation modeling was used to build a measurement model of pain to test correlations between indicators and the fit of the model by cognitive status. The model evaluates the theoretical constructs of pain to improve how pain is assessed and detected within cognitive levels.

RESULTS

Using pain frequency and intensity as the only indicators of pain, the overall prevalence of pain was 31.2%; however, analysis by cognitive status showed that 47.7% of the intact group was in pain, while only 18.2% of the severely, 29.4% of the moderately, and 39.6% of the mildly cognitively impaired groups were experiencing pain. This finding supports previous research indicating that pain is potentially under-reported in severely cognitively impaired elderly nursing home residents. With adjustments to the measurement model, a revised format containing affective, behavioral, and inferred pain indicates a better fit of the data to include these domains, as a more complete measure of the pain construct.

CONCLUSION

Pain has a significant effect on quality of life and long-term health outcomes in nursing home residents. Patients most at risk are those with mild to severe cognitive decline, or those unable to report pain verbally. Nursing homes are under great scrutiny to maintain standards of care and provide uniform high-quality care outcomes. Existing data from federally required resident surveys can serve as a valuable tool to identify indicators of pain and trends in care. Great responsibility lies in ensuring pain is included and monitored as a quality measure in long-term care, especially for residents unable to communicate their pain verbally.

Using the Folstein Mini Mental State Exam (MMSE) to explore methodological issues in cognitive aging research

Cognitive scales are used frequently in geriatric research and practice. These instruments are constructed with underlying assumptions that are a part of their validation process. A common measurement scale used in older adults is the Folstein Mini Mental State Exam (MMSE). The MMSE was designed to screen for cognitive impairment and is used often in geriatric research. This paper has three aims. Aim one was to explore four potential threats to validity in the use of the MMSE: (1) administering the exam without meeting the underlying assumptions, (2) not reporting that the underlying assumptions were assessed prior to test administration, (3) use of variable and inconsistent cut-off scores for the determination of presence of cognitive impairment, and (4) failure to adjust the scores based on the demographic characteristics of the tested subject. Aim two was to conduct a literature search to determine if the assumptions of (1) education level assessment, (2) sensory assessment, and (3) language fluency were being met and clearly reported in published research using the MMSE. Aim three was to provide recommendations to minimalize threats to validity in research studies that use cognitive scales, such as the MMSE. We found inconsistencies in published work in reporting whether or not subjects meet the assumptions that underlie a reliable and valid MMSE score. These inconsistencies can pose threats to the reliability of exam results. Fourteen of the 50 studies reviewed reported inclusion of all three of these assumptions. Inconsistencies in reporting the inclusion of the underlying assumptions for a reliable score could mean that subjects were not appropriate to be tested by use of the MMSE or that an appropriate test administration of the MMSE was not clearly reported. Thus, the research literature could have threats to both validity and reliability based on misuse of or improper reported use of the MMSE. Six recommendations are provided to minimalize these threats in future research.

Differential reports of pain and depression differentiate mild cognitive impairment from cognitively intact elderly participants

BACKGROUND

Positive associations between pain and depression in the general population have been well characterized; however, the interplay between pain, depression, and early cognitive decline, characterized as mild cognitive impairment (MCI), is poorly understood.

METHODS

The current study examined the association of self-reported pain complaints (measured by the 36-item Short Form Health Survey) and self-reported depressive symptoms (measured by the 30-item Geriatric Depression Scale) in cognitively intact participants (n = 492) and participants with a clinical diagnosis of MCI (n = 83).

RESULTS

Depressive symptoms and subjective reports of pain were significantly associated in the entire sample (r = .29; P < .0001). Multiple logistic regression modeling (adjusted for age, education, and APOE4 status as covariates) demonstrated that while depressive symptoms were positively associated with the diagnosis of MCI (P < .001), subjective pain reports were negatively associated with MCI (P < .002).

CONCLUSION

While the negative association of subjective pain complaints with MCI might arguably be explained by the development of anosognosia, self-reports of depressive symptoms were actually increased in these participants, suggesting preserved insight into cognitive decline-associated symptoms. It is possible that preferential involvement of limbic circuitry in MCI could explain these findings. Future studies are needed to elucidate the reasons for the dissociation of pain and depressive symptoms in MCI described in the present article.

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

Purpose

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

Background/significance

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

Patients and methods

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

Results

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

Conclusion

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

Self-compassion in patients with persistent musculoskeletal pain: relationship of self-compassion to adjustment to persistent pain

CONTEXT

Self-compassion entails qualities such as kindness and understanding toward oneself in difficult circumstances and may influence adjustment to persistent pain. Self-compassion may be a particularly influential factor in pain adjustment for obese individuals who suffer from persistent pain, as they often experience heightened levels of pain and lower levels of psychological functioning.

OBJECTIVES

The purpose of the present study was to examine the relationship of self-compassion to pain, psychological functioning, pain coping, and disability among patients who have persistent musculoskeletal pain and who are obese.

METHODS

Eighty-eight obese patients with persistent pain completed a paper-and-pencil self-report assessment measure before or after their appointment with their anesthesiologist.

RESULTS

Hierarchical linear regression analyses demonstrated that even after controlling for important demographic variables, self-compassion was a significant predictor of negative affect (β=-0.48, P<0.001), positive affect (β=0.29, P=0.01), pain catastrophizing (β=-0.32, P=0.003), and pain disability (β=-0.24, P<0.05).

CONCLUSION

The results of this study indicate that self-compassion may be important in explaining the variability in pain adjustment among patients who have persistent musculoskeletal pain and are obese.

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.

Pain in dementia: recognition and treatment

The presentation and management of pain in older adults with dementia are highly complicated. This article addresses assessment challenges and nonpharmacological and pharmacological management strategies related to pain in those with dementia. Vigilant monitoring of comfort level and the effective use of multidimensional pain management strategies could substantially increase quality of life for older adults with dementia.

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.

Neurological diseases and pain

Chronic pain is a frequent component of many neurological disorders, affecting 20-40% of patients for many primary neurological diseases. These diseases result from a wide range of pathophysiologies including traumatic injury to the central nervous system, neurodegeneration and neuroinflammation, and exploring the aetiology of pain in these disorders is an opportunity to achieve new insight into pain processing. Whether pain originates in the central or peripheral nervous system, it frequently becomes centralized through maladaptive responses within the central nervous system that can profoundly alter brain systems and thereby behaviour (e.g. depression). Chronic pain should thus be considered a brain disease in which alterations in neural networks affect multiple aspects of brain function, structure and chemistry. The study and treatment of this disease is greatly complicated by the lack of objective measures for either the symptoms or the underlying mechanisms of chronic pain. In pain associated with neurological disease, it is sometimes difficult to obtain even a subjective evaluation of pain, as is the case for patients in a vegetative state or end-stage Alzheimer's disease. It is critical that neurologists become more involved in chronic pain treatment and research (already significant in the fields of migraine and peripheral neuropathies). To achieve this goal, greater efforts are needed to enhance training for neurologists in pain treatment and promote greater interest in the field. This review describes examples of pain in different neurological diseases including primary neurological pain conditions, discusses the therapeutic potential of brain-targeted therapies and highlights the need for objective measures of pain.

Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them

OBJECTIVE

There has been a growing recognition of the need for better pharmacologic management of chronic pain among older adults. To address this need, the National Institutes of Health Pain Consortium sponsored an "Expert Panel Discussion on the Pharmacological Management of Chronic Pain in Older Adults" conference in September 2010 to identify research gaps and strategies to address them. Specific emphasis was placed on ascertaining gaps regarding use of opioid and nonsteroidal anti-inflammatory medications because of continued uncertainties regarding their risks and benefits.

DESIGN

Eighteen panel members provided oral presentations; each was followed by a multidisciplinary panel discussion. Meeting transcripts and panelists' slide presentations were reviewed to identify the gaps and the types of studies and research methods panelists suggested could best address them.

RESULTS

Fifteen gaps were identified in the areas of treatment (e.g., uncertainty regarding the long-term safety and efficacy of commonly prescribed analgesics), epidemiology (e.g., lack of knowledge regarding the course of common pain syndromes), and implementation (e.g., limited understanding of optimal strategies to translate evidence-based pain treatments into practice). Analyses of data from electronic health care databases, observational cohort studies, and ongoing cohort studies (augmented with pain and other relevant outcomes measures) were felt to be practical methods for building an age-appropriate evidence base to improve the pharmacologic management of pain in later life.

CONCLUSION

Addressing the gaps presented in the current report was judged by the panel to have substantial potential to improve the health and well-being of older adults with chronic pain.

Non-verbal cues to osteoarthritic knee and/or hip pain in elders

Behavioral cues are believed to be useful to identify pain among elders who may be experiencing pain but unable to express it. To examine this assumption, we recruited 192 elders who could verbally express pain to determine whether regression models combining behavioral cues (motor and gait patterns) predicted verbal pain reports. In the best model, age (p < .01) and subscales that measured guarding (p < .001) and joint flexion (p < .01) motor patterns were significant predictors of verbal pain reports. The receiver operating characteristic curve indicated that the best cutoff for predictive probability was 40-44%, with a fair to good C statistic of .78 (SD = .04). With a 40% cutoff, sensitivity and specificity were 71.6% and 71.0%, respectively. The investigators concluded that the final model could serve as a building block for the development of a tool using behavioral cues to identify elders' pain.

Challenges in pain assessment in cognitively intact and cognitively impaired older adults with cancer

PURPOSE/OBJECTIVES

To describe approaches to pain assessment in cognitively intact and cognitively impaired older adults with cancer.

DATA SOURCES

MEDLINE literature search, personal reference collection, and clinical experience.

DATA SYNTHESIS

A systematic and comprehensive pain assessment is the cornerstone of effective treatment strategies. Determining the effect of pain on older adults' ability to function is as important as rating pain intensity. Evidence-based recommendations exist to guide practice.

CONCLUSIONS

The undertreatment of pain in older adults persists despite a plethora of published guidelines addressing pain assessment and management. Unrelieved pain affects recovery from illness and all aspects of life. Systematic and ongoing assessment is elementary to effective pain management, yet assessments frequently are neither completed nor documented. Because pain is subjective and individual responses to pain interventions vary widely and are unpredictable, assessment is vital to comprehensive pain care in all clinical settings. Reliable and validated pain assessment tools for cognitively intact and cognitively impaired older adults are available to guide practice.

IMPLICATIONS FOR NURSING

Pain assessment is a core competency for nurses in all clinical settings. Comprehensive, individualized, and ongoing assessment provides the information necessary so that clinicians can develop interventions to relieve patients' pain and improve their quality of life. Nurses have the knowledge, skills, and tools to adequately screen and comprehensively assess pain in older adult patients, including those with cognitive impairment. By using this knowledge, nurses can change systems and practices, have a significant effect on improving pain care, and increase quality of life and function of older adults with pain.

Abbey Pain Scale: development and validation of the Japanese version

AIM

The purpose of this study was to develop and validate the Japanese version of the Abbey Pain Scale (APS-J), to assess pain of older adults who live in nursing homes in Japan.

METHODS

In this study, the data were collected from residents in two nursing homes in Japan to include: demographics, the Barthel Index, Folstein Mini-Mental Examination (MMSE), APS-J and Verbal Descriptor Scale (VDS) for pain. Two researchers independently assessed the residents' pain using the APS-J while the residents walked or were transferred from bed to wheelchair. Intraclass correlation coefficients (ICC) for inter-rater and test-retest reliability, Chronbach's alpha-value of the APS-J, and correlation between the APS-J and other variables were examined.

RESULTS

Data were obtained from 171 residents. The ICC for inter-rater and test-retest reliability were 0.824 and 0.657, respectively. Internal consistency was 0.645 for the total sample and 0.719 for those with an MMSE score of 0 (n = 58). Multiple regression analysis showed that contractures (P < 0.001), previous injuries (P < 0.001), the MMSE (P = 0.003) and paralysis (P = 0.018) were independently associated with the APS-J. The APS-J and VDS were moderately correlated (r = 0.49; P < 0.01). The APS-J total score and subscales, "change in body language" and "physical changes", were significantly different among subjects with different MMSE score groups.

CONCLUSION

Findings show some evidence for the reliability and validity of APS-J.