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Guliani H, Hadjistavropoulos T, Jin S, Lix LM. Pain-related health care costs for long-term care residents. BMC Geriatr 2021; 21:552. [PMID: 34649517 PMCID: PMC8515764 DOI: 10.1186/s12877-021-02424-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 08/26/2021] [Indexed: 12/05/2022] Open
Abstract
Background We tested for differences in direct health care costs among long-term care (LTC) residents age 65 and older with clinically significant pain (CSP) and with no pain or non-daily mild pain (NP/NDMP). We are not aware of any other large scale investigation that examined the cost of pain in LTC environments. Methods Population-based administrative health data from Saskatchewan, Canada for 2004 to 2015 were used to compare direct health care costs for CSP and NP/NDMP groups up to one year after admission to LTC. Total accumulated costs for hospitalization, physician services, LTC, and prescription drugs were calculated in 2015 Canadian dollars. Group differences were tested using generalized linear models with generalized estimating equations. Results Amongst 24,870 LTC residents, 8289 (33.3%) were censored due to death or discharge in the 365-day study observation period. Of the 16,581 (66.7%) observed residents, 5683 (34.3%) had CSP at admission. Residents (66.3% female) had a mean age of 85 years (SD = 7.4). The mean annual total direct health care cost per resident was higher among the CSP group (CAD $8063) than the NP/NDMP group (CAD $6455). This difference was found even after including LTC costs, and for each cost component (i.e., CSP residents had higher hospitalization, physician, and prescription drug costs). Similar results were obtained after controlling for demographics, comorbidities, physical and cognitive impairment, prior health care costs, and facility characteristics. Conclusion The higher costs incurred by CSP residents compared to NP/NDMP residents are likely underestimated because pain problems are often missed in residents with dementia, who comprise a large portion of the LTC population. Improved pain care can reduce such costs and improve quality of life. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02424-2.
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Affiliation(s)
- Harminder Guliani
- Department of Economics, University of Regina, 3737 Wascana Pkwy, Regina, SK, S4S 0A2, Canada
| | - Thomas Hadjistavropoulos
- Department of Psychology and Centre on Aging and Health, University of Regina, 3737 Wascana Pkwy, Regina, SK, S4S 0A2, Canada.
| | - Shan Jin
- Saskatchewan Health Quality Council, 241 - 111 Research Drive Saskatoon, Saskatoon, SK, 7N 3R2, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, MB, R3E 0W3, Canada
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Atee M, Morris T, Macfarlane S, Cunningham C. Pain in Dementia: Prevalence and Association With Neuropsychiatric Behaviors. J Pain Symptom Manage 2021; 61:1215-1226. [PMID: 33068708 DOI: 10.1016/j.jpainsymman.2020.10.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT Pain is linked to behaviors and psychological symptoms of dementia (BPSD); however, it often remains underrecognized in this population. OBJECTIVES We aimed to investigate the prevalence and intensity of pain in people living in aged care homes with BPSD and by dementia subtypes and the association between pain intensity and BPSD. METHODS A 1-year retrospective cross-sectional analysis was conducted on BPSD and the presence of pain in referrals to a national BPSD support service using the Neuropsychiatric Inventory and PainChek®, respectively. Referrals were categorized into two groups: pain group and no pain group. RESULTS Of the 479 referrals (81.9 ± 8.3 years old) included in the analysis, two-thirds (65.6%) had pain identified, with almost half (48.4%) of these categorized as experiencing moderate-severe pain. Pain was highly prevalent (range: 54.6-78.6%) in all subtypes of dementia, particularly in mixed dementia and dementia with Lewy bodies. Compared with the no pain group, the pain group had 25.3% more neuropsychiatric behaviors, 33.6% higher total severity of these behaviors, and 31.4% higher total distress caused to caregivers. For all results, effect sizes were small to medium (η²p = 0.04-0.06). Despite a high prevalence of aggressive or agitated behaviors across the entire group, the pain group was 3.8 times more likely to experience these behaviors than referrals not in pain. CONCLUSION There is a strong need to consider the possibility of pain as a contributor to behavioral changes in aged care residents living with dementia.
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Affiliation(s)
- Mustafa Atee
- The Dementia Centre, HammondCare, Wembley, Western Australia, Australia; Faculty of Health Sciences, School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia.
| | - Thomas Morris
- The Dementia Centre, HammondCare, St Leonards, New South Wales, Australia
| | - Stephen Macfarlane
- The Dementia Centre, HammondCare, St Leonards, New South Wales, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Colm Cunningham
- The Dementia Centre, HammondCare, St Leonards, New South Wales, Australia; School of Public Health & Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Bowers B. Improving practice and informing policy development: The impact of gerontological nursing research. Geriatr Nurs 2020; 41:32-37. [PMID: 32024595 DOI: 10.1016/j.gerinurse.2020.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Nurses have always approached the clinical care challenges they encounter with a combination of critical observation and a profound concern for human suffering. Beginning in earnest in the early 1980s, nurse researchers have pursued the answers to questions about the wellbeing of older adults, particularly those suffering from serious, chronic conditions. This paper offers three exemplars of nursing research domains that illustrate the creativity and commitment of nurse researchers seeking to understand and improve pervasive clinical problems experienced by older adults and to demonstrate the profound influence these activities have had on the evolution of the science and the quality of care for older adults. The impact of this work is reflected in practice protocols, institutional policies, government oversight, and improved outcomes for patients.
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Affiliation(s)
- Barbara Bowers
- University of Wisconsin-Madison, School of Nursing, 5133 Signe Skott Cooper Hall, Madison, WI 53705, United States.
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Gagliese L, Gauthier LR, Narain N, Freedman T. Pain, aging and dementia: Towards a biopsychosocial model. Prog Neuropsychopharmacol Biol Psychiatry 2018; 87:207-215. [PMID: 28947182 DOI: 10.1016/j.pnpbp.2017.09.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/20/2017] [Accepted: 09/21/2017] [Indexed: 12/30/2022]
Abstract
Dementia is a progressive disease associated with irreversible impairment and loss of cognitive abilities. About half of older people with dementia experience pain. In this paper, we propose that pain in older people with dementia can be conceptualized as the final result of the interaction of three heterogeneous phenomena, pain, aging, and dementia, which are created and influenced by the interactions of predisposing, lifelong, and current biopsychosocial factors. We review pain assessment in people with dementia using both self-report and observational/behavioral measures. We then review the biological/sensory, psychological (cognitive and affective) and social dimensions of pain in dementia. The available data suggest that dementia does not impact pain threshold or tolerance. To date, there is little research on the social dimension of pain in dementia. Changes in the affective domain in response to experimental pain have been contradictory with evidence supporting both increased and decreased unpleasantness and emotional responsiveness in people with dementia compared to healthy controls. Clinically, depression is a significant burden for older people with dementia and chronic pain. The relationship between pain and other neuropsychiatric symptoms is controversial, and there is insufficient evidence on which to base conclusions. Some of the most important dementia-related changes may arise in the cognitive domain, including impairments of semantic and episodic memory for pain, executive function, and pain anticipation. Changes in brain activation and interconnectivity support many of these conclusions. Despite methodological limitations, we conclude there are compelling preliminary data to support a biopsychosocial framework of pain and dementia. Future research directions, especially the need for improved assessment tools, are highlighted.
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Affiliation(s)
- Lucia Gagliese
- School of Kinesiology and Health Science, York University, 4700 Keele St., Toronto M3J 1P3, Canada; Department of Anesthesia & Pain Management, Toronto General Hospital, Canada; Department of Supportive Care, Princess Margaret Cancer Centre, Canada; Campbell Family Cancer Research Institute, Ontario Cancer Institute, University Health Network, 200 Elizabeth St., Toronto M5G 2C5, Canada; Department of Anesthesia, Mount Sinai Hospital, 600 University Ave, Toronto M5G 1X5, Canada; Faculty of Medicine, University of Toronto, 1 King's College Cir #3172, Toronto M5S 1A8, Canada; Department of Psychiatry, Toronto General Hospital, Canada.
| | - Lynn R Gauthier
- Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, 1050 Avenue de la Médecine, Québec G1V 0A6, Canada; l'Équipe de recherche Michel-Sarrazin en oncologie psychosociale et soins palliatifs, Canada; CHU de Québec-Université Laval Research Center, Oncology Research Axis, Canada; Université Laval Cancer Research Center, 9 Rue McMahon, Québec G1R 3S3, Canada
| | - Nadine Narain
- Department of Anesthesia & Pain Management, Toronto General Hospital, Canada
| | - Tamlyn Freedman
- Department of Anesthesia & Pain Management, Toronto General Hospital, Canada
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Content validation of a Critical Appraisal Tool for Reviewing Analgesia Studies (CATRAS) involving subjects incapable of self-reporting pain. Pain Rep 2018; 3:e670. [PMID: 30123860 PMCID: PMC6085143 DOI: 10.1097/pr9.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/08/2018] [Accepted: 06/11/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction This article reports the content validation of a Critical Appraisal Tool designed to Review the quality of Analgesia Studies (CATRAS) involving subjects incapable of self-reporting pain and provide guidance as to the strengths and weakness of findings. The CATRAS quality items encompass 3 domains: level of evidence, methodological soundness, and grading of the pain assessment tool. Objectives To validate a critical appraisal tool for reviewing analgesia studies involving subjects incapable of self-reporting pain. Methods Content validation was achieved using Delphi methodology through panel consensus. A panel of 6 experts reviewed the CATRAS in 3 rounds and quantitatively rated the relevance of the instrument and each of its quality items to their respective domains. Results Content validation was achieved for each item of the CATRAS and the tool as a whole. Item-level content validity index and kappa coefficient were at least greater than 0.83 and 0.81, respectively, for all items except for one item in domain 2 that was later removed. Scale-level content validity index was 97% (excellent content validity). Conclusions This 67-item critical appraisal tool may enable critical and quantitative assessment of the quality of individual analgesia trials involving subjects incapable of self-reporting pain for use in systematic reviews and meta-analysis studies.
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Ammaturo DA, Hadjistavropoulos T, Williams J. Pain in Dementia: Use of Observational Pain Assessment Tools by People Who Are Not Health Professionals. PAIN MEDICINE 2017; 18:1895-1907. [PMID: 27837033 DOI: 10.1093/pm/pnw265] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Pain is prevalent among older adults but is often underestimated and undertreated, especially in people with severe dementia who have limited ability to self-report pain. Pain in patients with moderate to severe dementia can be assessed using observational tools. Informal caregivers (relatives of seniors with dementia) are an untapped assessor group who often bear the responsibility of care for their loved ones. Our objective was to evaluate the ability of laypeople to assess pain using observational measures originally developed for use by health care professionals. Design We employed a quasi-experimental design and presented videos depicting patients with dementia (portrayed by actors) displaying pain behaviors or during a calm relaxed state (no pain) to long-term care nurses and laypeople. Participants rated the pain behaviors observed in each video by completing two standardized observational measures that had been previously developed for use by long-term care staff. Results As expected, both laypeople and nurses were able to effectively differentiate painful from nonpainful situations using the standardized tools. Both groups were also able to discriminate among gradations of pain (i.e., no pain, mild, moderate, severe) and required comparable amounts of time to complete the assessments. Conclusions We conclude that, as hypothesized, the instruments under study can be used for the assessment of pain by laypeople. This is the first study to validate these instruments for use by laypeople. The use of these tools by laypeople (under the guidance of health professionals) has the potential of facilitating earlier detection and treatment of pain in older adults with dementia who live in community settings.
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Affiliation(s)
- Delaine A Ammaturo
- Department of Psychology and Centre on Aging and Health, University of Regina, Regina, Saskatchewan, Canada
| | - Thomas Hadjistavropoulos
- Department of Psychology and Centre on Aging and Health, University of Regina, Regina, Saskatchewan, Canada
| | - Jaime Williams
- Department of Psychology and Centre on Aging and Health, University of Regina, Regina, Saskatchewan, Canada
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Parsons C. Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem. Ther Adv Drug Saf 2017; 8:31-46. [PMID: 28203365 PMCID: PMC5298466 DOI: 10.1177/2042098616670798] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilization, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimize prescribing for this vulnerable patient group. Although there has been a considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life expectancy is limited. The development of tools to assess medication appropriateness in people with mild to moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes, including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities, and to examine the impact of PIP on health outcomes.
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Affiliation(s)
- Carole Parsons
- Queen’s University Belfast, 97 Lisburn Road, Belfast, Northern Ireland BT9 7BL, UK
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Abstract
PURPOSE The study purposes were twofold: (1) to explore barriers to pain management and those associated with implementing a pain management program in long-term care (LTC); and (2) to develop an interprofessional approach to improve pain management in LTC. METHODS A case study approach included both qualitative and quantitative components. We collected data at two LTC sites using seven focus groups for the licensed nurses, unregulated care providers and physicians, and 10 interviews with other health care provider groups, administration, and residents. We reviewed documents and administered a short survey to study participants to assess perceptions of barriers to pain management. RESULTS The findings revealed barriers to effective LTC pain management at the resident/family, health care provider, and system levels. We then developed a six-tiered model with proposed interventions to address these barriers. CONCLUSIONS This model can guide the development of innovative approaches to improving pain management in LTC settings.
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Hoffmann F, van den Bussche H, Wiese B, Glaeske G, Kaduszkiewicz H. Diagnoses indicating pain and analgesic drug prescription in patients with dementia: a comparison to age- and sex-matched controls. BMC Geriatr 2014; 14:20. [PMID: 24520876 PMCID: PMC3937236 DOI: 10.1186/1471-2318-14-20] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 02/10/2014] [Indexed: 01/26/2023] Open
Abstract
Background The evidence of undertreatment of pain in patients with dementia is inconsistent. This may largely be due to methodological differences and shortcomings of studies. In a large cohort of patients with incident dementia and age- and sex-matched controls we examined (1) how often they receive diagnoses indicating pain, (2) how often they receive analgesics and (3) in which agents and formulations. Methods Using health insurance claims data we identified 1,848 patients with a first diagnosis of dementia aged ≥ 65 years and 7,385 age- and sex-matched controls. We analysed differences in diagnoses indicating pain and analgesic drugs prescribed between these two groups within the incidence year. We further fitted logistic regression models and stepwise adjusted for several covariates to study the relation between dementia and analgesics. Results On average, patients were 78.7 years old (48% female). The proportions receiving at least one diagnosis indicating pain were similar between the dementia and control group (74.4% vs. 72.5%; p = 0.11). The proportion who received analgesics was higher in patients with dementia in the crude analysis (47.5% vs. 44.7%; OR: 1.12; 95% CI: 1.01-1.24), but was significantly lower when adjusted for socio-demographic variables, care dependency, comorbidities and diagnoses indicating pain (OR: 0.78; 95% CI: 0.68-0.88). Analgesics in liquid form such as metamizole and tramadol were more often used in dementia. Conclusions Our findings show a comparable documentation of diagnoses indicating pain in persons with incident dementia compared to those without. However, there still seems to be an undertreatment of pain in patients with dementia. Irrespective of dementia, analgesics seem to be more often prescribed to sicker patients and to control pain in the context of mobility.
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Affiliation(s)
- Falk Hoffmann
- Centre for Social Policy Research, Division Health Economics, Health Policy and Outcomes Research, University of Bremen, Postfach 33 04 40, D-28334 Bremen, Germany.
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Ma Y, Wang S, Tian Y, Chen L, Li G, Mao J. Disruption of persistent nociceptive behavior in rats with learning impairment. PLoS One 2013; 8:e74533. [PMID: 24040273 PMCID: PMC3770575 DOI: 10.1371/journal.pone.0074533] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 08/04/2013] [Indexed: 12/02/2022] Open
Abstract
Despite the subjective nature of pain experience with cognitive and affective dimensions, preclinical pain research has largely focused on its sensory dimension. Here, we examined the relationship between learning/memory and nociceptive behavior in rats with combined learning impairment and persistent nociception. Learning impairment was induced by bilateral hippocampal injection of a mixed Aβ solution, whereas persistent nociception produced in these rats by complete Freund's adjuvant-induced ankle inflammation. Those rats with learning impairment showed a diminished development of thermal hyperalgesia and mechanical allodynia and a shorter time course of nociceptive behavior without alteration of their baseline nociceptive threshold. In rats with pre-established hyperalgesia and allodynia due to ankle inflammation, bilateral intra-hippocampal injection of cycloheximide (a protein synthesis inhibitor) promoted the earlier recovery of nociceptive behavior. Moreover, expression of Aβ, NR1 subunit of the N-methyl-D-aspartate receptor, and protein kinase Cγ was upregulated, whereas the choline acetyl transferase expression was downregulated, in the hippocampus, thalamus, amygdala, and/or spinal cord of rats with combined learning impairment and persistent nociception. The data indicate that learning impairment could disrupt the response to a state of persistent nociception, suggesting an important role for cognitive maladaptation in the mechanisms of chronic pain. These results also suggest that a preclinical model of combined learning impairment and persistent nociception may be useful to explore the brain mechanisms underlying the transition from acute to chronic pain.
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Affiliation(s)
- Yuxin Ma
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Anatomy, School of Basic Medicine, Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Shuxing Wang
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Yinghong Tian
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Lucy Chen
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Guoying Li
- Department of Anatomy, School of Basic Medicine, Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
| | - Jianren Mao
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Hadjistavropoulos T, LaChapelle D, Hale C, MacLeod FK. Age- and appearance-related stereotypes about patients undergoing a painful medical procedure. ACTA ACUST UNITED AC 2013. [DOI: 10.1163/156856900750228060] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
INTRODUCTION Ageing, a common background in dementia, is usually associated with painful disorders. Nevertheless, the use of analgesics is limited due to poor communication. On the other hand, dementia lesions are placed in the nociceptive pathways. For this reason, the painful experience becomes different and distinctive for every lesional type. COURSE The lateral nociceptive pathway (lateral thalamic nuclei and primary parietal cortex), which is in charge of the primary pain perception, is preserved in dementia. Thereafter, the shear painful perception, including pain intensity and threshold, remains unmodified. Distinctly, the medial pain pathways are affected by dementia lesions. In this pathway are included: the intralaminar thalamic nuclei, the pons (locus ceruleus:LC), the mesencephalon (periaacueductal grey substance: PGS), the hypothalamus (paraventricular nuclei, mamilary tuberculum) and different areas of the parietal (primary, secondary, operculum), temporal (amigdala, hypoccampus) and frontal (anterior cingular: ACC). As a consequence, the features of pain executed by these areas will be compromised: the cognitive assessment, the mood and emotion inherent to pain, the pain memory or the autonomic responses are modified in dementia. Specifically, in Alzheimer's disease (AD) there is a reduction in the anticipatory and avoidance responses and also a flattening of the autonomic responses. These are essentially secondary to the degenerative changes in the medial temporal (pain memory) and ACC (cognitive and mood aspects) areas. In vascular dementias, there is a cortico-subcortical deafferentation secondary to the white matter lesions. The consequence is the presence of hyperpathy and hyperalgesia. In the frontotemporal dementias, there is a reduction in pain expressivity. It is linked to the lesions in the orbitofrontal and anterior temporal areas, which are responsible of the emotional aspects of pain. In Parkinson's disease, painful conditions are a common characteristic. They are attributed to an early lesion in the LC, which reduces its prominent antinociceptive activity. Finally, in the demented patients there is a lack of expectations to analgesic treatments. This means an absence of the placebo effect, which is, alongside the pharmacokinetic action, an inherent part of the analgesic response. The placebo response is related to activity in the ACC and PGS. Giving its lack, higher doses of analgesics are necessary in dementias. CONCLUSIONS The assessment of pain in dementia is rather complex, which is the main reason for the scarcity of the analgesic treatment in dementias. It must be specific and systematic. For this purpose, the pain scales are a useful tool. For communicative patients, simple visual scales are helpful, meanwhile in the non-communicative patients the multidimensional scales are the most suitable. By this means, the expressive, motor, emotional, functional and social interactions are evaluated. Pain may be responsible of progression and cognitive deterioration in dementia. This evolution could be reversible, and consequently it has to be foreseen in order to implement analgesic treatment. Trying to minimize adverse events, it has to be potent but closely monitored.
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Pickering G, Jourdan D, Dubray C. Acute versus chronic pain treatment in Alzheimer's disease. Eur J Pain 2012; 10:379-84. [PMID: 16087372 DOI: 10.1016/j.ejpain.2005.06.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2005] [Revised: 06/18/2005] [Accepted: 06/30/2005] [Indexed: 11/25/2022]
Abstract
Several studies have suggested a lower consumption of analgesics in patients with Alzheimer's disease (AD) than in cognitively intact individuals (ND), but little attention has been paid to a distinction in analgesic consumption between acute and chronic pain treatment. The aim of this prospective and longitudinal study is a comparison in AD and ND residents at selection, and one year later, of analgesic consumption for acute and chronic pain, with an assessment of cognitive status (with the Mini Mental State Examination (MMSE)). Three hundred institution residents (150 AD and 150 ND), 20% male and 80% female (84.4 +/- 8.3 years old), were included in this study. Analgesic consumption and MMSE were reassessed at one year's distance (period 1 P1 and 2 (P2)). Analgesic consumption for acute pain was not significantly different for AD and ND at selection time or one year later, while MMSE declined significantly for AD (6 +/- 7 (P1) versus 4 +/- 6 (P2) p < 0.01, and ND individuals 23 +/- 5 (P1) versus 20 +/- 6 (P2), p < 0.01, respectively). Chronic pain analgesic consumption however was significantly lower in AD than in ND (p < 0.01). These findings may suggest a dissociation between sensory-discriminative (lateral pain system) and motivational-affective (medial pain system) aspects of pain in individuals with AD. This dissociation must be further investigated as it may have important consequences for pain evaluation and pain treatment in this vulnerable population.
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Influence of dementia on multiple components of pain. Eur J Pain 2012; 13:317-25. [DOI: 10.1016/j.ejpain.2008.05.001] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Revised: 04/17/2008] [Accepted: 05/01/2008] [Indexed: 11/20/2022]
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Darchuk KM, Townsend CO, Rome JD, Bruce BK, Hooten WM. Longitudinal Treatment Outcomes for Geriatric Patients with Chronic Non-Cancer Pain at an Interdisciplinary Pain Rehabilitation Program. PAIN MEDICINE 2010; 11:1352-64. [DOI: 10.1111/j.1526-4637.2010.00937.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Brown CA. Pain in communication impaired residents with dementia: Analysis of Resident Assessment Instrument (RAI) data. DEMENTIA 2010. [DOI: 10.1177/1471301210375337] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Pain has been identified as a significant and under-reported problem in the older adult and those persons with dementia who may face an impaired ability to communicate that they are in pain. Their pain, under-diagnosed and under-treated, has functional implications, such as decreased ambulation, mood and sleep disturbances, impaired appetite and exacerbation of cognitive functioning. Methods: Resident Assessment Instrument (RAI) data were analyzed in order to 1) identify a pain profile of all of the residents living in the facility across two sampling periods (December 2005 and December 2006) and 2) compare the pain profile of residents categorized into two subgroups (intact communication/impaired communication). Findings: Consistent with the literature, clear differences were demonstrated between pain reporting and management for communication impaired residents with dementia and residents with intact communication. Several incongruent findings were also demonstrated. Conclusions: The RAI is useful to identify patterns but insufficient in itself for pain management purposes in this vulnerable group. Pain assessment tools developed for this population must be employed.
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Hadjistavropoulos T, Fitzgerald TD, Marchildon GP. Practice guidelines for assessing pain in older persons with dementia residing in long-term care facilities. Physiother Can 2010; 62:104-13. [PMID: 21359040 DOI: 10.3138/physio.62.2.104] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Frail patients with dementia most frequently present with musculoskeletal pain and mobility concerns; therefore, physiotherapy interventions for this population are likely to be of great benefit. However, physiotherapists who work with older adults with dementia confront a considerable challenge: the communication impairments that characterize dementia make it difficult to assess pain and determine its source. For an effective physiotherapy programme to be implemented, valid pain assessment is necessary. This paper is intended to provide practice guidelines for pain assessment among older persons with dementia. SUMMARY OF KEY POINTS Over the last several years, there has been tremendous research progress in this area. While more research is needed, several promising assessment methodologies are available. These methodologies most often involve the use of observational checklists to record specific pain behaviours. RECOMMENDATIONS We encourage the ongoing and regular evidence-based pain assessment of older persons with dementia, using standardized procedures. Without regular and systematic assessment, pain problems will often go undetected in this population. Given the need for systematic pain assessment and intervention for long-term care populations with mobility concerns and muculoskeletal pain problems, we call for increased involvement of physical therapists in long-term care facilities.
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Affiliation(s)
- Thomas Hadjistavropoulos
- Department of Psychology and Centre on Aging and Health, University of Regina, Regina, Saskatchewan, Canada.
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Fox P, Solomon P, Raina P, Jadad A. Barriers and Facilitators in Pain Management in Long-Term Care Institutions: A Qualitative Study. Can J Aging 2010. [DOI: 10.1353/cja.2004.0032] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
ABSTRACTThe purpose of this study was to identify barriers to the management of pain in long-term care institutions. Formal caregivers practising in four long-term care institutions in Hamilton, Ontario participated in eight focus groups. Participants included 6 physicians, 19 registered nurses, 8 registered practical nurses, 13 health care aides and 8 occupational therapists or physiotherapists. Three types of barriers were found: caregiver-related, patient-related and systems-related. Four themes for facilitating pain management were identified: (a) caregivers knowing the patient, (b) family support, (c) caregivers demonstrating understanding and compassion, and (d) teamwork by caregivers. Formal caregivers practising in long-term care institutions encounter a multitude of barriers that hinder the adequate assessment and treatment of pain, such as caregiver beliefs and knowledge and cognitive impairment in patients. Innovative strategies and strong political will are needed to overcome them.
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Aubin M, Verreault R, Savoie M, LeMay S, Hadjistavropoulos T, Fillion L, Beaulieu M, Viens C, Bergeron R, Vézina L, Misson L, Fuchs-Lacelle S. Validité et utilité clinique d'une grille d'observation (PACSLAC-F) pour évaluer la douleur chez des aînés atteints de démence vivant en milieu de soins de longue durée. Can J Aging 2010. [DOI: 10.3138/cja.27.1.45] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
ABSTRACTThis study presents the validation of the French Canadian version (PACLSAC-F) of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). Unlike the published validation of the English version of the PACSLAC, which was validated retrospectively, the French version was validated prospectively. The PACSLAC-F was completed by nurses working in long-term care facilities after observing 86 seniors, with severe cognitive impairment, in calm, painful or distressing but non-painful situations. The test-retest and inter-observer reliability, the internal consistency, and the discriminent validity were found to be satisfactory. To evaluate the convergent validity with the DOLOPLUS-2 and the clinical relevance of the PACSLAC, it was also completed by nurses during their work shift, with 26 additional patients, for three days per week during a period of four weeks. These results encourage us to test the PACSLAC in a comprehensive program of pain management targeting this population.
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21
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Tsai PF, Beck C, Richards KC, Phillips L, Roberson PK, Evans J. The Pain Behaviors for Osteoarthritis Instrument for Cognitively Impaired Elders (PBOICIE). Res Gerontol Nurs 2010; 1:116-22. [PMID: 20078024 DOI: 10.3928/19404921-20080401-07] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Older adults with severe cognitive impairment have trouble responding to questions about their osteoarthritis knee or hip pain, which makes pain management difficult. Therefore, the Pain Behaviors for Osteoarthritis Instrument for Cognitively Impaired Elders (PBOICIE) was developed as an alternative. This article reports the development and psychometric testing of the PBOICIE in three studies. The 6-item PBOICIE was not associated with the Verbal Descriptor Scale but was significantly associated with Keefe's method for observing pain behaviors in patients with knee osteoarthritis, with r=0.36 to 0.55, indicating good concurrent validity. The 6-item PBOICIE was able to discriminate older adults' pain behaviors before and after administration of an analgesic agent (2.9+/-1.89 versus 1.97+/-1.98; p<0.001). This study has shown that multifaceted pain assessments are needed in older adults with osteoarthritis knee or hip pain, as the observed behaviors did not parallel but added information to verbal report.
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Affiliation(s)
- Pao-Feng Tsai
- College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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22
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Pickering G, Gibson SJ, Serbouti S, Odetti P, Ferraz Gonçalves J, Gambassi G, Guarda H, Hamers JP, Lussier D, Monacelli F, Pérez-Castejón Garrote JM, Zwakhalen SM, Barneto D, Wary B. Reliability study in five languages of the translation of the pain behavioural scale Doloplus. Eur J Pain 2009; 14:545.e1-10. [PMID: 19747865 DOI: 10.1016/j.ejpain.2009.08.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 08/10/2009] [Accepted: 08/10/2009] [Indexed: 11/24/2022]
Abstract
Non-verbal pain assessment scales are useful tools for pain evaluation in persons with communication disorders and moderate-severe dementia. The Doloplus was one of the first scales to be developed and validated as a pain assessment tool in older adults with dementia. This study aims at evaluating the translation of the Doloplus scale in five languages, as regards test-retest and inter-rater reliability. Results show that both tests are good or excellent for the English, Italian, Portuguese and Spanish versions and moderate for the Dutch version. These results bring a unique opportunity to include the translated Doloplus scale in daily assessment of elderly persons with communication disorders, and future studies should focus on enriching the validation of the scale in each language.
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Affiliation(s)
- G Pickering
- CHU Clermont-Ferrand, Centre de Pharmacologie Clinique, F-63003 Clermont-Ferrand, France.
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23
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Decker SA. Behavioral Indicators of Postoperative Pain in Older Adults With Delirium. Clin Nurs Res 2009; 18:336-47. [DOI: 10.1177/1054773809341734] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The undertreatment of postoperative pain in older adults with delirium is attributed, in part, to the inability to complete self-report pain assessment instruments. Patients’ loss of verbal skills to self-report pain and the lack of reliable and valid postoperative pain assessment instruments for use in older adults with delirium prompted the design of a study to identify common and subtle behavioral indicators of pain. Sixteen experienced registered nurses participating in four focus groups identified behavioral indicators of pain.Transcript analysis resulted in 89 behaviors indicative of pain. Seven researchers with expertise in pain and cognitive impairment in older adults reached 80% agreement on 22 behavioral indicators. The behavioral indicators were classified within one of four pain behavior categories (nonverbal cues/behaviors, vocalizations, facial expressions, and change in usual behavior), and each behavioral indicator was identified as common or subtle. Findings provide evidence of content validity for the pain behaviors.
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Affiliation(s)
- Sheila A. Decker
- The University of Texas Health Science Center at Houston,TX,
USA,
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24
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Pain and Aging: The Emergence of a New Subfield of Pain Research. THE JOURNAL OF PAIN 2009; 10:343-53. [DOI: 10.1016/j.jpain.2008.10.013] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 10/22/2008] [Accepted: 10/28/2008] [Indexed: 11/19/2022]
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Abstract
ABSTRACTA description of the social construction of dementia among elderly residents of a nursing ward is offered, based on ethnographic fieldwork conducted in an Israeli geriatric centre. This account focuses on the construction of positive social identities and the ascription of roles for residents labelled as ‘demented’. The findings illustrate the split between personal and social identity in dementia. The applicability of conventional socio-psychological constructs such as ‘I’ and ‘me’ regarding dementia is questioned, as the spoken manifestations of these constructs is critically examined from a symbolic interactionist perspective.
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26
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Keeney CE, Scharfenberger JA, O'Brien JG, Looney S, Pfeifer MP, Hermann CP. Initiating and sustaining a standardized pain management program in long-term care facilities. J Am Med Dir Assoc 2008; 9:347-53. [PMID: 18519117 DOI: 10.1016/j.jamda.2008.02.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Revised: 02/15/2008] [Accepted: 02/15/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To identify current pain management practices in the long-term care setting; and, implement and evaluate a comprehensive pain management program in the long-term care setting. DESIGN An interventional pilot study. SETTING Community-based long-term care facilities. METHODS This study was conducted in two phases. Phase I consisted of interviewing long-term care facility administrators to ascertain current pain management policies and practices. This information was used to develop the Phase II intervention that involved collecting benchmark data, creating or modifying pain policies and procedures, implementing a pain management program and presenting educational programs. MEASUREMENTS Interviews with long term care administrators; facility and resident demographic data; chart audits for pain assessment and management data; pharmacy audits; telephone surveys. RESULTS Pain management policies and practices were inadequate prior to the study intervention. No facilities had policies or procedures that required ongoing (daily, weekly, etc.) pain assessment. Only one facility had mechanisms in place for measuring the presence or intensity of pain in their non-verbal, cognitively-impaired residents. Following the pain management program intervention, pain assessment significantly increased. and treatment for pain was provided for the vast majority of those indicating pain. All sites had a standardized pain assessment program in place one-year post-study completion. CONCLUSIONS Standardized pain management programs are critical to improving pain management in long-term care settings. Improvement in long-term care pain management can be obtained through a comprehensive pain management program that involves staff education, changes in pain policies and procedures, and identifying pain management as a quality indicator.
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Affiliation(s)
- Cynthia E Keeney
- Interdisciplinary Program for Palliative Care and Chronic Illness, University of Louisville Department of Medicine, Louisville, KY 40202, USA.
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28
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Kunz M, Scharmann S, Hemmeter U, Schepelmann K, Lautenbacher S. The facial expression of pain in patients with dementia. Pain 2007; 133:221-8. [PMID: 17949906 DOI: 10.1016/j.pain.2007.09.007] [Citation(s) in RCA: 186] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Revised: 08/21/2007] [Accepted: 09/10/2007] [Indexed: 11/25/2022]
Abstract
The facial expression of pain has emerged as an important pain indicator in demented patients, who have difficulties in providing self-report ratings. In a few clinical studies an increase of facial responses to pain was observed in demented patients compared to healthy controls. However, it had to be shown that this increase can be verified when using experimental methods, which also allows for testing whether the facial responses in demented patients are still typical for pain. We investigated facial responses in 42 demented patients and 54 aged-matched healthy controls to mechanically induced pain of various intensities. The face of the subject was videotaped during pressure stimulation and was later analysed using the Facial Action Coding System. Besides facial responses we also assessed self-report ratings. Comparable to previous findings, we found that facial responses to noxious stimulation were significantly increased in demented patients compared to healthy controls. This increase was mainly due to an increase of pain-indicative facial responses in demented patients. Moreover, facial responses were closely related to the intensity of stimulation, especially in demented patients. Regarding self-report ratings, we found no significant group differences; however, the capacity to provide these self-report ratings was diminished in demented patients. The preserved pain typicalness of facial responses to noxious stimulation suggests that pain is reflected as validly in the facial responses of demented patients as it is in healthy individuals. Therefore, the facial expression of pain has the potential to serve as an alternative pain assessment tool in demented patients, even in patients who are verbally compromised.
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Affiliation(s)
- Miriam Kunz
- Physiological Psychology, Otto-Friedrich University Bamberg, Germany.
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29
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Aubin M, Giguère A, Hadjistavropoulos T, Verreault R. [The systematic evaluation of instruments designed to assess pain in persons with limited ability to communicate]. Pain Res Manag 2007; 12:195-203. [PMID: 17717611 PMCID: PMC2670710 DOI: 10.1155/2007/705616] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Chronic pain is often underdetected and undertreated in long-term care facilities. The use of self-report measures of pain (such as the visual analogue scale) is often problematic for older adults residing in long-term care because of the high prevalence of visual and auditory deficits and severe cognitive impairment. Observational measures of pain have been developed to address this concern. A systematic grid designed to assess the properties of existing observational measures of pain was used for seniors with dementia. The grid focused on the evaluation of content validity (12 items), construct validity (12 items), reliability (13 items) and clinical utility (10 items). Among the 24 instruments that were evaluated, several were deemed to be promising in the assessment of pain among older persons with severe dementia. Nonetheless, additional research is needed before their routine integration in the practices of long-term care settings.
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Affiliation(s)
- Michèle Aubin
- Université Laval, département de médecine familiale, Québec, Canada.
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30
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Achterberg WP, Pot AM, Scherder EJ, Ribbe MW. Pain in the nursing home: assessment and treatment on different types of care wards. J Pain Symptom Manage 2007; 34:480-7. [PMID: 17616332 DOI: 10.1016/j.jpainsymman.2006.12.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2006] [Revised: 12/20/2006] [Accepted: 12/22/2006] [Indexed: 11/30/2022]
Abstract
The assessment and management of pain in nursing homes have been shown to be suboptimal, but no study has evaluated differences in clinical setting within these homes. The prevalence and management of pain on different care wards (psychogeriatric, somatic, and rehabilitation) was studied on 562 newly admitted Dutch nursing home residents. Pain was measured according to the Nottingham Health Profile (perceived pain) and the Minimum Data Set pain observation items (frequency and intensity). Pain frequency differed significantly across the different ward types: on psychogeriatric wards (n=247), it was 27.1%; on somatic wards (n=181), 53.9%; and on rehabilitation wards (n=129), 57.8%. Being admitted on a psychogeriatric ward was significantly related to less pain compared to being admitted on a somatic ward, even when adjusted for possible confounders such as age, gender, cognitive status, activities of daily living, pain-related disorders, and depression (odds ratio [OR] 0.38 [95% confidence interval (CI)=0.23-0.62]). Patients on psychogeriatric wards who had pain received less pain medication, adjusted for frequency and intensity of pain (OR 0.37 [95% CI=0.23-0.59]), compared to patients on somatic wards. We conclude that admission to a psychogeriatric care ward, independent of cognition, is associated with lower pain prevalence, and also with lower levels of pain treatment.
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Affiliation(s)
- Wilco P Achterberg
- Institute for Research in Extramural Medicine (EMGO), Vrije Universiteit Medical Center, Amsterdam, The Netherlands.
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31
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Kaasalainen S. Pain Assessment in Older Adults With Dementia: Using Behavioral Observation Methods in Clinical Practice. J Gerontol Nurs 2007; 33:6-10. [PMID: 17598622 DOI: 10.3928/00989134-20070601-03] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pain assessment in older adults with dementia recently has received considerable attention from both researchers and clinicians as evidenced by a surge of published behavioral observation tools for pain assessment in this vulnerable population. These behavioral observation methods offer a promising strategy to improve pain assessment in older adults who are not able to communicate their pain verbally. However, some concerns exist related to the interpretation and clinical utility of these methods for decision making related to pain management interventions. This article provides an overview of the general state of knowledge on the use of behavioral observation methods in older adults and discusses the use of such methods to guide decision making in clinical settings.
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Affiliation(s)
- Sharon Kaasalainen
- School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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32
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Regnard C, Reynolds J, Watson B, Matthews D, Gibson L, Clarke C. Understanding distress in people with severe communication difficulties: developing and assessing the Disability Distress Assessment Tool (DisDAT). JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2007; 51:277-92. [PMID: 17326809 DOI: 10.1111/j.1365-2788.2006.00875.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Meaningful communication with people with profound communication difficulties depends on the ability of carers to recognize and translate many different verbal cues. Carers appear to be intuitively skilled at identifying distress cues, but have little confidence in their observations. To help in this process, a number of pain tools have been developed, but this sits uncomfortably with the lack of evidence that pain has any specific signs or behaviours. A palliative care team working with people with intellectual disabilities developed the Disability Distress Assessment Tool (DisDAT) to document a wide range of signs and behaviours of distress and when an individual is content. METHOD The tool was piloted with 16 carers and 8 patients. It was then assessed using quantitative and qualitative methods, employing 56 carers in routine clinical situations with 25 patients, most with severe communication difficulties. Carers of 10 patients participated in semi-structured interviews exploring the signs and behaviours demonstrated by patients when distressed and when content. These same 10 patients were observed for distress cues during different activities. RESULTS It became clear that distress did not have a common meaning among carers, but there was a clear understanding that distress did not just cover physical pain. The range of distress cues was wide, with no evidence that any cues were specific to particular causes. Although some distress cues were common between patients, each patient had a distinct pattern of distress cues. In addition, different carers identified a different range of distress cues, while the length of the relationship did not influence the number of cues identified. Most distress cues were a change from the norm, but some patients demonstrated distress as an absence of content cues. Carers found the DisDAT simple to use and useful, and several felt that DisDAT would have helped advocate for the patients in previous conflicts with clinical teams. CONCLUSIONS There was no evidence that pain has any specific signs or behaviours. The preliminary and assessment phases showed that distress was a useful clinical construct in providing care. The DisDAT reflected patients' distress communication identified by a range of carers, and provided carers with evidence for their intuitive observations of distress.
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Affiliation(s)
- C Regnard
- St Oswald's Hospice, Newcastle City Hospitals NHS Trust and Northgate and Prudhoe NHS Trust, Newcastle Upon Tyne, UK.
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33
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Costardi D, Rozzini L, Costanzi C, Ghianda D, Franzoni S, Padovani A, Trabucchi M. The Italian version of the pain assessment in advanced dementia (PAINAD) scale. Arch Gerontol Geriatr 2007; 44:175-80. [PMID: 16730814 DOI: 10.1016/j.archger.2006.04.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2004] [Revised: 04/17/2006] [Accepted: 04/19/2006] [Indexed: 11/24/2022]
Abstract
Pain is an unpleasant sensory and emotional experience. It's recognized to be modified by individual memory, expectation, and emotion. The most accurate evidence of pain and its intensity is based on patient's description and self-report. One of the main problems in assessing pain in dementia concerns with the impairment of communication and memory. Unfortunately, the most used tools to evaluate pain have been developed for normal aging people, requiring verbal and cognitive skills. Therefore, proper instruments are urged to be developed, tested, and validated to assess pain in a cognitively impaired population. The purpose of this study was to assess the validity of the PAINAD in the Italian version as a reliable tool for measuring pain in demented people.
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Affiliation(s)
- D Costardi
- Geriatric Rehabilitation Unit, Richiedei Medical Center, Via Sgrazzutti 1, I-25036 Palazzolo s/O, and Department of Neurology, University of Brescia, Italy.
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34
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Snow AL, Shuster JL. Assessment and treatment of persistent pain in persons with cognitive and communicative impairment. J Clin Psychol 2007; 62:1379-87. [PMID: 16937350 DOI: 10.1002/jclp.20317] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pain management is a challenge when working with persons who have cognitive impairment that affects their ability to understand and communicate. This article focuses on pain assessment and treatment in persons who have dementia, but the challenges and principles are relevant to the spectrum of cognitive impairment. Fundamental principles guiding pain assessment and treatment in this population are (1) that behavioral disturbance is the result of an unmet need that causes discomfort, (2) that the behavioral disturbances that result from the unmet need of uncontrolled pain may be identical to those caused by other unmet needs (e.g., thirst, needing to toilet, understimulation, overstimulation, depression, psychosis, uncomfortable clothing), and therefore (3) that any pain treatment protocol for this population must target discomfort behaviors in general and then attempt to determine their causes. Pain assessment and treatment approaches based on these principles are outlined, and then two cases are presented to illustrate the application of these approaches.
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Affiliation(s)
- A Lynn Snow
- Center for Mental Health and Department of Psychology, University of Alabama and Tuscaloosa Veterans Affairs Medical Center, Tuscaloosa, AL 35487, USA.
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35
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Abstract
This article analyzes the Pain Terminology adopted by the International Association for the Study of Pain (IASP), noting that most of their pain categories are defined in terms of a reference standard of "normal" pain. Given the lack of any officially adopted operational definition of the word "normal," we argue that the use of this word expresses and maintains a paradigm that drives many clinicians' reasoning about their patients' pain. We offer evidence that this uninterrogated paradigm is being tacitly used to differentiate legitimate pain reports from malingering and drug seeking. We consider this unsubstantiated "folk" sense of "normal" in light of evidence-based, rationalized prototypes based on statistical analysis of empirical evidence. We conclude that evidence for consistency in the experience and expression of pain and for clinician accuracy in evaluating the veracity of that pain is lacking; therefore, the logical preconditions needed for a rationalized, evidence-based prototype of "normal" pain have yet to be met. We conclude that the use of "normal" as a reference standard leads to ineffective and inhumane management of patient pain and to the danger that third parties, such as insurance companies and drug enforcement agencies, will use this unsubstantiated reference standard to arbitrarily limit pain therapy options. The authors recommend that the word "normal" be expunged from the International Association for the Study of Pain, Pain Terminology.
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Affiliation(s)
- Ruth J Cronje
- Scientific and Technical Communication Program, Department of English, University of Wisconsin, Eau Claire, Eau Claire, WI 54702, USA.
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Lövheim H, Sandman PO, Kallin K, Karlsson S, Gustafson Y. Poor staff awareness of analgesic treatment jeopardises adequate pain control in the care of older people. Age Ageing 2006; 35:257-61. [PMID: 16547117 DOI: 10.1093/ageing/afj067] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Undertreatment of pain is a common problem in geriatric care. The aim of this study was to compare the caring staff 's answers concerning the resident's pain treatment with actual pharmacological pain treatment in a cross-sectional survey of the geriatric care population in the county of Västerbotten, Sweden. METHODS A cross-sectional study in all geriatric care units in the county of Västerbotten, Sweden, including 3,724 inhabitants aged 65 years and over. The mean age was 83.3 and the number of cognitively impaired 2,047 (55.0%). Medication data were obtained from prescription records. The member of staff who knew the resident best judged their pain based on observations the preceding week. RESULTS The reported pain prevalence in the sample was 56.7%. Of those residents reported to suffer from pain, 27.9% received no analgesics as regular medication. In 72.7% of those cases with reported pain and no pharmacological treatment, the staff member who knew the resident best still thought that the resident was receiving treatment for her/his pain. CONCLUSION A large proportion of the old people in geriatric care settings suffer from pain, and undertreatment of pain appears to be a significant problem. Even when the resident was not receiving pharmacological treatment for their pain, the assessor, who was expected to know the resident best, still believed in a majority of cases that the resident was receiving treatment. This highlights the need for better communication between the various professional categories involved in geriatric care.
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Affiliation(s)
- Hugo Lövheim
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, SE-901 85 Umeå, Sweden.
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37
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Rader J, Barrick AL, Hoeffer B, Sloane PD, McKenzie D, Talerico KA, Glover JU. The Bathing Of Older Adults with Dementia. Am J Nurs 2006; 106:40-8, quiz 48-9. [PMID: 16575237 DOI: 10.1097/00000446-200604000-00026] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Older adults who need assistance with bathing often find the activity to be both physically and emotionally demanding, as do their caregivers. Research has identified several contributing factors, including pain; fatigue and weakness; confusion; anxiety resulting from being naked in front of strangers, being afraid of falling, and being in a noisy or unfamiliar place; and discomfort from cold or drafty bathing areas or harsh water sprays. The authors of this article make the case for the elimination of forced bathing. Research supports this change in philosophy and practice, whereby bathing is not a task to be performed but rather a human interaction. Inexpensive, practical, and evidence-based alternatives are discussed.
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Abstract
AIM This paper reports on a study examining the level of agreement between the pain perceptions of nursing assistants, older people without dementia and patients with Alzheimer's dementia. It was hypothesized that nursing assistants would overestimate the pain experience of patients with Alzheimer's dementia. BACKGROUND There is now increasing evidence that, in contrast to other subtypes of dementia, patients with Alzheimer's disease might experience a decrease in pain. It is unfortunate that these latest insights into the complex relationship between subtypes of dementia and pain are not always included in education programmes for nursing assistants. METHOD Twenty patients with Alzheimer's disease and 17 older people with arthrosis and/or osteoporosis but no dementia and their personal nursing assistants participated in the study. Pain experience was assessed using the Coloured Analogue Scale for the assessment of Pain Intensity and Pain Affect, the Faces Pain Scale, and the Checklist of Non-verbal Pain Indicators. The data were collected in 2002-2003. RESULTS Before and after walking, the absolute difference in pain evaluation between nursing assistants and older people without dementia was statistically significantly less than the difference in pain evaluation between nursing assistants and patients with Alzheimer's disease on the Coloured Analogue Scale for Pain Intensity (P = 0.007 and P = 0.04, respectively) and on the Coloured Analogue Scale for Pain Affect (P = 0.009 and P = 0.01, respectively). CONCLUSION Nursing assistants may overestimate the extent of suffering from pain of patients with Alzheimer's disease. They might be very well able to estimate this pain, provided they were educated about new insights into the influence of the various subtypes of dementia on pain.
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Affiliation(s)
- Erik Scherder
- Clinical Neuropsychology, Vrije Universiteit, Amsterdam, The Netherlands.
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Fisher SE, Burgio LD, Thorn BE, Hardin JM. Obtaining Self-Report Data From Cognitively Impaired Elders: Methodological Issues and Clinical Implications for Nursing Home Pain Assessment. THE GERONTOLOGIST 2006; 46:81-8. [PMID: 16452287 DOI: 10.1093/geront/46.1.81] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE We developed and evaluated an explicit procedure for obtaining self-report pain data from nursing home residents across a broad range of cognitive status, and we evaluated the consistency, stability, and concurrent validity of resident responses. DESIGN AND METHODS Using a modification of the Geriatric Pain Measure (GPM-M2), we interviewed 61 residents from two nursing homes (Mini-Mental State Examination score, M = 15 +/- 7) once a week for 4 consecutive weeks. We collected additional data by means of chart review, cognitive status assessments, and surveys of certified nursing assistants. We used descriptive and correlational analyses to address our primary aims. RESULTS Eighty-nine percent of residents completed all four scheduled interviews. Cognitive status was not significantly correlated with number of nonresponses and prompts for yes-no questions, but it was significantly correlated with nonresponses and prompts for Likert-scale questions (r = -.48, p <.001 and r = -.59, p <.001, respectively). Completion time for the 17-item pain measure (M = 13 min) was not predicted by cognitive status. Residents' scores on the GPM-M2 were significantly correlated with number of chronic pain-associated diagnoses, r =.37, p <.01, and internal consistency was excellent, alpha = 0.87 - 0.91. Residents' GPM-M2 scores were stable over time, r =.74-.80, p <.0001, for all comparisons. IMPLICATIONS Using explicit protocols and reporting procedural data allows researchers and clinicians to better understand and apply results of self-report studies with cognitively impaired elders. Results suggest that many nursing home residents can provide consistent and reliable self-report pain data, given appropriate time and assistance.
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Affiliation(s)
- Susan E Fisher
- VA Pittsburgh Healthcare System, Behavioral Health Service Line (116A-H), 7180 Highland Drive, Pittsburgh, PA 15206, USA.
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Herr K, Bjoro K, Decker S. Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review. J Pain Symptom Manage 2006; 31:170-92. [PMID: 16488350 DOI: 10.1016/j.jpainsymman.2005.07.001] [Citation(s) in RCA: 333] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2005] [Indexed: 11/19/2022]
Abstract
To improve assessment and management of pain in nonverbal older adults with dementia, an effective means of recognizing and evaluating pain in this vulnerable population is needed. The purpose of this review is to critically evaluate the existing tools used for pain assessment in this population to provide recommendations to clinicians. Ten pain assessment tools based on observation of behavioral indicators for use with nonverbal older adults with dementia were evaluated according to criteria and indicators in five areas: conceptualization, subjects, administration, reliability, and validity. Results indicate that although a number of tools demonstrate potential, existing tools are still in the early stages of development and testing. Currently, there is no standardized tool based on nonverbal behavioral pain indicators in English that may be recommended for broad adoption in clinical practice.
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Affiliation(s)
- Keela Herr
- Adult & Gerontological Nursing, College of Nursing, The University of Iowa, 52242, USA.
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Zwakhalen SMG, Hamers JPH, Abu-Saad HH, Berger MPF. Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatr 2006; 6:3. [PMID: 16441889 PMCID: PMC1397844 DOI: 10.1186/1471-2318-6-3] [Citation(s) in RCA: 302] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2005] [Accepted: 01/27/2006] [Indexed: 11/13/2022] Open
Abstract
Background Pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40–80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia. Methods This systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales. Results Twenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales (DOLOPLUS2; ECPA; ECS; Observational Pain Behavior Tool; CNPI; PACSLAC; PAINAD; PADE; RaPID; Abbey Pain Scale; NOPPAIN; Pain assessment scale for use with cognitively impaired adults) were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities. Conclusion Based on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility.
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Affiliation(s)
- Sandra MG Zwakhalen
- Department of Health Care Studies, Section of Nursing Science, Universiteit Maastricht, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Jan PH Hamers
- Department of Health Care Studies, Section of Nursing Science, Universiteit Maastricht, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Huda Huijer Abu-Saad
- School of nursing, Faculty of Medicine, American University of Beirut, P.O.Box 11-0236, Riad El-Solh / Beirut 1107 2020, Lebanon
| | - Martijn PF Berger
- Department of Methodology and Statistics, Universiteit Maastricht, The Netherlands
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Abstract
Pain assessment is critical to optimal pain management interventions. While pain is a highly subjective experience, its management necessitates objective standards of care. The WILDA approach to pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors-offers a concise template for assessment in patients with acute and chronic pain.
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Affiliation(s)
- R Fink
- University of Colorado Hospital, Denver 80262, USA.
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Kerr D, Wilkinson H. Responding to pain needs of people with a learning disability/intellectual disability and dementia: What are the key lessons? ACTA ACUST UNITED AC 2006. [DOI: 10.1515/ijdhd.2006.5.1.69] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Scherder EJA, Swaab DF. Chapter 55 Pain in dementia. HANDBOOK OF CLINICAL NEUROLOGY 2006; 81:817-XX. [PMID: 18808877 DOI: 10.1016/s0072-9752(06)80059-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Tsai PF, Means KM. Osteoarthritic knee or hip pain: possible indicators in elderly adults with cognitive impairment. J Gerontol Nurs 2005; 31:39-45. [PMID: 16130361 DOI: 10.3928/0098-9134-20050801-13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Many elderly individuals with cognitive impairment (CI) suffer from chronic pain resulting from osteoarthritis (OA). They have diminished ability to communicate their pain to health care providers, and when pain is undetected, it may be untreated. A method of detecting chronic OA pain in elderly individuals with Cl and measuring treatment outcomes is thus urgently needed. This article examines indicators of chronic OA pain in cognitively intact elderly individuals that could be used to identify pain in elderly individuals with Cl. The review suggests that patients with severe knee or hip OA pain tend to show specific motor patterns, disturbances of gait patterns, and reduction of activity level. Therefore, these behaviors could serve as alternatives to verbal report of chronic pain in elderly individuals with Cl and knee or hip OA.
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Affiliation(s)
- Pao-Feng Tsai
- College of Nursing , University of Arkansas for Medical Sciences, Little Rock 72205, USA
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Rodriguez CS, VanCott ML. Speech impairment in the postoperative head and neck cancer patient: nurses' and patients' perceptions. QUALITATIVE HEALTH RESEARCH 2005; 15:897-911. [PMID: 16093369 DOI: 10.1177/1049732305278903] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Communication between postoperative head and neck cancer patients with speech impairment and their health care providers is challenging. These challenges emerge during a period when the patient must communicate needs related to symptoms such as pain or concerns of significance in the absence of the traditional communication process. Content analysis methods facilitated understanding of the perspective of the postoperative head and neck cancer patient experiencing pain and a speech impairment, and the examination of the nurses' view in the assessment and management of this population. The authors identified self-report of pain as a critical component of pain assessment regardless of the presence of a speech impairment. Significant levels of frustration were associated with the nurses' goal of addressing the pain management needs of the speech impaired and the patients' pursuit of reporting the uniqueness of their pain experience.
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Abstract
TOPIC Pain assessment is a particular challenge among individuals with advanced dementia who lack the ability to formulate and express their experience of discomfort. PURPOSE Awareness of pain scales and methods specifically designed for use with nonverbal individuals with dementia is critical to expanded use and testing in clinical settings. SOURCES Computerized literature searches using four databases revealed the five observational scales and two caregiver reports methods reviewed. CONCLUSIONS A small number of valid, reliable, and sensitive scales are available for use by nurses and allied health personnel. Each has strengths and limitations and all would benefit from additional testing.
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Affiliation(s)
- Marianne Smith
- College of Nursing, University of Iowa, Iowa City, IA, USA.
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Demographic disparities in the prescription of patient-controlled analgesia for postoperative pain. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.acpain.2004.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Molony SL, Kobayashi M, Holleran EA, Mezey M. Assessing Pain as a FIFTH VITAL SIGN IN LONG-TERM CARE FACILITIES: Recommendations from the Field. J Gerontol Nurs 2005; 31:16-24. [PMID: 15799633 DOI: 10.3928/0098-9134-20050301-06] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In long-term care facilities, pain management is complex because dementia, delirium, and other reasons for residents' altered communication ability are a significant barrier to pain assessment. The purpose of this study was to explore the status of implementation of pain as a fifth vital sign in a sample of long-term care facilities. A three-round Delphi survey was used to obtain consensus from personnel in 60 long-term care facilities in NY State. Findings are presented in terms of recommendations related to pain criteria, assessment methods, frequency of pain assessment, responsibility for pain assessment, monitoring strategies, education, documentation, and pain management education. The results of this study highlight many important considerations in the treatment of pain as a fifth vital sign in long-term care facilities. Evidence-based practice will be facilitated by further research related to underexplored aspects of pain assessment and management, and further attention to care delivery systems that support continued knowledge acquisition and the implementation of best practices.
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Closs SJ, Cash K, Barr B, Briggs M. Cues for the identification of pain in nursing home residents. Int J Nurs Stud 2005; 42:3-12. [PMID: 15582634 DOI: 10.1016/j.ijnurstu.2004.05.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2004] [Revised: 04/26/2004] [Accepted: 05/11/2004] [Indexed: 12/11/2022]
Abstract
The aim of this section of a larger study was to identify the range of cues from which pain was inferred for a sample of residents with various levels of cognitive impairment in 15 UK nursing homes. Sixty-five nursing home staff and 36 informal carers of the 113 residents were interviewed. There was extensive use of body movements, facial expressions, and verbal and vocal cues and a considerable degree of interpretation of cues was used. There was little difference between the types of cue used by formal and informal carers, although informal carers tended to identify more of all types. There were differences in cues identified according to level of cognitive impairment, in particular, the interpretation of body movements. A simple model of the interaction between cognitive deficit, cue type and level of cue interpretation was proposed.
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Affiliation(s)
- S José Closs
- School of Healthcare, Baines Wing, University of Leeds, Leeds LS2 9UT, UK.
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