Assessing pain in cognitively impaired older adults with cancer

Are nurse`s needs assessment methods robust enough to recognise palliative care needs in people with dementia? A scoping review

BACKGROUND

People with dementia are most at risk of experiencing serious health related suffering, if they do not have a palliative care approach introduced early enough in the illness. It can be challenging for nurses to assess experienced needs of people, who are thought no longer able to self-report such as people with dementia. Assessment help to understand the care the patient and their family need promptly. It is unknown how nurses recognise holistic palliative care needs in people with dementia during routine care.

METHODS

Scoping review where EMBASE, MEDLINE, CINAHL, PsycInfo databases, and references were searched with an advanced search strategy, which was built on three concepts (nurses, dementia, and nursing assessment) using corresponding Medical Subject Headings. Data were charted in a piloted extraction form, based on the assessment domains within the nursing process followed by summarise and synthesise results narratively.

RESULTS

37 out of 2,028 qualitative and quantitative articles published between 2000 and 2021, and relating to 2600 + nurses, were identified. Pain was sole focus of assessment in 29 articles, leaving 8 articles to describe assessment of additional needs (e.g., discomfort). Nurses working in a nursing home assess pain and other needs by observing the persons with dementia behaviour during routine care. Nurses in the acute care setting are more likely to assess symptoms with standard assessment tools at admission and evaluate symptoms by observational methods. Across settings, about one third of pain assessments are supported by person-centred pain assessment tools. Assessments were mostly triggered when the person with dementia vocalised discomfort or a change in usual behaviour was observed. Nurses rely on family members and colleagues to gain more information about needs experienced by people with dementia.

CONCLUSION

There is a scarcity of evidence about techniques and methods used by nurses to assess needs other than pain experienced by people with dementia. A holistic, person-centred screening tool to aid real-time observations at the bedside and used in conversations with health care professionals and families/friends, may improve need recognition other than pain, to ensure holistic needs could then be addressed timely to improve care in people with dementia.

The Discomfort Behavior Scale: a measure of discomfort in the cognitively impaired based on the Minimum Data Set 2.0

Because persons with cognitive impairment often cannot self-report pain, it is imperative to develop instruments that use observable indicators. The purpose of this study was to develop and test the psychometric properties of the Discomfort Behavior Scale (DBS), which is comprised of 17 items from the Minimum Data Set (MDS). MDS data from 29,120 cognitively impaired nursing home residents were used for psychometric testing. Factor analyses of the DBS indicated that it reflects a single discomfort dimension. The items are tau equivalent, allowing unity weighting and simple summation to create scale scores, and the internal consistency was good. The DBS has potential to be useful in studies of efforts to improve pain management in cognitively impaired residents of nursing homes.

Pain assessment and management in the patient with mild to moderate cognitive impairment

The gold standard for pain screening and assessment is the patient report. Research shows that many patients with mild to moderate cognitive impairment retain the ability to report pain. All patients should be given the opportunity to self-report their pain using valid and reliable tools.

Institutionalizing effective pain management practices: practice change programs to improve the quality of pain management in small health care organizations

The Resource Center of the American Alliance of Cancer Pain Initiatives provided templates, faculty, and ongoing consultation to assist seven state pain initiatives to implement programs to improve pain management practices. A total of 113 health care organizations participated. Each organization committed to support a team of two to three staff through a 10-month pain quality improvement process, which included a site visit, two educational conferences, pre- and postprogram analyses of the organizational structures in place to support pain assessment and management, quality improvement work plan development, and patient survey data collection. Postprogram results showed statistically significant increases in the presence of structural elements that are critical to effective pain management, as well as statistically significant, though modest, decreases in the percentage of patients who reported pain of any severity, and specifically moderate to severe pain, in the previous 24 hours. The largest changes occurred in long-term care facilities. Nevertheless, the percentage of patients in moderate to severe pain remained unacceptably high.

Pain Assessment: An Overview

Pain assessment is an integral part of providing quality patient care. Treatment of pain is driven by the findings of the pain assessment. Pain assessment provides health care professionals with the information necessary to effectively mange a patient's course of treatment and plan of care. To assess and manage pain with the best possible outcomes, the health care provider must depend on the patient's subjective description in addition to objective tools. Barriers, related to the patient's religion or cultural beliefs, and/or lack of knowledge on the part of the health care providers often impede proper assessment and treatment of patients' pain.