Topics in Geriatrics: Pain Assessment in Nonverbal Older Adults with Dementia

Geriatric Wiki Assignment 

Topics in Geriatrics: Pain Assessment in Nonverbal Older Adults with Dementia

            Older adults with dementia cannot always communicate when and where they have pain, making it impossible for patients in this population to use the gold standard self-reported pain measures. For patients in this population, it is imperative that clinicians use behavioral observation and changes in function to screen for pain. It is estimated the older adults with dementia also have painful conditions in addition to cognitive impairment with a prevalence of 49-83%1. Thus, the purpose of this publication is to provide a resource for clinicians assessing pain in older adults with dementia or other cognitive impairments that are unable to communicate.

Objectives:

1.      Learn the various ways to assess pain in older adults with dementia.

2.      Learn when and how to administer and score pain assessments used in older adults with dementia.

3.      Learn about the evidence behind each pain assessment tool.

4.      Provide access to the various pain assessment tools for older adults with dementia.

'''Pain Assessment Tools '''

'''1.     Pain Assessment in Advanced Dementia (PAINAD) scale2 http://dementiapathways.ie/_filecache/04a/ddd/98-painad.pdf '''

a.       Uses 5 indicators:

i. breathing: labored breathing or hyperventilating

ii. vocalization: moaning or crying

iii. facial expression: frowning or grimacing

iv. body language: clenching fists or pushing away caregivers

v. consolability: an inability to be comforted

b.      Fast and easy; can be administered in 5 minutes or less through observation

c.       Each item is scored on 0-2 scale; when all 5 items are totaled a patient’s, score can range from 0 (no pain) to 10 (severe pain).

d.      Internal consistency: 0.50–0.67 0.69–0.74 Interrater reliability: r = 0.82–0.97 0.75–0.81 Test-retest: r = 0.90 (P!.001) Time interval: morning/ evening skift scores r = 0.88 (interval: 15 d) r = 0.89 1

'''2.     Checklist for Nonverbal Pain Indicators (CNPI)1 https://kentuckyonehealth.org/documents/Nursing/CNPI.pdf '''

http://prc.coh.org/pdf/Assess%20Cog%209-09.pdf 

a.       6 items: nonverbal vocalizations, facial grimacing or wincing, bracing, rubbing, restlessness, vocal complaints. Items scored on dichotomous scale: present (1) or absent (0) at rest and on movement Total score range 0–121

b.      Common obvious behaviors observed by direct observation

c.       internal consistency: 0.54–0.64 Interrater reliability: r= 0.62–0.82 Percent agreement: 74%–94% r= 0.45–0.69 Test-retest: 34%–41% ; r= 0.23–0.661

d.      In long-term care: Sensitivity: 55% Specificity: 85% Convergent validity1

'''3.     Pain Assessment Checklist for Seniors with Severe Dementia (PACSLAC)1 https://geriatricpain.org/sites/geriatricpain.org/files/wysiwyg_uploads/pacslac_checklist_with_sm_logo.pdf '''

a.       60 items, four dimensions: Facial expression (N = 13) Activity/body movements (N = 20) Social/ personality/ mood (N = 12) Physiologic/eating/ sleeping/vocal (N = 15) Score range 0–60

b.      Internal consistency: Retrospective data: 0.85 Total tool: 0.62–0.84 Subscales: 0.12–0.76 Interrater reliability: 0.92 Test-retest: Good intrarater reliabilities

c.       Can be completed in 5 minutes

d.      Item reduction and subscale revisions needed

e.       Preferred by nurses over PAINAD

'''Who should I use these pain assessment tools with?'''

-         '''PAINAD scale3: '''nonverbal adults with severe dementia; has not been tested in adults with mild dementia

o '''When: '''

§  Admission

§  Every 8 hours

§  One hour following pain intervention

§  Anytime a change in status is reported

o '''How '''

§  Observe the older adult for 3-5 minutes during activity/with movement (such as bathing, turning, transferring).

§  For each item included in the PAINAD, select the score (0, 1, 2) that reflects the current state of the behavior.

§  Add the score for each item to achieve a total score. Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items).

§  After each use, compare the total score to the previous score received. An increased score suggests an increase in pain, while a lower score suggests pain is decreased.

§  CNA should report any changes or scores to the nurse for follow-up assessment

-         '''CNPI scale4: cognitively impaired older '''adults living in LTC facilities

o Acute care settings require further investigation

o   The Checklist of Non-Verbal Pain Indicators has been shown to be a reliable and valid assessment tool in older adults with acute or chronic pain, in critical care units and adults with dementia.4

o '''When '''

§  Admission

§  Every 8 hours

§  One hour following pain intervention

§  Anytime a change in status is reported

o '''How5 : '''

§  Instructions for use: Observe the patient at rest and with movement. 0 = behavior not observed 1 = behavior is observed (even briefly) during either while at rest or with activity 2 = behavior is observed BOTH while at rest and during activity Add the “With Movement” and “At Rest” columns to come up with a total score. For example: Total score of 0 would indicate no indicators were observed with either movement or at rest A total score of 5 would be reached if all indicators of pain were observed, but only with movement A total score of 10 would be reached if all indicators of pain were observed both at rest and with activity

-         '''PACSLAC scale6: '''adults with severe dementia in acute settings, LTC settings

o '''When: '''

§  Admission

§  Every 8 hours

§  One hour following pain intervention

§  Anytime a change in status is reported

o '''How: '''

§  Use during activity or movement

§  Total the score at each use

§  Compare previous scores

'''References '''

1.      Bjoro, Karen, and Keela Herr. “Assessment Of Pain In The Nonverbal And/or Cognitively Impaired Older Adult.” ''Current Therapy in Pain'', 2008, pp. 237–262., doi:10.1016/b978-1-4160-4836-7.00005-5.

2.      Ann Horgas, and Lois Miller. “Pain Assessment in People with Dementia.” American Journal of Nursing, vol. 108, no. 7, July 2008, pp. 62–70., doi:10.1097/01.NAJ.0000325648.01797.fc.

3.     Warden, V, Hurley AC, Volicer, V. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc, 4:9-15. Developed at the New England Geriatric Research Education & Clinical Center, Bedford VAMC, MA.

4.      Nygaard HA. Jarland M. (2006). The Checklist of Nonverbal Pain Indicators (CNPI): testing of reliability and validity in Norwegian nursing homes. Age & Ageing. 35(1):79-81

5.      Feldt KS. (2000) The checklist of nonverbal pain indicators. Pain Management Nursing, 1(1):13-21.

6.      Fuchs-Lacelle, S. & Hadjistavropoulos, T. (2004). Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Management Nursing, 5(1), 37-49.