Improving Assessment and Treatment of Pain for Older Adults with Dementia

By Karen S. Feldt, PhD, RN, GNP-BC

Introduction

Assessment of pain for cognitively impaired older adults is complicated by changes in memory, language skills, abstraction, and difficulties conceptualizing distress as pain. Under-treatment of pain for cognitively impaired older adults can be improved using instruments that are easily understood, and observation measures that detect pain during movement. This article reviews a few pain assessment instruments and treatment strategies for older adults with dementia.

Pain Assessment Instruments

Pain assessment instruments selected for older adults with dementia need to be simple and readily available to nurses. If patients say "no" to simple questions about pain, nurses should use pain synonyms to see if older adults identify with other pain words, such as aching, stiff, dull, pressure, burning, shooting, cramping, sore, uncomfortable, etc. Identifying the character of the pain can lead to more appropriate treatment measures^1-2.

Cognitively impaired older adults who have reading and language skills may be able to use the Verbal Descriptor Scale (VDS), a pain intensity tool that has been used successfully in a variety of settings.^{1, 2-7} Pain severity descriptions in this tool use simple language: "no pain," "slight pain," "extreme pain," and "pain as bad as it could be." When used in large bold print format, older adults can simply point to the words that describe their pain⁸. The simplicity of the scale makes it easy to use for routine assessments or evaluations of pain treatment outcomes.

The numeric rating scale (NRS) is not recommended for older adults with moderate to severe cognitive impairment, but may be used successfully in higher educated patients with mild cognitive impairment ^5-7. The NRS is usually asked verbally: "On a scale of 1 to 10, with 1 being very little pain, and 10 being the worst pain you can imagine, how would you rank your pain?" It requires a good attention span and the ability to cognitively change a perceived feeling into a number and rank it-- skills that are absent in persons with moderate to severe dementia.

The Faces Pain Scale is a series of facial expressions representing different degrees of pain intensity.⁹ This scale has been tested with cognitively intact older adults as well as older adults with dementia with mixed findings by researchers: some identify that it was preferred by minority older adults and has strong construct validity and test-retest reliability^4,10,11, but other research found it to be less strongly related to ratings on other pain scales, poorly understood, and less reliable^4,5,12. Nurses who wish to use this scale should determine if the older adult understands the faces as representation of pain before proceeding.

Assessment of pain for nonverbal or profoundly impaired elders requires careful observation for pain behavior during movement (i.e. daily care) or palpation of suspected painful area. Family members may know the patient's previous history of pain and use of analgesics. Other evidence of pain should be documented including: poor appetite, depressive symptoms, sleep problems, change of function, agitated behavior, refusal of care, moans, groans, or crying.

Many instruments to detect pain in non-verbal, cognitively impaired elders have been developed and tested. The Checklist of Nonverbal Pain Indicators (CNPI) was developed as a simple observational tool designed to assess pain in cognitively impaired elders⁸ and has been used with hospitalized older adults and older adults in long term care facilities^6,13,14. Nurses observe the patient at rest and with movement for the following behaviors: nonverbal vocalizations (defined as sighs, gasps, moans, groans, cries), facial grimacing or wincing (defined as furrowed brow, narrowed eyes, clenched teeth, tightened lips, jaw drop, distorted expression), bracing (defined as clutching or holding onto furniture or equipment or affected area during movement), rubbing (massaging affected area), restlessness (defined as constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still), and vocal complaints (defined as words expressing discomfort or pain: "ouch," "that hurts," cursing during movement; and exclamations of protest "stop," "that's enough." The number of behaviors present at the time of assessment is the pain score. Cognitively impaired older adults show few pain behaviors at rest.

One or two pain behaviors on the CNPI at rest or with movement may warrant treatment. Given the low frequency of pain behaviors on the CNPI in older adults who are able to report pain on the VDS, a significant amount of pain may go untreated if nurses assume that several behaviors must be present for pain to be treated.^6,8

The PAINAD scale has five items for nurses to observe in older adults with dementia including: noisy breathing, negative vocalization, facial expression, body language, and consolability. Nurses rate these behaviors on a 3-point scale of intensity (0 to 2) providing an overall possible score of 10¹⁵. The PAINAD scale is easy for nursing staff to use, correlates with other pain measures, and has been used in long term care settings. One concern about the PAINAD scale is that the authors structured the scale to offer a 0-10 score, similar to the 0-10 Verbal Numeric Rating Scale. However, research does not support a direct 1:1 correlation of the ratings on a behavioral scale with those self ratings on a Verbal Numeric Scale^{16, 17}. As with the CNPI, nurses should understand that even low scores on the PAINAD may warrant pain treatment.

Recommendations for Improving Pain Treatment for Cognitively Impaired Elders

The best approaches to improving pain treatment for cognitively impaired elders are the same basic principles that are taught for management of pain in other populations^1-2.

1. Believe the patient's pain report. Although cognitively impaired patients speak in fragments and have difficulty selecting words, these fragmented comments give clues to the possibility of pain. Document these as signals and as part of the assessment of pain.
2. Plan treatment for care needs. Dementia patients who are combative during morning care may do better if a scheduled analgesic is given a half hour before attempting to manipulate older, stiffened joints.
3. Stay ahead of pain. Elderly patients often wait until they are miserable before requesting prn pain medication. Cognitively impaired older adults may not even remember that pain medication is available to them. Use prescribed medications at intervals that keep patients comfortable.
4. Take responsibility for pain management and focus on the goal of comfort for these patients. Patients with routine pain should get routine non-pharmacological approaches for pain and/or routine medications.
5. Communicate what works across settings. Good communication across settings, realistic tapering to oral opioids, and use of scheduled medications will enhance rehabilitation for cognitively impaired older adults.
6. Offer routine analgesics as a medication trial for profoundly impaired patients who are distressed and calling out. Pain treatment may yield a better outcome than sedation with benzodiazepines or use of antipsychotics.
7. Document evidence of relief or lack of relief. Pain management plans need ongoing re-evaluation by all members of the healthcare team, including the patient and family members.
8. Assess for serious side effects. Medically complex patients require careful assessment for side effects of constipation or sedation. Nurses should know the maximum doses for specific medications (e.g. acetaminophen should not exceed 4 grams per 24 hours). Simple approaches such as using cherry liquid acetaminophen (which may cause diarrhea) with oral morphine concentrate (which causes constipation) offer a way of balancing side effects of both medications. Finding the balance of comfort versus adverse effects is more art than science, and non-pharmacological approaches are a key part of this balance.
9. Know morphine equivalencies. Education on morphine equivalencies of various pain medications will help nurses understand appropriate transitions from one medication to another.
10. Pain assessment is a necessary vital sign. Comfort should be a goal on every older adult's care plan. If pain assessment is listed on the vital sign record, it is a reminder for frequent re-evaluation of discomfort. Adequate pain relief can maximize physical functioning and improve the quality of life for older adults with cognitive impairment.

Summary

Pain can be a complex and frustrating problem when caring for older adults with dementia. There are excellent "state of the science" reviews on appropriate assessment instruments for cognitively impaired older adults^16-17. Education about pharmacological and non-pharmacological strategies for pain management can assist staff to achieving the goal of comfort for older adults with dementia.

About the Author: Karen Feldt, PhD, is an Associate Professor at the College of Nursing for Seattle University and a Gerontological Nurse Practitioner.

References

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