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

Physiological Biomarkers for Assessment of Pain during Routine Blood Tests for Older Adults with Dementia in Long-Term Residential Care

OBJECTIVE

Evaluating pain in individuals with dementia can be difficult when verbal communication is limited. Vocalization has emerged as a potential avenue for assessments of pain in nonverbal populations. This study aimed to evaluate if physiological assessments of vocalization were correlated with observational assessments of pain during routine blood tests for persons with dementia.

DESIGN

A cross-sectional descriptive study.

SETTING AND PARTICIPANTS

Sixty older adults (aged ≥65 years old) with dementia requiring routine finger puncture and peripheral venipuncture for routine blood tests were recruited by purposive sampling from 3 long-term care facilities in Taiwan.

METHODS

Observational assessments were conducted with the Pain Assessment in Advanced Dementia (PAINAD) instrument; physiological biomarkers of vocalization were assessed with a noninvasive sensing device and microphone (NISDM). Assessments were conducted simultaneously in one session during situations of increasing pain levels: at rest, making a sound, finger puncture, and peripheral venipuncture. PAINAD scores were compared with signal recording measures from the NISDM. Analysis of variance and Pearson correlation coefficient assessed correlations between observational and physiological measures.

RESULTS

Most participants were female (63.3%); mean age was 81.27 years (SD = 9.69); Clinical Dementia Rating was 2.23 ± 0.70; and Mini-Mental State Examination was 7.07 ± 6.95. Signal recording measures using the NISDM during finger puncture and venipuncture were significantly greater compared with measures at rest and making sound, indicating higher signal levels were associated with pain. PAINAD scores were significantly correlated with physiological measures for vocalization variables of sound amplitude (r = 0.49, P < .001), shimmer (r = 0.63, P < .001), and inhalation-to-exhalation amplitude ratio (r = 0.48, P < .001).

CONCLUSIONS AND IMPLICATIONS

Elevated vocalizations detected with the NISDM were correlated with increased pain scores on the PAINAD instrument. Physiological measures of pain using novel vocalization biomarkers have the potential to enhance the quality of care for individuals with dementia and limited communication abilities.

Examining pain, function, behavioral symptoms and associations with engagement in meaningful activity for residents with dementia in assisted living

OBJECTIVES

The purpose of this study was to examine factors associated with engagement in meaningful activity among residents with dementia in assisted living. We hypothesized that greater functional independence, less pain, and lower behavioral and psychological symptom severity would be associated with higher engagement in meaningful activity after controlling for residents' age, gender, comorbidities, and cognition. Understanding factors associated with engagement in meaningful activity can help to inform strategies for optimizing engagement among residents with dementia in assisted living.

METHOD

This descriptive study used baseline data from a randomized controlled trial, Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD). Linear regression was used to examine factors associated with engagement in meaningful activity.

RESULTS

A total of 71 residents from 5 assisted living settings were included in the sample. Most participants were female (n = 52, 73%), White (n = 62, 87%), and mean age was 85 years old (SD = 8.2). Controlling for age, gender, comorbidities, and cognition, pain was significantly associated with engagement in meaningful activity (b= -2.09, p < 0.05). There were no associations found between function and behavioral symptoms with engagement in meaningful activity.

CONCLUSION

Findings from this study show that pain is a significant factor that is negatively associated with residents' engagement in meaningful activity. Ongoing research is needed to help improve pain management for residents with dementia in assisted living and support their engagement in meaningful activity.

[Prevalence and clinical characteristics of pain in patients with advanced chronic disease]

OBJECTIVES

Determine pain prevalence and clinical characteristics in patients with advanced chronic disease and identify breakthrough pain frequency.

DESIGN

Observational, descriptive, cross-sectional study.

LOCATION

Three primary care teams and one intermediate care hospital.

PARTICIPANTS

All patients with advanced chronic disease.

MAIN MEASUREMENTS

A semi-structured interview was performed to collect demographic, clinical, and specific variables of pain using validated scales. Patient location (home, nursing home or hospital) and advanced chronicity trajectory (organ failure, oncological disease, dementia, or multimorbidity) were recorded. Pain was assessed based on the Brief Pain Inventory (BPI) and, in cases of disabling dementia, using the Pain Assessment in Advanced Dementia (PAINAD). A statistical descriptive, comparative analysis between variables was performed using the R software.

RESULTS

Of all patients selected, 223 (60.4%) were included. Prevalence of pain: 83.9% (n=187), with no differences based on location or trajectory. Significant differences in pain intensity based on location (P=.0046) (moderate-severe in patients at home, moderate in hospital patients, and mild in nursing home patients) and on trajectory (P<.0001) (moderate-severe in patients with organ failure and multimorbidity, moderate in patients with cancer, and mild in patients with dementia). Global functional impact of pain was mild-moderate, emotional impact was severe in 41.5% of patients (n=51), and breakthrough pain was observed in 8.6% (n=13).

CONCLUSIONS

Pain must always be explored and assessed in patients with advanced chronicity, since it was highly prevalent in all locations and trajectories, being particularly intense in patients at home with organ failure and multimorbidity. Breakthrough pain was found in non-oncological trajectories.

A systematic review of prevalence of pain in nursing home residents with dementia

BACKGROUND

The prevalence of dementia in nursing home (NH) residents is high, and pain is a troublesome symptom for them. Several studies since 2010 have focused on pain in NH residents with dementia, but there is a lack of systematic reviews on the prevalence of pain in NH residents with dementia.

AIM

To systematically review observational studies published from 2010 to 2023 on how pain is assessed and prevalence of pain found in NH residents with dementia.

METHODS

A systematic search was conducted in the MEDLINE, PubMed, PsycINFO, Embase, CINAHL, AgeLine, and Cochrane databases for studies published from January 2010 to August 2023. Studies were included if they were observational studies with a quantitative design where self-report, staff assessment, and/or chart review were used to define the prevalence of pain in samples or subsamples of NH residents with dementia.

RESULTS

Of 184 studies considered, 25 were included. The studies assessed pain as daily, present, clinically relevant, chronic, intermittent, persistent pain and/or if pain affected quality of life. The prevalence of pain was high in most studies of NH residents with dementia independent of whether pain was reported as presence of pain or clinically relevant pain, but the prevalence varied from 8.6% to 79.6%. This prevalence was quite stable across the NH stay, but higher towards the end of life (up to 80.4%). Study designs and methodologies differed considerably. About half relied on an observational assessment inventory.

CONCLUSION

The number of studies focusing on pain in NH residents with dementia was restricted and methodologies differed considerably. Relatively few studies used an observational assessment inventory. In view of the fact that residents with dementia may have difficulties communicating pain, clinicians should pay attention to pain in these residents, systematically and reliably uncover pain by use of observational inventories, and subsequently treat pain to secure high quality care.

Physicians' and nurses' experience of using the Abbey Pain Scale (APS) in people with advanced cancer: a qualitative content analysis

BACKGROUND

The Abbey Pain Scale (APS), an observational scale used to assess pain in people with end-stage dementia, is also widely used in Sweden to assess pain in patients with advanced cancer. It is unclear whether the APS is appropriate in this context. This study aims to explore physicians' and nurses' experiences of using a Swedish translation of the APS (the APS-SE) in people with advanced cancer.

METHODS

Conventional qualitative content analysis was used to analyse interviews with physicians (n = 6) and nurses (n = 6) working in oncology and specialised palliative care about their experiences of using the APS-SE.

RESULTS

Three categories were created: fills a need, not always on target, and does not fully suit the clinical situation. Participants reported that although the APS-SE provides support in a challenging situation, it sometimes misses the mark: it does not distinguish well between pain and other types of suffering and its pain score tends not to reflect professionals' intuitive perceptions of patients' suffering. Some parts of the APS-SE were not considered useful, and others were perceived as ethically questionable.

CONCLUSION

Health professionals greatly need an observational pain assessment tool for people with advanced cancer. The APS-SE is helpful in this context, but participants did not perceive it as ideal. Its problems seem inherent to the original APS rather than related to its translation from English to Swedish. Further research is needed to provide a more suitable pain assessment tool for patients with advanced cancer.

Efficacy of non-pharmacological interventions to reduce pain in people with dementia: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To identify the efficacy of non-pharmacological interventions designed to reduce pain in people with dementia.

BACKGROUND

Pain is prevalent among patients with dementia but frequently remains untreated. Although non-pharmacological interventions have been used to reduce pain in people with dementia, the efficacy of these interventions for pain management in people with dementia has not been thoroughly synthesised.

DESIGN

Systematic review and meta-analysis.

METHODS

The study was conducted in accordance with PRISMA guidelines and Cochrane criteria for systematic reviews. A comprehensive search was performed using the Academic Search Complete, CINAHL, Cochrane Library, EMBASE, MEDLINE, PubMed, OVID and Web of Science databases, from databases inception to 13 March 2022. The modified Cochrane risk-of-bias tool (ROB-2) was used to evaluate the methodological quality of each included study. Standardised mean differences (SMDs) with 95% confidence intervals (CIs) were synthesised using a random-effects model to assess the efficacy of non-pharmacological interventions for reducing pain in people with dementia (using Stata 16.0).

RESULTS

The final analysis assessed 12 studies, including 989 persons with dementia. Non-pharmacological interventions were found to reduce pain in 4-8 weeks after the interventions (SMD: -0.32; 95% CI: -0.62 to -0.02). However, the effects of intervention frequency and patient age remain unknown.

CONCLUSIONS

Non-pharmacological interventions are effective for reducing pain in people with dementia. Further investigations remain necessary to explore the effectiveness of specific non-pharmacological therapies for pain reduction in people with dementia (e.g. aromatherapy, play activity, singing or robotic care).

RELEVANCE TO CLINICAL PRACTICE

The findings of this study can guide healthcare practitioners when considering the use of non-pharmacological pain management methods for people with dementia and may improve the implementation of these methods in clinical practice.

PATIENT OR PUBLIC CONTRIBUTIONS

The study suggests non-pharmacological interventions to reduce pain and underlines the relevance of health provider's viewpoints. The types, duration and length of follow-up of non-pharmacological interventions can be offered based on patient's conditions and the standard of clinical practice.

Opioids in the Elderly Patients with Cognitive Impairment: A Narrative Review

Introduction

Assessment and management of pain in elderly people with cognitive impairment is particularly challenging. Physiological changes due to aging as well as comorbidities and polypharmacy are responsible for a complex clinical approach. Concomitantly, in cognitive impairment, including advanced dementia, changes in the central nervous system along with changes in the peripheral nervous system due to aging have a significant impact on pain perception. Sometimes clinicians decide to prescribe opioids to relieve pain, also without a clear indication. This review aims to investigate the effect of opioids in elderly patients with cognitive impairment.

Methods

A literature search of PubMed/Medline, Scopus, and Cochrane databases was conducted using keyword searches to generate lists of articles that were screened for relevance by title and abstract to give a final list of articles for full-text review. Further articles were identified by scanning the reference lists of the full-text articles.

Discussion

This review discusses the complex physiological and pharmacological changes in the elderly as well as the neurological changes that affect pain perception in this population. Additionally, it focuses on cognitive impairment and pain in Alzheimer’s disease and other dementias, the pain assessment in the elderly with cognitive impairment as well as the safety of opioid use in the elderly. Information regarding opioid prescription in nursing homes and recorded indications for opioid use, type and dosing of opioids, and compliance of treatment in advanced dementia are also provided.

Conclusions

Opioid prescription in the elderly population with cognitive impairment is particularly complex. All healthcare professionals involved in the care of such patients need to be aware of the challenges and strive to ensure analgesic use is guided by appropriate and accurate pain assessment.

Knowledge and Attitudes towards Palliative Care: Validation of the Spanish Version of Questionnaire on Palliative Care for Advanced Dementia

Background: Palliative care is essential in the care of people with advanced dementia, due to the increasing number of patients requiring care in the final stages of life. Nurses need to acquire specific knowledge and skills to provide quality palliative care. The Questionnaire on Palliative Care for Advanced Dementia (qPAD) is useful for assessing knowledge and attitudes toward palliative care, but its adaptation to the Spanish language and analysis of its effectiveness and usefulness for the Spanish culture is lacking. Objective: To report on the Spanish language adaptation and psychometric analysis of the qPAD. Methods: The Questionnaire on Palliative Care for Advanced Dementia Spanish version (qPAD-SV) was obtained from a process that included translation, back-translation, comparison with other language versions, expert review, and pilot study. Content validity, criterion validity, and reliability of the questionnaire were analyzed. The difficulty and discrimination indices of items composing the knowledge subscale were also calculated. Results: Adequate content validity index obtained after the analysis of qPAD-SV by a heterogeneous group of experts was found (overall CVI = 0.96; 0.95 for the Knowledge subscale and 0.99 for the Attitudes subscale). Significant correlations with the Palliative Care Knowledge test (rho = 0.368, p < 0.001) and Self-Efficacy in Palliative Care Scale (rho = 0.621, p < 0.001) show an adequate criterion validity. Cronbach’s alpha coefficients for the Knowledge subscale (0.60) and the Attitudes subscale (0.91) supported the reliability of the qPAD-SV. The questionnaire had an overall difficulty index of 0.71, with three items that could be considered difficult or very difficult, and eleven items that could be considered very easy. Discussion: Although it shows internal consistency, validity, and difficulty indices similar to those obtained by qPAD versions in other languages, a reformulation of the items with lower content validity or discrimination indices and those that show difficulties in their comprehension is an aspect to be taken into account to improve this tool. Conclusions: The qPAD-SV is a useful instrument in Spanish to measure the knowledge of Spanish nurses in palliative care and is suitable for international comparisons.