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Patrick KS, Gunstad J, Spitznagel MB. Pain in the Context of Virtual Neuropsychological Assessment of Older Adults. Arch Clin Neuropsychol 2024; 39:157-166. [PMID: 37644879 PMCID: PMC10879923 DOI: 10.1093/arclin/acad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE Pain and cognitive impairment are prevalent and often co-occur in older adults. Because pain may negatively affect cognitive test performance, identification of pain in the context of neuropsychological evaluation is important. However, pain detection based on self-report presents challenges, and pain is often under-detected in this population. Alternative methods (e.g., video-based automatic coding of facial biomarkers of pain) may facilitate pain identification and thus enhance interpretation of neuropsychological evaluation results. METHOD The current study examined pain in the context of virtual neuropsychological assessment in 111 community-dwelling older adults, first seeking to validate the use of software developed to automatically code biomarkers of pain. Measures of pain, including self-report of acute and chronic pain and automatic coding of pain, were compared while participants completed neuropsychological testing. RESULTS Self-reported pain was negatively associated with poorer performance on a measure of executive function (both acute and chronic pain) and a global cognitive screening measure (acute pain only). However, self-reported acute and chronic pain did not correlate significantly with most neuropsychological tests. Automatic coding of pain did not predict self-report of pain or performance on neuropsychological tests beyond the influence of demographic factors and psychological symptoms. CONCLUSIONS Though results were largely not significant, correlations warrant further exploration of the influence of pain on neuropsychological test performance in this context to ensure that pain does not influence test performance in individuals with higher levels of pain and in other samples.
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Affiliation(s)
- Karlee S Patrick
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - John Gunstad
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - Mary B Spitznagel
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
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2
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Sabater-Gárriz Á, Molina-Mula J, Montoya P, Riquelme I. Pain assessment tools in adults with communication disorders: systematic review and meta-analysis. BMC Neurol 2024; 24:66. [PMID: 38368314 PMCID: PMC10873938 DOI: 10.1186/s12883-024-03539-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/15/2024] [Indexed: 02/19/2024] Open
Abstract
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 .
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Affiliation(s)
- Álvaro Sabater-Gárriz
- Balearic ASPACE Foundation, Marratxí, Spain
- Department of Nursing and Physiotherapy, University of Balearic Islands, Palma, 07122, Spain
- Research Institute on Health Sciences (IUNICS), University of the Balearic Islands, Palma, 07122, Spain
- Health Research Institute of the Balearic Islands (IdISBa), Palma, 07010, Spain
| | - Jesús Molina-Mula
- Department of Nursing and Physiotherapy, University of Balearic Islands, Palma, 07122, Spain
- Health Research Institute of the Balearic Islands (IdISBa), Palma, 07010, Spain
| | - Pedro Montoya
- Research Institute on Health Sciences (IUNICS), University of the Balearic Islands, Palma, 07122, Spain
- Health Research Institute of the Balearic Islands (IdISBa), Palma, 07010, Spain
| | - Inmaculada Riquelme
- Department of Nursing and Physiotherapy, University of Balearic Islands, Palma, 07122, Spain.
- Research Institute on Health Sciences (IUNICS), University of the Balearic Islands, Palma, 07122, Spain.
- Health Research Institute of the Balearic Islands (IdISBa), Palma, 07010, Spain.
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3
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Kodagoda Gamage MW, Todorovic M, Moyle W, Pu L. Cultural Influence on Nurses' Pain Observations Related to Dementia: An Integrative Review. Pain Manag Nurs 2023:S1524-9042(23)00028-0. [PMID: 36907689 DOI: 10.1016/j.pmn.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 01/17/2023] [Accepted: 01/29/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Nurses play a pivotal role in pain observation in people living with dementia. However, currently, there is little understanding of the influence culture may have on the way nurses observe pain experienced by people living with dementia. AIM This review explores the influence of culture on nurses... pain observations experienced by people living with dementia. SETTINGS Studies were included regardless of the setting (e.g., acute medical care, long-term care, community). DESIGN An integrative review. PARTICIPANTS/SUBJECTS PubMed, Medline, Psychological Information Database, Cochrane Library, Scopus, Web of Science, Cumulative Index of Nursing and Allied Health Literature, and ProQuest were included in the search. METHODS Electronic databases were searched using synonyms for "dementia," "nurse," "culture," and "pain observation." The review included ten primary research papers following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS Nurses reported that pain observation in people living with dementia is challenging. Four themes were identified by data synthesis: (1) using behaviors for pain observation; (2) information from carers for pain observation; (3) pain assessment tools for pain observation; and (4) role of knowledge, experience, and intuition in pain observation. CONCLUSIONS There is a limited understanding of the role of culture on nurses' pain observations. However, nurses take a multifaceted approach to observing pain using behaviors, information from carers, pain assessment tools, and their knowledge, experience, and intuition.
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Affiliation(s)
- Madushika Wishvanie Kodagoda Gamage
- Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia; School of Nursing and Midwifery, Nathan, Griffith University, Brisbane, Queensland, Australia; Department of Nursing, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka.
| | - Michael Todorovic
- Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia; School of Nursing and Midwifery, Nathan, Griffith University, Brisbane, Queensland, Australia
| | - Wendy Moyle
- Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia; School of Nursing and Midwifery, Nathan, Griffith University, Brisbane, Queensland, Australia
| | - Lihui Pu
- Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia; School of Nursing and Midwifery, Nathan, Griffith University, Brisbane, Queensland, Australia
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4
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Kutafina E, Becker S, Namer B. Measuring pain and nociception: Through the glasses of a computational scientist. Transdisciplinary overview of methods. FRONTIERS IN NETWORK PHYSIOLOGY 2023; 3:1099282. [PMID: 36926544 PMCID: PMC10013045 DOI: 10.3389/fnetp.2023.1099282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/04/2023] [Indexed: 02/12/2023]
Abstract
In a healthy state, pain plays an important role in natural biofeedback loops and helps to detect and prevent potentially harmful stimuli and situations. However, pain can become chronic and as such a pathological condition, losing its informative and adaptive function. Efficient pain treatment remains a largely unmet clinical need. One promising route to improve the characterization of pain, and with that the potential for more effective pain therapies, is the integration of different data modalities through cutting edge computational methods. Using these methods, multiscale, complex, and network models of pain signaling can be created and utilized for the benefit of patients. Such models require collaborative work of experts from different research domains such as medicine, biology, physiology, psychology as well as mathematics and data science. Efficient work of collaborative teams requires developing of a common language and common level of understanding as a prerequisite. One of ways to meet this need is to provide easy to comprehend overviews of certain topics within the pain research domain. Here, we propose such an overview on the topic of pain assessment in humans for computational researchers. Quantifications related to pain are necessary for building computational models. However, as defined by the International Association of the Study of Pain (IASP), pain is a sensory and emotional experience and thus, it cannot be measured and quantified objectively. This results in a need for clear distinctions between nociception, pain and correlates of pain. Therefore, here we review methods to assess pain as a percept and nociception as a biological basis for this percept in humans, with the goal of creating a roadmap of modelling options.
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Affiliation(s)
- Ekaterina Kutafina
- Institute of Medical Informatics, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Faculty of Applied Mathematics, AGH University of Science and Technology, Krakow, Poland
| | - Susanne Becker
- Clinical Psychology, Department of Experimental Psychology, Heinrich Heine University, Düsseldorf, Germany
- Integrative Spinal Research, Department of Chiropractic Medicine, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Barbara Namer
- Junior Research Group Neuroscience, Interdisciplinary Center for Clinical Research Within the Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Institute of Physiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
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5
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Smith TO, Harvey K. Psychometric properties of pain measurements for people living with dementia: a COSMIN systematic review. Eur Geriatr Med 2022; 13:1029-1045. [PMID: 35622210 PMCID: PMC9553783 DOI: 10.1007/s41999-022-00655-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/28/2022] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Toby O Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, NDORMS, University of Oxford, Oxford, OX3 7LD, UK.
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK.
| | - Karmen Harvey
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK
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Observing Pain in Individuals with Cognitive Impairment: A Pilot Comparison Attempt across Countries and across Different Types of Cognitive Impairment. Brain Sci 2021; 11:brainsci11111455. [PMID: 34827454 PMCID: PMC8615509 DOI: 10.3390/brainsci11111455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/12/2021] [Accepted: 10/28/2021] [Indexed: 01/23/2023] Open
Abstract
Facial expression is a key aspect in observational scales developed to improve pain assessment in individuals with cognitive impairments. Although these scales are used internationally in individuals with different types of cognitive impairments, it is not known whether observing facial expressions of pain might differ between regions or between different types of cognitive impairments. In a pilot study, facial responses to standardized experimental pressure pain were assessed among individuals with different types of cognitive impairments (dementia, mild cognitive impairment, Huntington’s disease, and intellectual disability) from different countries (Denmark, Germany, Italy, Israel, and Spain) and were analyzed using facial descriptors from the PAIC scale (Pain Assessment in Impaired Cognition). We found high inter-rater reliability between observers from different countries. Moreover, facial responses to pain did not differ between individuals with dementia from different countries (Denmark, Germany, and Spain). However, the type of cognitive impairment had a significant impact; with individuals with intellectual disability (all being from Israel) showing the strongest facial responses. Our pilot data suggest that the country of origin does not strongly affect how pain is facially expressed or how facial responses are being scored. However, the type of cognitive impairment showed a clear effect in our pilot study, with elevated facial responses in individuals with intellectual disability.
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7
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Anderson AR, Hyden K, Failla MD, Carter MA. Policy Implications for Pain in Advanced Alzheimer's Disease. Pain Manag Nurs 2021; 22:3-7. [PMID: 32684495 PMCID: PMC7854970 DOI: 10.1016/j.pmn.2020.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/05/2020] [Accepted: 06/15/2020] [Indexed: 12/13/2022]
Abstract
Untreated pain in people with Alzheimer's disease continues to be a serious public health problem. Pain is a subjective and complex experience that becomes increasingly challenging to assess as cognition declines. Our understanding of pain processing is incomplete, particularly for special populations such as people living with Alzheimer's disease, and especially in the advanced stages of the disease. Pain-processing networks in the brain are altered in Alzheimer's disease, yet evidence suggests people living with Alzheimer's disease do not experience less pain. Rather, their pain is not adequately recognized or treated. Although scholarly publications provide important assistance, recent widespread reports and guidelines do not include sufficient guidance, especially as Alzheimer's disease progresses to the last stages. Additionally, current pain measurements may not accurately evaluate pain in this condition, and the existing definitions of pain are not adequate when considering the effects of Alzheimer's disease on pain-processing in the brain. There is a need for new, widespread policies, guidelines, and definitions to help clinicians adequately manage pain in people with Alzheimer's disease. These will need to hinge on continued research because it remains unclear how Alzheimer's disease impacts central pain processing, pain expression, and communication of pain. In the meantime, policies and guidelines need to highlight current best practices as well as the fact that pain continues in Alzheimer's disease.
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Affiliation(s)
| | - Karen Hyden
- University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Michelle D Failla
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael A Carter
- University of Tennessee Health Science Center College of Nursing, Memphis, Tennessee
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8
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Giménez-Llort L, Bernal ML, Docking R, Muntsant-Soria A, Torres-Lista V, Bulbena A, Schofield PA. Pain in Older Adults With Dementia: A Survey in Spain. Front Neurol 2020; 11:592366. [PMID: 33329344 PMCID: PMC7715009 DOI: 10.3389/fneur.2020.592366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/19/2020] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Lydia Giménez-Llort
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain.,Institut de Neurociències, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Maria Luisa Bernal
- Department of Pharmacology and Physiology, University of Zaragoza, Zaragoza, Spain.,Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | | | - Aida Muntsant-Soria
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain.,Institut de Neurociències, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Virginia Torres-Lista
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain.,Institut de Neurociències, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Antoni Bulbena
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Patricia A Schofield
- Abertay University, Dundee, United Kingdom.,Sheffield Hallam University, Sheffield, United Kingdom
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9
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Starr LT, Magan KC. Model of Empathic Pain Assessment and Treatment in Persons With Dementia. Res Gerontol Nurs 2020; 13:264-276. [PMID: 32286670 DOI: 10.3928/19404921-20200402-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/04/2020] [Indexed: 12/21/2022]
Abstract
The current article presents an evidence-based model for understanding clinical empathy's relationship with the assessment and treatment of pain in persons with advanced dementia. A literature review informed creation of an interdisciplinary conceptual framework of clinician empathy in pain assessment and treatment among persons with advanced dementia. Driven by observation of behaviors indicating pain in persons with dementia unable to self-report, the model represents the cognitive, affective, ethical, and behavioral components of clinical empathy involved in assessing and treating pain, relevant patient outcomes, and contextual factors influencing empathy and outcomes; and provides a framework for testing clinical empathy interventions to improve adverse outcomes in persons with advanced dementia. Understanding the relationship between clinician empathy and the assessment and treatment of pain in persons with advanced dementia may improve care quality and help reduce pain behaviors in this patient population. This model may be used to inform pain research in persons with dementia and develop clinical interventions and clinician education programs. [Research in Gerontological Nursing, 13(5), 264-276.].
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10
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[Pain and pain management in old age: special features and recommendations]. Z Gerontol Geriatr 2020; 54:507-512. [PMID: 32676737 DOI: 10.1007/s00391-020-01765-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/30/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Pain is highly prevalent in older persons and has a variety of causes. In geriatric patients, especially in patients with dementia, pain is often not sufficiently recognized and therefore frequently remains untreated. For the affected patient group this can have far-reaching consequences for their functional and cognitive abilities and may consequently lead to loss of autonomy. OBJECTIVE Existing deficits of pain assessment for geriatric patients are described, with a primary focus on those patients suffering from cognitive impairments and pain. In addition, the influence of multimorbidity on pain management in old age is considered in detail. METHODS The diagnostics and measurement of pain in older individuals are described based on recent literature and corresponding instruments used in the assessment of pain are outloned. The authors pay special attention to the possibilities of pain measurement in patients with higher grade cognitive impairments and non-communicative patients. CONCLUSION A standardized pain assessment should be an integral component in the care and treatment of geriatric patients and individuals suffering from dementia. Validated instruments for pain measurement exist for both groups and should be integrated into daily clinical practice.
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11
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Kappesser J, Voit S, Lautenbacher S, Hermann C. Pain assessment for cognitively impaired older adults: Do items of available observer tools reflect pain-specific responses? Eur J Pain 2020; 24:851-862. [PMID: 31981281 DOI: 10.1002/ejp.1536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/06/2020] [Accepted: 01/16/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND A number of observational tools are available to assess pain in cognitively impaired older adults, however, none of them can yet be regarded as a "gold standard". An international research initiative has created a meta-tool compiling the facial, vocalization and body movement items of the majority of available tools. Objective of this study was to investigate the pain specificity and the validity of these items. METHOD N = 34 older adults with or without cognitive impairment were videotaped in three different conditions (one reference, two painful conditions) in their nursing homes. They were further asked to self-report their pain in each condition. The occurrence of non-verbal behaviours was coded as present or absent using the items of the meta-tool. RESULTS The majority of non-verbal behaviours was not pain sensitive as they occurred less than three times across participants and conditions. Of the remaining items, two facial items ("pained expression" and "raising upper lip"), one vocalization item ("using pain-related words") and one body movement item ("guarding") were found to be pain specific and valid. One additional item, the vocalization item "gasping", was pain specific, but not associated with pain self-report, and three additional items, the facial items "frowning" and "narrowing eyes" and the vocalization item "mumbling" were correlated with pain self-report but did not help to separate pain from non-pain conditions. CONCLUSIONS Systematic evaluation of items of existing observational pain assessment tools under naturalistic conditions seems a promising approach in the process of further investigating and improving tools. SIGNIFICANCE Only few items stemming from observational pain assessment tools were found to be pain sensitive and specific as well as valid in this study. The investigation of existing tools not only on tool but additionally on item-level can provide helpful insights and thereby can help to improve the original tools and establish a gold standard for nonverbal pain assessment in older adults with cognitive impairments.
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Affiliation(s)
- Judith Kappesser
- Department of Clinical Psychology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Stefanie Voit
- Department of Clinical Psychology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Stefan Lautenbacher
- Department of Physiological Psychology, University of Bamberg, Bamberg, Germany
| | - Christiane Hermann
- Department of Clinical Psychology, Justus-Liebig-University Giessen, Giessen, Germany
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12
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Kunz M, de Waal MWM, Achterberg WP, Gimenez-Llort L, Lobbezoo F, Sampson EL, van Dalen-Kok AH, Defrin R, Invitto S, Konstantinovic L, Oosterman J, Petrini L, van der Steen JT, Strand LI, de Tommaso M, Zwakhalen S, Husebo BS, Lautenbacher S. The Pain Assessment in Impaired Cognition scale (PAIC15): A multidisciplinary and international approach to develop and test a meta-tool for pain assessment in impaired cognition, especially dementia. Eur J Pain 2019; 24:192-208. [PMID: 31487411 DOI: 10.1002/ejp.1477] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Over the last decades, a considerable number of observational scales have been developed to assess pain in persons with dementia. The time seems ripe now to build on the knowledge and expertize implemented in these scales to form an improved, "best-of" meta-tool. The EU-COST initiative "Pain in impaired cognition, especially dementia" aimed to do this by selecting items out of existing observational scales and critically re-assessing their suitability to detect pain in dementia. This paper reports on the final phase of this collaborative task. METHODS Items from existing observational pain scales were tested for "frequency of occurrence (item difficulty)," "reliability" and "validity." This psychometric testing was carried out in eight countries, in different healthcare settings, and included clinical as well as experimental pain conditions. RESULTS Across all studies, 587 persons with dementia, 27 individuals with intellectual disability, 12 Huntington's disease patients and 59 cognitively healthy controls were observed during rest and movement situations or while receiving experimental pressure pain, respectively. The psychometric outcomes for each item across the different studies were evaluated within an international and multidisciplinary team of experts and led a final selection of 15 items (5x facial expressions, 5x body movements, 5x vocalizations). CONCLUSIONS The final list of 15 observational items have demonstrated psychometric quality and clinical usefulness both in their former scales and in the present international evaluation; accordingly, they qualified twice to form a new internationally agreed-on meta-tool for Pain Assessment in Impaired Cognition, the PAIC-15 scale. SIGNIFICANCE Using a meta-tool approach by building on previous observational pain assessment scales and putting the items of these scales through rigorous empirical testing (using experimental as well as clinical pain studies in several European countries), we were able to identify the best items for pain assessment in individuals with impaired cognition. These selected items form the novel PAIC15 scale (pain assessment in impaired cognition, 15 items).
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Affiliation(s)
- Miriam Kunz
- Department of Medical Psychology and Sociology, University of Augsburg, Augsburg, Germany.,Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margot W M de Waal
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Lydia Gimenez-Llort
- Department of Psychiatry and Forensic Medicine, Institut de Neurociències, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Frank Lobbezoo
- Department of Orofacial Pain & Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands
| | - Elisabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Annelore H van Dalen-Kok
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Ruth Defrin
- Department of Physical Therapy, School of Health Professions, Sackler Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Sara Invitto
- Department of Biological and Environmental Science and Technologies, DiSTeBA, University of Salento, Lecce, Italy
| | - Ljubica Konstantinovic
- Faculty of Medicine, University of Belgrade, Clinic for Rehabilitation "Dr Miroslav Zotovic", Belgrade, Serbia
| | - Joukje Oosterman
- Radboud University Nijmegen, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Laura Petrini
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Liv-Inger Strand
- Department of Global Public Health and Primary Care, Physiotherapy Research Group, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Marina de Tommaso
- Applied neurophysiopathology and Pain Unit, Aldo Moro University, Bari, Italy
| | - Sandra Zwakhalen
- Care and Public Health Research Institute (CAPHRI), Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, Centre for Elderly and Nursing Home Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
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Abstract
Facial expressions of pain are not undefined grimaces, but they convey specific information about the internal state of the individual in pain. With this systematic review, we aim to answer the question of which facial movements are displayed most consistently during pain. We searched for studies that used the Facial Action Coding System to analyze facial activity during pain in adults, and that report on distinct facial responses (action units [AUs]). Twenty-seven studies using experimental pain and 10 clinical pain studies were included. We synthesized the data by taking into consideration (1) the criteria used to define whether an AU is pain-related; (2) types of pain; and (3) the cognitive status of the individuals. When AUs were selected as being pain-related based on a "pain > baseline" increase, a consistent subset of pain-related AUs emerged across studies: lowering the brows (AU4), cheek raise/lid tightening (AUs6_7), nose wrinkling/raising the upper lip (AUs9_10), and opening of the mouth (AUs25_26_27). This subset was found independently of the cognitive status of the individuals and was stable across clinical and experimental pain with only one variation, namely that eye closure (AU43) occurred more frequently during clinical pain. This subset of pain-related facial responses seems to encode the essential information about pain available in the face. However, given that these pain-related AUs are most often not displayed all at once, but are differently combined, health care professionals should use a more individualized approach, determining which pain-related facial responses an individual combines and aggregates to express pain, instead of erroneously searching for a uniform expression of pain.
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