Pain in nursing home residents. Comparison of residents' self-report and nursing assistants' perceptions. Incongruencies exist in resident and caregiver reports of pain; therefore, pain management education is needed to prevent suffering

Development, evaluation, and implementation of an online pain assessment training program for staff in rural long-term care facilities: a case series approach

Background

Pain among long-term care (LTC) residents, and especially residents with dementia, is often underassessed and this underassessment has been attributed, in part, to gaps in front-line staff education. Furthermore, although evidence-based clinical guidelines for pain assessment in LTC are available, pain assessment protocols are often inconsistently implemented and, when they are implemented, it is usually within urban LTC facilities located in large metropolitan centers. Implementation science methodologies are needed so that changes in pain assessment practices can be integrated in rural facilities. Thus, our purpose was to evaluate an online pain assessment training program and implement a standardized pain assessment protocol in rural LTC environments.

Methods

During the baseline and implementation periods, we obtained facility-wide pain-related quality indicators from seven rural LTC homes. Prior to implementing the protocol, front-line staff completed the online training program. Front-line staff also completed a set of self-report questionnaires and semi-structured interviews prior to and following completion of the online training program.

Results

Results indicated that knowledge about pain assessment significantly increased following completion of the online training program. Implementation of the standardized protocol resulted in more frequent pain assessments on admission and on a weekly basis, although improvements in the timeliness of follow-up assessments for those identified as having moderate to severe pain were not as consistent. Directed content analysis of semi-structured interviews revealed that the online training program and standardized protocol were well-received despite a few barriers to effective implementation.

Conclusions

In conclusion, we demonstrated the feasibility of the remote delivery of an online training program and implementation of a standardized protocol to address the underassessment of pain in rural LTC facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03020-8.

Validity of the Rotterdam Elderly Pain Observation Scale for institutionalised cognitively impaired Dutch adults

BACKGROUND

The Rotterdam Elderly Pain Observation Scale (REPOS) has not yet been validated for institutionalised cognitively impaired adults. To fill this gap of knowledge, we tested psychometric properties of the REPOS when used for pain assessment in this population.

METHODS

In this multicentre observational study, residents were filmed during a possibly painful moment and at rest. Healthcare professionals were asked to rate residents' pain by means of a Numeric Rating Scale (NRS)-proxy. Two researchers assessed pain with the REPOS and the Chronic Pain Scale for Non Verbal Adults with Intellectual Disabilities (CPS-NAID) from video-recordings.

RESULTS

In total, 168 observations from 84 residents were assessed. Inter-observer reliability between the two researchers was good, with Cohen's kappa 0.72 [95% confidence interval (CI) 0.64 to 0.79]. Correlation between the REPOS and CPS-NAID for a possibly painful moment was 0.73 (95% CI 0.65 to 0.79). Sensitivity (85%) and specificity (61%) for the detection of pain were calculated with REPOS ≥ 3 and NRS ≥ 4 as a reference value. Item response theory analysis shows that the item grimace displayed perfect discrimination between residents with and without pain.

CONCLUSION

The REPOS is a reliable and valid instrument to assess pain in cognitively impaired individuals.

An Eye Tracking Investigation of Pain Decoding Based on Older and Younger Adults' Facial Expressions

Nonverbal pain cues such as facial expressions, are useful in the systematic assessment of pain in people with dementia who have severe limitations in their ability to communicate. Nonetheless, the extent to which observers rely on specific pain-related facial responses (e.g., eye movements, frowning) when judging pain remains unclear. Observers viewed three types of videos of patients expressing pain (younger patients, older patients without dementia, older patients with dementia) while wearing an eye tracker device that recorded their viewing behaviors. They provided pain ratings for each patient in the videos. These observers assigned higher pain ratings to older adults compared to younger adults and the highest pain ratings to patients with dementia. Pain ratings assigned to younger adults showed greater correspondence to objectively coded facial reactions compared to older adults. The correspondence of observer ratings was not affected by the cognitive status of target patients as there were no differences between the ratings assigned to older adults with and without dementia. Observers' percentage of total dwell time (amount of time that an observer glances or fixates within a defined visual area of interest) across specific facial areas did not predict the correspondence of observers' pain ratings to objective coding of facial responses. Our results demonstrate that patient characteristics such as age and cognitive status impact the pain decoding process by observers when viewing facial expressions of pain in others.

Validation of the Rotterdam Elderly Pain Observation Scale in the Hospital Setting

BACKGROUND

The Rotterdam Elderly Pain Observation Scale (REPOS) has been proven useful to assess pain in noncommunicative and cognitively impaired nursing home residents. We evaluated whether the REPOS is also reliable and valid for pain assessment in the hospital setting.

METHODS

In this prospective multicenter observational study, surgical patients were observed perioperatively at bedside and internal medicine patients were filmed during a possible painful moment and at rest. Pain behavior was assessed from the video recordings with the REPOS and the Pain Assessment Checklist for seniors with Severe Dementia-Dutch language (PACSLAC-D). Longitudinal associations between REPOS score and numeric rating scale pain ratings from observers and nurses (NRS_obs and NRS_proxy ) corrected for patients' gender were assessed with linear mixed models.

RESULTS

In total, 72 patients were included; 118 observations of surgical and 68 observations of internal medicine patients were analyzed. Interobserver reliability between the researcher and 2 other observers was good, with Cohen's kappa values of 0.71 (confidence interval [CI] 0.59 to 0.83) and 0.84 (CI 0.74 to 0.94), respectively. The intraobserver reliability of the principal investigator was good, with Cohen's kappa 0.82 (CI 0.67 to 0.91). Linear mixed modeling revealed correlation values between the REPOS and NRS_obs of 0.67 and the REPOS and NRS_proxy of 0.73. Optimal sensitivity (78%) and specificity (90%) for the detection of pain were found with a REPOS cutoff score of ≥3, using an NRS score of ≥4 as the reference value.

CONCLUSIONS

The REPOS is reliable and valid for the assessment of postoperative and chronic pain in hospital patients who cannot self-report pain.

Pain assessment in the older population: what the literature says

Assessment of pain in the older adult presents a number of challenges, especially related to communication. This commentary summarises the revised evidence-based Guidelines on the Assessment of Pain in Older Adults which have been developed by the British Pain Society and British Geriatrics Society. The guideline summarises the pain assessment tools that have been developed and validated for use in the older population. Recommendations are made for use of specific tools in older people and in those with dementia. The need for education and training of health care professionals is emphasised. Gaps in the evidence are identified as subjects for future research. It is hoped that the guideline will improve recognition of pain in older people, and help to drive the future research agenda.

Certified Nursing Assistants' Understanding of Nursing Home Residents' Pain

Pain is a significant problem for nursing home residents, yet its assessment is complex. Certified nursing assistants (CNAs) spend significant time with residents, but their role in understanding residents' pain is largely unexplored. The current qualitative grounded theory study analyzed interviews with 16 CNAs who described their experiences caring for residents in pain. Findings revealed how CNAs understood, recognized, interpreted, and responded to residents' pain. CNAs were found to differentiate between pain that they considered normal (everyday pain) and new pain judged significant enough to report to licensed nurses. CNAs exhibited a holistic understanding of pain, knowledge of strategies to identify and interpret pain, and actions to independently mitigate and report pain. Although additional confirmatory data are needed, the differentiation made between everyday and reportable pain may have important clinical implications suggesting that CNAs should always report to a licensed nurse when they perceive or suspect that residents have pain. [Journal of Gerontological Nursing, 44(4), 29-36.].

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

Background

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

Aims and objectives

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

Methods

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

Results

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

Limitations

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

Conclusions

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

Funding

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

The experience of chronic pain in elderly nursing home residents

The overall purpose of the study reported here was to explore the experience of being old and in chronic pain while living in a nursing home. The aims of the study were to discover what it was like for older people to live with chronic pain, and how and in what way chronic pain impacts on their lives. One major theme from the study is presented here, ‘Being constantly pained’, as it represents the essential feature of the lived experience of pain. In presenting the findings, seven sub-themes are discussed, including: ‘the painfulness of pain’, ‘the certainty/uncertainty of pain’, ‘overwhelming pain’, ‘unvoicing pain’, ‘being old and worn out’, ‘being forgotten’ and ‘taking punishment’. The findings of this study have the potential to increase understanding of the experience of chronic pain in elderly people by nurses and other healthcare professionals. In addition, the findings also have implications for the provision of healthcare in nursing homes and for conducting research with those who are very old. In a climate of limited government funding and support for services in nursing homes, the data highlight concerns about the role of unqualified staff in this setting.

Healthcare providers' accuracy in assessing patients' pain: A systematic review

OBJECTIVE

Healthcare providers satisfy an important role in providing appropriate care in the prevention and management of acute and chronic pain, highlighting the importance of providers' abilities to accurately assess patients' pain. We systematically reviewed the literature on healthcare providers' pain assessment accuracy.

METHODS

A systematic literature search was conducted in PubMed and PsycINFO to identify studies addressing providers' pain assessment accuracy, or studies that compared patients' self-report of pain with providers' assessment of pain.

RESULTS

60 studies met the inclusion criteria. Healthcare providers had moderate to good pain assessment accuracy. Physicians and nurses showed similar pain assessment accuracy. Differences in pain assessment accuracy were found according to providers' clinical experience, the timing of the pain assessment, vulnerable patient populations and patients' pain intensity.

CONCLUSION

Education and training aimed at improving providers with poor pain assessment accuracy is discussed especially in relation to those with limited clinical experience (<4 years) or a great deal of clinical experience (>10 years) and those providing care for vulnerable patient populations.

PRACTICE IMPLICATIONS

More research on characteristics that influence providers' pain assessment accuracy and trainings to improve pain assessment accuracy in medical and continuing education may improve pain treatment for patients.

Biobehavioral measures as outcomes: a cautionary tale

This article discusses the use of biobehavioral measures as outcomes for health care intervention studies. Effect size (ES) values for salivary cortisol and observation-based measures of pain and agitation were examined. Effects pre to post treatment were assessed separately for nursing home residents with and without acute psychotic symptoms. This study revealed large positive effects on both pain and agitation measures in the group with acute psychotic symptoms and small-to-medium positive effects on these same measures in the group without acute psychotic symptoms. In both of these groups, the ES values were not consistently positive on the cortisol measures. Prior to determining whether a measure can be used to estimate minimum clinically important differences, it is essential to consider if the biomarker will be responsive to therapy in the populations and contexts being studied.

Exploring nursing assistants' roles in the process of pain management for cognitively impaired nursing home residents: a qualitative study

AIM

To explore nursing assistants' roles during the actual process of pain management (assessment, reporting, implementation of pain-relieving interventions and re-assessment) for cognitively impaired home residents with pain.

BACKGROUND

Nursing assistants provide most of the direct care to residents and represent the major taskforce in nursing homes. They may develop specialized knowledge of residents' pain experience that enables them to play both a pivotal role in pain assessment and possibly a supporting role in pain treatment. Currently, there is a lack of research into nursing assistants' functions in pain management.

DESIGN

This is a descriptive, exploratory qualitative study.

METHODS

Forty-nine nursing assistants were recruited from 12 nursing homes, 12 of them participating in semi-structured individual interviews and 37 in 8 semi-structured focus groups. All interviews were carried out from May to September 2010. Data collected via both data collection methods were transcribed verbatim and analysed by content analysis.

RESULTS

Nursing assistants were found to play four roles in the pain management process: (1) pain assessor; (2) reporter; (3) subordinate implementing prescribed medications; and (4) instigator implementing non-pharmacological interventions.

CONCLUSIONS

This study highlights the importance of nursing assistants in successful pain assessment and identifies their possible supporting roles in other aspects of pain management. However, nursing assistants' scope of practice resulted in their functions in pain management being continually undervalued by other healthcare professionals. Continuous in-service training, the use of a standardized pain management protocol and strategies for building coherent work teams in nursing homes are suggested to improve this situation.

Prevalence of pain in institutionalized adults with intellectual disabilities: a cross-sectional approach

Information about pain prevalence in institutionalized individuals with intellectual disabilities is scarce, most likely because communication problems impede pain assessment. We aimed to inventory pain prevalence and actual pain management in intellectually disabled individuals living in a representative special care facility in the Netherlands. Caregivers rated the residents' present pain and overall pain during the preceding week on an 11-point numerical rating scale (NRS-11). In addition, behavioral pain assessment was performed with validated pain scales; the Rotterdam Elderly Pain Observation Scale (REPOS) or Checklist Pain Behavior (CPG). Ratings suggested that 47 of the 255 included residents (18%) suffered from pain either at present or during the preceding week, 14 of whom (30%) experienced pain on both occasions. Most of these 47 (85%) residents with pain had no analgesic prescription, not even in the case of severe pain (NRS 7 or higher). Ratings for nearly one out of every five residents suggested they suffered pain. This proportion is lower than in other studies and could imply that caregivers probably underestimate residents' prevalence of pain. Pain treatment might be inadequate in light of the low percentage of analgesic prescriptions. To prevent unnecessary suffering in institutes for residents with an intellectual disability (ID) we recommend use of a pain protocol including a validated pain measurement instrument.

Perceptions of pain medication in the elderly

Individual interpretation of pain can vary among patients as well as in certain populations. Patients' and health care providers' assessment of pain and its treatment modalities can affect goals of therapy and overall success of treatment. Exploring these related perceptions will allow a more effective approach to the management of pain in the elderly population and improve the use of appropriate pain medications. This literature review will provide a better understanding of the associated emotional, physical, and perceptional aspects of pain within the elderly population and discuss barriers associated with the effective treatment of pain. This knowledge will serve as a resource for geriatric practitioners to select and provide appropriate therapeutic interventions for pain management in the elderly population.

Certified nursing assistants' perspectives of nursing home residents' pain experience: communication patterns, cultural context, and the role of empathy

This study explored the following issues related to pain management among nursing home (NH) residents: 1) communication patterns between NH residents and certified nursing assistants (CNAs) about pain; 2) how race and ethnicity influence NH residents' pain experiences; and 3) CNAs' personal experiences with pain that may affect their empathy toward the resident's pain experience. The study consisted of a convenience sample of four focus groups (n = 28) from a NH in central Florida. A content analysis approach was used. Data were analyzed with the use of Atlas.ti version 6.2. The content analysis identified four main themes: 1) attitudes as barriers to communication about resident pain care; 2) cultural, religious, and gender influences of resident pain care by CNAs; 3) the role of empathy in CNAs care of residents with pain; and 4) worker strategies to detect pain. Attitudes among CNAs about resident cognitive status and perceived resident burden need to be recognized as barriers to the detection and reporting of pain by CNAs and should be addressed. In addition, NHs should consider a person-centered approach to pain that is culturally competent given the cultural influences of both residents and staff. Finally, educational programs for CNAs that include empathy-inducing scenarios could potentially improve the care provided by CNAs when dealing with residents' pain.

Making the investment count: revision of the Minimum Data Set for nursing homes, MDS 3.0

BACKGROUND

The Minimum Data Set (MDS) is a potentially powerful tool for implementing standardized assessment in nursing homes (NHs). Its content has implications for residents, families, providers, researchers, and policymakers, all of whom have expressed concerns about the reliability, validity, and relevance of MDS 2.0. Some argue that because MDS 2.0 fails to include items that rely on direct resident interview, it fails to obtain critical information and effectively disenfranchises many residents from the assessment process.

PURPOSE

Design a major revision of the MDS, MDS 3.0, and evaluate whether the revision improves reliability, validity, resident input, clinical utility, and decreases collection burden.

DESIGN AND METHODS

In the form design phase, we gathered information from a wide range of experts, synthesized existing literature, worked with a national consortium of VA researchers to revise and test eight sections, pilot tested a draft MDS 3.0 and revised the draft based on results from the pilot. In the national validation and evaluation phase, we tested MDS 3.0 in 71 community NHs and 19 VHA NHs, regionally distributed throughout the United States. The sample was selected based on scheduled MDS 2.0 assessments. Comatose residents were excluded. A total 3822 residents of community NHs in eight states were included. The evaluation was designed to test and analyze inter-rater agreement (reliability) between research nurses and between facility staff and research nurses, validity of key sections, response rates for interview items, anonymous feedback on changes from participating nurses, and time to complete the MDS assessment.

RESULTS

The reliability for research nurse to research nurse and for research nurse to facility staff was good or excellent for most items. Response rates for the resident interview sections were high: 90% for cognitive, 86% for mood, 85% for preferences, and 87% for pain. Staff survey responses showed increased satisfaction with clinical relevance, validity and clarity compared with MDS 2.0. The test version of the MDS 3.0 took 45% less time for facilities to complete.

IMPLICATIONS

Improving the reliability, accuracy, and usefulness of the MDS has profound implications for NH care and public policy. Enhanced accuracy supports the primary legislative intent that MDS be a tool to improve clinical assessment and supports the credibility of programs that rely on MDS.

Undertreatment of pain in older adults: an application of beneficence

Inadequate pain control, especially in older adults, remains a significant issue when caring for this population. Older adults, many of whom experience multiple acute and chronic conditions, are especially vulnerable to having their pain seriously underassessed and inadequately treated. Nurses have an ethical obligation to appropriately treat patients' pain. To fulfill their ethical obligation to relieve pain in older patients, nurses often need to advocate on their behalf. This article provides an overview of the persistent problem of undertreated pain in older adults and explores how nurses can meet this ethical duty through the application of Beauchamp and Childress' three principles of beneficence.

How nursing personnel judge patients’ pain

The study examined how nurses, student nurses, and nurse's aides judge patients' level of pain from five indicators: facial grimacing, maintenance of abnormal body position, restriction of movement, complaints about pain, and signs of possible depression. In Toulouse, France, 214 participants were presented with 48 vignettes describing an elderly patient suffering from osteoarthritis who showed various levels of these signs. The three most important factors in judging pain were the difficulty in making social contact with the patient, the patient's avoidance of changing position, and her avoidance of movements. The nurses put more emphasis on the difficulty in making social contact than did the student nurses and nurse's aides. In all groups, each sign of pain contributed independently and additively to the level of pain that the patient was thought to be experiencing.

Evidence-based practice guideline: wheelchair biking for the treatment of depression

Depression is a problem that will continue to burden older adults and challenge health care providers. Failing to recognize and effectively treat depression in institutionalized older adults is sanctioning these members of society to live their final years in despair and emotional suffering. The wheelchair biking program described in this evidence-based practice guideline provides a refreshing, safe, innovative tool to address depression and improve quality of life in older adults.

Development of a composite pain measure for persons with advanced dementia: exploratory analyses in self-reporting nursing home residents

CONTEXT

Experts agree that pain assessment in noncommunicative persons requires data from sources that do not rely on self-report, including proxy reports, health history, and observation of pain behaviors. However, there is little empirical evidence to guide clinicians in weighting or combining these sources to best approximate the person's experience.

OBJECTIVES

The aim of this exploratory study was to identify a combination of observer-dependent pain indicators that would be significantly more predictive of self-reported pain intensity than any single indicator. Because self-reported pain is usually viewed as the criterion measure for pain, self-reported usual and worst pains were the dependent variables.

METHODS

The sample consisted of 326 residents (mean age: 83.2 years; 69% female) living in one of 24 nursing homes. Independent variables did not rely on self-report: surrogate reports from certified nursing assistants (CNAs) using the Iowa Pain Thermometer (IPT), Checklist of Nonverbal Pain Indicators (CNPI), Cornell Scale for Depression in Dementia (CSDD), Pittsburgh Agitation Scale (PAS), number of painful diagnoses, and Minimum Data Set (MDS) pain variables.

RESULTS

In univariate analyses, the CNA IPT scores were correlated most highly with self-reported pain. The final multivariate model for self-reported usual pain included CNA IPT, CSDD, PAS, and education; this model accounted for only 14% of the variance. The more extensive of the two final models for worst pain included MDS pain frequency, CSDD, CNA IPT, CNPI, and age (R(2)=0.14).

CONCLUSION

Additional research is needed to develop a predictive pain model for nonverbal persons.

Nurses' opinions of pain and the assessed need for pain medication for the elderly

The undertreatment of pain in the elderly living in nursing homes is a significant problem. In Swedish nursing homes, the registered nurse on duty is often responsible for 20-40 patients during the day with no daily contact from attending physicians. The aim of this study was to investigate the opinions of registered nurses regarding pain and the assessed need for pain medication for elderly patients using patient scenarios. Two patient scenarios were used in this study; a questionnaire and background information was provided. The scenarios consisted of one smiling patient and one grimacing patient, both with the same numeric rating scale value of pain, blood pressure, pulse rate, and respiration rate. Three questions regarding pain assessment and management followed the scenarios. The questionnaire was sent to all 128 registered nurses working daytime in elderly care in both municipal nursing homes and municipal home care in the mid-Sweden region. A total of 56 nurses participated, providing an answering frequency of 45%. Results showed that registered nurses with more experience did not have the same opinion about pain as the smiling patient and gave inadequate medication, which was not in accordance with recommendations from the county hospital and the World Health Organization.

Validating nurses' and nursing assistants' report of assessing pain in older people with dementia

AIMS AND OBJECTIVES

To evaluate the usefulness of registered nurses' (RNs) and nursing assistants' (NAs) pain report among 304 institutional older people with dementia and elucidate the factors influencing the agreement of pain reports within dyadic assessors.

BACKGROUND

Using informant reports has been suggested as an effective strategy to solve the dilemma of pain assessment in people with dementia. However, the validity of pain information provided by institutional caregivers is still under-investigated.

DESIGN

A prospective study was undertaken in six dementia special care units in Northern Taiwan.

METHODS

Both the four-item pain inventory and Doloplus-2 scale were used to investigate different raters' pain reports.

RESULTS

Across pain variables, fair to moderate agreement was noted in RNs' assessment (Kappa = 0.29-0.42), but poor agreement in NAs assessment (Kappa = 0.11-0.24). Comparing mean scores on intensity, frequency of pain and Doloplus-2, statistically systematic bias existed in most pairs, but the greater bias occurred in NAs' assessment. In logistic regression analysis, when pain was assessed by the pain inventory, residents' cognitive impairment level and caregiver's age were associated with the agreement of pain presence perceived in either resident-nurse or resident-NA pairs. Nevertheless, when pain was rated by the Doloplus-2 scale, only residents' physical function influenced the agreement of pain report for both research assistants (RAs)-nurse and RAs-NA pairs.

CONCLUSIONS

Nurses' pain report across pain variables may be more reliable than NAs. Furthermore, factors influencing the agreement of pain assessed by self-report measurement or behavioural observations may be different, needing further investigation.

RELEVANCE TO CLINICAL PRACTICE

Pain inquiry and behavioural observation should be performed routinely as the fifth vital sign for developing effective care plans. Institutional caregivers should be used as alternative or complementary informants for assessing pain in older people with dementia.

Descriptive, exploratory study of the role of nursing assistants in Australian residential aged care facilities: the example of pain management

AIM

This study explored the experiences of nursing assistants (NAs) who work with older people in residential aged care facilities (RACFs), to ascertain their role in Australian RACFs. Experiences with pain management were used as an example to explore their work role.

METHODS

A descriptive, exploratory qualitative approach was used to examine NAs' experiences. Participants included six NAs from three RACFs in regional Western Australia. In-depth interviews focused on the NAs' experiences of providing care to older people in RACFs and in particular their experiences providing pain management for residents.

RESULTS

The role of NAs often extends beyond their scope of practice. NAs describe making clinical decisions, initiating clinical care and advocating for residents.

CONCLUSIONS

NAs represent a majority of the staff in Australian RACFs and they have a significant role in clinical care. There is a need to ensure that NAs are adequately prepared and supported in their role.

Understanding nursing assistants' experiences of caring for older people in pain: the Australian experience

This study examined the experiences of nursing assistants (NAs), who have worked with older people in residential aged care facilities (RACFs) who are in pain, to ascertain the role that NAs play in the pain management process. A descriptive, exploratory qualitative approach was used to examine NAs' experiences. Six NAs employed in three RACFs in regional Western Australia participated in the study. In-depth interviews focusing on the NAs' experiences of caring for older people in pain were conducted. This study provided an understanding of the care needs of older residents in pain and illuminated the role of NAs in the pain management process. The central role that NAs play in RACFs was highlighted, as were the responsibilities associated with pain management. Nursing assistants may be responsible for initiating and implementing pain management treatments for older residents. This is outside the scope of practice for NAs; therefore, it is imperative that the preparation of NAs give them adequate knowledge to perform this role. As well, it may be timely to consider regulation of this large group of workers who are performing clinical tasks in RACFs.

Assessment of pain: can caregivers or relatives rate pain in nursing home residents?

Aim. To compare pain reports of nursing home residents to ratings by proxies. Background. It is not easy to assess pain in cognitively impaired residents. For residents who are unable to report pain intensity themselves, proxies (i.e. relatives or caregivers) might serve as sources of information. The utility of these proxies in assessing residents' pain is not clear however. Design. A multicenter cross-sectional study. Methods. Pain intensity was rated on a Numeric Rating Scale; proxies were asked how certain they were about their observations. Agreements on ratings were computed by means of intra class correlation (ICC) coefficients for continuous variables and multiple linear regression analyses were performed with the level of pain intensity by proxies as the dependent variable. Results. The sample consisted of 174 residents (median age 82 years), of whom 124 were cognitively impaired and 50 intact, and 293 proxies: 171 caregivers and 122 relatives. All three parties reported median pain intensity during the preceding week as 6.0. Data were consistent with low-to-moderate correlation coefficients between residents and caregivers (ICC = -0.12 to 0.25), residents and relatives (ICC = -0.51 to 0.48) and caregivers and relatives (ICC = 0.03 to 0.31). Residents themselves judged pain intensity at rest significantly higher than did proxies (p = 0.05). Caregivers scored significantly higher ratings for residents on analgesics (p = 0.001) and significantly lower pain ratings if they were more satisfied with the prescribed analgesics (p = 0.01). Conclusions. Proxy report of relatives and caregivers on presence and intensity of pain is unreliable, especially for cognitively impaired persons. The use of a standardised pain observation scale could be helpful. Relevance to clinical practice. Pain management in nursing home residents could be improved by educating caregivers about assessment and treatment of chronic pain. Relatives should be informed about chronic pain and learn how to alleviate pain through non-pharmacological interventions.

Disparities in pain management between cognitively intact and cognitively impaired nursing home residents

This study tests the association between residents' cognitive impairment and nursing homes' pain management practices. We used chart abstraction to collect data on 551 adults in six North Carolina nursing homes. From the standard data collected in the Minimum Data Set, 24% of residents experienced pain in the preceding week. Reports of pain decreased as cognitive abilities declined: nurses completing the Minimum Data Set reported pain prevalence of 34%, 31%, 24%, and 10%, respectively, for residents with no, mild, moderate, and severe cognitive impairment (P<0.001), demonstrating a "dose-response"-type result. Eighty percent of cognitively intact residents received pain medications, compared to 56% of residents with severe impairment (P<0.001). Cognitively impaired residents had fewer orders for scheduled pain medications than did their less cognitively impaired peers. Yet the presence of diagnoses likely to cause pain did not vary based on residents' cognitive status. We conclude that pain is underrecognized in nursing home residents with cognitive impairment and that cognitively impaired residents often have orders for "as needed" analgesics when scheduled medications would be more appropriate.

Pilot Project: The Chronic Pain Diary: Assessing Chronic Pain in the Nursing Home Population

The goal of this pilot project was to evaluate the use of a self-report diary for assessing chronic pain in nursing home residents. Data collected 14 days prior to the use of the diary were compared with data collected 14 days after diary completion. Following diary implementation, pain levels, pain-related nursing entries, and use of as-needed medication increased. There was a statistically significant increase in the number of scheduled medications. Future research, using a randomized design and multiple sites, is needed to examine the effectiveness of self-reported pain diaries in assessing chronic pain in the communicative nursing home population.

Pain and pain medication use in community-dwelling older adults

BACKGROUND

Pain is a common symptom and significant problem for older adults; up to one half of community-dwelling older adults have pain that interferes with normal function.

OBJECTIVE

The goal of this study was to investigate the prevalence of pain among a racially and gender-balanced sample of community-dwelling older adults and evaluate sociodemographic factors associated with the reporting of pain. Both nonprescription (over-the-counter [OTC]) and prescription pain medications used by the participants and the sociodemographic factors associated with having medication prescribed were considered.

METHOD

This was a population-based, prospective, observational study. Subjects were participants in the University of Alabama at Birmingham (UAB) Study of Aging, a stratified random sample of Medicare beneficiaries who completed in-home interviews (1999-2001). Assessments included sociodemographic factors and pain; interviewers listed all prescription and OTC pain medications used. Pain medications were coded as NSAIDs, opiates, and miscellaneous pain medications. A composite ordinal measure reflecting pain severity and frequency ranged from 0 = no pain to 4 = dreadful or agonizing pain > or =4 times per week.

RESULTS

There were 1000 participants in the UAB Study of Aging (mean [SD] age, 75.3 [6.7] years; 50% black; 50% male; 51% rural residence). Seventy-four percent of the subjects reported pain; among these, 52% had daily pain, with 26% reporting dreadful or agonizing pain. Logistic regression controlling for other sociodemographic factors (age, gender, race, education, income, and marital status) found that rural residence (odds ratio [OR], 1.42; 95% CI, 1.1-1.9; P = 0.02) was significantly associated with the reporting of pain. Prescription pain medications were used by 35% of persons with pain and by 17% without pain (P < 0.001); OTC pain medications were used by 52% of persons with pain and by 45% of persons without pain (P = 0.06). Of persons reporting pain, 28% were taking neither prescription nor OTC pain medications; 16% took both and 20% took only prescription pain medications. Logistic regression found that factors associated with taking a prescription pain medication were: unmarried status (OR, 1.56; 95% CI, 1.1-2.2) and pain frequency/severity (OR, 1.39; 95% CI, 1.3-1.6). Taking an OTC pain medication was associated with lower odds of taking a prescription pain medication (OR, 0.50; 95% CI, 0.4-0.7). Age, gender, race, education, rural residence, transportation difficulty, income, and being on Medicaid were not associated with prescription pain medication use.

CONCLUSIONS

Prescription pain medication use was associated with pain frequency/severity after adjusting for sociodemographics and OTC pain medications in this study of community-dwelling older adults, suggesting that even with medications, individuals remained in pain.

Substantial Daily Pain Among Nursing Home Residents

OBJECTIVE

To evaluate the prevalence of substantial daily pain among nursing home residents aged 65 and older.

DESIGN, SETTING, AND METHODS

The Minimum Data Set (MDS) annual or admission assessment, available September 2002, for Alabama nursing home residents was used. Logistic regression was used to examine the association of such pain with nursing home characteristics as well as resident-specific factors.

RESULTS

The analysis is based on 27,628 nursing home residents 65 and older with mean age of 82.8 years; 20% African American; 25% male. Seventeen percent had substantial daily pain. By nursing home, reported substantial daily pain prevalence ranged from 0% to 54.7%. The prevalence of pain was less in smaller nursing homes (P < .001). Bivariate correlations were significant for all sociodemographic and mental status variables; number of medications; dementia; thyroid, musculoskeletal, neurological, pulmonary, and sensory disorders; allergies; anemia; and cancer. Factors independently correlated with substantial daily pain included (odds ratio, 95% confidence interval) sociodemographic characteristics: white race (1.5, 1.3-1.7), female (1.3, 1.2-1.5), married (1.1, 1.0-1.2), admission within year (2.0, 1.8-2.1); nursing home characteristics: nonprofit or government financing (1.3, 1.2-1.5), greater number of residents (1.4, 1.3-1.5); subject-specific conditions: no cognitive impairment (1.6, 1.5-1.7), communication ability (1.4, 1.2-1.5), sad mood/depression (1.5, 1.4-1.6), taking 10 or more medications (2.0, 1.9-2.2), musculoskeletal disease (1.9, 1.7-2.0), anemia (1.1, 1.0-1.2), and cancer (1.6, 1.4-1.8). Lower odds of substantial daily pain were associated with older age, rural locale, dementia, and thyroid, neurological, pulmonary, and sensory disorders.

DISCUSSION

This study highlights within-state variation in MDS reporting by nursing home as well as resident-specific factors associated with daily substantial pain. Rural, for-profit, and low-occupancy nursing homes had less documented pain. Communication ability and not having cognitive impairment were important factors in having such pain reported.

Symptom distress and quality-of-life assessment at the end of life: the role of proxy response

This study sought to advance understanding of the relationships among proxy and patient reports of symptom distress and quality of life (QOL). English-speaking adults (n=86), their nurses (n=86), and family caregivers (n=49) from 11 hospice/palliative care organizations completed the Memorial Symptom Assessment Scale (MSAS) and McGill Quality of Life Questionnaire (MQOL) at hospice/palliative care enrollment, at 1 week, 2 weeks, then monthly until death or discharge. Patients and proxies provided similar average reports of symptom distress, both physical and psychological, but MSAS correlations were generally poor. MQOL correlations were higher for nurse-patient than for patient-caregiver dyads. Based on small differences between ratings but only moderate levels of correlation, proxy response appears to be a fair substitute for patient response, suggesting that symptom and QOL reports should be obtained from all available respondents throughout the course of clinical care or research in the hospice/palliative care setting.

The assessment of older people's needs in care homes

In many countries there is a concern to improve assessment procedures for older people to avoid misplacement in nursing homes and ensure that rehabilitation takes place where possible. The study examined assessment documentation in 126 care homes in North West England. On a set of core domains for assessing need, the level of coverage varied considerably. The use of standardised scales was infrequent apart from those that measured risk of developing pressure sores. Some important key domains were infrequently mentioned on the assessment forms including mental health, pain, oral health and foot care. The most frequently covered items were the activities of daily living. There were clear differences in the assessment approaches employed in different types of home. The lack of inclusion of certain key health areas on some assessment forms suggests that the well-being and quality of life of some residents may be poorly addressed, and that further work is required for the standard of assessment in care homes to match that in community-based care.

Pain in Alzheimer's disease: nursing assistants' and patients' evaluations

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.

Obtaining Self-Report Data From Cognitively Impaired Elders: Methodological Issues and Clinical Implications for Nursing Home Pain Assessment

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.

Osteoarthritic knee or hip pain: possible indicators in elderly adults with cognitive impairment

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.

Characteristics Associated With Pain in Long-Term Care Residents With Dementia

This article describes the prevalence, assessment, and treatment of pain, as well as characteristics associated with pain, in 331 residents with dementia in 45 assisted living facilities and nursing homes. Overall, 21% of residents had pain, and pain was more commonly reported in for-profit facilities, and for those receiving professional assessment and treatment.

Pain assessment in nonverbal older adults with advanced dementia

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.

Assessing Pain as a FIFTH VITAL SIGN IN LONG-TERM CARE FACILITIES: Recommendations from the Field

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.

Religious and nonreligious coping in older adults experiencing chronic pain

Chronic pain is a significant problem among older adults. Undertreated or poorly managed pain can affect the physical, psychological, social, emotional, and spiritual well-being of older people. Several researchers have found that individuals turn to a wide array of cognitive and behavioral coping strategies when experiencing high levels of chronic pain. In addition, there is a growing body of evidence that supports an association between health outcomes and the use of religious coping to manage pain. Thus, the purpose of this descriptive, cross-sectional study was to explore the use of religious and nonreligious coping in older people who were experiencing chronic pain. Specific aims were to (a) describe the chronic pain experiences of older people; (b) examine the frequency and type of religious and nonreligious coping strategies used by older people to manage chronic pain; and (c) determine if there were differences in the use of religious and nonreligious coping across gender and race. Mean age of this convenience sample of 200 community-dwelling adults was 76.36 years (SD = 6.55). On average, study participants reported that their pain was of moderate intensity. Lower extremities were the most frequently reported painful body locations. Findings from this study support prior research that suggests older people report using a repertoire of pharmacologic and nonpharmacologic strategies to manage chronic pain. Older women and older people of minority racial background reported using religious coping strategies to manage their pain more often than did older Caucasian men. Older women also reported using diversion and exercise significantly more often than did older men.

Chronic pain in elderly nursing home residents: the need for nursing leadership

The incidence of chronic pain amongst elderly people in nursing homes is very high, making pain in this population a serious problem for aged care facilities. Research studies reveal a pattern of poor pain management in this setting despite the high incidence of pain suggesting that the management of pain in nursing homes is limited in scope and only partially effective. What is not fully appreciated by health professionals is the impact pain has on the lives of elderly people who live in nursing homes. In the study reported here a phenomenological method was used involving several in depth interviews with elderly people over a period of 9 months. Field notes of observations were also recorded as the participants went about their everyday lives in the nursing home. The discussion focuses on some of the themes drawn from the study with an emphasis on a key theme 'being constantly pained'. The findings of the study highlight what it is like to experience pain and how this impacts on everyday lives of elderly people. The paper concludes with some suggestions for health professional for improving care in this area.