Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools

Assessing eating ability and mealtime behaviors of persons living with dementia: A systematic review of instruments

This systematic review aimed to describe the characteristics of instruments that assess eating ability and/or mealtime behaviors in persons living with dementia, and evaluate their psychometric properties. Five databases were searched for relevant records between 1/1/1980 and 5/25/2023. Records included instruments assessing eating ability and/or mealtime behaviors of people with dementia. The psychometric quality of the instruments was evaluated using the Psychometric Assessment for Self-report and Observational Tools (PAT). 45 eligible instruments were identified from 115 records. While 38 instruments were scored as having low psychometric quality, 7 had moderate quality. Edinburgh Feeding Evaluation in Dementia (EdFED), Mealtime Difficulty Scale for older adults with Dementia (MDSD), and Dementia Hyperphagic Behavior Scale (DHBS) were scored as having the highest quality (total PAT score = 9). Further refinement of existing instruments and additional psychometric testing in larger, diverse samples will improve pragmatic use in dementia mealtime care research and practice.

End-of-Life Care of Persons with Alzheimer's Disease and Other Dementias

End-of-life (EOL) care has been a common option for patients with terminal medical conditions such as cancers. However, the utilization of EOL care in Alzheimer disease and other dementing conditions have become available relatively recently. As the end-stage dementia approaches, the clinicians and caregivers become faced with numerous clinical challenges-delirium, neuropbehavioral symptoms, the patient's inability to communicate pain and associated discomfort, food refusal, and so on. In addition to providing quality clinical care to the EOL patients, clinicians should pay special attention to their families, assuring that their loved ones will receive supportive measures to improve quality of life (QOL).

Palliative sedation determinants: systematic review and meta-analysis in palliative medicine

BACKGROUND

The utilisation of palliative sedation is often favoured by patients approaching end of life due to the presence of multiple difficult-to-manage symptoms during the terminal stage. This study aimed to identify the determinants of the use of palliative sedation.

METHODS

To identify pertinent observational studies, a comprehensive search was performed in PubMed, Embase, Cochrane Library, and PsycINFO databases from their inception until March 2022. The methodological quality of the chosen prospective and retrospective cohort studies was assessed using the Newcastle Ottawa Scale, while the Agency for Healthcare Research and Quality was used to evaluate the methodological quality of the selected cross-sectional studies. For each potential determinant of interest, the collected data were synthesised and analysed, and in cases where data could not be combined, a narrative synthesis approach was adopted.

RESULTS

A total of 21 studies were analysed in this research, consisting of 4 prospective cohort studies, 7 retrospective cohort studies, and 10 cross-sectional studies. The findings indicated that several determinants were significantly associated with palliative sedation. These determinants included younger age, male gender, presence of tumours, dyspnoea, pain, delirium, making advanced medical end-of-life decisions, and dying in a hospital setting.

CONCLUSIONS

The findings of our review could help physicians identify patients who may need palliative sedation in advance and implement targeted interventions to reverse refractory symptoms, develop personalized palliative sedation programs, and ultimately improve the quality of palliative care services.

TRIAL REGISTRATION

PROSPERO registration number CRD42022324720.

Association between pain and cognitive and daily functional impairment in older institutional residents: a cross-sectional study

BACKGROUND

Pain is often neglected in disabled older population, especially in Taiwan where the population of institutional residents is rapidly growing. Our study aimed to investigate pain prevalence and associated factors among institutional residents to improve pain assessment and management.

METHODS

This nationwide study recruited 5,746 institutional residents in Taiwan between July 2019 and February 2020. Patient self-report was considered the most valid and reliable indicator of pain. A 5-point verbal rating scale was used to measure pain intensity, with a score ranging from 2 to 5 indicating the presence of pain. Associated factors with pain, including comorbidities, functional dependence, and quality of life, were also assessed.

RESULTS

The mean age of the residents was 77.1 ± 13.4 years, with 63.1% of them aged over 75 years. Overall, 40.3% of the residents reported pain, of whom 51.2% had moderate to severe pain. Pain was more common in residents with comorbidities and significantly impacted emotions and behavior problems, and the mean EQ5D score, which is a measure of health-related quality of life (p < .001). Interestingly, pain was only related to instrumental activities of daily living (IADL) and not activities of daily living (ADL). On the other hand, dementia was significantly negatively associated with pain (p < .001), with an estimated odds of 0.63 times (95% CI: 0.53-0.75) for the presence of pain when compared to residents who did not have dementia.

CONCLUSIONS

Unmanaged pain is common among institutional residents and is associated with comorbidities, IADL, emotional/behavioral problems, and health-related quality of life. Older residents may have lower odds of reporting pain due to difficulty communicating their pain, even through the use of a simple 5-point verbal rating scale. Therefore, more attention and effort should be directed towards improving pain evaluation in this vulnerable population .

Perioperative analgesia in the elderly

The administration of analgesic drugs in elderly patients should take into account age-related physiological changes, loss of efficiency of homeostatic mechanisms, and pharmacological interactions with chronic therapies. Underestimation of pain in patients with impaired cognition is often linked to difficulties in pain assessment. In the preoperative phase, it is essential to assess the physical status, cognitive reserve, and previous chronic pain conditions to plan effective analgesia. Furthermore, an accurate pharmacological history of the patient must be collected to establish any possible interaction with the whole perioperative analgesic plan. The use of analgesic drugs with different mechanisms of action for pain relief in the intraoperative phase is a crucial step to achieve adequate postoperative pain control in older adults. The combined multimodal and opioid-sparing strategy is strongly recommended to reduce side effects. The use of various adjuvants is also preferable. Moreover, the implementation of non-pharmacological approaches may lead to faster recovery. High-quality postoperative analgesia in older patients can be achieved only with a collaborative interdisciplinary team. The aim of this review is to highlight the perioperative pain management strategies in the elderly with a special focus on intraoperative pharmacological interventions.

Observation of urinary tract infection signs and symptoms in nursing home residents with impaired awareness or ability to communicate signs and symptoms: The development of supportive tools

BACKGROUND

Antibiotics are often inappropriately prescribed for urinary tract infections (UTIs) in nursing home (NH) residents. Research emphasises the importance of prescribing antibiotics only if there are UTI-related signs and symptoms (S&S). However, for many NH residents it is challenging to find out whether such S&S are present, for example due to cognitive disorders.

OBJECTIVES

To provide insight into the assessment of UTI-related S&S in NH residents with impaired awareness or ability to communicate S&S, and to develop supportive tools for the observation of UTI-related S&S in this subgroup of NH residents, by nursing staff.

METHODS

We performed a practice-based study using mixed methods. Data of 295 cases of suspected UTI were analysed to determine how often UTI-related S&S were 'not assessed/non-assessable' in residents with and without dementia. Barriers and facilitators in observing UTI-related S&S in NH residents with impaired awareness or ability to communicate S&S were derived from interviews and focus groups with nursing staff. Literature review, focus group data, additional telephone interviews and questionnaires with nursing staff were used in a step-by-step process, including pilot testing, to develop supportive tools for the observation of UTI-related S&S.

RESULTS

UTI-related S&S were assessable in the majority of NH residents with dementia. The proportion 'not assessed/non-assessable' S&S in residents with dementia increased with increasing severity of dementia. In residents with very severe dementia, up to 58% of the S&S were 'not assessed/non-assessable'. Knowing the resident, working methodologically, and being sufficiently skilled to interpret observations in residents facilitate the assessment of UTI-related S&S. Insights acquired during the different study elements resulted in the development of an observation checklist and a 24-h observation tool.

CONCLUSIONS

The more NH residents have impaired awareness of ability to communicate S&S, the more difficult it seems to be to assess UTI-related S&S. The observation checklist and 24-h observation tool developed in the current study may support nursing staff in their observation of UTI-related S&S in this group of NH residents.

Development and psychometric testing of the dyadic communication observational coding scheme in DEmentia care (DCODE): family dyadic communication in dementia

OBJECTIVES

Understanding family dyadic communication in dementia is essential to promote the well-being of family caregivers and persons living with dementia. The Dyadic Communication Observational coding scheme in DEmentia care (DCODE) was developed and tested to assess family dyadic communication in dementia.

METHODS

The DCODE was developed from a review of literature, expert review, and pretesting. A secondary analysis of the 75 in-home care video observations from 19 family caregiver-care recipient dyads was conducted to test psychometric properties.

RESULTS

The DCODE consists of 43 caregiver items and 41 care recipient items. We observed internal consistency, intra-rater reliability, and inter-rater reliability as adequate. Content validity and convergent validity were moderate. Predictive validity was moderate in predicting caregiver burden. The overall psychometric properties demonstrated a moderate quality of the DCODE.

CONCLUSIONS

Findings provided the preliminary psychometric evidence of the DCODE as a promising instrument to assess family dyadic communication in dementia. Future testing for concurrent, divergent, and structural validity of the DCODE is needed.

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.

The Relationship Between Rejection of Care Behaviors and Pain and Delirium Severity in Hospital Dementia Care

Background and Objectives

Rejection of care is common in hospitalized persons living with dementia. However, distinguishing between rejection of care behaviors related to care practices or other causes, such as pain or delirium, is challenging. The purpose of this study is to further understand the relationship between rejection of care and pain and delirium in hospitalized patients with dementia by identifying which rejection of care behaviors are associated with pain and delirium.

Research Design and Methods

Care encounters between hospitalized patients with dementia (n = 16) and nursing staff (n = 53) were observed on 88 separate occasions across 35 days. Rejection of care was measured using the 13 behaviors from the Resistiveness to Care Scale. Pain and delirium severity were measured using a variety of scales including the Pain Assessment in Advanced Dementia Scale, Checklist of Nonverbal Pain Indicators, and numeric rating scale for pain severity and the Confusion Assessment Method-Severity short form and Delirium Observation Screening Scale for delirium severity. Linear mixed modeling was used to determine the relationship between rejection of care behaviors and pain and delirium severity for each measure.

Results

About 48.9% of the observations included rejection of care, 49.9% included a patient in pain, and 12.5% included a patient with delirium. Cry, push away, scream/yell, and turn away indicated a higher pain severity across pain measures. No rejection of care behaviors were found to indicate delirium severity.

Discussion and Implications

Certain rejection of care behaviors may be helpful in identifying pain in hospitalized patients with dementia, suggesting that caregivers should be cognizant of pain when these rejection of care behaviors are present. However, in this sample rejection of care behaviors was not found to be useful for identifying delirium severity in hospital dementia care.

Pain assessment tools for use in infants: a meta-review

BACKGROUND

Identifying pain in infants is challenging due to their inability to self-report pain, therefore the availability of valid and reliable means of assessing pain is critical.

OBJECTIVE

This meta-review sought to identify evidence that could guide the selection of appropriate tools in this vulnerable population.

METHODS

We searched Scopus, Medline, Embase, CINAHL, MIDRIS, EMCare and Google Scholar for eligible systematic reviews. Eligible reviews documented psychometric properties of available observational tools used to assess pain in infants.

RESULTS

A total of 516 reviews were identified of which 11 met our inclusion criteria. We identified 36 pain assessment tools (evaluated in 11 reviews) of which seven were reported in at least three reviews. The level of evidence reported on the psychometric properties of pain assessment tools varied widely ranging from low to good reliability and validity, whilst there are limited data on usability and clinical utility.

CONCLUSIONS

Currently, no observer administered pain assessment tool can be recommended as the gold standard due to limited availability and quality of the evidence that supports their validity, reliability and clinical utility. This meta-review attempts to collate the available evidence to assist clinicians to decide on what is the most appropriate tool to use in their clinical practice setting. It is important that researchers adopt a standard approach to evaluating the psychometric properties of pain assessment tools and evaluations of the clinical utility in order that the highest level of evidence can be used to guide tool selection.

Chewing and Swallowing Abilities of Persons Living With Dementia: A Systematic Review of Psychometric Properties of Instruments

Background and Objectives

It is critical to use validated instruments to diagnose and manage chewing and swallowing problems of persons living with dementia. The study aimed to synthesize the characteristics and psychometric quality of instruments that assess the chewing and swallowing abilities of persons living with dementia.

Research Design and Methods

The systematic review was used to conduct this study. We searched 5 electric databases for records published from January 1, 1980, to July 8, 2022. Records were eligible if they included any instrument to assess chewing ability or swallowing ability in the dementia population. Eight characteristics of eligible instruments were extracted from the records: (1) development process, (2) operationalized concept/construct, (3) sample and setting, (4) administration method, (5) items, (6) scoring format/interpretation, (7) reliability, and (8) validity. The psychometric assessment for self-report and observational tool was used to evaluate 12 psychometric properties of eligible instruments.

Results

In total, 11,074 records were reviewed. Thirty-five eligible instruments, including observational tools, self-report questionnaires, and physiological instruments, were identified from 60 records. All 8 instruments assessing chewing ability were evaluated as having low psychometric quality, and only 3 out of 27 instruments assessing swallowing ability were evaluated as having moderate psychometric quality. Fifteen instruments were tested for only 1 type of psychometric property, limiting the overall evaluation of psychometric evidence.

Discussion and Implications

The study findings inform the use and adaptation of appropriate instruments for practice and research. All existing instruments warrant further validation in larger samples to expand use in diverse care settings. This review described and evaluated current instruments measuring chewing and swallowing abilities and potential use in research and clinical practice to plan for and evaluate the effectiveness of mealtime and oral care practice and reduce health-related negative outcomes of persons living with dementia.

Psychometric Properties of Instruments Measuring Dyadic Communication and Environment in Dementia Care: A Systematic Review

BACKGROUND AND OBJECTIVES

A valid and reliable assessment of dementia dyadic communication and environment is essential to understand and facilitate social interaction and quality care. This review described the characteristics and evaluated psychometric properties of instruments that assess dyadic communication and environment between persons living with dementia and their caregivers.

RESEARCH DESIGN AND METHODS

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Literature published until June 30, 2021, was searched. Ten psychometric properties and the ratio of sample size to the number of items were evaluated using the Psychometric Assessment for Self-report and Observational Tool.

RESULTS

A total of 3,708 scholarly records was identified, and 24 eligible instruments from 48 scholarly records were evaluated. Twenty-two instruments assessed dyadic communication, and 2 assessed both dyadic communication and environment. Eighteen instruments were developed to assess task-related communication and 15 for paid (professional) caregivers. All instruments were scored as low psychometric quality (score range = 0-7). Behavioral Observation Scoring System was scored the highest (total score = 7), followed by Dyadic Dementia Coding System, Grid for observation of physical and verbal behaviors of caregiver and resident, and Trouble-Indicating Behaviors and Repair (total score = 6). These instruments had low psychometric evidence for internal consistency, content validity, and structural validity.

DISCUSSION AND IMPLICATIONS

Existing instruments are in the early stages of development and validation in dementia population. Further testing is needed in diverse communication types in paid and unpaid dementia caregiver populations.

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.

Association of the RASS Score with Intensity of Symptoms, Discomfort, and Communication Capacity in Terminally Ill Cancer Patients Receiving Palliative Sedation: Is RASS an Appropriate Outcome Measure?

Background:

Palliative sedation is sometimes needed for refractory symptoms, and the Richmond Agitation–Sedation Scale (RASS) is one of the key measures. The primary aim of this study was to explore the association between RASS and degree of distress quantified by other measures: Item “symptom control” of Support Team Assessment Schedule (STAS, item 2), Discomfort Scale for Dementia of Alzheimer Type (Discomfort Scale), and Noncommunicative Patient's Pain Assessment Instrument (NOPPAIN), as well as a communication capacity measured by the Communication Capacity Scale (CCS), item 4.

Methods:

This was a prospective observational study on terminally ill cancer patients with palliative sedation in a palliative care unit of a designated cancer hospital. Primarily responsible palliative care physicians rated RASS, Discomfort Scale, NOPPAIN, and CCS just before sedation and 1, 4, 24, and 48 hours after, and ward nurses rated STAS at the same time. Since the ward nurses evaluated STAS during palliative sedation, we regarded STAS as a standard of distress measure.

Results:

A total of 249 assessments were performed for 55 patients. RASS was moderately to highly associated with symptom intensity measured by STAS, discomfort measured by the Discomfort Scale, and pain measured by NOPPAIN (r = 0.63 to 0.73). But communication capacity measured by CCS is not parallel with RASS and demonstrated a valley shape. In 82 assessments with an RASS score of −1 to −3, 11 patients (13%) had physical symptoms of STAS of 2 or more.

Conclusions:

RASS can roughly estimate physical distress in patients with palliative sedation, but a measure to more precisely quantify the symptom experience is needed.

Development of a Composite Pain Scale in Foals: A Pilot Study

Prompt pain management is crucial in horses; however, tools to assess pain are limited. This study aimed to develop and pilot a composite scale for pain estimation in foals. The “Foal Composite Pain Scale” (FCPS) was developed based on literature and authors’ expertise. The FCPS consisted of 11 facial expressions, 4 behavioural items, and 5 physical items. Thirty-five pain-free foals (Control Group) and 15 foals experiencing pain (Pain Group) were used. Foals were video-recorded at different time points: the Control Group only at inclusion (C), while the Pain Group at inclusion (T1), after an analgesic treatment (T2), and at recovery (T3). Physical items were also recorded at the same time points. Videos were scored twice by five trained observers, blinded to group and time points, to calculate inter- and intra-observer reliability of each scale item. Fleiss’ kappa values ranged from moderate to almost perfect for the majority of the items, while the intraclass correlation coefficient was excellent (ICC = 0.923). The consistency of FCPS was also excellent (Cronbach’s alpha = 0.842). A cut-off ≥ 7 indicated the presence of pain. The Pain Group scores were significantly higher (p < 0.001) than the Control Group and decreased over time (T1, T2 > T3; p = 0.001). Overall, FCPS seems clinically applicable to quantify pain and improve the judgment of the quality of life in foals, but it needs modifications based on these preliminary findings. Consequently, further studies on a larger sample size are needed to test the feasibility and validity of the refined FCPS.

A Novel Method for Digital Pain Assessment Using Abstract Animations: Human-Centered Design Approach

Background

Patients with chronic pain face several challenges in using clinical tools to help them monitor, understand, and make meaningful decisions about their pain conditions. Our group previously presented data on Painimation, a novel electronic tool for communicating and assessing pain.

Objective

This paper describes the human-centered design and development approach (inspiration, ideation, and implementation) that led to the creation of Painimation.

Methods

We planned an iterative and cyclical development process that included stakeholder engagement and feedback from users. Stakeholders included patients with acute and chronic pain, health care providers, and design students. Target users were adults with acute or chronic pain who needed clinical assessment and tracking of the course of their pain over time. Phase I (inspiration) consisted of empathizing with users, understanding how patients experience pain, and identifying the barriers to accurately expressing and assessing pain. This phase involved understanding how patients communicate pain symptoms to providers, as well as defining limitations of current models of clinical pain assessment tools. In Phase II (ideate) we conceptualized and evaluated different approaches to expressing and assessing pain. The most promising concept was developed through an iterative process that involved end users and stakeholders. In Phase III (implementation), based on stakeholder feedback from initial designs and prototypes of abstract pain animations (painimations), we incorporated all concepts to test a minimally viable product, a fully functioning pain assessment app. We then gathered feedback through an agile development process and applied this feedback to finalizing a testable version of the app that could ultimately be used in a pain clinic.

Results

Engaging intended users and stakeholders in an iterative, human-centered design process identified 5 criteria that a pain assessment tool would need to meet to be effective in the medical setting. These criteria were used as guiding design principles to generate a series of pain assessment concept ideas. This human-centered approach generated 8 highly visual painimations that were found to be acceptable and useable for communicating pain with medical providers, by both patients with general pain and patients with sickle cell disease (SCD). While these initial steps continued refinement of the tool, further data are needed. Agile development will allow us to continue to incorporate precision medicine tools that are validated in the clinical research arena.

Conclusions

A multiphase, human-centered design approach successfully resulted in the development of an innovation that has potential to improve the quality of medical care, particularly for underserved populations. The use of Painimation may especially benefit the medical care of minority populations with chronic and difficult-to-treat pain, such as adults with SCD. The insights generated from this study can be applied to the development of patient-reported outcomes tools that are more patient-centered, engaging, and effective.

[A systematic review of distress due to pneumonia experienced by older people with end-stage dementia]

AIM

Many older people with end-stage dementia die of pneumonia, but the details of their distress have been unclear. The present study clarified the distress experienced by such individuals due to pneumonia.

METHODS

We searched for literature corresponding to 5 clinical questions (CQs) concerning including "What distress is experienced by older people with end-stage dementia due to pneumonia (CQ1) ?" using a search formula with the Web version of the Central Medical Magazine, MEDLINE (STN)/EMBASE (STN), Cochrane Library, and extracted 604 articles. Forty-two articles corresponding to 5 CQs were extracted by primary screening using abstracts, and 17 articles were adopted after the secondary screening. A total of six articles corresponding to CQ1 were ultimately analyzed.

RESULTS

Older people with end-stage dementia who died of pneumonia reported more discomfort and dyspnea than those who died of dehydration. Their main symptoms were respiratory symptoms, such as cough, sputum, and dyspnea, a fever and somnolence. Distress such as dyspnea and discomfort among older people with end-stage dementia recovering from pneumonia peaked on the day of the diagnosis. Furthermore, in older people with end-stage dementia dying of pneumonia, distresses began approximately one week before death and peaked on the day before death. A few days before death, several distressing symptoms, such as pain, dyspnea and restlessness/agitation, were often observed at the same time.

CONCLUSIONS

If older people with end-stage dementia contract pneumonia and die from it, attentive palliative care is needed to manage their severe discomfort, dyspnea and other sources of distress.

Dyadic interactions and physical and social environment in dementia mealtime care: a systematic review of instruments

Using valid instruments to measure dyadic interactions and physical and social environment during mealtime care of persons with dementia is critical to evaluate the process, fidelity, and impact of mealtime interventions. However, the characteristics and quality of existing instruments remain unexplored. This systematic review described the characteristics and synthesized the psychometric quality of instruments originally developed or later modified to measure mealtime dyadic interactions and physical and/or social dining environment for people with dementia, on the basis of published reports between January 1, 1980 and December 31, 2020. We identified 26 instruments: 17 assessed dyadic interactions, one assessed physical environment, and eight assessed physical and social environment. All instruments were used in research and none in clinical practice. All instruments were observational tools and scored as having low psychometric quality, except for the refined Cue Utilization and Engagement in Dementia (CUED) mealtime video-coding scheme rated as having moderate quality. Reasons for low quality are the use of small samples compared with the number of items, limited psychometric testing, and inadequate estimates. All existing tools warrant further testing in larger diverse samples in varied settings and validation for use in clinical practice. The refined CUED is a potential tool for use and requires testing in direct on-site observations.

Pain Assessment for Individuals with Advanced Dementia in Care Homes: A Systematic Review

Pain is prevalent in older people, especially in those with advanced dementia who have communication impairments. Although pain is recognised to be present in this population, it is often under-assessed and ineffectively managed. The assessment of pain in advanced dementia is extremely challenging and complex, particularly in institutional settings such as care homes. This study systematically reviews the literature to examine and characterise the evidence for the use of pain assessment tools in care homes with individuals living with advanced dementia. Relevant publications were sourced from electronic bibliometric medical databases including AMED, CINAHL Plus, Medline, PsycINFO, EMBASE, TRIP Pro, Google Scholar, and HINARI. The database search was supplemented by screening citations and reference lists, in addition to a grey literature searches. The search identified 2221 studies, among which 26 were included in the review. The majority of the studies were observational, which created a rich source of data to create four major themes. The findings were informed and shaped by working with key stakeholders to develop a conceptual model that can contribute to developing evidence-based practice. This highlights the importance of a comprehensive, multi-disciplinary approach to pain assessment in this population, which is beyond the use of tools.

Non-pharmacological interventions for pain in people with dementia: A systematic review

CONTEXT

Pain commonly occurs in people living with dementia but is often undertreated. Non-pharmacological interventions are a safer first-line option for pain management, but evidence-based interventions for people living with dementia have not been established. An increasing number of studies have examined the effect of non-pharmacological interventions in pain management. However, the evidence that specifically focuses on people living with dementia has not been systematically reviewed.

OBJECTIVES

This review aimed to systematically synthesize current evidence on non-pharmacological interventions to manage pain in people living with dementia.

METHODS

A comprehensive search of the literature was conducted in PubMed, CINAHL, Scopus, and Web of Science databases. Studies were included if they were 1) peer-reviewed original quantitative research, 2) tested the effect of non-pharmacological interventions on pain in people with dementia, and 3) English language. Studies were excluded if they 1) included both pharmacological and non-pharmacological interventions and did not report separate results for the non-pharmacological interventions; 2) enrolled participants with and without dementia and did not have separate results reported for individuals with dementia; 3) tested dietary supplements as the intervention; and 4) were not original research, such as reviews, editorials, commentaries, or case studies. Title, abstract, and full text were screened. Quality assessment was conducted using the Cochrane Risk of Bias tool and Johns Hopkins Level of Evidence. Pain assessment tools, participant characteristics, study designs, intervention condition, and results were extracted. Results were synthesized through grouping the type of the interventions and weighting evidence based on quality and design of the studies.

RESULTS

A total of 11 articles and 12 interventions were identified. A total of 486 participants were included. Interventions that have shown a positive impact on pain include ear acupressure, music therapy, reflexology, tailored pain intervention, painting and singing, personal assistive robot, cognitive-behavioral therapy, play activity, and person-centered environment program. Nevertheless, a majority of the interventions were only evaluated once. Moreover, most studies had similar sample characteristics and setting.

CONCLUSION

Overall, the quality of included studies were mostly low to mixed quality and most participants only had mild to moderate baseline pain, which limits detection of the intervention's effect. Hence, these findings need to be duplicated in studies with a greater sample size, a more diverse population (race, gender, and settings), and a more rigorous design to validate the results.

Care home residents’ quality of life and its association with CQC ratings and workforce issues: the MiCareHQ mixed-methods study

Background

Care home staff have a critical bearing on quality. The staff employed, the training they receive and how well they identify and manage residents’ needs are likely to influence outcomes. The Care Act 2014 (Great Britain. The Care Act 2014. London: The Stationery Office; 2014) requires services to improve ‘well-being’, but many residents cannot self-report and are at risk of exclusion from giving their views. The Adult Social Care Outcomes Toolkit enables social care-related quality of life to be measured using a mixed-methods approach. There is currently no equivalent way of measuring aspects of residents’ health-related quality of life. We developed new tools for measuring pain, anxiety and depression using a mixed-methods approach. We also explored the relationship between care home quality, residents’ outcomes, and the skill mix and employment conditions of the workforce who support them.

Objectives

The objectives were to develop and test measures of pain, anxiety and depression for residents unable to self-report; to assess the extent to which regulator quality ratings reflect residents’ care-related quality of life; and to assess the relationship between aspects of the staffing of care homes and the quality of care homes.

Design

This was a mixed-methods study.

Setting

The setting was care homes for older adults in England.

Participants

Care home residents participated.

Results

Three measures of pain, anxiety and low mood were developed and tested, using a mixed-methods approach, with 182 care home residents in 20 care homes (nursing and residential). Psychometric testing found that the measures had good construct validity. The mixed-methods approach was both feasible and necessary with this population, as the majority of residents could not self-report. Using a combined data set (n = 475 residents in 54 homes) from this study and the Measuring Outcomes in Care Homes study (Towers AM, Palmer S, Smith N, Collins G, Allan S. A cross-sectional study exploring the relationship between regulator quality ratings and care home residents’ quality of life in England. Health Qual Life Outcomes 2019;17:22) we found a significant positive association between residents’ social care-related quality of life and regulator (i.e. Care Quality Commission) quality ratings. Multivariate regression revealed that homes rated ‘good/outstanding’ are associated with a 12% improvement in mean current social care-related quality of life among residents who have higher levels of dependency. Secondary data analysis of a large, national sample of care homes over time assessed the impact of staffing and employment conditions on Care Quality Commission quality ratings. Higher wages and a higher prevalence of training in both dementia and dignity-/person-centred care were positively associated with care quality, whereas high staff turnover and job vacancy rates had a significant negative association. A 10% increase in the average care worker wage increased the likelihood of a ‘good/outstanding’ rating by 7%.

Limitations

No care homes rated as inadequate were recruited to the study.

Conclusions

The most dependent residents gain the most from homes rated ‘good/outstanding’. However, measuring the needs and outcomes of these residents is challenging, as many cannot self-report. A mixed-methods approach can reduce methodological exclusion and an over-reliance on proxies. Improving working conditions and reducing staff turnover may be associated with better outcomes for residents.

Future work

Further work is required to explore the relationship between pain, anxiety and low mood and other indicators of care homes quality and to examine the relationship between wages, training and social care outcomes.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 19. See the NIHR Journals Library website for further project information.

Instruments for pain assessment in patients with advanced dementia: A systematic review of the evidence for Latin America

OBJECTIVE

Pain treatment is an essential component of care for elderly patients with advanced dementia. The objective of this study was to identify and analyze the different scales used for pain assessment in elderly persons diagnosed with dementia, in the literature available at the Latin American level.

METHOD

A systematic review was performed on the existing scales for pain assessment in elderly people diagnosed with Alzheimer's disease, vascular dementia, and dementia with Lewy bodies.

RESULTS

226 articles were retrieved from the PUBMED, BIREME, and Scielo databases, of which a total of 10 articles entered the systematic review. The instruments identified in these publications were PAINAD, Abbey, McGill, and PACSLAC, while the Colored Pain Scale, Faces Pain Scale, and VAS scales were used as the silver standard. In Spanish, the Abbey scale, and in Portuguese, the PACSLAC scale showed the best reliability and validity coefficients.

SIGNIFICANCE OF RESULTS

It is concluded that there are only two appropriate scales for the assessment of pain in people with dementia in the region of interest of this study. It is recommended to generate more evidence for a more accurate assessment of pain in people with dementia.

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.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The Short-Term Kinetics of sICAM-1 after Induction of Acute Experimental Pain in Healthy Volunteers

Intercellular adhesion molecule-1 (ICAM-1) mediates extravasation of leukocytes, releasing proinflammatory cytokines or endogenous opioids in the inflamed tissue. Thus, ICAM-1 is a crucial component of peripheral antinociception. Previously, we demonstrated a significant correlation between the soluble form of ICAM (sICAM-1) in serum and pain intensity reported by chronic pain patients. The present study examines the role and kinetics of sICAM-1 in experimentally induced acute pain. Three groups of 10 subjects were exposed to 10 min of high (capsaicin-enhanced) or low-intensity heat pain or cold pain, respectively. Thermal stimuli were induced using a device for quantitative sensory testing. Topical capsaicin significantly increased heat pain intensity without the risk of thermal tissue damage. Pain intensity was recorded every minute during testing. sICAM-1 concentrations in serum were determined by ELISA before, immediately after, and 60 min after test termination. Among all experimental groups, sICAM-1 significantly decreased immediately after pain induction. After 60 min, sICAM-1 concentrations returned towards initial values. Interestingly, a linear correlation was found between the extent of sICAM-1 changes and the initial concentrations. Whereas high initial values led to a distinct decrease of sICAM-1, low concentrations tended to increase. There was no statistically significant correlation between levels or alterations of serum sICAM-1 and pain intensity reported by the test subjects. In contrast to our previous findings in chronic pain patients, the present results show that sICAM-1 values do not correlate with the intensity of acute experimental pain. However, we were able to detect short-term changes of sICAM-1 after induction of nociceptive thermal stimuli, suggesting that this marker is part of a demand-oriented homeostatically controlled system.

Are Chronic Pain Patients with Dementia Being Undermedicated?

In dementia, neuropathological changes alter the perception and expression of pain. For clinicians and family members, this knowledge gap leads to difficulties in recognizing and assessing chronic pain, which may consequently result in persons with dementia receiving lower levels of pain medication compared to those without cognitive impairment. Although this situation seems to have improved in recent years, considerable geographical variation persists. Over the last decade, opioid use has received global attention as a result of overuse and the risk of addiction, while the literature on older persons with dementia actually suggests undertreatment. This review stresses the importance of reliable assessment and the regular evaluation and monitoring of symptoms in persons with dementia. Based on current evidence, we concluded that chronic pain is still undertreated in dementia.

Interrater Variability in Pain Assessment of Long-term Care Residents with Dementia

PURPOSE

People with dementia are at great risk of their pain being undetected. In long-term care facilities, certified nursing assistants are on the front-line to detect whether a resident with dementia is experiencing pain, but research on certified nursing assistants' abilities to accurately assess pain are scarce. This study aims to examine certified nursing assistants' pain assessment skills using a simulated standardized video context.

DESIGN

A cross-sectional study was conducted.

METHODS

Fifty certified nursing assistants and 40 individuals with no professional experience in the field of care (controls) watched the same video of an older adult woman with dementia experiencing pain. Afterwards, they completed visual analog scales (pain intensity, affective distress), an observational pain assessment scale (Algoplus), and a set of questionnaires.

RESULTS

In both groups, pain intensity assessment and empathic reaction scores showed important interrater variability. Moreover, certified nursing assistants and controls did not differ in detecting the presence of pain or assessing its intensity. But certified nursing assistants displayed lower empathic reactions and dispositions. Certified nursing assistants pain assessment scores decreased with experience and expertise.

CONCLUSIONS

The practice of pain assessment is challenging for certified nursing assistants in long-term care facilities. Their professional status does not prevent inter-personal inconsistency and tends to lower their empathic dispositions. Personal determinants may interfere with their assessment behaviors and must be considered to enhance pain management for residents with dementia.

Pain prevalence among residents living in nursing homes and its association with quality of life and well-being

BACKGROUND

Pain is common and often more complex to assess among nursing homes residents with cognitive impairments. Thus, more research is needed of different pain assessment methods in elderly care and how these assessments outcomes are related to quality of life, as there mostly should be a negative relationship. There is a risk that pain are under diagnosed among persons with cognitive impairment.

AIM

The aim was to describe and compare pain prevalence among nursing home residents (1) using different pain assessment methods (2) in relation to cognitive status and to (3) examine associations between pain and quality of life or well-being.

METHODS

A cross-sectional correlational design was used, participants were 213 nursing home residents and data were collected through interviews using standardised protocols. Instrument used were Katz index of ADL, Mini-Mental-State-Examination, Quality of Life in Late-Stage Dementia scale, WHO-5 well-being index, Numeric Rating Scale and Doloplus-2 scale.

RESULTS

The results showed high pain prevalence, but no significant difference based on cognitive level. Pain classification at the individual level varied somewhat when different instruments are used. The results indicated that use of a single-item proxy-measure for pain tends to show higher pain prevalence and was not statistically significant related to quality of life. The relationship with quality of life was statistically significant when self-rated pain instruments or multi-component observation were used.

CONCLUSIONS

The study shows that it is difficult to estimate pain in residents living at nursing homes and that it continues to be a challenge to solve. Self-rated pain should be used primarily to assess pain, and a multi-component observation scale for pain should be used when residents are cognitively impaired. Both self-rated pain and multi-component observation also support the well-known link between pain and quality of life. Single-item proxy assessments should only be used in exceptional cases.

The effect of PARO robotic seals for hospitalized patients with dementia: A feasibility study

Robotic seals have been studied in long-term care settings; though, no studies of patients with dementia in the acute care setting have been reported. The purpose of this study was to evaluate the feasibility of PARO interventions for hospitalized patients with dementia, determine physiological effects and describe social-affective interactions. Using a prospective descriptive design with pre-post PARO intervention physiological measurements, we studied 55 participants who received up to five 15-min PARO interventions. The PARO was favorably accepted for 212 (95%) of the 223 PARO interventions. Differences in pre- and post-physiological measures for mean arterial pressure, pulse, respiration, oxygenation, stress, and pain levels were evaluated using Wilcoxon Signed Rank test with statistically significant pre and post differences (p=<0.05); however, the differences were not clinically significant. Participants (95%) demonstrated beneficial PARO interactions with the most frequent interactions being speaking and petting. The PARO shows promise for enhancing social and affective responses for hospitalized patients with dementia.

Pain in Older Adults With Dementia: A Survey in Spain

The risk of suffering pain increases significantly throughout life, reaching the highest levels in its latest years. Prevalence of pain in nursing homes is estimated to range from 40 to 80% of residents, most of them old adults affected with dementia. It is already known that pain is under-diagnosed and under-treated in patients with severe cognitive impairment and poor/absent verbal communication, resulting in a serious impact on their quality of life, psychosocial, and physical functioning. Under-treated pain is commonly the cause of behavioral symptoms, which can lead to misuse of antipsychotic treatments. Here, we present two Regional and National Surveys in Spain (2015–2017) on the current practices, use of observational tools for pain assessment, guidelines, and policies. Results, discussed as compared to the survey across central/north Europe, confirm the professional concerns on pain in severe dementia, due to poor standardization and lack of guidelines/recommendations. In Spain, observational tools are scarcely used because of their difficulty and low reliability in severe dementia, since the poor/absent verbal communication and comprehension are considered limiting factors. Behavioral observation tools should be used while attending the patients, in a situation including rest and movement, should be short (3–5 min) and scored using a numeric scale. Among the pain items to score, “Facial expression” and “Verbalization” were considered essential and very useful, respectively. This was in contrast to “Body movements” and “Vocalizations,” respectively, according to the survey in central/north Europe. Scarce time availability for pain assessment and monitoring, together with low feasible and time-consuming tools, can make pain assessment a challenge. The presence of confounding factors, the low awareness and poor knowledge/education of specific tools for this population are worrisome. These complaints draw future directions to improve pain assessment. More time available, awareness, and involvement of the teams would also benefit pain assessment and management in cognitive impairment. The experiences and opinions recorded in these surveys in Spain and other E.U. countries were considered sources of knowledge for designing the “PAIC-15 scale,” a new internationally agreed-on meta-tool for Pain Assessment in Impaired Cognition and the “Observational pain assessment” in older persons with dementia.

Mealtime caregiving knowledge, attitudes, and behaviors for persons living with dementia: A systematic review of psychometric properties of instruments

BACKGROUND

Using valid instruments to assess caregiving knowledge, attitudes, skills, and behaviors in mealtime care for people living with dementia is critical to evaluate the process and effects of mealtime assistance interventions. Yet, the quantity and psychometric quality of such instruments are unknown.

OBJECTIVES

This systematic review described and evaluated psychometric properties of instruments that were developed and used to assess mealtime caregiving knowledge, attitudes, skills, and behaviors for people with dementia.

METHODS

We searched Pubmed, CINAHL, AgeLine, PsychINFO, and Cochrane Library for records published between January 1st, 1980 and June 31st, 2019, with follow-up searches by December 20th, 2019. Records were eligible if they included any instrument developed, tested, and/or used to measure the concepts of interest, including mealtime caregiving knowledge, attitudes, skills, and/or behaviors. After eligible records were identified, instruments that were reported in the eligible records were identified and extracted. Instruments were eligible if they were originally developed to measure the concepts of interest or developed in non-mealtime activities and later used or tested to measure the concepts of interest. From eligible records, eight characteristics of eligible instruments were extracted: (1) development process, (2) the concept/construct the instrument operationalizes, (3) sample and setting the instrument was used/tested in, (4) administration method, (5) description of items, (6) scoring format/interpretation, (7) reliability, and (8) validity. The psychometric quality of eligible instruments was evaluated using a newly developed psychometric quality assessment tool.

RESULTS

A total of 9438 records were retrieved and 19 eligible instruments were identified. Ten instruments assessed mealtime caregiving skills or behaviors; 5 assessed attitudes, intention, self-efficacy, empathy; and 4 assessed knowledge. All instruments were scored as having low psychometric quality, except for Mealtime Engagement Scale with moderate psychometric quality in assessing mealtime engagement toward people with dementia. Reasons for low psychometric quality included limited psychometric testing, inadequate estimates of psychometric properties, and use of small sample size.

CONCLUSIONS

While all instruments warrant further testing, Mealtime Engagement Scale demonstrated moderate psychometric quality with preliminary evidence of reliability and validity to assess mealtime engagement toward people with dementia. Future testing of Mealtime Engagement Scale is needed in larger diverse samples in different care settings to accumulate psychometric evidence and expand the use.

Provincial legislative and regulatory standards for pain assessment and management in long-term care homes: a scoping review and in-depth case analysis

BACKGROUND

Among Canadian residents living in long-term care (LTC) facilities, and especially among those with limited ability to communicate due to dementia, pain remains underassessed and undermanaged. Although evidence-based clinical guidelines for the assessment and management of pain exist, these clinical guidelines are not widely implemented in LTC facilities. A relatively unexplored avenue for change is the influence that statutes and regulations could exert on pain practices within LTC. This review is therefore aimed at identifying the current landscape of policy levers used across Canada to assess and manage pain among LTC residents and to evaluate the extent to which they are concordant with evidence-based clinical guidelines proposed by an international consensus group consisting of both geriatric pain and public policy experts.

METHODS

Using scoping review methodology, a search for peer-reviewed journal articles and government documents pertaining to pain in Canadian LTC facilities was carried out. This scoping review was complemented by an in-depth case analysis of Alberta, Saskatchewan, and Ontario statutes and regulations.

RESULTS

Across provinces, pain was highly prevalent and was associated with adverse consequences among LTC residents. The considerable benefits of using a standardized pain assessment protocol, along with the barriers in implementing such a protocol, were identified. For most provinces, pain assessment and management in LTC residents was not specifically addressed in their statutes or regulations. In Alberta, Saskatchewan, and Ontario, regulations mandate the use of the interRAI suite of assessment tools for the assessment and reporting of pain.

CONCLUSION

The prevalence of pain and the benefits of implementing standardized pain assessment protocols has been reported in the research literature. Despite occasional references to pain, however, existing regulations do not recommend assessments of pain at the frequency specified by experts. Insufficient direction on the use of specialized pain assessment tools (especially in the case of those with limited ability to communicate) that minimize reliance on subjective judgements was also identified in current regulations. Existing policies therefore fail to adequately address the underassessment and undermanagement of pain in older adults residing in LTC facilities in ways that are aligned with expert consensus.

How do patients with Alzheimer's disease imagine their pain?

INTRODUCTION

Pain is underdiagnosed and undertreated in patients with Alzheimer's disease (AD). Pain management is of major importance in this population to limit behavioural and functional consequences. Our study aimed to assess the capacity of AD patients to represent pain using a questionnaire exploring daily painful situations and to determine the most appropriate pain scale assessment.

METHODS

Twenty-eight patients with mild AD, 21 with moderate AD and 28 matched controls underwent the Situation Pain Questionnaire (SP-Q) and assessed imaginary pain with four pain scales. Two scores were compared between the three groups: the P(A) discrimination score and the response bias β score. P(A) reflects the degree of discrimination between high-pain and low-pain events, whereas the β score means the degree to which situations are considered as painful.

RESULTS

Our results showed that AD patients hardly discriminated the high- from low-pain events. Compared to controls, the mean P(A) score was significantly lower for Mild AD (p < 0.03) and Moderate AD (p < 0.004). In addition, the β score indicated that the response bias is higher for AD patients (p < 0.01) in that they overestimated the level of pain.

CONCLUSION

The present results suggest that patients with Mild and Moderate AD are able to recognize and assess an imagined painful situation even though their pain tolerance is lower than that of controls. The pain scales used should be chosen according to the cognitive, sensorial and personal profiles of the patients.

SIGNIFICANCE

The present research is significant because it examines how patients with Alzheimer's disease understand and assess painful situations. Cognitive impairments can modify this ability. Pain is a sensory and subjective experience and to define its feeling can help us in our clinical practice.

Prevalence of Pain on Admission by Level of Cognitive Impairment in Nursing Homes

PURPOSE

To provide contemporary estimates of pain by level of cognitive impairment among US nursing home residents without cancer.

METHODS

Newly admitted US nursing home residents without cancer assessed with the Minimum Data Set 3.0 at admission (2010-2016) were eligible (n=8,613,080). The Cognitive Function Scale was used to categorize level of cognitive impairment. Self-report or staff-assessed pain was used based on a 5-day look-back period. Estimates of adjusted prevalence ratios (aPR) were derived from modified Poisson models.

RESULTS

Documented prevalence of pain decreased with increased levels of cognitive impairment in those who self-reported pain (68.9% no/mild, 32.9% severe) and those with staff-assessed pain (50.6% no/mild, 37.2% severe staff-assessed pain). Relative to residents with no/mild cognitive impairment, pharmacologic pain management was less prevalent in those with severe cognitive impairment (self-reported: 51.3% severe vs 76.9% in those with no/mild; staff assessed: 52.0% severe vs 67.7% no/mild).

CONCLUSION

Pain was less frequently documented in those with severe cognitive impairment relative to those with no/mild impairments. Failure to identify pain may result in untreated or undertreated pain. Interventions to improve evaluation of pain in nursing home residents with cognitive impairment are needed.

A systematic and psychometric review of tests measuring nurses' wound care knowledge

Wound care is an important realm of nurses' clinical responsibilities, and a broad knowledge and range of skills are needed to perform efficient and safe patient care. Nurses' knowledge on this matter can be measured using knowledge tests. This study aims to identify, define, and analyse the knowledge tests developed for the measurement of nurses' wound care knowledge, and to evaluate the psychometric properties of the tests. This study was a systematic literature review. A total of 52 studies and 18 instruments were found. Of the 18 instruments, only 5 had been used more than once and were successful in a psychometric evaluation. These five instruments were analysed on the basis of their psychometric properties by using Zwakhalen et al.'s (2006) psychometric testing framework. According to the analysis, the Pressure Ulcer Knowledge Test (PUKT) and the Pressure Ulcer Knowledge Assessment Tool (PUKAT) were the most valid and reliable instruments for measuring nurses' wound care knowledge. Most of the instruments identified and analysed focused on pressure ulcers, indicating that future instruments could focus more on other types of wounds or on wound care in general in order to receive a broader understanding of nurses' wound care knowledge.

Musculoskeletal Pain in Older Adults: A Clinical Review

Persistent pain in older adults is a widely prevalent and disabling condition that is the manifestation of multiple contributing physical, mental, social, and age-related factors. To effectively treat pain, the clinician must assess and address contributing factors using a comprehensive approach that includes pharmacologic and nonpharmacologic therapies within the context of a strong therapeutic relationship among the patient, caregivers, and a multidisciplinary team. This article reviews the current understanding of persistent pain in older adults and suggests a general approach to its assessment and management, followed by specific considerations for musculoskeletal pain conditions commonly seen in older adults.

Supporting good quality, community-based end-of-life care for people living with dementia: the SEED research programme including feasibility RCT

Background

In the UK, most people with dementia die in the community and they often receive poorer end-of-life care than people with cancer.

Objective

The overall aim of this programme was to support professionals to deliver good-quality, community-based care towards, and at, the end of life for people living with dementia and their families.

Design

The Supporting Excellence in End-of-life care in Dementia (SEED) programme comprised six interlinked workstreams. Workstream 1 examined existing guidance and outcome measures using systematic reviews, identified good practice through a national e-survey and explored outcomes of end-of-life care valued by people with dementia and family carers (n = 57) using a Q-sort study. Workstream 2 explored good-quality end-of-life care in dementia from the perspectives of a range of stakeholders using qualitative methods (119 interviews, 12 focus groups and 256 observation hours). Using data from workstreams 1 and 2, workstream 3 used co-design methods with key stakeholders to develop the SEED intervention. Worksteam 4 was a pilot study of the SEED intervention with an embedded process evaluation. Using a cluster design, we assessed the feasibility and acceptability of recruitment and retention, outcome measures and our intervention. Four general practices were recruited in North East England: two were allocated to the intervention and two provided usual care. Patient recruitment was via general practitioner dementia registers. Outcome data were collected at baseline, 4, 8 and 12 months. Workstream 5 involved economic modelling studies that assessed the potential value of the SEED intervention using a contingent valuation survey of the general public (n = 1002). These data informed an economic decision model to explore how the SEED intervention might influence care. Results of the model were presented in terms of the costs and consequences (e.g. hospitalisations) and, using the contingent valuation data, a cost–benefit analysis. Workstream 6 examined commissioning of end-of-life care in dementia through a narrative review of policy and practice literature, combined with indepth interviews with a national sample of service commissioners (n = 20).

Setting

The workstream 1 survey and workstream 2 included services throughout England. The workstream 1 Q-sort study and workstream 4 pilot trial took place in North East England. For workstream 4, four general practices were recruited; two received the intervention and two provided usual care.

Results

Currently, dementia care and end-of-life care are commissioned separately, with commissioners receiving little formal guidance and training. Examples of good practice rely on non-recurrent funding and leadership from an interested clinician. Seven key components are required for good end-of-life care in dementia: timely planning discussions, recognising end of life and providing supportive care, co-ordinating care, effective working with primary care, managing hospitalisation, continuing care after death, and valuing staff and ongoing learning. Using co-design methods and the theory of change, the seven components were operationalised as a primary care-based, dementia nurse specialist intervention, with a care resource kit to help the dementia nurse specialist improve the knowledge of family and professional carers. The SEED intervention proved feasible and acceptable to all stakeholders, and being located in the general practice was considered beneficial. None of the outcome measures was suitable as the primary outcome for a future trial. The contingent valuation showed that the SEED intervention was valued, with a wider package of care valued more than selected features in isolation. The SEED intervention is unlikely to reduce costs, but this may be offset by the value placed on the SEED intervention by the general public.

Limitations

The biggest challenge to the successful delivery and completion of this research programme was translating the ‘theoretical’ complex intervention into practice in an ever-changing policy and service landscape at national and local levels. A major limitation for a future trial is the lack of a valid and relevant primary outcome measure to evaluate the effectiveness of a complex intervention that influences outcomes for both individuals and systems.

Conclusions

Although the dementia nurse specialist intervention was acceptable, feasible and integrated well with existing care, it is unlikely to reduce costs of care; however, it was highly valued by all stakeholders (professionals, people with dementia and their families) and has the potential to influence outcomes at both an individual and a systems level.

Future work

There is no plan to progress to a full randomised controlled trial of the SEED intervention in its current form. In view of new National Institute for Health and Care Excellence dementia guidance, which now recommends a care co-ordinator for all people with dementia, the feasibility of providing the SEED intervention throughout the illness trajectory should be explored. Appropriate outcome measures to evaluate the effectiveness of such a complex intervention are needed urgently.

Trial registration

Current Controlled Trials ISRCTN21390601.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research, Vol. 8, No. 8. See the NIHR Journals Library website for further project information.

Reliability, validity, and responsiveness of multidimensional pain assessment tools used in postoperative adult patients: a systematic review of measurement properties

OBJECTIVE

The objective of this systematic review was to synthesize the best available evidence relating to the measurement properties of the multidimensional pain assessment tools used to assess postoperative pain in adults.

INTRODUCTION

Pain is a common and poorly managed occurrence in patients during the postoperative period. Currently, postoperative pain is usually evaluated with assessment tools that measure one dimension of pain, namely pain intensity, resulting in inadequate management of postoperative pain. It is important to understand the complex nature of pain by considering all dimensions for optimal postoperative pain management. Systematic, robust evidence is lacking regarding the most psychometrically reliable and valid multidimensional pain assessment tool for adult postoperative patients.

INCLUSION CRITERIA

This systematic review considered all study types for inclusion. Studies were considered if they assessed the measurement properties of a multidimensional pain assessment tool in adult postoperative patients within two weeks post-surgery. The outcomes included measurement of at least one of the psychometric properties, including reliability, validity, and responsiveness.

METHODS

A three-step search strategy was undertaken, including a search of the MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL databases performed in October 2019. We also searched Dissertation Abstracts International, ProQuest Dissertations and Theses, MedNar, and ClinicalTrials.gov to identify unpublished studies. The title and abstracts of the studies were reviewed by two independent reviewers against the inclusion/exclusion criteria. The methodological quality of the potential studies was assessed independently by three reviewers using the COSMIN checklist.

RESULTS

Seventeen studies involving five multidimensional postoperative pain assessment tools were included in the review: American Pain Society Pain Outcomes Questionnaire-Revised; Brief Pain Inventory; Houston Pain Outcome Instrument; McGill Pain Questionnaire; and the Quality Improvement in Postoperative Pain Management Postoperative Pain Questionnaire. The two most commonly used tools were the Brief Pain Inventory and the American Pain Society Pain Outcomes Questionnaire-Revised, which were assessed in six studies each. The included studies mainly reported internal consistency reliability, with four of the five identified tools demonstrating high Cronbach's alpha values ranging from 0.72 to 0.92. However, the Houston Pain Outcome Instrument demonstrated mixed findings, with eight of the nine subscales having moderate to high reliability while the expectations about pain subscale had poor reliability (α=0.003).

CONCLUSIONS

This review provides much needed information about the current tools used in many clinical, educational, and research settings. Of the five tools included in this review, the Brief Pain Inventory demonstrated strong evidence of psychometric validity and is recommended for use in assessing postoperative pain. Further psychometric validation of multidimensional postoperative pain assessment tools with emphasis on responsiveness and measurement error is required in order to accurately assess the minimal clinically important difference in postoperative pain outcomes.

Do you observe what I perceive? The relationship between two perspectives on the ability of people with cognitive impairments to use everyday technology

Objectives: Everyday technologies (ETs) can be challenging to use, particularly for older adults with cognitive impairments. This study evaluated the relationship between the self-perceived ability to use ET and observable performance of self-chosen and familiar, but challenging ETs in people with mild cognitive impairment (MCI) or dementia.Method: A self-perceived report, the Everyday Technology Use Questionnaire (S-ETUQ), and a structured observational tool, the Management of Everyday Technology Assessment (META), assessing the perceived and observed ability to use ET, were used in 41 people with MCI and 38 people with dementia. Correlations were investigated with non-parametric statistical tests.Results: In the dementia group, self-perceived report and observational scores correlated on a significant medium level (R_s=0.44, p = 0.006). In the MCI group, no significant correlation was found.Conclusion: The findings of this study suggest the ability of older adults with cognitive impairments to use ETs can be depicted with self-perceived reports as well as with observations. However, the combination of both approaches is recommended to get a comprehensive picture. While the S-ETUQ provides a broad picture of the use, presence and relevance of technologies in an individual's life, the META describes a specific human-technology interaction in detail. Furthermore, the results suggest people with early dementia retain the ability and insight to accurately reflect on their own ability to use ET, emphasizing the need to include their experiences in research and clinical work.

Patient safety incidents involving transdermal opioids: data from the Danish Patient Safety Database

Background Transdermal opioids are widely used among elderly adults with chronic pain. However, transdermal patches may be involved in a significant proportion of opioid-related patient safety incidents, as the application process includes several subprocesses, each associated with an individual risk of error. Objective The aim was to obtain specific knowledge on patient safety incidents related to transdermal opioid treatment within both the primary care sector and the hospital sector in Denmark. Setting The study is descriptive with data provided by the Danish Patient Safety Database. Methods We manually retrieved all patient safety incidents concerning transdermal opioids reported for 2018 from (1) the hospital sector and (2) the primary care sector. Study data were collected and managed using REDCap electronic data capture tools. Main outcome measure The available information for each incident was sorted into the following categories: location, medication process, type of problem, outcome at time of reporting, and outcome classification. Results A total of 866 patient safety incidents involving transdermal opioids were reported to the Danish Patient Safety Database in 2018. No fatal incidents were present in the database. In 386 cases, the incidents were reported as harmful, and these 386 cases were analysed. Most reports came from the primary care sector (nursing home, home care or social housing). The majority of incidents were related to the administration of the patch in the medication process, and the most prevalent problem was the omission of doses. Conclusion This study has demonstrated that the administration of transdermal opioids is challenging and may cause harm, particularly in the primary care sector. To improve patient safety, optimized systems, including guidelines on drug management and the continuing education of healthcare personnel in transdermal opioid management, are necessary. These guidelines should preferably incorporate reminders and checklists, since the omission of doses was the most reported problem.

Validation of Pain Assessment Checklist for Seniors with Limited Ability to Communicate-II (PACSLAC-II) in Iranian older adults with dementia living in nursing homes

BACKGROUND

Some dementia patients can self-report pain although the reports are not valid in severe dementia. Observational scales have been developed for pain assessment in these patients. This study aimed to assess the psychometric properties of the Persian version of Pain Assessment Checklist for Seniors with Limited Ability to Communicate-II (PACSLAC-II).

METHODS

This validation study was conducted on 138 older adults with dementia suffering from chronic pain who lived in nursing homes. The PACSLAC-II Persian version was applied through observations during activity and rest. Reliability of the PACSLAC-II was evaluated by Cronbach's alpha and intra-class correlation coefficients. Construct validity was determined by confirmatory factor analysis, divergent and convergent validity. The Spearman's rank correlation between PACSLAC-II scores and Faces Pain Scale was calculated for concurrent validity. Known-group validity during activity and rest was calculated by Wilcoxon signed ranks test.

RESULTS

Cronbach's alpha coefficient for facial expression (0.82), verbalisation (0.72), and body movement (0.84) subscales indicated good internal consistency. The intra-class correlation coefficients between two raters was 0.76 and in three times evaluation, the value was 0.76. Convergent validity with Iranian Brief Pain Inventory and divergent validity with 15-item Geriatric Depression Scale confirmed the construct validity of PACSLAC-II. Three factors structure of PACSLAC-II was approved, and most of the variance was explained by facial expressions. The PACSLAC-II can discriminate between pain and non-pain events and has a moderate correlation with Faces Pain Scale (r = 0.33).

CONCLUSIONS

PACSLAC-II Persian version is a valid and reliable scale for pain assessment in older adults with dementia.

Developing a Pain Intensity Measure for Persons with Dementia: Initial Construction and Testing

OBJECTIVE

The goal of this study was to identify a limited set of pain indicators that were most predicive of physical pain. We began with 140 items culled from existing pain observation tools and used a modified Delphi approach followed by statistical analyses to reduce the item pool.

METHODS

Through the Delphi Method, we created a candidate item set of behavioral indicators. Next, trained staff observed nursing home residents and rated the items on scales of behavior intensity and frequency. We evaluated associations among the items and expert clinicians' assessment of pain intensity.

SETTING

Four government-owned nursing homes and 12 community nursing homes in Alabama and Southeastern Pennsylvania.

PARTICIPANTS

Ninety-five residents (mean age = 84.9 years) with moderate to severe cognitive impairment.

RESULTS

Using the least absolute shrinkage and selection operator model, we identified seven items that best predicted clinicians' evaluations of pain intensity. These items were rigid/stiff body or body parts, bracing, complaining, expressive eyes, grimacing, frowning, and sighing. We also found that a model based on ratings of frequency of behaviors did not have better predictive ability than a model based on ratings of intensity of behaviors.

CONCLUSIONS

We used two complementary approaches-expert opinion and statistical analysis-to reduce a large pool of behavioral indicators to a parsimonious set of items to predict pain intensity in persons with dementia. Future studies are needed to examine the psychometric properties of this scale, which is called the Pain Intensity Measure for Persons with Dementia.

Psychometric Evaluation of a Pain Intensity Measure for Persons with Dementia

OBJECTIVE

The goal of this study was to conduct initial psychometric analyses of a seven-item pain intensity measure for persons with dementia (PIMD) that was developed using items from existing pain observational measures.

DESIGN AND METHODS

We evaluated validity by examining associations with an expert clinician's pain intensity rating (ECPIR) and an established pain observation tool (Mobilization Observation Behaviour Intensity Dementia [MOBID]). We also examined correlations between the PIMD and known correlates of pain: depression, sleep disturbances, agitation, painful diagnoses, and caregiver pain reports. We examined the differences between PIMD scores for "at rest" and "during movement" observations. We assessed reliability by calculating Cronbach's alpha and estimating inter-rater reliability using intraclass correlations (ICCs). Finally, we examined whether six additional "recent changes in behavior" items improved the PIMD's ability to predict expert clinicians' pain ratings.

SETTING

Sixteen nursing homes located in Alabama, Georgia, Pennsylvania, and New Jersey.

PARTICIPANTS

One hundred ninety residents with moderate to severe cognitive impairment, mean age of 84 years, 49.5% female, and 70% white.

RESULTS

PIMD during movement scores were highly correlated with the ECPIR and overall MOBID scores. As expected, there were large differences between at rest and during movement PIMD scores. Associations of PIMD with known correlates of pain were generally low and statistically nonsignificant. Internal consistency was supported with a Cronbach alpha of 0.72 and an inter-rater ICC of 0.82 for during movement PIMD scores.

CONCLUSIONS

Initial evaluation of the PIMD supports its validity and reliability. Additional testing is needed to evaluate the tool's sensitivity to changes in pain intensity.

Behavioral Pain Assessment Implementation in Long-Term Care Using a Tablet App: Case Series and Quasi-Experimental Design

BACKGROUND

Pain is often underassessed and undertreated among long-term care (LTC) residents living with dementia. When used regularly, the Pain Assessment Checklist for Seniors With Limited Ability to Communicate (PACSLAC) scales have been shown to have beneficial effects on pain assessment and management practices and stress and burnout levels in frontline staff in LTC facilities. Such scales, however, are not utilized as often as recommended, which is likely to be related to additional record-keeping and tracking over time involved with their paper-and-pencil administration.

OBJECTIVE

Using implementation science principles, we assessed the introduction of the PACSLAC-II scale by comparing two methods of administration-a newly developed tablet app version and the original paper-and-pencil version-with respect to the frequency of pain assessment and facility staff feedback.

METHODS

Using a case series approach, we tracked pain-related quality indicators at baseline, implementation, and follow-up periods. A quasi-experimental design was used to evaluate the effect of the method of administration (ie, paper-and-pencil only [n=18], tablet only [n=12], paper-and-pencil followed by tablet app [n=31], and tablet app followed by paper-and-pencil [n=31]) on pain assessment frequency and frontline staff stress and burnout levels. Finally, semistructured interviews were conducted with frontline staff to obtain perspectives on each method of administration.

RESULTS

The implementation effort resulted in a great increase in pain assessment frequency across 7 independent LTC units, although these increases were not maintained during the follow-up period. Frontline staff reported lower levels of workload in the paper-and-pencil followed by tablet app condition than those in the paper-and-pencil only (P<.001) and tablet app followed by paper-and-pencil (P<.001) conditions. Frontline staff also reported lower levels of workload in the tablet-only condition than those in the paper-and-pencil only condition (P=.05). Similarly, lower levels of emotional exhaustion were reported by frontline staff in the paper-and-pencil followed by tablet app condition than those in the paper-and-pencil only (P=.002) and tablet app followed by paper-and-pencil (P=.002) conditions. Finally, frontline staff reported higher levels of depersonalization in the paper-and-pencil only condition than those in the tablet app only (P=.008), paper-and-pencil followed by tablet app (P<.001), and tablet app followed by paper-and-pencil (P<.001) conditions. Furthermore, narrative data from individual interviews with frontline staff revealed a preference for the tablet app over the paper-and-pencil method of administration.

CONCLUSIONS

This study provides support for the use of either the tablet app or the paper-and-pencil version of the PACSLAC-II to improve pain-related quality indicators, but a reported preference for and lower levels of stress and burnout with the use of the tablet app method of administration suggests that the use of the tablet app may have more advantages compared with the paper-and-pencil method of administration.

Development of a Measure of Nociception for Patients With Severe Brain Injury

OBJECTIVES

Severe brain injury is often accompanied by painful comorbidities and by concurrent limitations in the ability to report pain. Assessment of nociception aids diagnosis and helps balance reduction in suffering with avoidance of sedating medications. Existing assessment methods confound patients' level of consciousness with the intensity of nociception, complicating pain assessment as consciousness evolves. We sought to develop a measure of nociception that is independent of the level of consciousness.

MATERIALS AND METHODS

We identified 15 behavioral and physiological items likely to be sensitive to nociception. We rated noncommunicative patients with traumatic brain injury in 4 different activities predicted to modulate nociception, on each of 2 days, one randomly chosen for acetaminophen administration. The level of consciousness and level of agitation were also measured.

RASCH ANALYSIS

Rasch analysis was used to assess item fit to an underlying dimension of nociception.

RESULTS

Five items that demonstrated poor fit to the dimension were removed. The 10 remaining items demonstrated acceptable fit. Scores were significantly influenced by activity and analgesic treatment and were largely independent of measures of consciousness and agitation. Accurate scores could be obtained in about 10 minutes and were robust to missing data.

DISCUSSION

The results provide evidence that the Brain Injury Nociception Assessment Measure (BINAM) is reliable and feasible to administer. It can assess the intensity of nociception largely independent of the level of consciousness. Further research is warranted on the impact of BINAM use on the care of patients with severe traumatic brain injury.