Can Adding a Standardized Observational Tool to Interdisciplinary Evaluation Enhance the Detection of Pain in Older Adults with Cognitive Impairments?

Pain assessment tools in adults with communication disorders: systematic review and meta-analysis

BACKGROUND

Verbal communication is the "gold standard" for assessing pain. Consequently, individuals with communication disorders are particularly vulnerable to incomplete pain management. This review aims at identifying the current pain assessment instruments for adult patients with communication disorders.

METHODS

A systematic review with meta-analysis was conducted on PubMed, PEDRO, EBSCOhost, VHL and Cochrane databases from 2011 to 2023 using MeSH terms "pain assessment, "nonverbal communication" and "communication disorders" in conjunction with additional inclusion criteria: studies limited to humans, interventions involving adult patients, and empirical investigations.

RESULTS

Fifty articles were included in the review. Seven studies report sufficient data to perform the meta-analysis. Observational scales are the most common instruments to evaluate pain in individuals with communication disorders followed by physiological measures and facial recognition systems. While most pain assessments rely on observational scales, current evidence does not strongly endorse one scale over others for clinical practice. However, specific observational scales appear to be particularly suitable for identifying pain during certain potentially painful procedures, such as suctioning and mobilization, in these populations. Additionally, specific observational scales appear to be well-suited for certain conditions, such as mechanically ventilated patients.

CONCLUSIONS

While observational scales dominate pain assessment, no universal tool exists for adults with communication disorders. Specific scales exhibit promise for distinct populations, yet the diverse landscape of tools hampers a one-size-fits-all solution. Crucially, further high-quality research, offering quantitative data like reliability findings, is needed to identify optimal tools for various contexts. Clinicians should be informed to select tools judiciously, recognizing the nuanced appropriateness of each in diverse clinical situations.

TRIAL REGISTRATION

This systematic review is registered in PROSPERO (International prospective register of systematic reviews) with the ID: CRD42022323655 .

Pain management for people with dementia: a cross-setting systematic review and meta-ethnography

Background

Pain management for people with dementia is challenging. There is limited understanding on the experiences of pain management from people with dementia, but also from those who support them. This study synthesised the qualitative evidence to explore the perspectives of people with dementia, their family, friends, carers and healthcare professionals to pain management.

Methods

A systematic literature review was undertaken of published and unpublished literature databases (to 01 November 2021). All qualitative research studies reporting the perspectives of people with dementia, their family, friends, carers and healthcare professionals to managing pain were included. Eligible studies were appraised using the Critical Appraisal Skills Programme (CASP) qualitative appraisal tool. A meta-ethnography analysis approach was adopted, with findings assessed against the GRADE-CERQual framework.

Results

Of the 3994 citations screened, 33 studies were eligible. Seven themes were identified from the data. There was moderate evidence from six studies indicating inequity of pain management for people with dementia. There was moderate evidence from 22 studies regarding anxieties on cascading pain information. There was moderate evidence from nine studies that familiarisation of the person with pain, their preferences, routines and behaviours were key factors to better pain management. Consistently, carers and healthcare professionals had a low opinion of the management of pain for people with dementia, with tensions over the 'best' treatment options to offer. This was associated with poor training and understanding on how pain 'should' be managed.

Conclusion

The findings highlight the challenges faced by people with dementia and pain, and those who support them. Improvements in education for people who support these individuals would be valuable across health and social care pathways. Supporting family members and relatives on pain experiences and treatment options could improve awareness to improve quality of life for people with dementia and pain and those who support them.

The influence of Alzheimer's disease stigma on pain assessment in older persons

INTRODUCTION

Pain of nursing homes residents with Alzheimer's disease remains under detected compared to their cognitively intact counterparts. Communication difficulties may partly explain this poor quality of care but the influence of stigmatization on pain assessment has never been explored.

RESEARCH QUESTION

The objective of this research was to analyze whether a diagnosis label of Alzheimer's disease or the stage of the disease may bias pain assessment scores and empathic reactions of health care staff in nursing homes.

METHODS

Two studies were conducted based on a similar experimental between-subjects design with a video showing an older adult woman experiencing undefined pain. Different labels and vignettes were manipulated to characterize the subject of the video. In the first study, 84 certified nursing assistants were asked to watch the video and then to assess the pain intensity and their empathic reaction. Participants were randomized in two conditions that varied the disease label (Alzheimer's disease vs no diagnosis). In the second study, 67 certified nursing assistants were enrolled who did not participate in the first study. They watched the same video as in the first study and assessed the pain intensity and their empathic reaction. They were randomized in two conditions that varied the stage of the Alzheimer's disease (mild stage vs severe stage).

RESULTS

Alzheimer's disease label had no influence on assessment scores. In contrast, the stage of the disease had a significant effect on the health care staff assessments with severe stage associated with lower pain intensity scores and empathic reactions.

CONCLUSION

These results confirm that the Alzheimer's disease stigma is a real phenomenon that tends to be mainly elicited by the symptoms of the acute phase of the disease. These findings are crucial to better understand the stigma related to Alzheimer's disease and to enhance the pain management of this frail population.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION

CRD42021282032.

Development and validation of the sleep assessment instrument for older adults with pain

BACKGROUND

The co-occurrence of chronic pain and sleep disturbance contribute to a significant functional and social impact in older adults. However, there are no validated instruments to measure sleep disturbance and pain in this population that could be used to screen or diagnose individuals or monitor treatment effectiveness.

OBJECTIVE

Our aim was to develop and validate a brief, practical, and comprehensive tool to assess the impact of co-occurring pain and sleep disturbance in older adults.

METHODS

Development and validation of a measurement tool for assessing pain and sleep in older adults consisting of seven items.

RESULTS

We applied the "Sleep Assessment Instrument for Pain in older adults" (SAIOAP) in a sample of 100 older individuals. A Cronbach's alpha of 0.602 indicated a moderate level of reliability, and item-total correlations of ≥0.4 for all items indicated good homogeneity. There were statistically significant correlations between the SAIOAP and sleep quality (PSQI, r=61.5), pain intensity (VNS, r=30.5), the multidimensional impacts of pain (GPM, r=40.5), depression (GEAP, r=45.5), comorbidity (r=27.9), and medication use (r=30.4). A ROC curve indicated a sensitivity of 73.2% and a specificity of 79.1% in relation to the prediction of sleep disturbances associated with pain in older adults.

CONCLUSIONS

The SAIOAP presented adequate metric properties and was demonstrated to be a simple and practical tool for the assessment of the impact of pain on sleep in older adults.

Pain and Associated Neuropsychiatric Symptoms in Patients Suffering from Dementia: Challenges at Different Levels and Proposal of a Conceptual Framework

Old age is critically associated with multi-morbidity, chronic pain, and high risk for dementia. Recognizing and treating pain is very much dependent on language comprehension and production. Both may be impaired in dementia. Moreover, neuropsychiatric symptoms may interact with pain perception. The main aims of the present article were 1) to identify key areas for future research to elucidate the relation between pain and associated neuropsychiatric symptoms in dementia, and 2) to provide a conceptual framework for ameliorating the clinical process of recognizing, assessing, and managing pain in non-communicating patients with advanced dementia.

Reliability and Feasibility of the Pain Assessment in Advanced Dementia Scale-Korean Version (PAINAD-K)

BACKGROUND

There is currently no observational instrument for assessing pain in aged patients who are unable to provide self-report in long-term care hospitals in Korea.

AIMS

The goal of this research was to culturally adapt and test the validity, reliability, and feasibility of the Korean version of the Pain Assessment in Advanced Dementia Scale.

DESIGN

This was a methodologic study aiming to translate the Pain Assessment in Advanced Dementia Scale.

PARTICIPANTS/SUBJECTS

The inpatients in a 270-bed LTC hospital in D metropolitan city were assessed pain levels.

METHODS

The Pain Assessment in Advanced Dementia (PAINAD) Scale was used as an observation scale to assess 192 long-term care hospital patients, with observation durations of 1 and 5 minutes.

RESULTS

The interrater reliability (1 minute) for the scale showed substantial kappa agreement of .62, and scores for the 1- and 5-minute observations showed almost perfect agreement of .95. The criterion validity of the scale (1 minute) was high relative to the Face-Legs-Activity-Cry-Consolability (FLACC) Scale, and low compared with the numeric rating scale (NRS). Discriminant validity was established between patients with and without pain. The feasibility of the Pain Assessment in Advanced Dementia Scale-Korean Version (PAINAD-K) (1 minute) indicated low sensitivity of 41.3% and high specificity of 92.6%.

CONCLUSIONS

Therefore, the PAINAD-K is a valid and reliable tool to determine the absence of pain in non-verbal aged patients.

The association between obesity and chronic pain among community-dwelling older adults: a systematic review and meta-analysis

OBJECTIVES

To systematically review studies and explore the association between obesity and chronic pain among community-dwelling older adults.

METHODS

A comprehensive literature search was conducted in 9 databases and the Pubmed search engine from their inception to March 19, 2020. Studies that investigated the associations between overweight/obesity and chronic pain among older people were obtained. Comprehensive Meta-analysis was used to meta-analyze the eligible studies.

RESULTS

Totally 14 studies with 40,999 participants were included in this review, and 8 of these studies were meta-analyzed. The meta-analyses showed that both overweight (pooled OR = 1.166, 95% CI: 1.104-1.232, p < 0.01) and obesity (pooled OR = 1.786, 95% CI: 1.530-2.085, p < 0.01) had significant associations with chronic pain among older adults.

CONCLUSIONS

Overweight and obesity are both associated with chronic pain among older adults. It is suggested that body weight control strategies might be incorporated into the pain management program for older adults with obesity.

Correlation between biomarkers of pain in saliva and PAINAD scale in elderly people with cognitive impairment and inability to communicate: descriptive study protocol

INTRODUCTION

Pain is an under-diagnosed problem in elderly people, especially in those with cognitive impairment who are unable to verbalise their pain. Although the Pain assessment in advanced dementia scale (PAINAD) scale is a tool recognised for its clinical interest in this type of patients, its correlation with the saliva biomarkers reinforced its utility. The aim of this research will be to correlate the scores of this scale with the levels of biomarkers of pain found in saliva samples of patients with cognitive impairment and inability to communicate.

METHODS AND ANALYSIS

This is an observational study. The level of pain will be evaluated using the PAINAD scale. Moreover, pain biomarkers, in particular secretory IgA and soluble tumour necrosis factor receptor type II, will be determined in saliva. Both assessments will be conducted in 75 patients aged over 65 years with advanced cognitive impairment and inability to communicate. The PAINAD scores will be correlated with the levels of these biomarkers of pain. A control group consisting of 75 healthy subjects aged over 65 years will be included in the study. Moreover, sociodemographic variables and variables related to pain, dementia and other clinical conditions will be recorded. The analysis will be performed with the statistical package SPSS V.22 and the software R.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Andalusian Human Research Ethics Committee. In addition, this study has been financed by the Junta de Andalucía through a regional health research fund (Research code: PI-0357-2017). The results will be actively disseminated trough a high-impact journal in our study area, conference presentations and social media.

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

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

Do Nursing Home Residents With Dementia Receive Pain Interventions?

This study compares pain interventions received by nursing home residents with and without dementia. Secondary data analyses of cross-sectional data from 50,673 nursing home residents in New York State were collected by the Minimum Data Set 3.0. Frequency distributions and bivariate analyses with χ2 tests were used to organize and summarize the data. Logistic regression analyses were performed to quantify the relationship between dementia and pain interventions. Our results show that residents with dementia had significantly fewer pain assessments and less reported pain presence than their counterparts. After adjusting for covariates, the results indicate that residents with dementia were significantly less likely to receive pro re nata and nonmedication pain intervention. However, there were no significant differences in scheduled pain medication between the 2 groups. To address the gap, we need more research to design a pain assessment tool that can differentiate severity of pain so that appropriate interventions can be applied.

Observational Pain Assessment Instruments for Use With Nonverbal Patients at the End-of-life: A Systematic Review

Purpose:

To review studies pertaining to the reliability and validity of observational pain assessment tools for use with nonverbal patients at the end-of-life, a field of research not documented by previous systematic reviews.

Methods:

Databases (PubMed, Embase, Epistemonikos, the Cochrane Library, and CINAHL) were systematically searched for studies from study inception to February 21, 2016 (update in May 9, 2018). Two independent reviewers screened study titles, abstracts, and full texts according to inclusion and exclusion criteria. Disagreements were resolved through consensus. Reviewers also extracted the psychometrics properties of studies of observational pain assessment instruments dedicated to a noncommunicative population in palliative care or at the end-of-life. A comprehensive quality assessment was conducted using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) to derive poor, fair, good or excellent ratings for the psychometric tests reported in each study.

Results:

Four studies linked to 4 different tools met the inclusion criteria. Study populations included dementia, palliative care and severe illness in the context of intensive care. All the studies included in this review obtained poor COSMIN ratings overall.

Conclusions:

At this point, it is impossible to recommend any of the tools evaluated given the low number and quality of the studies. Other analyses and studies need to be conducted to develop, adapt, or further validate observational pain instruments for the end-of-life population, regardless of the disease.

Psychometric Evaluation of the Electronic Pain Assessment Tool: An Innovative Instrument for Individuals with Moderate-to-Severe Dementia

BACKGROUND/AIMS

Pain is common in aged care residents with dementia; yet it often goes undetected. A novel tool, the electronic Pain Assessment Tool (ePAT), was developed to address this challenging problem. We investigated the psychometric properties of the ePAT.

METHODS

In a 10-week prospective observational study, the ePAT was evaluated by comparison against the Abbey Pain Scale (APS). Pain assessments were blindly co-performed by the ePAT rater against the nursing staff of two residential aged care facilities. The residents were assessed twice by each rater: at rest and following movement.

RESULTS

The study involved 34 residents aged 85.5 ± 6.3 years, predominantly with severe dementia (Psychogeriatric Assessment Scale - Cognitive Impairment score = 19.7 ± 2.5). Four hundred paired assessments (n = 204 during rest; n = 196 following movement) were performed. Concurrent validity (r = 0.911) and all reliability measures (κw = 0.857; intraclass correlation coefficient = 0.904; α = 0.950) were excellent, while discriminant validity and predictive validity were good.

CONCLUSION

The ePAT is a suitable tool for the assessment of pain in this vulnerable population.

Pain Assessment in Elderly with Behavioral and Psychological Symptoms of Dementia

Background:

Pain is under-detected and undertreated in people with dementia. The present study investigates the prevalence of pain in people with dementia hospitalized in nursing homes that are members of National Association of Third Age Residences (ANASTE) Calabria, and evaluates the association among pain, mood, and behavioral and psychological symptoms of dementia (BPSD).

Objective:

The aim of this study is to define the prevalence of pain in people with dementia in long term care facilities using scales of self-reporting and observational tools and, particularly, to study the relationship between pain and BPSD.

Methods:

A prospective observational study was carried out on 233 patients. Pain assessment was performed using self-reporting tools such as the Numeric Rating Scale (NRS) for patients with slight cognitive impairment or no cognitive impairment and observational tools such as Pain Assessment In Advanced Dementia Scale (PAINAD) for patients with moderate or severe cognitive impairment. Mood was evaluated through the Cornell Scale for Depression in Dementia (CSDD) while behavioral problems were assessed through the Cohen-Mansfield Agitation Inventory (CMAI) and Neuropsychiatric Inventory (NPI).

Results:

Only 42.5% of patients evaluated by NRS provided a reliable answer; of these, 20.4% reported no pain. The percentage of pain evaluated by PAINAD was 51.8% . Analysis of data showed a statistically significant correlation between diagnosis of pain and depressive symptoms, assessed with CSDD (p = 0.0113), as well as by single items of NPI, such as anxiety (p = 0.0362) and irritability (p = 0.0034), and F1 profile (Aggression) of CMAI (p = 0.01).

Conclusion:

This study confirms that self-report alone is not sufficient to assess pain in elderly people with dementia; the observational tool is a necessary and suitable way of assessing pain in patients with cognitive impairment. If not adequately treated, chronic pain can cause depression, agitation, and aggression in patients with dementia.

Assessment of Activities of Daily Living, Self-Care, and Independence

Activities of daily living (ADL) comprise the basic actions that involve caring for one's self and body, including personal care, mobility, and eating. In this review article, we (1) review useful clinical tools including a discussion on ways to approach ADL assessment across settings, (2) highlight relevant literature evaluating the relationship between cognitive functioning and ADLs, (3) discuss other biopsychosocial factors affecting ADL performance, (4) provide clinical recommendations for enhancing ADL capacity with an emphasis on self-care tasks (eating, grooming, dressing, bathing and toileting), and (5) identify interventions that treatment providers can implement to reduce the burden of ADL care.