Assessing Pain in Dementia Patients with Comorbid Delirium and/or Depression

Pain in older adults with severe limitations in ability to communicate is often assessed with observational methods. However, many of the behaviors that are used to assess pain often overlap with behavioral manifestations of delirium and depression. Such overlap can make the assessment of pain in patients with comorbid delirium and/or depression especially challenging. In this study, we assessed pain using the Doloplus-II (one of the most established pain assessment methods for seniors with dementia) and examined the extent to which each of its items were also predictive of delirium, depression, and dementia severity. As expected, several Doloplus-II items were found to be related to dementia severity, depression, and/or delirium. Clinicians assessing pain in dementia patients with comorbid depression or delirium should place less emphasis on items that have reduced specificity in identifying pain problems. Instead, assessment should be informed by items with higher specificity as well as other sources of information (e.g., results of physical examinations and information from caregivers). Although in this investigation we used the Doloplus-II to assess pain, it is likely that our findings generalize to other observational pain assessment measures developed for patients with dementia.     

Pain perception and tolerance in patients with frontotemporal dementia

Pain management in elderly people with cognitive impairment poses special challenges, due to difficulties in pain assessment and specific neurodegenerative changes along pain pathways. Most studies have concentrated on Alzheimer’s disease (AD) patients, in whom some contrasting findings have been found. For example, while psychophysical data suggest a selective blunting of the affective dimension of pain, pain-related fMRI signal increases have also been described. Few data have been reported in patients with frontotemporal dementia (FTD). By electrical stimulation, we have measured pain threshold and pain tolerance in clinically diagnosed FTD patients with SPECT cerebral hypoperfusion. We performed our analysis on two separate and overlapping subgroups selected on the basis of (1) neuropsychological scores below cut-off values (2) a strictly localized frontal and/or temporal hypoperfusion. We observed increased pain threshold in the first group and increased pain threshold and pain tolerance in the second group. Our results suggest differences in pain processing changes in distinct types of dementia, while at the same time caution that pain perception assessment may depend on the criteria adopted for diagnosis.     

Understanding Nurses’ Knowledge and Attitudes Toward Pain Assessment in Dementia: A Literature Review

BackgroundPain is underrecognized and undertreated in patients with dementia. It has been suggested that nurses’ attitudinal barriers may contribute to the challenges surrounding pain assessment and management in dementia.AimsThis integrative literature review aims to identify and explore nurses’ knowledge and attitudes towards pain assessment in older people with dementia and how it may affect pain management in this patient group.MethodElectronic searches were conducted in Web of Science, MEDLINE, Scopus, ProQuest, PubMed, and EBSCOhost from January 2008 to December 2018 for articles specifically focusing on nurses’ knowledge and attitudes towards pain assessment in older patients with dementia.ResultsTen studies were included in the review after meeting the inclusion criteria. Data extracted from each study included study design, aims and objectives, setting/sample, findings, and limitations. Patients with dementia are at greater risk of experiencing underassessment, undertreatment, and delayed treatment of pain due to nurses’ knowledge deficits and uncertainty in the decision-making process. Nurses see providing comfort and reducing pain as ethical obligation. However, they find pain assessment a challenge due to the complexity of recognizing painful behaviors, and difficulty differentiating between pain and behavioral disturbances in dementia. Poor multidisciplinary communication, time constraints, and workload pressure, as well as uncertainty about opioid use, are important barriers to effective pain assessment and management among patients with dementia.ConclusionIt is essential that nurses gain confidence in distinguishing signs and symptoms of pain from behavioral changes in dementia. It is important to improve interdisciplinary communication and to get physicians to listen and prioritize pain assessment and management.     

Pain in elderly people with dementia

Aging is associated with an increased risk of cognitive impairment, such as Alzheimer's disease, vascular dementia and frontotemporal dementia. These diseases not only impair brain tissues and the nervous system, but also affect patients' verbal and non-verbal communicative ability. It is difficult, for instance, to assess pain in the cognitively impaired elderly because pain perception draws heavily on a patient's subjective interpretation and tolerance level. To seek an effective solution for pain detection in patients with dementia is therefore essential. From a systematic literature review covering the past decade, this paper presents a synopsis of the difficulty of pain assessment in the elderly with cognitive impairment, changes in the academic concept of pain, and explores factors resulting in obstacles to pain recognition. The obstacles to pain assessment derive mainly from three general factors. Firstly, classic definitions of early stage pain are inappropriate when applied to the elderly with cognitive impairment. Secondly, pain indicators are also unclear for this population. Thirdly, pain instruments and informants are ineffective in evaluating elderly patients with varying cognitive levels. To address these obstacles, a sound, multifaceted model of pain assessment for elderly patients with different severities of cognitive impairment is presented. On the basis of the above literature review, multiple methods for detecting aspects of pain in elderly people with cognitive impairment is recommended. To test the feasibility of the multidimensional model of pain assessment, further study is needed.     

Protocolos de gestión del dolor en demencia avanzada

Pain management in advanced dementia is complex because of neurological deficits present in these patients, and nurses are directly responsible for providing interventions for the evaluation, management and relief of pain for people suffering from this health problem. In order to facilitate and help decision-makers, pain experts recommend the use of standardized protocols to guide pain management, but in Spain, comprehensive pain management protocols have not yet been developed for advanced dementia.This article reflects the need for an integrated management of pain in advanced dementia. From the review and analysis of the most current and relevant studies in the literature, we performed an approximation of the scales for the determination of pain in these patients, with the observational scale PAINAD being the most recommended for the hospital setting. In addition, we provide an overview for comprehensive management of pain in advanced dementia through the conceptual framework «a hierarchy of pain assessment techniques by McCaffery and Pasero» for the development and implementation of standardized protocols, including a four-phase cyclical process (evaluation, planning/performance, revaluation and recording), which can facilitate the correct management of pain in these patients.     

People with dementia and their relatives: personal experiences of Alzheimer's and of the provision of care

Little is known about the experiences of people with dementia, as there has been relatively little research carried out that includes their perspectives. In the past, user perspectives on experiences of dementia and on services have mostly been solicited from family carers, rather than from people with dementia themselves. It has been suggested that these studies may lack information and insight into the experiences of people with dementia. This study aimed at eliciting the views and feelings of people in all stages of dementia, as well as those of their relatives, on care services and on experiences of dementia. Twenty-seven people with dementia from residential and day care settings were interviewed and their daily lives videotaped. Interviews were also conducted with next of kin. This article reports on findings and issues arising from the study.     

Pain Assessment in Noncommunicative Elderly persons--PAINE

OBJECTIVES: We describe the validation of an informant-based pain assessment for persons suffering from dementia called Pain Assessment in Noncommunicative Elderly persons (PAINE) using 2 different samples. METHODS: In the first study, the participants included 80 residents from one nursing home. We assessed internal consistency using Cronbach alpha, interrater and test-retest reliability using Pearson correlations, and validity using receiver operating characteristic curve analyses, comparing PAINE to these criteria on the basis of reports from physicians, nurses, relatives, and the residents themselves. In the second study, the participants included 91 residents from 2 different nursing homes. We assessed validity by correlating scores on PAINE with those from other assessments designed to detect pain. RESULTS: PAINE shows adequate internal consistency and both interrater and test-retest reliability. It also shows adequate receiver operating characteristic curve results and reasonable correlations with the existing measures of pain in persons with dementia. DISCUSSION: PAINE has the advantage of using a comprehensive list of pain symptoms on the basis of systematic questioning of direct caregivers from several institutions. The validity results suggest that this assessment could be a useful tool in detecting pain in persons with dementia.     

Pain assessment in older people with dementia: literature review

Title.  Pain assessment in older people with dementia: literature review.
Aim.  This paper is a report of a literature review conducted to identify barriers to successful pain assessment in older adults with dementia and possible strategies to overcome such barriers.
Background.  Pain is frequently undetected, misinterpreted, or inaccurately assessed in older adults with cognitive impairment. These people are often unable to articulate or convey how they feel and are often perceived as incapable of experiencing or recalling pain.
Data sources.  Searches were conducted of CINAHL, Medline and other databases for the period 1993–2007 using the search terms pain, dementia, assess*, barrier* and obstacle*.
Methods.  Studies were critically appraised by two independent reviewers. Data were extracted using instruments specifically developed for the review. Studies were categorized according to levels of evidence defined by the Australian National Health and Medical Research Council and Joanna Briggs Institute.
Results.  Perceived barriers to successful pain assessment in people with dementia included lack of recognition of pain, lack of sufficient education and/or training, misdiagnosis or late diagnosis, and non-use of assessment tools. Barriers related to people with dementia included insufficient evidence, the possibility of a 'no pain' subset of people with dementia, type of pain, and stoical attitudes. Strategies proposed as means of overcoming these barriers included knowing the person, knowing by diversity/intuitive perception, education and training, and use of adequate tools.
Conclusion.  More extensive education and training about the relationship between pain and dementia are urgently needed, as is the development and implementation of an effective pain assessment tool specifically designed to detect and measure pain in older adults with all stages of dementia.     

Through seniors' eyes: an exploratory qualitative study to identify environmental barriers to and facilitators of walking.

This qualitative exploratory study examined environmental factors influencing the walking choices of elderly people using the photovoice approach. A total of 13 seniors in Ottawa, Canada, took photographs of barriers to and facilitators of walking in their neighbourhoods. These photos were displayed during 3 focus-group sessions and served as touchstones for discussion. A total of 22 seniors, including 8 of the 13 photographers, participated in the focus-group sessions. The findings show that environmental hazards related to traffic and falls risks can be significant barriers to walking for seniors, and that connectivity can truly exist for the elderly only if convenience, hazard-free routes are available. They also indicate that simple amenities such as benches and washrooms might facilitate walking for seniors. A neighbourhood that is activity-friendly for seniors will also be a good place for everyone else to live, work, and play. The use of photovoice as a method was well received by the participants and provided rich information that may not have been captured through other means.     

老年痴呆患者疼痛评估及管理最佳证据总结

目的 总结老年痴呆患者疼痛评估及管理的最佳证据,为老年痴呆患者疼痛的评估和管理提供证据支持,改善老年痴呆患者的疼痛护理质量。方法 用PICO模型构建循证护理问题,按照“6S”证据金字塔模型依次检索2010年1月1日—2020年2月29日发布在UpToDate、BMJ Best Practice、JBI、NICE、RNAO、CINAHL、中国生物医学数据库、知网、万方等数据库的相关文献,2名具备硕士学位的循证护理师独立进行文献质量评价及证据筛查,证据汇总后由项目团队综合归类。结果 共纳入文献12篇：证据总结3篇,指南2篇,系统评价5篇,随机对照试验2篇。从纳入的文献中共提取55条证据,最终综合成26条最佳证据共6个维度,分别是疼痛评估时机与量表、疼痛评估方法、干预措施、疼痛管理、培训与教育、组织保障。结论 临床管理者需重视老年痴呆患者疼痛评估,使用适宜疼痛评估工具及方法,采取针对性干预措施,并且需对医务人员进行老年痴呆患者疼痛相关知识的培训,在证据应用的过程中应评估临床情景及现有的医疗环境,制订符合临床实际的老年痴呆患者疼痛管理计划。     

Pain and dementia - an application to practice: an example

wall s . & white t. (2012) Pain and dementia – an application to practice: an example. International Journal of Older People Nursing 7 , 227–232
doi: 10.1111/j.1748‐3743.2012.00330.x There are fundamental clinical implications around assessment and evaluation of pain as well as management strategies for pain that have the potential of impacting and improving client outcomes. It is these principles that have been used to develop a training module on pain and dementia with widespread application to a range of settings. This study serves to provide an overview of this process as it translates evidence of pain in people living with dementia to practice for clinicians working in the field.     

Assessing pain in people with dementia. 1: the challenges

This article is the first of a two-part unit on dementia and pain assessment. It examines literature that describes the problem of pain for people with dementia and the challenges nurses face in undertaking pain assessments.     

Using facial expressions to assess musculoskeletal pain in older persons.

Past research examined measures of pain among seniors who were experiencing movement-related exacerbations of musculoskeletal pain and obtained clear support for the utility of the behavioural coding of pain-related body movements (e.g., bracing, guarding). Support for the utility of the Facial Action Coding System (FACS), which involves the objective coding of facial reactions, was not as strong. The findings concerning FACS could have been an artifact of the methodology that was used. Specifically, the duration of the facial reactions was not taken into account and the patients suffered from a variety of painful conditions. Thus, the physical activities involved in the study could have been painful for some patients but not for others. The present study corrected these methodological concerns by accounting for the duration of facial reactions and ensuring that all patients suffered from the same painful condition. Participants were 82 post-surgical (knee replacement) inpatients. Cognitive status was assessed using the Modified Mini Mental Status Examination. Under physiotherapist's supervision, the patients performed structured activities (i.e., reclining, standing, knee bends). Facial reactions were coded using FACS. Facial reactions varied as a function of the degree to which the various activities were strenuous. The results support the utility of FACS in the assessment of musculoskeletal pain among seniors undergoing rehabilitation following knee surgery.     

The association of nurses' assessment and certainty to pain management and outcomes for nursing home residents in Jordan

Despite advances in dementia care, pain in people with dementia is still undertreated due to poor assessment, poor treatment, and factors relating to nurses' critical thinking and decision-making skills. The purpose of the study is to examine temporally based relationships between change in behavior, the nurses' level of certainty regarding pain, assessment scope, and outcomes of pain. The findings of the study were consistent with the Response to Certainty of Pain model. This study found high percentage of variances accounted for by nurses' level of certainty due to potential unexpected confounding variables. This study may provide a new understanding of the relationship between nurses' certainty, assessment scope, and patient outcomes for people with dementia. Improved understanding of this relationship and how it relates to the problem of unrelieved pain in people with dementia is crucial.     

Pain management skills of regional nurses caring for older people with dementia: a needs analysis

An exploratory survey of the pain management education needs of 197 nurses working with older people with dementia was undertaken in a regional area of Queensland, Australia. The analysis indicated that nurses in this setting might not have the knowledge base to manage pain effectively; and that respondents have essentially negative perceptions of the availability and appropriateness of current pain management education programs. Consistent with non-metropolitan nurses generally, respondents expressed a preference for pain management education that had a significant face-to-face component allied with ongoing mentorship and support on completion of the program. The obstacles to attending such programs were also typical of the problems facing regional and rural nurses throughout Australia. These were identified as: inability to pay for courses; lack of information on what is available; distance to travel to education; and a perceived lack of employer support due to an inability to replace those staff attending education. Positive aspects include the degree to which participants were responsive and interested in dementia pain management and their access to, and acceptance of, non-medical pain therapies. The findings suggest a definite need for a dementia pain management program for aged care nurses, specifically tailored to their needs and to the constraints of the regional practice setting.     

Families' and children's postoperative pain--literature review

The purpose of this study was to describe the findings of a literature review focusing on the viewpoint of family members in children's postoperative pain assessment and management. The study was based on empirical studies of families and children's postoperative pain published in 1991-2000. Eleven articles found in two databases (PubMed + Cinahl) were nonrandomly selected for an analysis. Qualitative deductive content analysis was used to investigate what is known about family members' views on children's postoperative pain based on empirical studies. The findings showed that families are a source of support for children in postoperative pain. However, parents have criticized pain-related instructions provided by the hospital staff. In addition, they have described difficulties in identifying and managing children's pain at home. Further research is needed to deepen our understanding on children's postoperative pain as a family experience. Family nursing theories could be used more in studies focusing on children's postoperative pain. More attention should be paid on parents' needs and on their counseling about children's pain in clinical pediatric nursing.