US Pharm.
2007;32(5):37-52.
In
1999, the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) introduced new pain management standards. The goal of these standards
was to make more health care professionals cognizant of the subjective nature
of pain and to improve the efficiency of pain assessment interviews and the
adequacy of management strategies. While improvement has been seen in many
areas, the literature reveals that some health care professionals
ineffectively assess and treat pain in the elderly.1
Adequate pain management
should comprise both a thorough pain assessment and a highly effective and
safe treatment strategy. Many factors contribute to the difficulty in
obtaining an adequate assessment of pain in the elderly and providing optimal
treatment to the patient.2 Among these factors are barriers to
conducting a sufficient pain assessment interview, problems deciding which
assessment tool to use based on a patient's degree of cognitive function,
inadequacy in comprehending the important differences among tools, and
choosing an inappropriate treatment strategy.1,2 This article will
provide a review of the complexity of pain assessment in the cognitively
impaired patient and improve the pharmacist's ability to assess pain.
Barriers to Pain Assessment
A thorough pain
assessment is essential for effective pain management. If inaccuracies are
made while assessing pain, it will be impossible for an optimal management
regimen to ensue. Health care professionals must be aware of barriers that
might negatively impact pain assessment, and they should make every effort to
resolve these issues. Three main categories of barriers have been described in
the literature: those concerning the patient or the patient's
family/caregiver; those among health care professionals; and those within the
health care system.2 Barriers conveyed by these three distinct
groups have a vital role in the inadequacy of pain assessment and management.
Identifying, anticipating, and resolving such barriers are important steps in
improving a patient's pain experience.
The most prevalent barriers
involving elderly patients, families, and/or caregivers include psychocultural
biases and fears of side effects, addiction and tolerance, loss of
independence, and medication costs.2-5 Psychocultural biases can be
described as beliefs influenced by one's opinions or background. For example,
many elderly patients falsely believe that pain is a normal process of aging.
2 This view can lead to an unintentional poor pain assessment by the
health care professional, since the patient may be reluctant to admit to a
"normal process." It is vital to inform patients that even though many disease
processes such as osteoarthritis may be a consequence of aging, being in pain
is not. Reinforcing the JCAHO's stance on the right of the patient to receive
adequate pain management may also prove to be beneficial. This is especially
true of patients who falsely believe that seeking pain relief is indicative of
being a "weak" or "bad" patient. Health care professionals should be mindful
that many elderly patients are extremely reluctant to report pain.4
Patients fear that a host of tests will lead to a diagnosis that may result in
a loss of independence.2 Health care professionals should be
empathetic to patients' fears and maximize patient education in order to
correct misconceptions. When a treatment strategy is chosen, health care
professionals should make every effort to include patients and their
caregiver(s) as members of the pain management team. This will help to ease
some of the anxiety associated with some treatment options. For example,
patients may experience apprehension if treatment with opioids is necessary.
2 Identifying and discussing myths regarding opioid-related side effects
and educating about the small incidence of addiction may allow patients to
understand their regimen and become more comfortable with it. Patients should
not fear addiction to the point where pain is left untreated. Lastly, health
care professionals should anticipate that uninsured or underinsured elderly
patients may fear health care or medication costs and become extremely
apprehensive about placing the burden on others.2 This fear may
govern a personal decision to not seek pain relief. Because psychocultural
biases are unique to individual patients, discussing beliefs about pain and
educating patients prior to initiating therapy will eradicate misconceptions
and lead to a more comprehensive pain assessment interview.
Health care professionals may
harbor prejudices about pain that can affect the success of pain assessments.
Some health care professionals might fixate on opioid addiction and lack
knowledge about it when assessing pain and choosing medications to treat pain.
4 These are among the most prevalent barriers affecting pain assessment
and management. An overly conscious fear of addiction might hinder the
selection of an appropriate treatment, such as opioid analgesics. However,
research reveals that less than 1% of individuals using opioids develop
addiction as a psychological dependence.4 Health care professionals
should therefore acknowledge the significance of this research and spend more
time meticulously assessing a patient's report of pain and less time
anticipating an addiction that may not occur.
Health care professionals who
are responsible for assessing patients' pain may inadvertently perpetuate
barriers by confusing many pain behaviors. Some health care practitioners
routinely confuse addiction with pseudoaddiction.6 The American
Pain Society defines addiction as impaired control over drug use, compulsive
drug use, and/or continued drug use despite harm.6 Pseudoaddiction,
in many ways, is iatrogenic, meaning that it is induced inadvertently when
health care professionals provide less than adequate relief of pain.6
For example, health care professionals may interpret the patient's early
request for pain medications as a sign of possible addiction. However,
patients with inadequately managed pain may tend to display "drug-seeking"
behavior. Understandably, these patients may ask for their medications earlier
than patients whose pain is adequately managed in an effort to gain relief.
Therefore, health care professionals should research whether or not the
initial pain assessment was comprehensive, whether the chosen treatment is
optimal to manage the type of pain the patient is experiencing, whether
medications are inadvertently being administered at intervals longer than the
proven analgesic duration, and whether the patient has either a new injury or
a new diagnosis that may generate or exacerbate pain.
In addition, some health care
professionals confuse tolerance with pseudotolerance. Tolerance can be defined
as needing increased amounts of drug to produce the same analgesic effect.
6 However, this increased need for medication should not be viewed as an
addiction. For example, patients with type 2 diabetes may eventually need more
exogenous insulin due to cell resistance. This does not mean that the patient
is becoming "addicted" but rather that exposure to the drug results in changes
that lead to a reduction in the drug's effects. Therefore, there is a need for
more insulin to produce the same glycemic effect. In pseudotolerance,
medication increases cannot be owed to a reduction in the drug's effects.6
Other factors, such as disease progression (i.e., radiating pain) or new
disease (i.e., new injury), must be taken into consideration.6
Performing a thorough pain assessment interview should help to differentiate
between the aforementioned phenomena.
Many clinicians share the
erroneous belief that it is impossible to assess pain in elderly patients with
cognitive impairment, and therefore, it is impossible to treat the pain.
4,7 In fact, a 1998 study by Horgas and Tsai concluded that the more
disoriented, withdrawn, and functionally impaired nursing home residents were,
the fewer the number of analgesics that were prescribed and administered.7
Pain assessment is complicated by its subjectivity. In fact, no one
definition of pain clearly explains its multidimensional and complicated
aspects. In 1968, Margo McCaffery best defined pain as "whatever the
experiencing person says it is, existing whenever he/she says it does."
4 This flaccid definition represents an unbiased view of pain, which the
pharmacist must possess.
Barriers involving the health
systems have decreased substantially since the JCAHO standards were
introduced, explaining the patient's right to adequate pain management. As a
result of the guidelines, there has been more of an emphasis on the importance
of pain assessment and management within institutions. However, systemic
barriers still include a lack of institutional standards, a lack of systematic
assessment, a lack of visibility of pain documentation, and the placement of
pain at a lower priority level than other conditions.8
Pain Assessment Interview
Key questions have
been developed to help conduct a thorough pain assessment interview in all
patients. These questions focus on the intensity, location, and character of
pain. Useful mnemonics such as "ABCDE" and "PQRST" prompt those conducting the
pain interview to the pertinent questions that should be asked. Table 1
describes these mnemonics in more detail.9 The following questions
should be included in all pain assessments.4,9
•
Where is the pain?
• When did the pain
start?
• How often does the
pain occur?
• What does the pain
feel like?
• Has pain intensity
changed?
Determining what makes
the pain worse or better, whether the pain affects physical and social
function, and what type of treatments have worked in the past is vital to
adequate pain assessment interviews. For the cognitively impaired patient,
questions asked during the pain interview should be limited to those with
simple yes or no answers since changes in mental status may impair the
patient's ability to process and relay information.10 Health care
professionals must maintain keen pain assessment strategies and tailor pain
assessments to meet individual patient needs based on the patient's level of
cognition.
During the assessment of pain,
health care professionals should also be cognizant of the effects of untreated
or undertreated pain on patient behavior. Paying attention to changes in
patient behavior is extremely important when dealing with cognitively impaired
or non-verbal patients. A paradigm of inadequate pain management exists and
includes negative effects on physical function, psychological morbidity, and
social or societal sequelae.11 As a consequence of this,
appropriate individuals should assess possible sleep disturbances,
depression/anxiety, decreases in activities of daily living, disability, and
changes in relationships with friends or family.11 Being aware of
the sequelae of untreated or undertreated pain will lead to a more thorough
pain assessment.
Pain Assessment Tools
Pain assessment tools are used to
quantify a patient's report of pain. Accurate use of these tools is critical
to optimal medication selection. There are numerous pain assessment
instruments that evaluate pain intensity, pain location, pain behaviors, or a
combination of these factors.1 These assessment tools can be
further classified as unidimensional or multidimensional depending on the
number of pain dimensions measured.
Health care professionals
should not expect all pain-assessment tools to have the same rate of success
in all patients. Data show that the usefulness of many tools declines in the
cognitively impaired geriatric population.1,7 Because there is
difficulty in using certain tools in cognitively impaired patients,
discrepancies governing the successfulness of use exist.3 Many
elderly patients are eliminated from studies that test clinical tools due to
the difficulty noted in assessing pain in this population. As a consequence,
very little definitive information is available on the usefulness of these
instruments in patients with moderate to moderately severe cognitive
impairment.7 It is important for health care professionals to be
educated about the most widely used tools in clinical practice. Optimal tools
are those that consistently produce similar results when readministered in the
same patient (validity), have been evaluated as an appropriate representation
of a patient's report of pain (test-retest reliability), have consistency in
interpretation and scoring among/between raters (reliability), and are easy to
administer.1 Therefore, a review of recent literature dealing with
the use of different pain assessment tools in cognitively impaired elderly
patients is warranted.
Pain Intensity:
Self-report scales
measure subjective pain intensity, are typically unidimensional, and include
verbal descriptor scales, numeric rating scales, visual analog scales, and
face scales. These self-report scales are the most common methods of assessing
pain in clinical practice.7 They have demonstrated reliability and
validity and are considered sensitive measures of pain intensity in verbal,
cognitively intact older adults.7
The verbal descriptor scales
exist in many different forms but maintain the consistent concept of providing
a small list of adjectives to describe pain intensity. The advantages of
verbal descriptor scales are that they are easy to understand for many
patients, are quick to administer, and apply to different types of pain.7
The patient reads the descriptors, such as "no pain," "mild," "moderate," or
"severe," and chooses the best one. In some instances, the clinician reads the
list of adjectives and has the patient choose the one that best describes
their current pain severity. One disadvantage is that some patients may not
describe their pain using the exact adjectives used in the scales. For
example, some patients may not admit to having pain but may respond better to
terms such as "aching," "soreness," or "hurting."
7,12 For these patients, reports of pain intensity may not be very
accurate.
To alleviate the problem of
too few verbal descriptors, other descriptor scales with more adjectives may
be used. The McGill Pain Questionnaire (MPQ) is one alternative self-report
tool that uses more words to describe a patient's pain. The MPQ is a
multidimensional scale that measures three dimensions of pain and contains
several sections in addition to an extensive list of adjectives to describe
pain. Difficulties in using this scale include its length and high literacy
level.13 The reliability and validity has not been reported for
elderly patients.13
Several studies have assessed
the effectiveness of verbal descriptor scales in cognitively impaired
patients. The general consensus of the studies is that while patients were
consistent in reporting pain, there was not strong test-retest reliability
associated with these methods.7 For example, the patients would
consistently report that they had pain, but the adjectives chosen to describe
the pain would vary when the test was repeated. The probable cause of this
discrepancy is that cognitively impaired elderly may have difficulty in
choosing one word to quantify their pain.12 This concept is very
abstract and may be too difficult for a cognitively impaired patient to
interpret.12 Therefore, health care professionals who use these
scales for cognitively impaired patients should be conscious of this possible
problem and use caution when interpreting the results. Use of this tool in
cognitively impaired patients may lead to an incomplete pain assessment.
The simplest method, and
perhaps the most universally used scale measuring pain intensity, is the
numeric rating scale (NRS). This scale contains a numeric rating from 0
(indicating no pain) to 10 (indicating the worst pain imaginable), although
different versions exist. The numeric scale, like the verbal descriptor scale,
is easy to administer and can even be administered over the phone. This scale
has been shown to be both valid and reliable in cognitively intact elderly
individuals.7 There is conflicting literature relating to the use
of this pain scale in cognitively impaired elderly patients.7 One
reason for this conflict is a lack of standardization in clinical studies when
interpreting Mini-Mental State Examination (MMSE) criteria to categorize
levels of cognitive impairment. Some studies haven been conducted using
patients with mild-to-moderate impairment, while others may have been
conducted using patients with severe impairment.7 Some patients
with mild-to-moderate cognitive impairment successfully used the numeric
scale, while others with lower scores on the MMSE had extreme difficulty using
the scale. The same reasoning for difficulty in using the descriptor scales
can again be used to explain difficulty using the NRS. Choosing a number and
directly correlating that number with one's pain is a complex task, which may
be too difficult for the cognitively impaired patient to comprehend.7
The visual analog scale (VAS)
is another type of self-report scale that is widely used to measure pain
intensity. The VAS consists of a single 100-mm line with one end labeled "no
pain" and the other end labeled "most pain imaginable." This scale is
extremely difficult to use in the elderly with cognitive impairment.
Individuals must be able to think abstractly and coordinate sensory-motor and
visual skills. Successful use of this scale depends on placing a pencil mark
on the line to accurately reflect one's pain intensity.7,12 Because
the VAS is so complex, it is not an effective self-report tool for measuring
pain in older patients with cognitive impairment.
Two face scales that are
currently in use are the Wong-Baker FACES Pain Rating Scale (Figure 1)
and the Faces Pain ScaleñRevised (FPS-R). Both were first developed for
assessing pain in children and display either a series of faces with smiling
to tearful, frowning expressions or a set of faces showing different degrees
of distress.
When using the FACES Scale,
the patient points to the face that best describes the severity of pain that
is being experienced.14 For example, a smiling face is indicative
of no pain and a face with tears indicates the worst pain possible. A
numerical value is also associated with each face. This scale, in particular,
has been criticized for assessing emotion rather than pain. Patients who
interpret the FACES Scale as a way to assess emotion may have difficulty using
the scale, because the expression of emotion is gender and culturally based.
7 Crying is not equally acceptable between genders and may not be an
acceptable way of dealing with pain in some cultures.7,12 Moreover,
a smiling face may not directly correlate to a report of "no pain." Although
the patient may be in pain, he or she may be very satisfied with how the pain
is being perceived and managed by the health care staff. As a result, the
patient may mistakenly mark a smiling face to show approval of the pain
management team.
In comparison, the FPS-R uses
six to seven faces arranged with increasing looks of distress from "0 = no
pain" to "6 = worst pain imaginable." One advantage of the FPS is that it is
geared more toward adults than the FACES Scale. Some adults may respond better
to faces that are more adultlike than to the animated happy/sad faces of the
FACES Scale. Moreover, the rating system of the FPS-R does not confuse emotion
with pain severity. The major disadvantage of using face scales for the
cognitively impaired is that as cognitive impairment increases, the ability to
use the scales decreases.7,15 Patients with severe cognitive
impairment may point to the face they like the best rather than the one that
correlates with pain intensity. Therefore, it is reasonable to conclude that
the face scales are reliable and valid in patients with mild-to-moderate
impairment, but not in those with severe impairment.7,16
Pain Location:
Using both a pain map, which is typically a picture of a person or a doll, and
one's own body allows the patient to show where the pain is located. Pain maps
only allow for identification of changes in or consistency of pain location.
They do not allow assessment of pain intensity. Cognitively impaired patients
have had great success in using location instruments.7,17 Combining
a pain intensity scale and a location tool might provide optimal pain
assessment in the elderly.
Pain Behaviors:
Behavioral pain scales are used most often in cognitively impaired patients
in long-term care facilities. It is well known that untreated or inadequately
treated pain can lead to behavioral disturbances.1,12 The American
Geriatrics Society (AGS) has identified potential behaviors that may be an
indicator of pain in cognitively impaired patients: facial expressions,
negative verbalizations/vocalizations, specific agitated body movements,
changes in interpersonal interactions, changes in activity patterns or
routines, and further changes in mental status.1 A great deal of
research has been conducted identifying behavioral patterns associated with
pain, since addressing such factors could lead to an improvement in quality of
life.1,12 Several tools have been developed to help with the
identification of these behaviors. Although numerous scales exist, five types
of behavioral tools will be discussed in this review: the Discomfort Scale for
Dementia of the Alzheimer's Type (DS-DAT); the checklist of non-verbal pain
indicators (CNPI); the Face, Legs, Activity, Cry, and Consolability (FLACC)
scale; the Pain Assessment in Advanced Dementia (PAINAD) Scale; and the
Assessment of Discomfort in Dementia (ADD) protocol.1,12 Ideal
behavioral tools are those that have sound evaluation of usefulness,
reliability, and validity, as well as equal efficacy when compared to other
reputable tools.1 No specific tool is currently recommended for use
by the AGS.12
The DS-DAT is a nine-item list
requiring five minutes of observation to rate nonverbal behavior that is
predictive of distress in patients at rest. Items measuring frequency,
intensity, and duration are correlated with a score that corresponds to a
patient's level of discomfort.2 This tool was developed with the
severely cognitively impaired nonverbal patient in mind.1 Before
observation begins, the rater must wait 15 minutes after an intervention that
may have caused pain or discomfort for the patient, such as a position change
or feeding. One limitation of this tool is that only trained professionals can
administer the test; another is that it is extremely time consuming and
complicated.1
Since the invention of the
DS-DAT, a modified version, which contains only six items, has become
available. Three of the items that were reportedly hard to interpret--sad
facial expression, frowning, and relaxed body language--were removed.7
Although this scale was found to be just as useful as the original version,
it too is complicated, time consuming, and requires expertise. Both tools are
too labored for daily clinical practice, but have been shown to be extremely
beneficial when assessing pain in clinical studies.7 Extensive
training to guarantee consistent interrater reliability must be achieved
before routine use in clinical practice is justified. Researchers also
criticize that a scale that measures discomfort may not accurately and
consistently represent pain. Their rationale is that not all conditions that
cause discomfort result in pain.1
The CNPI is a six-item scale
designed to measure pain behaviors in postoperative cognitively impaired
adults both at rest and on movement. Like the DS-DAT, items are scored for an
interpretation of pain severity. A study comparing verbal descriptor scales
with the CNPI revealed a significant correlation in scoring among cognitively
intact and cognitively impaired older people.7,18,19 As evidenced
from clinical trials, facial grimacing and restlessness are the most easily
identified behaviors among raters. The CNPI measures these behaviors, whereas
other behavioral scales do not. This tool is both reliable and practical for
assessing pain behaviors in both cognitively impaired and cognitively intact
elderly patients in everyday clinical practice.18,19
The FLACC scale was first
developed for use in nonverbal children, and its use has been validated in
children ages 3 months to 7 years (Table 2).2,20 The tool
includes five items that are scored and interpreted. Recently, this scale has
been proposed for use in cognitively impaired elderly patients. However, many
of the pain behaviors observed on the scale have not been reported in elderly
patients with dementia and may not be representative of pain behaviors in this
group.1 Preliminary data suggest that the use of this tool in
elderly patients with dementia produces inconsistent reliability and validity.
1 Therefore, the routine usefulness of this scale in clinical practice
cannot be substantiated.
The PAINAD scale (Table 3
) was developed by the same team of professionals who developed the DS-DAT.
21 The purpose of the PAINAD scale was to avoid the limitations
experienced with the DS-DAT.1 The PAINAD scale was developed using
elements of the VAS, the FLACC scale, and the DS-DAT. It consists of five
items: breathing, negative vocalization, facial expression, body language, and
consolability. An objective description of each of the five items is outlined
in the scale. Total scores range from 0 (no pain) to 10 (maximal pain). The
tool may be simpler to understand and easier to use with limited training than
the DS-DAT.1 In comparison to the FLACC scale, it includes more
common pain behaviors displayed by the cognitively impaired elderly patient.
Comparative studies between the DS-DAT and PAINAD scale have shown that the
results of different raters are markedly similar, providing evidence of
validity.1 The PAINAD scale has been criticized for not being able
to detect pain in patients with subtle reactions to pain or subtle changes in
pain behaviors. Additional research is needed to improve internal consistency
among raters, though tool reliability is good for individual raters. This
scale would be most useful for assessing pain in cognitively impaired
geriatric patients who demonstrate significant changes in behavior secondary
to pain.
The ADD is a protocol
developed to assess and manage discomfort in long-term care facilities.1,7
This clinical tool consists of four steps, and assessment begins when a
resident's behavior changes. The first step is to look for physical problems
as a cause of behavioral changes. A physical examination should be conducted
to rule out possible malignancies and new locations of pain. If no physical
causes are noted during the physical examination, the second step is to
perform an extensive review of the patient's medical history. If no causes of
pain are identified, nonpharmacologic approaches to pain management should be
initiated. These nonpharmacologic interventions include physical therapy,
behavioral modification, distraction techniques, massage, meditation,
transcutaneous electrical nerve stimulation, and acupuncture.4 If
the nonpharmacologic intervention does not adequately control pain, the
patient can be provided with an as-needed analgesic. Asking family members or
caregivers if any treatment has been successful in the past may provide a good
starting point for choosing an appropriate analgesic agent. This protocol
demonstrates that the comfort needs of patients with dementia can be
identified and managed comprehensively.7 While no specific time
commitment has been described, it is reasonable to assume that the ADD
protocol takes a considerable amount of time; routine use of this protocol in
clinical practice may be too cumbersome.Ü Successful use requires making
complex clinical decisions; therefore, an advanced education in pain
assessment and management is required.1 Preliminary data support
the validity of the ADD protocol, but its reliability remains to be
established.
Conclusion
The patient's
self-report of pain is the single most reliable factor in successful pain
assessment. When the health care professional is equipped with an unbiased
view and advanced pain assessment strategies, a thorough pain assessment will
almost always ensue. Health care professionals must be cognizant of numerous
factors that can affect a thorough pain assessment, including cognitive
impairment, barriers to care, and nonverbalization. Tailoring the pain
assessment to the individual patient and knowing when and how to use different
assessment tools will substantially increase the probability of a
comprehensive pain assessment. Combining the appropriate tools to identify
pain intensity, location, and pain behavior is an appropriate strategy to
improve assessment outcome. Health care professionals must be educated about
the success and failure rates of widely used assessment tools in clinical
practice, and make a habit of choosing the best tool. The accuracy of the
assessment tool selection is critical to the adequacy of the pain management
regimen.
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