1. What are the challenges associated with accurate pain assessment among older people with dementia?
2. How to categorize some of the most effective tools for recognizing pain and improve pain assessment?
3. What are the available tools to aid pain assessment in people with dementia?
4. What is the role of nursing staff in assessing, managing and caring for older people in pain?
CHAPTER 1: INTRODUCTION AND BACKGROUND
Growing improvements in medical science and psychiatry the past decades has brought close and serious attention to interests in pain particularly from the elderly. To manage pain, pain assessment tools were developed and used for patients with dementia and for others who are suffering from cognitively impaired condition in response to their reduced capacity to inform others of the feeling, gravity, and nature of their pain and the imperative to identify and relieve it (Davies et al, 2004). They have evolved over the past few years and have constantly addressed the challenges brought by inaccurate assessment in the past. The tools however were focused on pain assessment from non-dementia patients which made them less significantly useful when dealing with patients in this conditional group. The challenge is that people with cognitive impairment are often unable to inform others about the pain they are experiencing. cognitively impaired older people, particularly those suffering from dementia cannot tell us about the pain they feel regardless of its nature, in a way that normal individuals can easily understand and express (Kaasalainen et al, 1998).
Pain is under-recognised and under-treated in older people. According to Royal College of Physicians, British Geriatrics Society and British Pain Society (2007), national UK statistics have indicated that pain or discomfort was reported by about half of those over 65 years old, and 56% of men and 65% of women aged 75 years and over.1 Higher prevalence estimates are obtained from samples of institutionalised older people, where 45–83% of patients report at least one current pain problem. In this alarming condition, it is good to note that serious efforts are implemented to correct errors of pain assessment among patients who are suffering from dementia. A literature search performed in PubMed (Medline) identified that 1,669 publications relating to pain management in dementia are published which helped to increase awareness on pain inside a dementia condition. Along with this statistical data, there are an estimated 35 million people suffering from dementia and its correspondent cases across the world. Despite of this significant number and the positive increase of occurrence every year where little is known about the experience and prevalence of pain in this group (Feldt et al, 1998; Kaasalainen et al, 1998; Wells et al 1997).
It may be a very debilitating condition that leaves people unable to carry out day to day activities, or it may have a significant effect on quality of life, or it may have a high mortality rate. Pain is an important measure of health care success. Medications and other pharmaceutical approaches maybe administered, yet they may not provide a feeling of wellness to the patient. The geriatric age group of cognitively impaired patients is a special case. Most of the discomfort feelings they encounter remain undetected. Some are under detected, and others endured by the patient. Knowing the level of assessment will give the nurse a clear understanding of the patient’s condition which in turn will result to proper administration of care.
The issue of improvement in detection of pain is a universal concept of care. Since the beginning of health care systems in the UK, the end goal has always been to improve the patient’s feeling either by removing pain completely, or lessening its perceived feeling to a certain degree. With this premise in place, all members of the health care team, and those in the social sector should keep in mind that those with cognitive impairment lack the proactive approach to report their feelings of discomfort. Knowing this, the responsibility of the health care provider is to know the patient’s feeling through observation. This is where sensitivity comes in. A health care provider that lacks sensitivity may not be able to provide a good assessment review. In turn, good assessment always starts with keen and sensitive observations. Pain assessment tools would enable more comprehensive pain assessment and would help nurses to make better informed and managed decisions about pain management regimens and action planning for cognitively impaired adults. Pain that result from physiological changes among old-aged dementia patients such as osteoarthritis, rheumatism, infection, or injury are often times left unmanaged due to the lack of self-verbalization. According to Christian Karlsson (2006) “the role of caregivers especially nurses in identifying pain is very important”. These complex conditions make the health care provider’s role, especially the nurse more critical as they are challenged to improve the ways of quantitatively and quantifiably measuring pain. This would ensure the potential for optimal levels of nursing care that provides comfort and appropriate patterns of rest and activity among patients with dementia. Improving pain assessment involves a multi-faceted approach. The nurse’s role should encompass the role of a health care provider and a patient advocate. Since the issue of under detection often time is persistent, the nurse should take a holistic approach in his assessment care.
Care specialists and those in the health profession are pain managers. Only a trained and experienced professional can detect the pain felt by a cognitively impaired individual. Hence, it is the primary responsibility of the nurse to be at the forefront of patient care. They need to understand the collaborative approach between various members of the health care team, the patient, as well as the significant others. Doing so will allow the nurse to formulate diagnosis that will enable them to address the specific need of the patient.
Dementia is a disease of old-age. Coupled with the normal changes in the human body, pain detection and feelings of discomfort are often times misinterpreted as normal part of ageing. This makes dementia patient a unique group to be looked into. Their situation is most of the time viewed as less serious, and is given minimal priority even by their loved ones. Incoherent thoughts, gaps in memory, fragmented logic and orientation, are viewed as normal for some. It is the right of every individual, regardless of age, to receive adequate health care. The public needs to be educated that dementia is a serious condition and thus, it is not normal. They should be aware about the specific manifestations of the disease so that they will become partners in health care as they serve as the frontline in reporting cases of dementia. Nursing is a profession of results. Given the right process and the appropriate tools, the goal is always to arrive on the planned outcome. Following thorough assessment, a clear diagnosis can be made, which will lead to the desired outcome. As expected, understanding the level of pain that dementia patients feel is expected to bring a thorough examination of the underlying causes of the disease.
Assessment has always been the major skill that a nurse needs to master. Without the art of thorough assessment, the nurse’s role becomes insignificant. The nurse, being the first line of defence for patient care, who also serves as the patient’s advocate, should understand that a major degree of the physician’s diagnosis and recommendation is reliant on the observable characteristics that the nurse notes in his assessment journal. More so, since a patient suffering from dementia requires special attention as compared to their normal counterparts, it is but more necessary for the nurse to understand the level of pain that the patient associates with his level of discomfort. Cognitively impaired patient may not have the ability to verbalize their feelings. Thus, it is the nurse’s assessment skill that will promote an avenue to know their current condition, and if the discomfort is a simple result of geriatric changes in the body, or an exaggerated response because of altered perception. This will enable the health care giver to properly manage the patient’s condition.
Knowing the nature of pain and how it impacts the life of a cognitively impaired patient will allow the nurse to understand the better approach in the care plan needed. As we all know, the normal population at their old age have a distinctive need as opposed to the old-aged dementia patient. The level of pain, their perception, and even its quality and duration is affected by the patient’s underlying anatomical and physiological degeneration. Likewise, cognitive impairment makes everything appear so severe. Knowing effective pain assessment will allow nurses to improve their skills, thereby resulting to customized care and better health management approach.
Any study concerning health analyzes the impact that it will bring for the betterment of the patient condition. Every approach should be supported by available facts, figures, tools, and processes in place. With that in consideration, the nurse should be in the first level of disease prevention and pain detection in order to improve the patient’s condition. To do this, the first step is to understand through assessment, the important characteristic of pain experienced by patients with dementia, in order to improve their condition.
CHAPTER 2: METHODOLOGY
The aims of this study are to systematically review the literature on pain in older people, to explain the challenges of accurate pain assessment in people with dementia, to be able to categorize the most efficient tools in recognizing pain and to be able to identify available studies in improving pain assessment. In addition to the aims is to identify available tools to aid pain assessment in people with dementia and to enhance the knowledge of healthcare providers regarding the evaluation of pain. It aims to increase the consciousness of pain in older people, challenge present beliefs and endorse the needed action by all who have the responsible and are involved in, assessing, managing and caring for older people in pain. Considering the aims of the study, the researcher desires to distinguish factors how to improve pain assessment in person diagnosed with dementia.
The researcher identified searched terms and healthcare related data bases in an electronic literature searching sessions. With the aid of mesh headings, the searched terms are; dementia, Alzheimer’s Disease, Frontotemporal dementia and vascular dementia and combination of pain assessment. Other dementia related topic such as delirium dementia, AIDS dementia, multi-infarct dementia and vascular dementia as it pass the inclusion criteria. Inclusion criteria include clients that are diagnosed with four types of dementia mentioned above. Age bracket is from 65 and above because dementia is very prevalent in both genders. The locations must be residential homes or long term facilities for the reason that most demented person are staying in this locations. The publication date should have at least 15 years old from the published dates, and written in English. On the other hand, the exclusion criteria includes reviews in patient with terminal illness or TLC such as cancer, patients with hearing problems, speech problems, and learning disabilities because the researcher wish to focused plainly on dementia and prevent confusion from other disabilities. Personal home based and hospital settings will be excluded as well because the hospital based often admitted for other illness not dementia, while home based will provide lack of data and professional assessment. The data based used electronically are PubMED, CiNAHL, Cochraine and Sceince Direct.
In PubMed, the word dementia has 150919 hits, 619 hits combined with pain assessment. Adding filters will result to 74 hits and 23 related studies upon thoroughly examined. CiNHAL data base has 31, 825 hits for the word dementia, 188 hits if consolidate with the word pain assessment, 49 hits after adding the filters and 26 related articles. Moreover, in Cochraine data base, there are 8,469 hits for the term demetia, 18 studies upun combined with the term pain assessment, and 7 related studies. Lastly, Science Direct data base has 6,030 hits in the word dementia, 680 hits in advance searched with the term pain assessment, 64 studies upon applying the limiters and has 8 related articles. The limiters includes age bracket of 65 and above, studies the available in English only, publication dates of 15 years from present date, and text available in in full and free.
Definition of Terms
Dementia-“Dementia” in clinical psychology is defined as a “syndrome due to disease of the brain, usually of a progressive nature, which leads to disturbances of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment.” Dementia which is a result of organic and non-organic conditions has been described as a complex network of symptoms characterized by global deterioration of cognitive functioning in a previously unimpaired person, beyond what might be expected from normal neurological changes as a result of aging.
Pian- The International Association for the Study of Pain has developed this definition: “Pain is an unpleasant sensory and emotional experience that we associate with tissue damage” (Merskey and Bogduk, 1994)
Selection of approach to literature review
There are different methods of conducting a literature review. These methods involve a narrative review, thematic synthesis, and meta-analysis. Under the narrative approach the researcher follows a less formalized approach to summarize large quantities of information. This particular approach involves the compilation of descriptive data and exemplars from individual studies and proves to be importance in the context of qualitative studies that attached great importance to context (Sutton and Booth, 2012). Further, narrative approach to literature review provides the deep and rich information as it hold the potential of remaining faithful to the integrity of the studies as a body while also preserving the idiosyncratic nature of individual studies. Unlike meta-analysis, where there must be a fit between the type and quality of the primary sources, a traditional narrative review can accommodate differences between the questions, research designs and the contexts of each of the individual studies. Indeed it disguises such distinctions by weaving together a common line of argument (Sutton and Booth, 2012).
On the other hand, thematic synthesis endeavours to provide a consistent analysis of content across included studies. It seeks to identify the range of factors that is significant for understanding of a particular phenomenon. It then seeks to organise these factors into the main or most common themes (Thomas and Nelson, 2010). Then there is framework synthesis that is used in primary qualitative research. It stems from recognition that the sheer volume and richness of qualitative research pose a challenge for rigorous analysis. Framework synthesis offers an approach that is highly structured in nature and is informed by a background material and team discussions to extract and synthesise findings (Thomas and Nelson, 2010).
Meta-analysis is a statistical method where the aggregation of a weighted average of the results of individual studies in order to calculate an overall effect size for an intervention (Thomas and Nelson, 2010). It is a quantitative literature review method used widely as an alternative approach to narrative literature review. It uses a set of statistical procedures to integrate, summarise or organize a set of reported statistical findings of studies that investigate the same research question using the same methods of measurement (Stutton and Booth, 2012).
The present study has followed a narrative approach to literature review for identifying, explaining and providing perspectives on issues associated with assessment and management of pain among demented elderly patients. Additionally, this particular approach will prove to be the best route for presenting new perspectives on this key issue being faced by a majority of elderly population in countries like UK and Australia. A critical analysis of the articles or studies being considered is possible under the flexible approach of narrative literature review. Most of the studies considered for review range from year 2001-2012 and were conducted in Australia and UK.
CHAPTER 3: NEED OF ASSESSING PAIN AMONG DEMENTED INDIVIDUALS
Elderly patients present several pain management problems. First, relatively little attention has been paid to the topic of geriatric pain control in medical or nursing texts. This is ironic because elderly people often suffer acute and chronic painful disease, have multiple disease, and take many medications. They may have more than one source of pain and an increased risk for drug-drug as well as drug-disease interactions. In this chapter the studies and reviews discussing the need and importance of assessing pain among elderly demented individuals have been presented to understand the future route to treatment resulting out of proper and correct assessment of pain.
Bachino et al. (2001) presented a detailed review about the importance of assessing pain regularly and treatment for non-communicative demented individuals. The discussion includes the issue of under-recognition and under-treatment of pain in geriatric settings and the unique features associated with experience of pain among individuals that are demented severely. The review also discuss the techniques of assessing pain and the key barriers associated with treatment of such pain among non-communicative elderly patients. The authors are focused on establishing the need of treating pain as a component necessary for humane care especially among demented individuals as the obligation of treating pain among these individuals is high due to their lack of capacity of seeking treatment on an independent basis. Concerned with the under-diagnosis and under-treatment of pain among elderly patients especially under geriatric settings, Bachino et al. (2001) conducted a systematic literature review to attain the objective of detailing the importance of regular assessment and treatment of pain for non-communicative demented individuals with a focus on under-diagnosis and under treatment of pain to provide recommendations for assessment of treatment of pain among non-communicative demented elderly individuals.
The study of Kamel et al. (2001) had a different focus from that of Bachino et al. (2001) as Kamel focused on use of some specific tools and instruments while Bachino focused more on theoretical part of pain among demented elderly where proper assessment is the key to effective treatment of pain. The combined study of these two reviews and articles provides a theoretical as well as practical approach to pain assessment among elderly demented individuals and the efficiency of various tools available and commonly used for the purpose.
The discussion starts with detailing the importance of assessing and treating pain on a regular basis so as to avoid severe consequences and ensuring treatment of pain much before excited pain receptors in the nervous system become less responsive to any kind of treatment. Some geriatric settings have been used by Bachino et al. (2001) to discuss the scope of the problem of under-recognition and under-treatment of pain along with discussing the key barriers to treatment of pain among these individuals. The focus of the review remained on presenting the statistics and facts in relation to under-recognition and under-treatment of pain especially among older adults. The target group of review was the non-communicative demented individuals unable to self-report the pain making it difficult to provide them adequate care and treatment for management of pain. It has been argued by Bachino et al. (2001) that little research work has been conducted focusing on elderly people with dementia in relation to management of pain specifically for those whose language abilities have been severely impaired due to the health condition. Bachino et al. (2001) have also discussed the existing recommendations concerned with assessment of pain among elderly demented patients explaining that there is a need to use a combination of assessment tools as no one pain assessment technique can prove to be effective for all patients and superior in every situation. The guidelines provide by American Medical Directors Association (AMDA) and the Agency for Health Care Researh and Quality (AHRQ) proved to be helpful in this regard but needs to be worked out in collaboration so as to develop better and more targeted pain assessment tools effective for usage with non-verbal patients. The results this review focused on discussing the applicability of various tools of assessing pain among demented patients thereby extending the scope of review and not limiting the discussion to mere literature review of challenges being faced while assessing and managing pain among demented elderly.
The review presented by Bachino et al. (2001) also explained the barriers in treatment of pain including individual-level factors, and system-level factors that act as major barriers to effective treatment of pain among elderly demented patients. These barriers comes in form of attitude of family members considering pain as a regular stage of dementia which does no need any specific intervention. Similarly caregivers believe that an increase in pain signifies the progression of disease and therefore need to be considered as a normal occurrence not requiring intervention. Further there are communication barriers among treatment professionals and lack of understanding resulting in ineffective treatment of pain among elderly with dementia. There is a need of collaborative approach to be followed by members of the treatment team as their individual contribution helps in better understanding of intensity of pain and its proper management. Further the collaboration of patient, family nurses, carers’ ad physicians is necessary for following a unique perspective towards management and treatment of pain among elderly with dementia. Therefore, the systematic review presented by Bachino et al. (2001) provided a detailed evaluation of pain assessment tools and challenges for treatment of pain to provide some key recommendations for improving the assessment and treatment of pain through a collaborative approach among various team member involved in treatment of pain among elderly demented individuals.
As per the recommendations provided by Bachino et al. (2001) there is a need of developing plans for treatment of individuals in collaboration with patients, members of their family and nursing assistants as well as nurse and physicians. Then Bachino et al. (2001) recommended the establishment of a pain treatment communication flowchart where the responsibility of each of the team member should be detailed in relation to assessment, treatment as well as follow-up pf treatment related with pain. Bachino et al. (2001) also focused on the need of encouraging hospitals and institutions offering long-term care to make considerable investment in pain educational programs for clinicians and staff members along with making professionals sensitive to the need and beliefs associated with pain among elderly demented individuals. These steps and key considerations will help in improving the assessment of pain among elderly non-communicate individuals through timely and regular recording of results of every pain assessment and developing treatment plan on the basis of such regular assessment and feedback.
Bachino has been successful in addressing a clearly focused issue about the need of regularly assessing pain among demented individuals. Proper and enough information was provided under the review about the population studies, i.e. the non-communicative demented individuals and the interventions required to make timely assessment through observational methods. Authors have also used appropriate sort of papers to address the question under review and followed a proper design of systematic review but without a meta-analysis. The results of the review were combined and it was reasonable to do so as the majority of studies reviewed by Bachino et al. (2001) focused on explaining the challenges being faced while identifying presence and intensity of pain among non-communicative individuals and the need of behaviour observational methods to achieve this particular goal. The results of the review also contributes to the objectives of this particular narrative review by clarifying the reasons for which it is necessary that pain assessment among demented individuals is studies and taken care of.
CHAPTER 4: DEMENTIA BARRIERS TO ASSESSMENT OF PAIN AMONG DEMENTED PATIENTS
Dementia is responsible for complicating the assessment of pain as it impairs memory, judgment and verbal communication (Horgas et al., 2009). It is to be noted that among elderly adults, pain is a persistent daily issue that is related with their physical and social disabilities, depression and poor quality of life. As per the statistics presented by Shega, Hougham and Stocking (2004) there are more than 53% of dementia patients experiencing pain in their daily life. This clarify the high prevalence of pain-related health conditions among elderly adults and is generally associated with conditions of peripheral vascular disease, cancer, hip fractures and osteoarthritis. The assessment as well as treatment of pain in adults with dementia pose some unique challenges as they fail to understand and self-report the intensity of pain. This is so as people with any disability in terms of memory or language or speech deficits are unable to have clear communication or express themselves in an effective manner (Buffman et al., 2007). Therefore, they fail to inform clearly about their pain and discomfort as well as its intensity in proper manner.
The limited ability of severe dementia patients to communicate and thus to express pain is a substantial barrier to pain assessment and management (Burns and Winblad, 2011). It is not clear whether dementia patients actually experience, or simply report less pain. There are differences in expression of pain and are reflected in differences in medication prescription. Several studies are available explaining that dementia patients were prescribed fewer analgesics, even when they had more behavioural indicators of pain documented (Burns and Winbald, 2011).
Epperson and Bonnel (2004) presented an article describing the challenges, identifying the tools and suggesting the strategies to assess pain among patients with dementia. The article was presented in a form of detailed literature review with critical analysis of available literature at every possible step to follow a systematic route to establishing the need of improving the knowledge and skills of advanced practice nurse (APN) in using methods of screening, pain assessment tools in case of self-reporting, assessment tools in case of observational pain and required nursing facility assessment tools so as to develop best practice in assessment of pain among patients with dementia.
Epperson and Bonnel (2004) have moved a step ahead from the evaluation conducted by other authors like Bachino et al. (2004) as Epperson and Bonnel (2004) has focused on challenges being faced while working with demented patients. The review presented by Epperson and Bonnel (2004) is more comprehensive in nature as it combined the challenges as well as tools and strategies for assessing pain among demented individuals.
The article presented by Epperson and Bonnel (2004) aimed to describe the challenges and identify the tools starts with identifying the basic problem of the complex relationship between dementia and assessment of pain as dementia is responsible for influencing the pain to a significant extent. The health conditions associated with dementia in the form of reducing language skills and impaired ability of patient to describe pain results in worsen the experience of pain at the same time act as a hurdle in accessing proper treatment in clinical settings (Epperson and Bonnnel, 2004). Epperson and Bonnel (2004) while identifying the problem focused on the need of identifying and utilizing the appropriate tools of pain assessment among patients with dementia. In order to seek the solution Epperson and Bonnel (2004) described the guidelines, strategies to screen for producing diagnoses of pain, pain scale variations and federally mandated standardized assessments. Under general guidelines the recommendations of the American Geriatrics Society (2002) were presented as being appropriate for managing the persistent pain in elderly patients. The focus was on the algorithm as recommended by the society which can be considered as a basic framework to initiate the assessment of pain in population of elderly individuals with dementia.
Further Epperson and Bonnel (2004) discussed the need of ‘at-risk’ diagnoses which help in having an advanced awareness of needs of the patients that can guide through future detailed diagnosis. Such at-risk diagnosis can provide information about the potential health condition like cardiac condition, musculoskeletal condition, or any other pain producing condition that can then be used for planning appropriate treatment of pain in pharmacological as well as non-pharmacological manner. Early awareness of pain producing health conditions can ensure timely treatment of pain in an appropriate manner (Epperson and Bonnel, 2004).
In the next step Epperson and Bonnel (2004) discussed the scales of self-reported pain which can prove to be useful only in cases of early stage of dementia. Here the utilization of one-dimensional and two dimensional pain scales have been discussed where it is required that the properties of selected tools is well understood in relation to specific patients for whom the assessment tools are required to be used. Some common self-reporting pain scales used and considered by Epperson and Bonnel (2004) includes Numeric Rating Scale (NRS), Wong-Baker Faces Scale, Visual Analogue Scale (VAS), Present Pain Intensity Scale of McGill Pain Questionnaire, and Verbal Descriptor Scale. There have been several observational scales used for pain assessment and includes Discomfort in Dementia of the Alzheimer’s Type (DSDAT) Scale, and Checklist of Nonverbal Pain Indicators. These scales have been considered for discussion in the review of Epperson and Bonnel (2004) so as to provide readers with a clarity over usage and appropriateness of each tool in a detailed manner.
Epperson and Bonnel (2004) also provided some key details associated with daily challenges that an ideal care facility needs to face and manage while providing elderly care. These potential issues may take the form of infrequency in documentation of the level of dementia being experienced by patients, lacking a concern for physical cues provided by patients’ body that can indicate the level of pain and discomfort being experienced by elderly demented patients. Through the discussion and review Epperson and Bonnel (2004) explains that APN should use the opportunity of responding to and impacting the care of patients that are elderly and demented experiencing pain. There is a need of having appropriate knowledge and understanding of various methods of screening including the self-reporting methods as well as observational methods that can be used for providing the basis for best practice in assessment of pain among demented elderly patients.
Epperson and Bonnel (2004) has been successful in clearly focusing and analysing the issue of appropriate knowledge about various screening methods that should be combined with self-reporting to assess pain among demented individuals. The review has remained critical in nature and therefore presents a well synthesized information explaining the role of nurses in assessing pain in a proper and appropriate manner.
Buffman et al. (2007) conducted a narrative literature review to provide an overview of assessment, treatment and management of pain in adults with cognitive impairments. In order to achieve the aim of presenting a literature review over the issue of difficulty in pain assessment and treatment among demented elderly individuals, Buffman et al. (2007) presented a review of various types of cognitive impairment and recent work related with best practices of managing pain among people with dementia along with discussing the development of assessment tools and pharmacological treatment.
The review has followed a narrative route to explain nature of cognitive impairment followed by various treatment routes being followed as best practices so as to provide direction to future research for meeting the challenges of providing pain related treatment and care in patients with delirium and in medical intensive care as well as palliative care settings.
In order to present the relevant literature Buffman et al. (2007) selected papers focused on assessment and treatment of pain among cognitively impaired elderly people and those discussing and assessing the effectiveness of various pharmacological and non-pharmacological modes of assessing and treating pain in older persons with cognitive impairment. Most of the articles have been selected from PubMed database and therefore focused on biomedical topic of dementia and challenges faced while assessing pain among elderly demented patients. Buffman et al. (2007) have considered around 100 studies to discuss various aspects of issues and challenges being faced during pain management among cognitively impaired elderly individuals. However, there is no information available about the basis of rejecting some studies and selecting some others while planning the narrative literature review.
Through conducting a detailed review of recent work specific to best practices for management of pain in dementia patients Buffman et al. (2007) have established the unique challenges posed by dementia due to its cognitive and verbal impairments. The analysis of previous studies as considered by Buffman et al. (2007) suggest that for elderly adults, lacking the ability of acknowledging the pain verbally, it is possible to find the clinical utility of behavioural observation. While people involved in rating need to be conscious about assessment of other needs of the patients including hunger, thirst, loneliness, boredom or restlessness. Most of the previous studies considered under the review presented by Buffman et al. (2007) have suggested the need to follow a comprehensive approach towards management of pain. Under this approach there is an inclusion of evaluations of behaviour, collateral information from family or caregivers familiar with patients’ past expressions of pain and usual preferences in terms of treatment along with diagnoses associated with painful sensations of any other physiological signs.
Buffman et al. (2007) also studied various treatment approaches available and being followed as per the available literature. The narrative review suggests that in order to treat pain among dementia patients there is a widespread usage of pharmacological as well as non-pharmacological modalities. The perception for pain is possible to be heightened due to vascular dementia and patients having discomfort in expressing pain verbally have a greater potential of unrelieved and unrecognized pain. The review also revealed that a greater interaction of cognitive and functional impairment, pain, depression and agitation can result in some serious conditions specifically among patients with dementia and there is high prevalence of some serious side effects. These side effects take the form of results in gastrointestinal bleeding and constipation and worsen the cognitive impairments, which need that need a focus of clinicians over pharmacological as well as non-pharmacological treatment along with using schedules doing for recurrent pain while using a regime to mitigate the side effects (Buffman et al., 2007).
The review conducted by Buffman et al. (2007) is also focused on challenges being faced while managing pain in delirium which is another actor putting a barrier to successful management of pain. This is so as this condition results in alteration of mental status affecting the ability of patient to report pain. The clinical identification of other physiological issues is often confronted by the condition of delirium resulting in an increase in pain and worsening of cognitive impairment. The clinicians should understand the unique responses of patients so that the factors associated with predictors and precipitation of delirium can be identified and taken care of at the appropriate time during treatment (Buffman et al., 2007).
Buffman et al. (2007) through a narrative literature review has remained successful explaining the fact that older persons have multiple medical problems and many potential sources of chronic discomfort, making it difficult to diagnose and treat pain in the patient population. The narrative literature review presented by Buffman et al. (2007) has contributed to present review by establishing the fact that the elderly represent a particularly vulnerable and challenging patient population in whom pain is often inadequately recognised and undertreated. The focus of the review has remained on older people to explain that as the population continues to age, the number of elderly surgical patients will increase. As such competency of health care providers in pain assessment and management in the elderly population is essential.
There exist a misconception that cognitively impaired older persons do not experience pain as severely as persons who are cognitively intact. Although some studies have suggested that elderly patients report lower pain intensity than younger patients, other studies have not demonstrated age differences (Sinatra and Viscusi, 2010). It has been noted that proportion of patients reporting pain did not change with the degree of dementia. Pain assessment in elderly may be complicated by concurrent illness, underreporting of symptoms, decline in cognitive function age-related physiologic changes. A review of the pain management literature suggest age-related differences underlying neurochemical, neuroanatomical, and neurophysiological mechanisms of pain (Carr and Jacox, 2011). Older persons may experience altered pain sensitivity, a muted and delayed clinical pain perception and altered quality of pain sensation when compared to younger adults (Sinatra and Viscusi, 2010). These facts have been well explained and considered under the narrative review presented by Buffman et al. (2007) helping the authors to achieve the basic objective of their review.
It has been suggested by several studies that a lower intensity of postoperative or procedural pain is reported by older compared to younger adults (Buffman et al., 2007). Elderly persons have demonstrated lower ratings of sensory and affective dimensions of pain in several reports. Evaluating the pain experience of the elderly patients may be further complicated by differences in pain symptoms manifestation when compared to younger patients. Reactions of the cognitively impaired person to painful stimuli may differ from the typical response of a cognitively intact older person (Carr and Jacox, 2011). For example, pathologic conditions that produce clear pain symptoms in younger patients may manifest as confusion, restlessness, aggression or fatigue in the elderly, resulting in misdiagnosis and delays in treatment.
Gagliese (2009) presented a critical review of various studies available on the issue of pain among elderly population. There is a dramatic growth in the field of pain and aging which assumed key differences between the pain in older and younger adults to a significant level. This is so as the data available form younger group cannot be generalised for older people and therefore there is a need to have separate studies under a subfield of pain and aging. The evidence for this assumption has been considered by Gagliese (2009) for presenting the possible interpretations of the results available on age-related rise, fall and stability in pain and discussing the challenges being faced under gerontological studies.
Gagliese (2009) presented a detailed and systematic literature review starting with a discussion over the domain of pain and aging subfield. Under this discussion, Gagliese (2009) focused on detailing the studies explaining the need of a separate field to study the relationship between pain and aging. This is so as with the difference in age there lies a significant level of difference between the experiences of pain as well its increase, decrease of getting stable with proper care and medication. Even the diagnosis of pain differs along with its intensity with the difference in age groups. The review presented by Gagliese (2009) focused on establishing the need of studying pain among older adults differently in comparison to that considered for younger adults.
Further Gagliese (2009) discusses the emergence of pain and aging subfield. The discussion has been made through detailing the growing number of publications in the sub field during past 20 years which was identified by Gagliese (2009) through detailed search of the Medline periodical database. The obstacles experienced in growth of the pain and aging subfield have also been discussed where lack of theoretical model to guide such growth, inadequate management and assessment of pain among elderly, and complexity of age relate patterns in pain prevalence have been considered as the major hurdles.
Gagliese (2009) detailed the research work conducted into pain and aging with a key focus of measurement of pain across the adult lifespan and age related patterns in pain. The discussion revealed that several studies have been conducted to establish the difference in age related patterns in pain among human beings. Gagliese (2009) argues that several studies are available for various different types of pain to support the age-related increase, decrease and stability in pain. There is a diversity among studies in pain epidemiology, experimental pain sensitivity in human and clinical pain which makes it difficult to present the findings in a heuristic manner.
Gagliese (2009) explained that there is a need of considering age-related patterns of pain as it act as the first step to identify the pain, its intensity and uniqueness acting as a guide to provide appropriate treatment for pain. Once the patterns are known it will become possible to shift the focus to identify the reasons of pain on the basis of age-related problems that may play a key role in such type of pain among elderly. Several approaches have been considered by Gagliese (2009) to attain this objective and includes prospective studies for identifying the risk factors differentiating elderly with herpes zoster. Then there are experimental models that can be used for identification of mechanisms for the age-related rise in pain due to manipulations of variables.
Therefore, the review presented by Gagliese (2009) provides sufficient evidence to establish the uniqueness of pain as experienced by elderly people and requires future research work and examination. Gagliese (2009) has been successful in presenting a systematic literature review with a focus on the issue of considering pain and aging as a subfield that needs to be studied as a separate domain. To achieve this objective, Gagliese (2009) has detailed the increasing rate of publications in the sub field and focusing the review on need of a theoretical model to guide the growth of this sub field of study about pain and aging.
The uniqueness of such a pain among elderly is characterised with prolonged recovery of tissues, age-specific inter-relationships of psychosocial factors necessary in case of chronic pain and nerve injuries. The review provided by Gagliese (2009) has contributed to the sub-field by clarifying the need of developing a model complementary to biopsychosocial models. It was also revealed that pain during aging is not uniform at every stage and is affected by the biopsychosocial spectrum in full. It is clear that the study and understanding of pain among elderly is complex in nature which calls for the development of a framework of pain and aging that is complementary to current biopsychosocial models. Such a model will help in refining the understanding about the unique features of pain experienced by older adults and thus an age-tailored prevention will follow through assessment and intervention protocols aimed at reducing the sufferings that are unnecessary and maximization of quality of life of older adults. However, the study fails to offer such appropriate model and leaves a wide gap calling for a need of detailed research work to develop the required model of pain assessment among elderly.
Jocelyn and While (2011) focused on alteration of pain related experience among demented individuals which hampers their ability of communicating such pain. With this focus Jocelyn and While (2011) conducted a systematic literature review with the aim of identifying observational pain scales that have been utilized clinically and prove to be feasible for usage by district nurses among demented individuals in their necessarily intermittent daily community practice. Jocelyn and While (2011) has recognised the fact that an inability of demented individuals to communicate their pain results in improper detection as well as improper treatment of pain among such individuals.
In order to conduct the literature review, Jocelyn and While (2011) considered the articles published between 1992-2009, available in English and accessible for retrieval and peer reviewed. EBSCO host along with Ovid SP and Expanded Academic ASAP database were used to conduct the initial literature search. The articles that were sources were also considered for their reference lists for identifying further relevant articles (Jocelyn and While, 2011). Some websites providing access to clinical guidelines and those with evidence-based database were also considered for search and included National Guideline Clearing house, The Joanna Briggs Institute and the Cochrane Library. Through the search four systematic reviews were identified providing the best available evidence associated with practices in assessment of pain.
The literature review conducted by Jocelyn and While (2011) did not delivered any consensus on the validity and reliability of pain scales. However, the authors conducted a further evaluation of the Non-communicative Patients Pain Assessment Instrument that provided information about benefits of the instrument being applied to the individual’s home because the instrument can be administered in a simple and easy manner by the family members too. However, no scale has been effective enough to provide a clear measure of intensity of pain and the rating guidelines that can prove to be helpful for the care givers. The literature review conducted by Jocelyn and While (2011) clarified the complexity of measuring pain among demented individuals that have lost the ability to communicate their pain. The review also clarifies that there is a need of collaborating the role of instruments to measure pain and the experience and abilities of clinicians, care givers and nurse as well as that of physicians to identify the stage of dementia and the associated level or intensity of pain. Such a collaborative approach is the only route to identify pain and its intensity among demented individuals which can be combined with the information obtained from family members to generate better results.
Jocelyn and While (2011) reviewed some observational scales as suggested by several authors like Herr (2006), Wilson (2009), Zwakhalen (2006) and Strolee (2005). The communicative ability of the person with dementia was the primary factor determining the use of self-reporting or observational pain scales. As per the basic assumption provided by American Geriatrics Society (2002) the most accurate and reliable evidence for identification of presence as well as intensity of pain is through experience shared by the individual experiencing pain. However, such a response from the individuals becomes difficult in case of demented adults and thus abstract thinking should be considered by the self-report scales. Several observational scales are available that can be used in cases where self-reporting is not possible as observational scales rely on autonomic responses to pain (Hadjistavropoulos et al., 2010). However, people with severe dementia may lack the classic signs of pain which makes observational scales inappropriate for a complete reliance while treating pain among demented individuals.
Jocelyn and While (2011) considered four systematic reviews where observational pain scales was the focus of the study to study pain among demented people. Through these reviews, Jocelyn and While (2011) identified 14 such scales of which those with highest psychometric qualities were considered for evaluation. However, as per the view of Jocelyn and While (2011) the four systematic reviews failed to provide a consensus on the definitive scales suitable for clinical practice. Such disparity among scales resulted due to several reasons. First reason is the usage of different frameworks for appraisal as considered under each review. Secondly there was a variation in inclusion criteria across reviews.
Further, Jocelyn and While (2011) focused on score interpretation of every scale considered as in absence of such a provision that can determine a cut-off score will hamper the decision making in relation to designing of treatment strategies. Considering this particular factor the four systematic reviews revealed that there lies a gap in evidence available for community nursing. This is so as assessment of pain among demented individuals facing language difficulties process to be a complex issue for patients as well as for care givers in the community environment (Jocelyn and While, 2011).
Jocelyn and While (2011) has remained successful in conducting a systematic literature review by focusing on the major issue of altering the pain related experience among demented people and identification of observational pain scales that can prove to be helpful in achieving the objective. Under this systematic review, authors have considered appropriate quantity and quality of articles to reach a consensus on validity and reliability of pain scales. However, when authors failed to reach such a consensus they shifted the focus of review on evaluation of Non-communicate Patients Pain Assessment Instrument. This shift clarifies the well-focused nature of the review where Jocelyn and While (2011) were determined to find a route to assess pain among non-communicative individuals.
Jocelyn and While (2011) also identified the gap in evidence available on assessment of pain in the community nursing environment while caring for demented patients. The evaluation of reliability and validity of observational tools is also required along with developing score interpretations of the scales when these are to be used at patients’ home. Opportunities exist in terms of following a collaborative approach of using observational tools and family members’ partnership which provides the advantage of the unique knowledge about the demented individual (Jocelyn and While, 2011).
CHAPTER 5: ASSESSMENT OF PAIN THROUGH SELF-REPORTING AND BEHAVIOURAL OBSERVATION TOOLS
Iersel, Timmerman and Mullie (2006) presented a review with the aim of describing the development and introduction of a pain scale for patients with cognitive impairment. The review has detailed the way new pain scale was developed and tested through a pilot study to identify the suitability of the scale among demented patients experiencing pain which generally remained under-estimated and thus under-treated. The review is narrative in nature explaining the situation of palliative care homes for older people and nursing homes in northwest Flanders of Belgium where pain of elderly generally remains undertreated.
Iersel et al. (2006) explained that due to nonverbal expression of cognitively impaired patients their pain was easily overlooked which affected their quality of life to a great extent. Therefore, in order to bring an improvement in quality of life of demented elderly there was a need of measuring pain behaviour in a systematic manner through an efficient scale. With this aim the nursing homes sought collaboration with the project team of ‘Fighting Pain Together’ (Iersel et al. (2006). The team was formed as a part of the project started as a European movement founded by the Swiss palliative and geriatric specialist Charles-Henri Rapin with the aim of reducing the suffering of pain in hospitals through offering adequate control of pain.
Under this collaboration with the team a pilot study was conducted by Denise Timmerman who was a pain specialist nurse of the ‘Fighting Pain Together’ team. The aim of the study was to identify a valid scale of identifying pain by nurses and nurse assistants on the basis of observation of behaviour of patients with cognitive impairment. The study was conducted through a questionnaire method where a comparison of Abbey and Pain Assessment in Advanced Dementia (PAINAD) scales was done through using a sample size of 17 nursing homes in the region of northwest Flanders of Belgium with 185 care providers to evaluate 157 patients.
The results of the study conducted by Timmerman revealed that there were not much differences reported between the two scales and clinicians considers both the scales to be useful in understanding pain behaviour among demented elderly patients. However, care givers remained unclear about the nature of pain being experienced by patients that can be emotional as well as physical in nature. It was the intuition of care givers that helped them in establishing the components of pain and level of discomfort. Therefore, the usage of any kind of pain scales are required to be collaborated with intuitive results and experience-based assessment of care givers so as to consider the differences among individuals and their behaviour patterns that may change over time (Iersel et al., 2006).
The review presented by Iersel, Timmerman and Mullie (2006) remained successful in providing a detailed assessment of various observational tools that are in use for assessing pain among demented elderly patients. The consideration of the review explains the theoretical as well as practical application of various observational tools and the way these tools are developed and studied before actually implemented in clinical settings. However, the major limitation of the review lies in its focus on a single scale of assessing and measuring pain and therefore the results cannot be generalized to a wider population of various scales available for such pain assessment.
Horgas et al. (2009) conducted a detailed study to investigate the relationship between self-report and behavioural indicators of pain among intact and cognitively impaired older adults. The research took the form of quasi experimental study where a correlational study of older adults was undertaken so as to conduct an investigation of pain among elderly with mild to moderate level of dementia. This was done keeping the fact in mind that it is not possible to experimentally manipulate the status of dementia (Horgas et al. 2009). In order to conduct the study the required data was collected from residents of nursing homes, assisted living and retirement apartments in north-central Florida. There were one hundred twenty-six adults as participants of the study and their mean age was 83 where 64 were cognitively intact while 64 were impaired cognitively. Care was taken to get the informed consent from cognitively intact participants and for cognitively impaired respondents the legally authorised representatives of selected participants were contacted to get the assent.
As per the procedure of the study, a brief screening interview was completed by the participants for confirming their eligibility for the study and for ascertaining the cognitive status. The eligible participants were interviewed about their pain and they completed an activity-based protocol that was designed for evoking behaviours related with pain among patients experiencing persistent pain. The procedures and protocols were used to measure the self-reported pain as well as observed pain behaviours. Under self-reported pain, participants were interviewed by a trained research assistant to inform about their experiences related with pain in terms of intensity of pain, duration of pain and location of pain.
Under observed pain behaviours a modified version of the Pain Behaviour Measure as provided by Keefe and Block (1982) was used for measuring behavioural indicators of pain. Here pain behaviour coding was undertaken by recording the activity protocols and scored earned by participants under the protocols. Further an assessment of cognitive status was undertaken with the usage of an 11-item screening instrument that is used widely for assessment of general cognitive status among elderly patients (Horgas et al. 2009).
Under the study Horgas et al. (2009) conducted an empirical study to establish the facts and found that there is a significant level of reduction in self-reporting of pain due to cognitive impairment only when there is a lack of control over analgesics. Horgas et al. (2009) explained that as per the available literature it has been established that the patients with cognitive impairment are less likely to self-report the pain in comparison to cognitively intact elderly people. However these results were analysed to highlight the need of controlling analgesics which can result in disappearance of these differences. It was found that the self-reported pain intensity increased for both cognitively intact and cognitively impaired groups after completion of activity-based protocol while cognitively impaired elderly people reported less-intense pain in comparison to their intact peer group. These results suggest the importance of protocol for exacerbating pain among those with painful conditions highlighting the need of mobility-based assessment of pain. This particular study has moved beyond the literature review