The relative meaning of absolute numbers: the case of pain intensity scores as decision support systems for pain management of patients with dementia

Pain Management in Cognitively Impaired Older Adults

BACKGROUND

Pain identification and management in cognitively impaired older adults, especially those with major neurocognitive disorder, are challenging because of communication barriers and health care providers who are unaccustomed to the patient's baseline behavioral and psychological conditions.

MANAGEMENT CONSIDERATIONS

Appropriately distinguishing pain-associated behaviors separate from dementia, utilizing effective assessment tools, and administering proper interventions and medications to treat pain promptly for this population need to be considered.

CONCLUSIONS

Nurses play critical roles in implementing various evidence-based assessment tools to assess pain and choosing appropriate pain management interventions by training and supporting other nurses to use these assessment tools and develop their critical assessment skills to quickly identify pain and evaluate pain management interventions.

A narrative review of staff views about dementia care in hospital through the lens of a systems framework

Background

Significant numbers of people with dementia are admitted into acute settings. They are likely to face poor health outcomes during hospitalisation. There is the need to fully understand the care provided to people with dementia through novel methods such as a systems approach (i.e. human interactions, policy, environment and equipment).

Aim

The aim of this literature review is to explore hospital practitioners' views on dementia care and to analyse findings using a systems approach.

Methods

We conducted a narrative review of primary studies that examined dementia care in acute settings. We analysed a total of 33 papers using Thomas and Harden's thematic synthesis guidelines.

Results

Thirty-three papers met the inclusion criteria for the review. The findings were as follows: (1) staff-patient relationships (e.g. coping with difficult behaviour), (2) staff-family relationships (e.g. the benefits of involving families in patient care), (3) staff-staff relationships (e.g. building a robust multidisciplinary team), (4) staff-patient care decisions (e.g. decisions directly related to the patient), (5) the environment (e.g. difficulty in adjusting to the hospital environment), (6) policies (e.g. hospital bureaucratic processes) and (7) equipment (e.g. pain assessment tools).

Conclusion

The paper revealed multidimensional challenges in the provision of dementia care within hospitals. We conclude that training programmes, hospital policies and processes aimed at improving outcomes for patients with dementia should adopt a systems approach which focuses on the relational, environmental, procedural and instrumental aspects of the hospital system.

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

Background

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

Methods

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

Results

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

Conclusion

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

Exploring ways to enhance pain management for older people with dementia in acute care settings using a Participatory Action Research approach

BACKGROUND

Dementia is a progressive condition that leads to reduced cognition, deteriorating communication and is a risk factor for other acute and chronic health problems. The rise in the prevalence of dementia means untreated pain is becoming increasingly common with healthcare staff being challenged to provide optimal pain management. This negatively impacts the person living with dementia and their carers. There is minimal evidence that explores the pain management experience of patients as they move through acute care settings.

OBJECTIVE

To understand the complexities of managing the pain of older people with dementia as they progress through acute care settings, with the view of assisting staff to improve practice.

METHOD

A Participatory Action Research approach, guided by the Promoting Action Research in Health Services framework, was used. Three Action Cycles were completed comprising of an exploratory audit and two case studies (Action Cycle One), three focus groups with a total of 14 participants (Action Cycle Two) and the development and implementation of immediate and long-term actions (Action Cycle Three).

RESULTS

Thematic analysis identified four themes that affected pain management practices. These were not knowing the patient; balancing competing priorities; knowledge and understanding of pain and dementia and not assimilating available information.

CONCLUSION

Pain management practices for patient living with dementia, across acute care settings, was influenced by shared ways of thinking and working. Not knowing the patient, fragmentation of information and having insufficient knowledge of the subtleties of dementia led participants to deliver task-focused, target and policy-driven care that was not person-centred in its approach. Facilitated reflection enabled acute care teams to actively participate in identifying problems and finding solutions to enhance practice.

Insights to Identifying and Managing Pain in Persons With Dementia in Long-Term Care: A Mixed Methods Study Comparing the Abbey Pain Scale and Pain Assessment in Advanced Dementia Scale

Pain is usually identified by specific behaviors driven by the need for relief; however, persons with dementia present a unique challenge for nurses in assessing and managing pain. The aim of this mixed methods study was to explore the relationship between two observational pain scales, expressed need-driven behaviors, and likelihood of medication administration for persons with dementia. The qualitative strand examined nurses' perceptions regarding facilitators and barriers to pain scale use. Quantitative data analysis indicated the Abbey Pain Scale was significantly correlated with behaviors (r[26] = 0.41, p < 0.05) and approached significance with medication administration (r[26] = 0.35, p = 0.067). Qualitative analysis identified three core themes: (a) Challenges in Assessing Persons With Dementia for Pain; (b) Facilitators and Barriers to Pain Management; and (c) Difficulty Caring for Persons With Dementia. Clinical implications suggest the need for a systematic, consistent method of observing pain-related behaviors in persons with dementia. [Journal of Gerontological Nursing, 47(2), 21-30.].

Disjunction, tension and dissonance within nursing pain care provision for the older hospitalized person: A focused ethnographic insight

AIMS

This study presents an ethnographic insight into the older hospitalized persons' experiences on how nurses provide pain care provision. The older persons' perceptions of culturally mediated barriers and facilitators are presented.

DESIGN

Focused ethnography.

METHODS

Multi-site across eight acute care units within two tertiary referral hospitals on the east coast of Australia collected over a one-year period from 2014 to 2015. Semi-structured interviews (n = 12) of older persons (11 hr). Twenty-three (23) semi-structured interviews with nine (9) registered nurses (12 hr 38 min). Participant observation (1,041 hr) during day, night and evening shifts.

RESULTS

The older person experienced disjunction within pain assessment by the reliance of nurses on objective measurement gained during functional task completion. Tension emerged during pain management when the older person was not included and/or options provided were not deemed effective. For some older persons this meant they undertook a decision to exclude their nurse from involvement in pain management. A thread woven throughout was a lack of communication, continuity of care and input from the older person.

CONCLUSION

This study has implications for the provision of nursing care of the older hospitalized person. Dissonance within pain care provision for the older person occurs during episodes of missed pain care. Understanding and insight is gained into aspects of missed communication opportunities between nurses and the experiences of missed pain care of the older person.

"A catalyst for action": Factors for implementing clinical risk prediction models of infection in home care settings

OBJECTIVE

The study sought to outline how a clinical risk prediction model for identifying patients at risk of infection is perceived by home care nurses, and to inform how the output of the model could be integrated into a clinical workflow.

MATERIALS AND METHODS

This was a qualitative study using semi-structured interviews with 50 home care nurses. Interviews explored nurses' perceptions of clinical risk prediction models, their experiences using them in practice, and what elements are important for the implementation of a clinical risk prediction model focusing on infection. Interviews were audio-taped and transcribed, with data evaluated using thematic analysis.

RESULTS

Two themes were derived from the data: (1) informing nursing practice, which outlined how a clinical risk prediction model could inform nurse clinical judgment and be used to modify their care plan interventions, and (2) operationalizing the score, which summarized how the clinical risk prediction model could be incorporated in home care settings.

DISCUSSION

The findings indicate that home care nurses would find a clinical risk prediction model for infection useful, as long as it provided both context around the reasons why a patient was deemed to be at high risk and provided some guidance for action.

CONCLUSIONS

It is important to evaluate the potential feasibility and acceptability of a clinical risk prediction model, to inform the intervention design and implementation strategy. The results of this study can provide guidance for the development of the clinical risk prediction tool as an intervention for integration in home care settings.

The effectiveness of interventions to improve pain assessment and management in people living with dementia: A systematic review and meta-analyses

AIMS

To synthesize and evaluate the effectiveness of interventions for nurses to improve the assessment and management of pain in people living with dementia.

DESIGN

Systematic review and meta-analyses of randomized controlled trials.

DATA SOURCES

CINAHL, Joanna Briggs Institute (JBI) EBP, Cochrane Library, PubMed, and Scopus databases were searched for all journal articles published between 2009 -2019.

REVIEW METHODS

Papers were included under population intervention comparator outcome (PICO) framework for: (a) people living with dementia aged 65 years and over; (b) interventions developed for nurses or other health professionals; (c) comparison group of standard care or control; and (d) outcome that measures the intervention effects on nurses and people living with dementia. Independent reviewers undertook critical appraisal, data abstraction, and synthesis. Meta-analyses were performed to determine the effectiveness of interventions.

RESULTS

Of 2099 titles and abstracts screened, six interventions with low-to-moderate risk of bias met inclusion criteria. Studies that implemented a routine pain assessment tool showed no effect on nurses' analgesic management. Studies that developed a comprehensive pain model involving multidisciplinary health professionals showed overall effects on pain assessment and management in dementia care. Physician involvement had an impact on analgesic management.

CONCLUSION

Comprehensive pain models improve nurses' pain assessment and management. A lack of balance between analgesia use and non-pharmacological pain management in dementia care is evident. Multidisciplinary health professionals' involvement is essential for effective intervention design for pain management in dementia.

IMPACT

Various pain assessment tools have been considered to assist identification and management of pain in people living with dementia. Nevertheless, challenges exist when caring for people living with dementia in pain. These findings support the development of a comprehensive pain model, which may be a more effective strategy than routine use of a pain tool alone for nurses to improve pain management in dementia care.

The challenge of pain identification, assessment, and management in people with dementia: a qualitative study

BACKGROUND

Painful conditions are common in older adults, including people with dementia. The symptoms associated with dementia (for example, diminished language capacity, memory impairment, and behavioural changes), however, may lead to the suboptimal identification, assessment, and management of pain. Research has yet to qualitatively explore pain management for community-dwelling people with dementia.

AIM

To explore pain identification, assessment, and management for community-dwelling people with dementia.

DESIGN & SETTING

A qualitative study was undertaken, set in England.

METHOD

Semi-structured interviews took place with people with dementia, family caregivers, GPs, and old-age psychiatrists. Data were analysed thematically.

RESULTS

Interviews were conducted with eight people with dementia, nine family caregivers, nine GPs, and five old-age psychiatrists. Three themes were identified that related to pain identification and assessment: gathering information to identify pain; the importance of knowing the person; and the use of pain assessment tools. A further three themes were identified that related to pain management: non-drug strategies; concerns related to analgesic medications; and responsibility of the caregiver to manage pain.

CONCLUSION

Identifying and assessing the pain experienced by people with dementia was challenging. Most people with dementia, family caregivers, and healthcare professionals supported non-drug strategies to manage pain. The minimal concerns associated with non-drug strategies contrasted the multifactorial concerns associated with analgesic treatment for people with dementia. Given the complexity of pain identification, assessment, and management, primary care should work together with family caregivers and community services, with case finding for pain being considered in all assessment and management plans.

The Influence of Chronic Pain on Number Sense and Numeric Rating Scale: A prospective Cohort Study

Background

Several studies have demonstrated an association between chronic pain and impairment of cognitive capabilities. Since the number sense is one of the cognitive ability involved in the evaluation of pain intensity using some pain measurement tools, impairment of number sense may impact pain assessment. Therefore, the validity of number-based pain assessment tools should be re-evaluated.

Objectives

This study aimed to determine whether number sense is altered in chronic and acute pain patients compared to healthy subjects.

Methods

Overall, 150 participants were recruited and divided into the three groups of controls, chronic and acute pain patients. Pain intensity was evaluated using numeric and verbal rating scales as pain assessment tools. Number sense was assessed using number naming, number marking, and line bisection tasks. Deviation from correct answers was measured for each task.

Results

Patients with chronic pain (migraine headache) had higher pain intensity scores than acute pain subjects. Chronic pain patients showed significant deviation from the expected responses compared to controls in the line bisection task.

Conclusions

Chronic pain patients may have impaired number sense and may differently use number-based pain assessment tools in comparison with healthy individuals.

Integrated Management of Pain in Advanced Dementia

AIM

Develop and evaluate the implementation of a protocol for comprehensive management of pain in advanced dementia.

METHOD

Quasi-experimental study carried out between September 2015 and May 2016 in an acute geriatric unit. Following development of the protocol and nurse training, 22 participants were recruited through consecutive sampling to form the intervention group (IG). Pain assessment was performed using the Pain Assessment in Advanced Dementia Spanish version (PAINAD-Sp) instrument and by nurse report-rating using the Numeric Rating Scale (NRS) and control group, with pain assessment through nurse-report using an NRS. Interventions carried out following perception of pain were done according to the actions algorithm created for this purpose. Follow-up was carried out daily during the hospital stay.

RESULTS

Some 98% of the actions were performed correctly following the protocol. All (100%) of patients had a scheduled prescription for analgesics. Significant differences between mean pain scores at admission and discharge were found through PAINAD-Sp using a Wilcoxon sign test of -2.9543 (p = .004). Analysis of pain perception scores revealed a statistically significant positive correlation between the number of nonpharmacological actions performed and the pain score values obtained in the IG (rho Spearman: 0.617, p < .001) and the control group (rho Spearman: 0.922, p < .001). A high correlation was also observed in the IG between assessments conducted using PAINAD-Sp and NRS (intraclass correlation coefficient: 0.921).

CONCLUSIONS

The implementation of an agreed-upon, standardized protocol for comprehensive pain management in advanced dementia, including nurse training, leads to systematic application of all the protocol stages, and therefore better pain management.

Epidemiology of pain and relation to psychiatric disorders

Chronic pain is a common pain condition. Some psychiatric disorders, such as anxiety and depression, are also common in the general population. Epidemiological studies found that some psychiatric disorders are more commonly found among persons with chronic pain (e.g., headache, back pain) than those without chronic pain. Why those psychiatric disorders co-occur with chronic pain, however, is not well understood. Further, studies demonstrated that some psychiatric disorders, such as depression, increase the risk of chronic pain as well as its persistence. It is also recognized that chronic pain has a negative impact on the persistence of psychiatric disorders. The observations from clinical studies suggest that chronic pain is not a common comorbidity among individuals with other psychiatric disorders, such as dementia and schizophrenia. It is not clear if this is a consequence of any specific biological mechanism, or methodology problems in the studies. This paper provides an overview on the distribution of chronic pain and psychiatric disorders, followed by a review of studies that have demonstrated the association between psychiatric disorders and chronic pain.

Orofacial pain assessment and management for patients with dementia: A meta-ethnography

Delivering dental treatment for patients with dementia can be challenging, and the complexity of treatment provision can increase as dementia progresses. Treatment at the later stages of dementia can be associated with ethical challenges and procedural risk meaning that a comprehensive patient assessment is crucial; the presence of orofacial pain is a key indication for active intervention from dental teams. To explore the process of oro-facial pain assessment and management, a comprehensive review of qualitative literature was undertaken by searching six electronic databases. No literature specific to orofacial pain assessment was identified. The inclusion criteria were widened to explore assessment and management of pain in general for patients with dementia. Meta-ethnography with reciprocal translation was used to identify key concepts and themes and synthesise information applicable to the dental setting. Three major themes arose as follows: challenges with pain assessment, challenges with pain management and logistics and education. Healthcare teams struggle with pain identification in patients with dementia though many signs were identified which may suggest a patient is experiencing pain. The long-term knowledge of individual patients held by family members and care teams can allow identification of deviation from patients' normal states; this knowledge can assist healthcare professionals in determining whether to provide specific treatments or interventions. Pain assessment tools were found to be problematic and are unlikely to be a practical solution to use for complex patients in dental settings. Education for dental and wider care teams on orofacial pain would be highly valuable; yet, this needs to be based on suitable evidence.

The Influence of Chronic Pain and Cognitive Function on Spatial-Numerical Processing

Chronic pain (CP) is linked to changes in cognitive function. However, little is known about its influence on number sense, despite the fact that intact numerical-spatial processing is a prerequisite for valid scale-based pain assessments. This study aimed to elucidate whether number sense is changed in CP, to determine if changes have an impact on pain assessments using pain rating scales and what patient factors might contribute. N = 42 CP patients and n = 42 matched controls were analyzed (age range: 33-68 years). Numerical-spatial abilities were investigated by using number line tasks, where participants either estimated the position of a given number (position marking) or the value of a predefined mark (number naming). Pain intensity was assessed using numerical rating (NRS), verbal rating (VRS), and visual analog (VAS) scales. Additional measures included attention and working memory, verbal intelligence, medication and depression. Results revealed that in number naming, patients deviated more from expected (correct) responses than controls, and that VAS scores were significantly higher than both NRS and VRS and correlated with deviations in position making. Changes in number naming were predicted by pain intensity, sex and IQ but not by attention, memory or opioid medication. This article presents new insight on which cognitive mechanisms are influenced by CP with the focus on numerical spatial abilities. It could therefore provide useful knowledge in developing new pain assessment tools specifically for patients suffering from CP.

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

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

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

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

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Intrathecal pain management: a team-based approach

Objective

Physician assistants (PAs), nurse practitioners (NPs), and registered nurses (RNs) provide professional services on pain management teams. This review provides an overview of the practical management of chronic pain with intrathecal (IT) therapy using an interprofessional approach (eg, physicians and other health care professionals), with a focus on the contributions of PAs, NPs, and RNs.

Methods

Narrative review based on literature searches of the Medline database and treatment guidelines on the use of IT therapy in the management of patients with chronic pain.

Results

The specific roles and responsibilities of PAs, NPs, and RNs in the management of patients receiving IT therapy vary by practice. In many pain treatment centers, PAs, NPs, and RNs are responsible for patient education, postimplant maintenance, and ongoing supportive care of patients receiving IT therapy. Topics that we address include patient selection, patient expectations and goal setting, medication selection, outcome assessment, and treatment adjustment. Currently, morphine and ziconotide (a nonopioid, selective N-type calcium channel blocker) are the only agents approved by the US Food and Drug Administration for IT analgesia. We provide relevant information on the dosing, titration, and adverse effect management of these medications for PAs, NPs, and RNs responsible for administering IT therapy.

Conclusion

PAs, NPs, and RNs are valuable members of IT pain management teams. Treatment success requires ongoing monitoring of efficacy and adverse effects, with corresponding adjustments to medication selection and dosing, in addition to good communication among the health care professionals involved in patient care.

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

Background

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

Aims and objectives

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

Methods

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

Results

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

Limitations

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

Conclusions

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

Funding

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

The assessment and management of pain in patients with dementia in hospital settings: a multi-case exploratory study from a decision making perspective

BACKGROUND

Pain is often poorly managed in people who have a dementia. Little is known about how this patient population is managed in hospital, with research to date focused mainly on care homes. This study aimed to investigate how pain is recognised, assessed and managed in patients with dementia in a range of acute hospital wards, to inform the development of a decision support tool to improve pain management for this group.

METHODS

A qualitative, multi-site exploratory case study. Data were collected in four hospitals in England and Scotland. Methods included non-participant observations, audits of patient records, semi-structured interviews with staff and carers, and analysis of hospital ward documents. Thematic analysis was performed through the lens of decision making theory.

RESULTS

Staff generally relied on patients' self-report of pain. For patients with dementia, however, communication difficulties experienced because of their condition, the organisational context, and time frames of staff interactions, hindered patients' ability to provide staff with information about their pain experience. This potentially undermined the trials of medications used to provide pain relief to each patient and assessments of their responses to these treatments. Furthermore, given the multidisciplinary environment, a patient's communication about their pain involved several members of staff, each having to make sense of the patient's pain as in an 'overall picture'. Information about patients' pain, elicited in different ways, at different times and by different health care staff, was fragmented in paper-based documentation. Re-assembling the pieces to form a 'patient specific picture of the pain' required collective staff memory, 'mental computation' and time.

CONCLUSIONS

There is a need for an efficient method of eliciting and centralizing all pain-related information for patients with dementia, which is distributed in time and between personnel. Such a method should give an overall picture of a patient's pain which is rapidly accessible to all involved in their care. This would provide a much-needed basis for making decisions to support the effective management of the pain of older people with dementia in hospital.