Self- and proxy report for the assessment of pain in patients with and without cognitive impairment: experiences gained in a geriatric hospital

Caregiver Burden Associated With Pediatric Chronic Pain: A Retrospective Study Using the Pediatric Electronic Persistent Pain Outcomes Collaboration Database

OBJECTIVES

This retrospective, cross-sectional study investigated the nature and extent of burden experienced by caregivers of children and adolescents with chronic pain, and factors associated with increased caregiver burden.

METHODS

The Pediatric Electronic Persistent Pain Outcomes Collaboration database provided prospectively collected data from 1929 families attending 9 pediatric chronic pain services across Australia and New Zealand. Data included demographic information, responses to child pain and functioning measures, caregiver work impairment, and psychosocial functioning.

RESULTS

Caregivers of children with chronic pain reported work impairment associated with their child's pain (mean: 15% ± SD 25 absenteeism; 38% ± SD 29 productivity lost), significantly worse than published international population norms (large-scale community survey data), most other caregiver samples of adults and children with other chronic conditions, and adult samples with various pain conditions. Caregivers reported considerable burden in multiple psychosocial functioning domains, particularly leisure functioning, pain-related catastrophizing, and adverse parenting behaviors (with greater pain-related avoidance). Caregiver psychosocial burden was significantly associated with child psychosocial functioning (β = -0.308, P < 0.01), school absenteeism (β = 0.161, P < 0.01), physical disability (β = 0.096, P < 0.05), and pain duration (β = 0.084, P < 0.05), but not pain intensity. Caregiver work productivity loss was significantly associated with school absenteeism (β = 0.290, P < 0.01), child physical disability (β = 0.148, P < 0.01), child health care utilization (β = 0.118, P < 0.05), and worst pain intensity (β = 0.101, P < 0.05).

DISCUSSION

These results highlight the significant and varied impacts experienced by caregivers of children with chronic pain. This work is novel in reporting significant work impairment and confirms psychosocial burden in a larger sample than previous studies.

Expanded nursing roles to promote person-centred care for people with cognitive impairment in acute care (ENROLE-acute): study protocol for a controlled clinical trial, process and economic evaluation

BACKGROUND

For people with cognitive impairment, hospitalisation is challenging and associated with adverse events as well as negative outcomes resulting in a prolonged hospital stay. Person-centred care can improve the quality of care and the experience of people with cognitive impairment during hospitalisation. However, current care processes in German hospitals are rarely person-centred. To enable successful implementation of person-centred care on hospital wards, change agents within the interprofessional team are key. The aim of this study is to test the feasibility and initial effects of a newly developed complex person-centred care intervention for people with cognitive impairment provided by expanded practice nurses in acute care.

METHODS

We will conduct an exploratory non-randomised controlled clinical trial with accompanying process and cost evaluation with three intervention and three control wards at one university hospital. The person-centred care intervention consists of 14 components reflecting the activities of expanded practice nurses within the interprofessional team on the intervention wards. The intervention will be implemented over a six-month period and compared with optimised care on the control wards. We will include people aged 65 years and older with existing cognitive impairment and/or at risk of delirium. The estimated sample size is 720 participants. The primary outcome is length of hospital stay. Secondary outcomes include prevalence of delirium, prevalence of agitation, sleep quality, and person-centred care. We will collect patient level data at six time points (t1 admission, t2 day 3, t3 day 7, t4 day 14, t5 discharge, t6 30 days after discharge). For secondary outcomes at staff level, we will collect data before and after the intervention period. The process evaluation will examine degree and quality of implementation, mechanisms of change, and the context of the complex intervention. The economic evaluation will focus on costs from the hospital's perspective.

DISCUSSION

The ENROLE-acute study will provide insights into the effectiveness and underlying processes of a person-centred care intervention for people with cognitive impairment provided by expanded practice nurses on acute hospitals wards. Results may contribute to intervention refinement and evidence-based decision making.

TRIAL REGISTRATION

Current controlled trials: ISRCTN81391868. Date of registration: 12/06/2023. URL: https://doi.org/10.1186/ISRCTN81391868.

Digital assistance systems in the field of incontinence care for individuals in need of long-term care (EASY): study protocol of a stratified randomised controlled trial

BACKGROUND

In general, urinary and faecal incontinence is a multifaceted problem that is associated with increasing burdens for those affected, a massive impairment of quality of life and economic consequences. Incontinence is associated with a high level of shame, which in particular reduces the self-esteem of those being incontinent and leads to additional vulnerability. Those affected by incontinence often perceive incontinence and the care they receiveas humiliating, hence they can no longer control their own urination; nursing care and cleansing support then lead to additional dependency. People with incontinence in need of care not uncommonly experience a poor communication and many taboos surrounding the issue as well as the use of force when incontinence products are changed.

AIMS AND METHODS

This RCT aims to validate the benefits of using a digital assistance system to optimise incontinence care and to enable statements concerning the effect of the assistance technology on nursing and social structures and processes as well as on the quality of life from the perspective of the person in need of care. In a two-arm, stratified, randomised, controlled interventional study, primarily incontinence-affected residents of four inpatient nursing facilities will be examined (n = 80). One intervention group will be equipped with a sensor-based digital assistance system, which will transmit care-related information to the nursing staff (via smartphone). The collected data will be compared to the data of the control group. Primary endpoints are falls occurring; secondary endpoints are quality of life and sleep, sleep disturbances and material consumption. In addition, nursing staff (n = 15-20) will be interviewed regarding the effects, experience, acceptance and satisfaction.

DISCUSSION

The RCT aims at the applicability and effect of assistance technologies on nursing structures and processes. It is assumed that, amongst other things, this technology may lead to a reduction of unnecessary checks and material changes, an improvement of life quality, an avoidance of sleep disturbances and thus an improvement of sleep quality as well as to a reduced risk of falling for people with incontinence in need of care. The further development of incontinence care systems is of social interest as this offers the prospect of improving the quality of care for nursing home residents with incontinence.

TRAIL REGISTRATION

Approval of the RCT is granted by the Ethics Committee at the University of Applied Sciences Neubrandenburg (Reg.-Nr.: HSNB/190/22). This RCT is registered at the German Clinical Trials Register on July 8^th, 2022, under the identification number DRKS00029635.

Cognitive impairment is associated with greater preoperative symptoms, worse health-related quality of life, and reduced likelihood of recovery after cervical and lumbar spine surgery

Background

Cognitive impairment (CI) is associated with prolonged hospital stays and increased complications; however, its role in symptom severity and health-related quality of life (HRQoL) among spine patients is unknown. We determined 1) prevalence of preoperative CI; 2) associations between CI and preoperative pain, disability, and HRQoL; and 3) association between CI and postoperative improvements in HRQoL.

Methods

This is a prospective cohort study of 453 consecutive adult spine surgery patients between October 2019 and March 2021. We compared pain (Numeric Rating Scale, NRS), pain-related disability (Oswestry/Neck Disability Index, O/NDI), and HRQoL (PROMIS-29 profile, version 2.0) among participants having severe (PROMIS-29 Cognitive Abilities score ≤30), moderate (31-35), or mild CI (36-40) or who were unimpaired (score >40), using analysis of variance. Likelihood of clinical improvement given the presence of any CI was estimated using logistic regression. All comparisons were adjusted for age, gender, comorbidity, and use of opioid medication during the last 30 days. Alpha=.05.

Results

Eighty-five respondents endorsed CI (38 mild; 27 moderate; 20 severe). Preoperatively, those with CI had more severe back pain (p=.005) and neck pain (p=.025) but no differences in leg or arm pain. Those with CI had greater disability on ODI (p<.001) and NDI (p<.001) and worse HRQoL in all domains (all, p<.001). At 6 and 12 months postoperatively, those with CI were less likely to experience clinical improvement in disability and HRQoL (anxiety, pain interference, physical function, and satisfaction with ability to participant in social roles) (all, p<.05).

Conclusions

CI was present in nearly 20% of spine patients before surgery and was independently associated with worse preoperative back and neck pain, disability, and HRQoL. Those with CI had approximately one-half the likelihood of achieving meaningful clinical improvement postoperatively. These results indicate a need to evaluate spine patients' cognitive impairment prior to surgery.

Level of Evidence

III.

Responsive Behaviors and Pain Management in Hospital Dementia Care: A Before and After Comparison of the “Serial Trial Intervention”

Purpose

Responsive behavior, often referred to as behavioral and psychological symptoms of dementia (BPSD), is among the most critical disorders in dementia whereby nursing personnel in hospitals are increasingly confronted with such symptoms. The purpose was to reduce the level of BPSD in an acute hospital environment through a stepwise procedure followed by the initiation of a needs-oriented treatment.

Methods

An open, prospective, interventional study with before-after comparisons was used to implement “Serial Trial Intervention” (STI) in three hospital wards (internal medicine, surgery, geriatric) after its adaption for hospital setting which was supplemented with a detailed pain assessment. Participants were 65 years and older. Potential causes of BPSD were clarified in a stepwise procedure and, if possible, eliminated. The primary outcome was the reduction in BPSD measured by the Neuropsychiatric Inventory (NPI-Q-12) while secondary outcomes were through the use of non-pharmacological and pharmacological interventions.

Results

No significant reduction in NPI-Q-12 could be found. However, significantly more mobilizations and changes of position were carried out. Higher antipsychotic use was seen in the after-groups presumably due to the higher rates of delirium and cognitive impairment. Furthermore, the data showed no increase in analgesic use.

Conclusion

No significant reduction in NPI-Q-12 was observed in the before-after study. The use of antipsychotics even increased most probably due to a higher incidence of deliriousness in the after-group. However, STI seemed to improve attention to underlying causes of BPSD as well as pain. Proof that STI leads to NPI-Q-12 reduction in hospitals is still pending.

Care home residents’ quality of life and its association with CQC ratings and workforce issues: the MiCareHQ mixed-methods study

Background

Care home staff have a critical bearing on quality. The staff employed, the training they receive and how well they identify and manage residents’ needs are likely to influence outcomes. The Care Act 2014 (Great Britain. The Care Act 2014. London: The Stationery Office; 2014) requires services to improve ‘well-being’, but many residents cannot self-report and are at risk of exclusion from giving their views. The Adult Social Care Outcomes Toolkit enables social care-related quality of life to be measured using a mixed-methods approach. There is currently no equivalent way of measuring aspects of residents’ health-related quality of life. We developed new tools for measuring pain, anxiety and depression using a mixed-methods approach. We also explored the relationship between care home quality, residents’ outcomes, and the skill mix and employment conditions of the workforce who support them.

Objectives

The objectives were to develop and test measures of pain, anxiety and depression for residents unable to self-report; to assess the extent to which regulator quality ratings reflect residents’ care-related quality of life; and to assess the relationship between aspects of the staffing of care homes and the quality of care homes.

Design

This was a mixed-methods study.

Setting

The setting was care homes for older adults in England.

Participants

Care home residents participated.

Results

Three measures of pain, anxiety and low mood were developed and tested, using a mixed-methods approach, with 182 care home residents in 20 care homes (nursing and residential). Psychometric testing found that the measures had good construct validity. The mixed-methods approach was both feasible and necessary with this population, as the majority of residents could not self-report. Using a combined data set (n = 475 residents in 54 homes) from this study and the Measuring Outcomes in Care Homes study (Towers AM, Palmer S, Smith N, Collins G, Allan S. A cross-sectional study exploring the relationship between regulator quality ratings and care home residents’ quality of life in England. Health Qual Life Outcomes 2019;17:22) we found a significant positive association between residents’ social care-related quality of life and regulator (i.e. Care Quality Commission) quality ratings. Multivariate regression revealed that homes rated ‘good/outstanding’ are associated with a 12% improvement in mean current social care-related quality of life among residents who have higher levels of dependency. Secondary data analysis of a large, national sample of care homes over time assessed the impact of staffing and employment conditions on Care Quality Commission quality ratings. Higher wages and a higher prevalence of training in both dementia and dignity-/person-centred care were positively associated with care quality, whereas high staff turnover and job vacancy rates had a significant negative association. A 10% increase in the average care worker wage increased the likelihood of a ‘good/outstanding’ rating by 7%.

Limitations

No care homes rated as inadequate were recruited to the study.

Conclusions

The most dependent residents gain the most from homes rated ‘good/outstanding’. However, measuring the needs and outcomes of these residents is challenging, as many cannot self-report. A mixed-methods approach can reduce methodological exclusion and an over-reliance on proxies. Improving working conditions and reducing staff turnover may be associated with better outcomes for residents.

Future work

Further work is required to explore the relationship between pain, anxiety and low mood and other indicators of care homes quality and to examine the relationship between wages, training and social care outcomes.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 19. See the NIHR Journals Library website for further project information.

Cognitive impairment and pain relief following hip fractures: a case control study

Hip fractures represent a significant workload of both emergency and orthopaedic departments within the National Health Service (NHS). Pain relief is key in treating hip fractures as highlighted by both National Institute of Clinical Excellence (NICE) and British Orthopaedic Association Standards for Trauma (BOAST) guidelines. However, the literature shows that patients with cognitive impairment tend to have inconsistent pain management, leading to worse outcomes. We conducted a case–control study looking at 296 patients who presented with hip fractures to a major trauma centre between 1 December 2019 and 30 May 2020. Cognition was assessed using pre-recorded Abbreviated Mental Test Scores (AMTS). There was no significant difference between pain relief provided to patients with or without cognitive impairment in both the pre-hospital (p = 0.208) and Accident & Emergency (A&E) (p = 0.154) setting. A larger proportion of patients in A&E did not receive any pain relief (18.6% versus 42.2%). Pre-hospital, the higher the pain score, the stronger the analgesia given (R = 0.435, p = 0.000). This relationship was present in both the cognitively impaired (R = 0.572, p = 0.000) and cognitively intact groups (R = 0.390 p = 0.000). Strength of analgesia and pain scores did not correlate in A&E (R = 0.014, p = 0.826). Cognition did not impact the time to analgesia both pre-hospital (p = 0.291) and in A&E (p = 0.332); however, patients waited significantly longer to receive pain relief in A&E (29.61 minutes versus 150.28 minutes). Fascia-iliaca blocks were administered to 58.4% of the cohort, with no significant difference noted between cognition status. Overall, cognition does not impact pain management both pre-hospital and in A&E. There is still room for improvement, particularly in the assessment of pain in the cognitively impaired. A possible solution is the utilisation of the Bolton Pain Assessment Tool, a validated pain assessment tool for the cognitively impaired that has been utilised in the trauma setting with good effect.

Underrecognition and undertreatment of thirst among hospitalized patients with restricted oral feeding and drinking

Thirst is distressing but overlooked by healthcare professionals. Patients experience thirst due to comorbidities, physical or cognitive limitations, and iatrogenesis. Nasogastric tube (NGT) use and nil-by-mouth(NBM) orders are common practices that can lead to thirst. However, thirst in these populations has never been formally studied. We aim to examine prevalence of recognition and treatment of thirst among NGT + NBM and NBM patients. Our descriptive study was conducted intermittently over 25 weeks, across 1.5 years, in 12 adult general medicine wards of a tertiary hospital. Cognitively intact NGT + NBM or NBM inpatients, defined as Abbreviated Mental Test score ≥ 8, were studied. One-time questionnaire was administered. Variables included: demography, co-morbidities, clinical condition, feeding route, thirst defined by thirst distress and/or intensity ≥ 3, pain, hunger and volume status. 88 NGT + NBM and NBM patients were studied. 69.3% suffered from thirst. Thirsty patients experienced significant thirst-related distress (mean score ± SD: 5.7 ± 2.5). Subjects with previous stroke and who were euvolemic tended towards thirst. 13.6% were asked about thirst by doctors or nurses. Thirst was a major source of patient distress in our study. We suggest that thirst needs to be actively identified and targeted to achieve person-centred care.

Probable Pain on the Pain Assessment in Impaired Cognition (PAIC15) Instrument: Assessing Sensitivity and Specificity of Cut-Offs against Three Standards

Observational pain scales can help to identify pain in persons with dementia who may have difficulty expressing pain verbally. The Pain Assessment in Impaired Cognition-15 (PAIC15) covers 15 items that indicate pain, but it is unclear how probable pain is, for each summed score (range 0–45). We aimed to determine sensitivity and specificity of cut-offs for probable pain on the PAIC15 against three standards: (1) self-report when able, (2) the established Pain Assessment in Advanced Dementia (PAINAD) cut-off of 2, and (3) observer’s overall estimate based on a series of systematic observations. We used data of 238 nursing home residents with dementia who were observed by their physician in training or nursing staff in the context of an evidence-based medicine (EBM) training study, with re-assessment after 2 months in 137 residents. The area under the ROC curve was excellent against the PAINAD cut-off (≥0.8) but acceptable or less than acceptable for the other two standards. Across standards and criteria for optimal sensitivity and specificity, PAIC15 scores of 3 and higher represent possible pain for screening in practice, with sensitivity and specificity against self-report in the 0.5 to 0.7 range. While sensitivity for screening in practice may be too low, a cut-off of 4 is reasonable to indicate probable pain in research.

Pain processing in older adults with dementia-related cognitive impairment is associated with frontal neurodegeneration

Experimental pain research has shown that pain processing seems to be heightened in dementia. It is unclear which neuropathological changes underlie these alterations. This study examined whether differences in pressure pain sensitivity and endogenous pain inhibition (conditioned pain modulation (CPM)) between individuals with a dementia-related cognitive impairment (N=23) and healthy controls (N=35) are linked to dementia-related neurodegeneration. Pain was assessed via self-report ratings and by analyzing the facial expression of pain using the Facial Action Coding System. We found that cognitively impaired individuals show decreased CPM inhibition as assessed by facial responses compared to healthy controls, which was mediated by decreased gray matter volume in the medial orbitofrontal and anterior cingulate cortex in the patient group. This study confirms previous findings of intensified pain processing in dementia when pain is assessed using non-verbal responses. Our findings suggest that a loss of pain inhibitory functioning caused by structural changes in prefrontal areas might be one of the underlying mechanisms responsible for amplified pain responses in individuals with a dementia-related cognitive impairment.

Associations between symptoms of pain, insomnia and depression, and frailty in older adults: A cross-sectional analysis of a cohort study

BACKGROUND

Frailty is prevalent in older adults and has adverse effects on multiple health outcomes. Pain, insomnia, and depressive symptoms are commonly seen and treatable symptoms in older adults and are associated with frailty. However, it is unknown whether these symptoms are independently associated with frailty and how they interact with each other creating a greater impact on frailty than individual symptoms. It is important to understand these associations for nurses to provide high-quality patient-centered care for older adults with frailty.

OBJECTIVES

To determine independent associations of pain, insomnia, and depressive symptoms with frailty and examine their synergistic impact on frailty among older adults.

DESIGN

A cross-sectional analysis of a cohort study.

SETTING

Communities in the United States.

PARTICIPANTS

Community-dwelling older adults from the National Health and Aging Trend Study (N = 7,609), a nationally representative survey of Medicare Beneficiaries in the United States.

METHODS

Frailty status was determined by five criteria of the Physical Frailty Phenotype: exhaustion, low physical activity, weakness, slowness, and shrinking. Pain was determined by self-reports of bothersome pain in the last month. Insomnia included self-reports of difficulty initiating sleep and difficulty maintaining sleep. Depressive symptom was assessed by the Patient Health Questionnaire-2. Logistic regression models were used adjusting for sociodemographic, health-related and behavioral covariates.

RESULTS

The sample was mainly under 80 years old (72%), female (57%), and non-Hispanic White (81%). Approximately 53% experienced bothersome pain, 11% had difficulty initiating sleep, 6% had difficulty maintaining sleep, and 15% had depressive symptom; 46% were pre-frail and 14% were frail. Independent associations with pre-frailty and frailty were found in pain (odds ratio [OR]: 1.81, 95% CI: 1.60, 2.04), difficulty initiating sleep (OR: 1.23, 95% CI: 1.04, 1.46) and depressive symptom (OR: 2.29, 95% CI: 1.85, 2.84). Interaction terms between pain and depressive symptom (OR: 1.87, 95% CI: 1.14, 3.07), and between difficulty initiating sleep and depressive symptom (OR: 2.66, 95% CI: 1.15, 6.13) were significant, suggesting a synergistic impact on pre-frailty and frailty.

CONCLUSIONS

Pain, difficulty initiating sleep, and depressive symptoms are independent risk factors of frailty and may have a synergistic impact on frailty. Interventions should be developed to address these symptoms to reduce the adverse effects of frailty.

Psychometric Properties of the Proxy-Reported Life-Space Assessment in Institutionalized Settings (LSA-IS-Proxy) for Older Persons with and without Cognitive Impairment

(1) Background: Life-space mobility assessments for institutionalized settings are scarce and there is a lack of comprehensive validation and focus on persons with cognitive impairment (CI). This study aims to evaluate the psychometric properties of the Life-Space Assessment for Institutionalized Settings by proxy informants (LSA-IS-proxy) for institutionalized, older persons, with and without CI. (2) Methods: Concurrent validity against the self-reported version of the LSA-IS, construct validity with established construct variables, test-retest reliability, sensitivity to change during early multidisciplinary geriatric rehabilitation treatment, and feasibility (completion rate, floor/ceiling effects) of the LSA-IS-proxy, were assessed in 94 hospitalized geriatric patients (83.3 ± 6.1 years), with and without CI. (3) Results: The LSA-IS-proxy total score showed good-to-excellent agreement with the self-reported LSA-IS (Intraclass Correlations Coefficient, ICC_3,1 = 0.77), predominantly expected small-to-high correlations with construct variables (r = 0.21–0.59), good test–retest reliability (ICC_3,1 = 0.74), significant sensitivity to change over the treatment period (18.5 ± 7.9 days; p < 0.001, standardized response mean = 0.44), and excellent completion rates (100%) with no floor/ceiling effects. These results were predominantly confirmed for the sub-scores of the LSA-IS-proxy and were comparable between the sub-groups with different cognitive status. (4) Conclusions: The LSA-IS-proxy has proven to be feasible, valid, reliable, and sensitive to change in hospitalized, geriatric patients with and without CI.

Methodology for developing and evaluating diagnostic tools in Ayurveda - A review

Ayurveda has a holistic and person-centric approach towards health and disease, which in turn necessitates consideration of several factors in the process of a diagnostic workup. This concept of personalised diagnosis brings about a high level of variability among the clinicians with respect to their assessment methods and disease diagnosis. Developing and validating diagnostic tools for diseases enumerated in the Ayurvedic classical textbooks can help in standardising the clinical approach, even when attempting to arrive at a patient specific diagnosis. However, diagnostic research is a very less explored area in Ayurveda and there are no established standards for developing and evaluating diagnostic tools. This paper reviews the methodology for the development and validation of diagnostic tools, available in published literature and proposes to integrate this in the field of Ayurveda. The search was conducted on online databases including PubMed, Science Direct, Scopus, and Google scholar, with keywords - ayurvedic diagnosis, diagnostic tool development, validity, reliability, and diagnostic test assessment. The articles were screened based on their comprehensiveness, relevance, and feasibility, and the methodology elaborated in the selected articles was organized into a framework that can be adopted in Ayurveda. We have also tried to examine the methodological challenges of integrating the fundamentals of ayurvedic diagnosis within the current methods of diagnostic research and explored possible solutions. The proposed tool development process involves both qualitative and quantitative components, which may be carried out in three phases that include setting the diagnostic criteria, tool development and validation, and diagnostic test assessment.

Holistic pain assessment in older people and older people living with dementia

Pain occurs in a wide range of diseases and long-term conditions associated with ageing and can affect every aspect of an individual's life, reducing their ability to recover, their independence and their quality of life. The assessment of pain is an important aspect of nurses' role and requires them to obtain detailed information on how the older person experiences pain and how pain is affecting their life. However, there are many challenges to effective pain assessment in older people, including challenges concerning communication and cognition. This article provides an overview of pain assessment in older people, particularly those living with dementia, based on the author's expertise and on relevant literature, notably the recently revised UK national guidelines on the assessment of pain in older people.

Who Doesn't Come Home? Factors Influencing Mortality Among Long-Term Care Residents Transitioning to and From Emergency Departments in Two Canadian Cities

Residents of long-term care (LTC) whose deaths are imminent are likely to trigger a transfer to the emergency department (ED), which may not be appropriate. Using data from an observational study, we employed structural equation modeling to examine relationships among organizational and resident variables and death during transitions between LTC and ED. We identified 524 residents involved in 637 transfers from 38 LTC facilities and 2 EDs. Our model fit the data, (χ² = 72.91, df = 56, p = .064), explaining 15% variance in resident death. Sustained shortness of breath (SOB), persistent decreased level of consciousness (LOC) and high triage acuity at ED presentation were direct and significant predictors of death. The estimated model can be used as a framework for future research. Standardized reporting of SOB and changes in LOC, scoring of resident acuity in LTC and timely palliative care consultation for families in the ED, when they are present, warrant further investigation.

Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment

Pain management is a vital component of patient care, particularly in the emergency setting. Pain can hinder the opportunities to treat and manage pain-causing conditions and remains one of the primary reasons patients seek emergency medical care, yet despite this, pain often remains under-acknowledged, under-assessed and undertreated. Despite the importance of effective management of acute pain, there are currently no well-defined emergency medicine guidelines at a European level to support healthcare professionals in achieving this goal. The European Society for Emergency Medicine (EUSEM) identified this as a significant unmet requirement, for improving day-to-day patient management and for providing guidance to trainees and non-emergency medicine physicians. Under the auspices of EUSEM, a programme-the European Pain Initiative-was launched with the aim of providing information, advice and guidance on pain management in pre-hospital and emergency department settings. Search terms were developed to search MEDLINE, Cochrane database, Google Scholar and EMBASE online databases to return English language articles published in the last 10 years. A working package of reference materials was evaluated against inclusion and exclusion criteria and levels of evidence ascribed. A short survey was developed by the European Pain Initiative Steering Committee for completion by EUSEM members to evaluate actual clinical practice. A working document of > 800 publications was identified for further review and evaluation against agreed criteria. Some further publications were included by the Steering Committee to explore older literature for long-established analgesics, or newly emergent literature that was considered important for inclusion but was identified as the guideline development was underway. This article provides the methodology used to inform the guidelines, including survey results of EUSEM members on assessment and treatment of acute pain. A companion manuscript in this issue presents an evidence-based review and recommendations for individualised evaluation of acute pain in patients in emergency settings.

[The Mainz Pain Staging System is also suitable for grading chronic pain in inpatient geriatric patients]

INTRODUCTION

The Mainz Pain Staging System (MPSS), which has been validated primarily in middle-aged and chronic low back pain patients, is designed to predict prognosis and control the use of resources at baseline. In multi-morbid and functionally impaired patients (geriatric patients) with multiple causes of pain, it is unclear whether this instrument can be implemented at all and whether it permits statements to be made on the severity of pain chronification.

MATERIALS AND METHODS

Therefore, 173 consecutive patients with pain were classified in the second week of inpatient geriatric treatment according to the MPSS. For validation, the questions from the "Pain interview for geriatric patients" (SgP) were used. In addition, the MPSS was compared with the personal history of the duration of the main pain.

RESULTS

With the exception of the questions on medication intake, the items in the MPSS could be collected predominantly by self-assessment. Even with current analgesic therapy, MPSS has significant correlations with sensory, affective, and emotional dimensions of pain from the SgP. The data on duration correlated with only one category of MPSS (spatial aspects of pain).

CONCLUSION

MPSS can be used in multi-morbid and functionally impaired elderly patients undergoing inpatient treatment. Chronification features are more pronounced at higher stages than at lower levels. Only one category of the MPSS cannot be collected by self-assessment. The possibilities of prognosis estimation and resource control using the MPSS should be further investigated for these patients.

Mild to Moderate Cognitive Impairment Does Not Affect the Ability to Self-Report Important Symptoms in Patients With Cancer: A Prospective Longitudinal Multinational Study (EPCCS)

CONTEXT

Patients with advanced cancer commonly suffer from both distressing symptoms and cognitive impairment, but the effect of cognitive impairment on the reliability and validity of symptom self-report is unknown.

OBJECTIVES

To evaluate the reliability and validity of symptom self-report in cancer outpatients with and without mild to moderate cognitive impairment.

METHODS

This was an analysis of the longitudinal European Palliative Care Cancer Symptom study of adults with incurable cancer in specialized palliative care (30 centers across 12 countries). Patients who could not comply with the study because of severe cognitive impairment were excluded. Cognitive status on the Mini-Mental State Examination short version and nine symptoms (pain, tiredness, drowsiness, nausea, appetite, breathlessness, depression, anxiety, and well-being) using the revised Edmonton Symptom Assessment System were self-reported at baseline and one-month follow-up. Reliability was analyzed using intraclass correlation coefficients and validity using regression of each symptom with health-related quality of life (HrQoL) measured with European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 for Palliative Care.

RESULTS

A total of 1047 patients were included: mean age of 62.9 years; 54.4% women; main cancer types were of digestive organs (26.6%), breast (21.6%), and lungs (21.2%). Cognitive impairment was present in 181 (17.3%) at baseline and associated with worse self-reported tiredness, drowsiness, appetite, and depression. Reliability (intraclass correlation coefficient) and validity (associations with HrQoL) were similar between people with/without cognitive impairment across the nine symptoms, except breathlessness, which showed a weaker relation to HrQoL in patients with cognitive impairment. Findings were robust in sensitivity analyses and after controlling for potential confounders.

CONCLUSION

In advanced cancer, self-report of nine major symptoms was reliable and valid also in people with mild-to-moderate cognitive impairment.

TRIAL REGISTRATION

ClinicalTrials.gov database (NCT01362816).

Nursing Education Intervention Effects on Pain Intensity of Nursing Home Residents with Different Levels of Cognitive Impairment: A Cluster-Randomized Controlled Trial

PURPOSE

Pain management in nursing homes is challenging and pain prevalence remains high. The objective of this study was to improve the pain situation of nursing home residents following a nursing-related educational intervention within a cluster-randomized controlled trial (2016-2018).

PARTICIPANTS

Clusters were nursing homes from one nursing home operator in Bavaria, Germany. Nursing home residents who were permanently registered in the facilities, at least 60 years of age, and who themselves or their legal guardians provided informed consent were included.

INTERVENTION

In addition to the implementation of pain nurses and pain care assistants, staff of the intervention group received an educational intervention in pain management, containing classroom (quality circles) and web-based training for nurses.

METHODS

Based on the Mini-Mental State Examination (MMSE), residents were either interviewed (MMSE 10-30) using self-report instruments or observed (MMSE 0-9) by proxy assessment. The primary outcome in residents able to self-report was maximum pain intensity according to Brief Pain Inventory (BPI); in those not able to self-report treatment-relevant pain above cut-off (≥2) on the Pain Assessment in Advanced Dementia (PAINAD).

RESULTS

Out of 20 randomly selected clusters, 9 nursing homes from the control, and 6 nursing homes from the intervention group participated. Multilevel linear (n=347 residents, MMSE 10-30) and logistic regression (n=222 residents, MMSE 0-9) analyses were conducted. Maximum pain intensity was higher after intervention (B=1.32, p<0.01), decreased with a better quality of life (B=-0.07, p<0.001), and was lower when dementia diagnoses were present (B=-1.12, p<0.01). PAINAD scores before and after intervention did not differ significantly (OR=0.89, p=0.724), but chances to exhibit treatment-related pain were higher with decreasing MMSE (OR=0.94, p<0.05).

CONCLUSION

While no significant positive intervention effect was measured, findings suggest nurses' raised awareness towards pain management. Overall results indicate that large-scale educational interventions seem to be less effective in complex nursing home settings without also including specific individual-based intervention measures.

Self-report Pain Scale Reliability in Veterans and Service Members With Traumatic Brain Injuries Undergoing Inpatient Rehabilitation

INTRODUCTION

Pain in trauma patients with traumatic brain injury (TBI) may heighten cognitive-behavioral impairment and impede rehabilitation efforts. Multiple self-report pain assessment tools have been shown reliable in cognitively intact adults and children but are understudied in the cognitively impaired, particularly in persons with TBI. The objective of this study was to assess the utility and reliability of four pain assessment instruments among TBI patients during inpatient rehabilitation and the influence of cognitive impairment.

METHODS

Participants self-completed four pain intensity measures, the Verbal Descriptor Scale, Faces Pain Scale (Faces), Numerical Rating Scale (NRS), and Color-Enhanced Visual Analog Scale (CAS), during five study visits over a 2-week period. Data were collected on time to completion and most preferred pain measure. To assess scale reliability, participants re-rated their current pain. To assess scale responsiveness, standard mean response was measured across time and a worst past pain experience was rated. Cognitive impairment was assessed with the Memory, Orientation, and Amnesia Test.

RESULTS

The NRS was the most preferred measure by participants at every time point in the study. Mean pain measure completion time for all measures was under 11 seconds and did not significantly change during the study period. All scales showed very high test-retest reliability, with very strong correlations. Standard mean response from day 0 to 14 ranged from 0.387 to 0.532 across the scales. When stratified by cognitive impairment, the mean scores were consistently nominally higher for impaired participants, reaching statistical significance only for the CAS and Faces at baseline. In the cognitive impaired group, reliability for the Faces showed some weakening, as did the VAS to a milder degree.

CONCLUSIONS

All four pain measures demonstrated good utility, very high test-retest reliability, and satisfactory responsiveness. Greater cognitive impairment was associated with elevated pain ratings, especially in the Faces and CAS. The NRS was the most preferred by patients, regardless of cognitive impairment level.

Use of analgesics in acute stroke patients with inability to self-report pain: a retrospective cohort study

BACKGROUND

Pain is a common and burdensome complication in patients with acute stroke. We assessed the impact of impaired communication in stroke patients on pain assessment and treatment.

METHODS

We included 909 (507 male, mean age 71.8 years) patients admitted to our stroke unit from 01/2015 to 12/2015 in the analysis. Patients were assigned to four groups: able to communicate (AC), not able to communicate prior to index stroke (P-NAC), due to focal symptoms of index stroke (S-NAC), due to a reduced level of consciousness (C-NAC). Pain prevalence, documentation of pain and use of analgesics were evaluated. C-NAC patients were excluded from analyses regarding analgesic treatment due to relevant differences in patient characteristics.

RESULTS

746 patients (82.1%) were classified as AC, 25 (2.8%) as P-NAC, 90 (9.9%) as S-NAC and 48 (5.3%) as C-NAC. Pain was documented on the Numeric Rating Scale and in form of free text by nurses and physicians. Nurses documented pain more frequently than physicians (p < 0.001). Pain prevalence was 47.0% (n.s. between groups). The use of analgesic medication increased from 48.7% in the AC group, to 76.0% in the P-NAC group, and 77.8% in the S-NAC group (p < 0.001). Opioid use was significantly more frequent in NAC patients (p < 0.001). The response to the treatment was poorly documented with significantly lowest rates in S-NAC patients (p < 0.001).

CONCLUSIONS

Our study suggests that post-stroke pain in patients with inability to communicate is not attended enough, not systematically assessed and therefore not sufficiently treated.

Advances in pain management for older patients with cancer

The population of older patients is growing with a rising prevalence of cancer diagnoses and cancer-related pain syndromes. Older patients are also vulnerable to misleading pain evaluations and under treatment with opioids. Barriers to the effective and safe management of analgesics include pain assessments and the complex management of the best analgesic choice and dose-titration while achieving the fewest side effects. In this review, we will provide an overview of the challenges present in assessment and treatment choices, along with practical tips for routine clinical practice.

[Assessing pain in patients with dementia]

The diagnostics of pain in older people with cognitive impairments should always consist of a subjective self-report of pain and a structured observation of pain behavior. It is important to note that the subjective self-report of pain becomes less valid with increasing cognitive decline (starting with a moderate degree of dementia). The external observation of pain behavior should include at least the three behavioral domains facial expressions, body movements and vocalization and should be performed during resting situations and during activities of daily living. Moreover, the patient should be observed for at least 3 min. Online forms of training have recently been developed and are freely available for training in external observation.

Quality of life in nursing home residents with pain: pain interference, depression and multiple pain-related diseases as important determinants

AIM

Quality of life is an essential outcome parameter in geriatric research and presents an important indicator for the evaluation of care treatments. The present study analyses potential impact factors on health-related quality of life (HRQOL) of nursing home residents (NHR) who are in pain.

METHODS

Data came from the cRCT 'PIASMA'. Statistical analyses of 146 respondents were carried out by multiple linear regressions based on the EQ-5D index (Euroquol Quality of Life) as dependent variable. Potential impact factors were applied and categorised in five blocks: pain intensity and interference (according to the Brief Pain Inventory), intervention effect, sex and age, pain-related diagnoses, and scales regarding depressive symptoms and cognitive impairment (based on the Geriatric Depression Scale and the Mini-Mental State Examination).

RESULTS

On average, residents showed a pain intensity of 18.49, a pain interference of 29.61, a MMSE score of 22.84, a GDS score of 5.65 and an EQ-5D index of 0.52. Residents with more diagnoses, more depressive symptoms, and a higher pain interference showed a significantly reduced HRQOL.

CONCLUSION

Findings underline the importance of identifying and applying treatment options for both pain (especially interference) and depressive disorders to maintain HRQOL of NHR.

[Assessing pain in patients with dementia]

The diagnostics of pain in older people with cognitive impairments should always consist of a subjective self-report of pain and a structured observation of pain behavior. It is important to note that the subjective self-report of pain becomes less valid with increasing cognitive decline (starting with a moderate degree of dementia). The external observation of pain behavior should include at least the three behavioral domains facial expressions, body movements and vocalization and should be performed during resting situations and during activities of daily living. Moreover, the patient should be observed for at least 3 min. Online forms of training have recently been developed and are freely available for training in external observation.

Effects of age and cognitive function on data quality of standardized surveys in nursing home populations

Background

Data quality is of special concern when it comes to survey research in nursing homes. Very little is known about specifics of cognitively impaired elderly in responding to survey questions. This study examines effects of cognitive impairment, age, gender, and interview duration on the data quality in a sample of 659 nursing home residents (NHR).

Methods

Within a cross-sectional design, survey methodology was used to evaluate the pain situation in 13 nursing homes. Residents were stratified into NHR with no/mild (Mini-Mental State Examination MMSE: 18–30) and NHR with moderate (MMSE: 10–17) cognitive impairment. Data quality is measured by item nonresponse (INR). Correlation analyses, ANCOVA, linear and logistic regression models are applied.

Results

Neither interview duration nor gender have effects on item nonresponse. Age accounts for higher INR (β = 0.12, p < 0.001). Cognitive impairment strongly predicts INR (β = − 0.40, p < 0.001). INR significantly differs between NHR with no/mild (3.98%) and moderate cognitive impairment (11.85%). The likelihood of INR > 5% for residents with moderate cognitive impairment is 3.8-times (p < 0.001) of that for those with no/mild impairment.

Conclusions

Surveys are adequate for residents with no/mild cognitive impairment but data quality is threatened in residents with moderate impairments. Precision and validity of responses from NHR with progressed cognitive impairment are potentially limited and results may be biased. The results clearly do support the need for a multidisciplinary ‘general theory’ of the question−/answer-process which has to be also inclusive for cognitively impaired elderly persons.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1258-0) contains supplementary material, which is available to authorized users.

Use of pain scales and observational pain assessment tools in hospital settings

Pain is a personal, individual and subjective experience. The complex and dynamic nature of pain makes its assessment and management challenging for healthcare professionals. Various pain scales are available that can assist in identifying the patient's experience of pain; however, these tend to reduce this experience to a measure of pain intensity. The use of pain scales also requires patients to communicate and describe their pain; when this is not possible, it is necessary for healthcare professionals to observe patient behaviours that may indicate pain. Various observational pain assessment tools have been developed to assist in recognising and assessing pain. This article discusses the various pain scales and observational pain assessment tools that are available, and the evidence to support their use.

Influence of cognitive impairment on pain assessment and management in the emergency department: A retrospective cross-sectional study

OBJECTIVES

To quantify the impact of cognitive impairment on pain assessment and management practices in the ED.

METHODS

A retrospective, cross-sectional study of patient records was conducted for all elderly patients (65 years or older) who presented to the ED of a large Western Australian tertiary hospital with a fracture because of a fall between 6 February and 14 December 2015. Of 327 records identified, 318 were suitable for data extraction. Of these, 120 patients had a cognitive impairment. Primary outcome measures were the method and frequency of pain assessment, and the delay to the administration of a pain intervention after pain was first assessed for patients with and without a cognitive impairment.

RESULTS

Patients with a cognitive impairment were less likely to have their pain assessed with a standardised pain assessment tool (55% vs 91.4%, P < 0.001), and 9.4 times more likely to have their pain assessed using ad hoc assessments only (95% confidence interval 4.6-19.1). The median time between ED presentation and a patient's first pain assessment was longer for patients with cognitive impairment (28 vs 17 min; P < 0.001), as was the time between repeat assessments (81 vs 62 min; P < 0.004). The median times to receive a pain intervention following pain assessment were 51 and 50 min for cognitively intact and impaired patients, respectively (P = 0.209, after adjustment for the first pain score).

CONCLUSION

Pain is inadequately and inappropriately assessed for elderly patients with a cognitive impairment in the ED, resulting in delays in initiation of pain management.

Literature review to characterize the empirical basis for response scale selection in pediatric populations

BACKGROUND

Despite the importance of response option selection for patient-reported outcome measures, there seems to be little empirical evidence for the selected scale type. This article provides an overview of the published research on response scale types and empirical support within pediatric populations.

METHODS

A comprehensive review of the scientific literature was conducted to identify response scale option types appropriate for use in pediatric populations and to review and summarize the available empirical evidence for each scale type.

RESULTS

Eleven review/consensus guideline/expert opinion articles and 20 empirical articles that provided guidance or evidence regarding pediatric response scale selection were identified. There was general consensus that 5-point verbal rating scales, including Likert scales, were appropriate for children aged 7 or 8 and older, while graphical or faces scales are often used in pediatric studies with children of younger ages.

CONCLUSION

In general, the verbal rating scale, numeric rating scale, visual analogue scale, and graphical scales have each demonstrated to be reliable and valid response option formats in specific contexts among pediatric populations; however, their appropriateness is dependent upon sample age. When selecting response scales, it is important to consider target population and context of use during the development of patient-reported outcome measures, especially with respect to tense, recall period, attribution, number of options, etc. In addition to age, cognitive development is an important aspect to consider for optimizing pediatric self-reported measures. More research is needed to determine clinically relevant changes and differences within pediatric research, which includes different response scale options.

Contrasts in older persons' experiences and significant others' perceptions of existential loneliness

BACKGROUND

As frail older people might have difficulties in expressing themselves, their needs are often interpreted by others, for example, by significant others, whose information health care staff often have to rely on. This, in turn, can put health care staff in ethically difficult situations, where they have to choose between alternative courses of action. One aspect that might be especially difficult to express is that of existential loneliness. We have only sparse knowledge about whether, and in what way, the views of frail older persons and their significant others concerning existential loneliness are in concordance.

OBJECTIVE

To contrast frail older (>75) persons' experiences with their significant others' perceptions of existential loneliness.

METHODS

A case study design was chosen for this study. Individual interviews with frail older persons (n = 15) and interviews with their significant others (n = 19), as well as field notes, served as a basis for the study. A thematic analysis was used to interpret data.

ETHICAL CONSIDERATIONS

This study was conducted in accordance with the principles of research ethics.

FINDINGS

The findings showed three themes: (1) Meaningless waiting in contrast to lack of activities, (2) Longing for a deeper connectedness in contrast to not participating in a social environment and (3) Restricted freedom in contrast to given up on life.

DISCUSSION

Knowledge about the tensions between older persons' and their significant others' views of existential loneliness could be of use as a basis for ethical reflections on the care of older people and in the encounter with their significant others.

CONCLUSION

It is of importance that health care professionals listen to both the frail older person and their significant other(s) and be aware of whose voice that the care given is based on, in order to provide care that is beneficial and not to the detriment of the older person.

Development and Validation of the Symptom Assessment to Improve Symptom Control for Institutionalized Elderly Scale

OBJECTIVES

To validate a newly developed multiple symptom self-assessment tool in nursing homes.

DESIGN

Thirty prevalent symptoms identified in the literature were classified by a 2-round Delphi procedure to a top 10 of the most relevant, burdensome symptoms. Because no existing symptom scale fully covered this top 10, we developed a new scale, consisting of a horizontal numerical scale for the top 10 symptoms, with the possibility to add and rate 3 other symptoms. This scale was validated.

SETTING AND PARTICIPANTS

Hundred seventy-four participants, mean age 85 (±5.94) years, were recruited from 7 nursing homes (86%) and 3 acute geriatric wards (14%).

METHODS

To test the construct validity, participants with and without a palliative status were enrolled. Participants completed the Symptom Assessment to Improve Symptom Control for Institutionalized Elderly (SATISFIE) scale on day 0 and day 1 (intrarater reliability). Nurses completed the scale on day 0 (inter-rater reliability). Descriptive statistics described the characteristics of the study population and symptom scores. Differences in symptom scores between palliative and nonpalliative participants were analyzed with the Mann-Whitney U test. Intrarater and inter-rater reliability were calculated by means of an intraclass correlation coefficient. Factor analysis searched for possible symptom clusters. Feasibility was evaluated by measuring the assessment time and by providing a questionnaire for the nurses.

RESULTS

In the nonpalliative group (n = 130), the highest self-rated median scores were pain on day 1 [median 3, interquartile range (IQR) 0-5] and pain on day 2. In the palliative group (n = 44), the highest median self-rated scores were fatigue on day 1 [median 5 (IQR 0-6)], lack of energy on day 1 and 2 [both median 5 (IQR 0-8)]; and depressed feeling on day 2 [median 3 (IQR 0-5)]. Nurse assessments median scores were the highest for depressed feeling [median 5 (IQR 1-7)], fatigue [median 4.5 (IQR 0-6.5)], and lack of energy, [median 3 (IQR 0-6)] in the palliative group. In the nonpalliative group, none of the median scores was 3 or more. Intraclass correlation coefficients for intrarater reliability varied between 0.65 and 0.89 and for inter-rater reliability (patients-nurses) between 0.18 and 0.63. Mean assessment time for nurses was 2.0 minutes [standard deviation (SD) = 1.01]. For participants, it decreased from 10.5 minutes (SD = 5.41) at the first assessment to 7.5 minutes (SD = 3.72) at the second assessment. Nurses determined the SATISFIE instrument to be useful, applicable in daily practice, and sufficiently comprehensible for the patients.

CONCLUSIONS

The SATISFIE scale is a valid and feasible instrument for regular, multiple symptom assessment in institutionalized older persons.

Can an observational pain assessment tool improve time to analgesia for cognitively impaired older persons? A cluster randomised controlled trial

OBJECTIVE

The primary objective of the study was to measure the impact of an observational pain assessment dementia tool on time from ED arrival to first dose of analgesic medicine.

METHODS

A multisite cluster randomised controlled trial was conducted to test the Pain Assessment in Advanced Dementia (PAINAD) tool. Patients aged 65 years or older suspected of a long bone fracture were screened for cognitive impairment using the Six-Item Screening (SIS) tool. Patients scoring 4 or less on SIS (intervention sites) were assessed for pain using PAINAD. Control sites, assessed pain using standard methods. The primary outcome was time to first dose of analgesia and was analysed on an intention-to-treat basis with a sensitivity analysis.

RESULTS

We enrolled 602 patients, of which 323 (54%) were at intervention sites (n=4). The median time to analgesia was 82 min (IQR 45-151 min). There was no statistically significant difference in median time to analgesia for intervention 83 (IQR 48-158 min) and non-intervention 82 min (IQR 41-147 min) sites (p=0.414). After adjusting for age, fracture type, arrival mode and triage category, there remained no significant difference in time to analgesia (HR 0.97, 95% CI 0.80 to 1.17, p=0.74). Of the 602 patients enrolled, 273 actually had cognitive impairment. A sensitivity analysis demonstrated patients at intervention sites received analgesia 13 min sooner (90 vs 103 min, p=0.91).

CONCLUSION

Use of the PAINAD was not associated with a shorter time to analgesia, although there was a clinically important but non-significant improvement in the cognitively impaired patient group. Further research is needed to address this clinically important and complex issue.

Pain Assessment of Elderly Patients with Cognitive Impairment in the Emergency Department: Implications for Pain Management-A Narrative Review of Current Practices

Elderly people are susceptible to both falls and cognitive impairment making them a particularly vulnerable group of patients when it comes to pain assessment and management in the emergency department (ED). Pain assessment is often difficult in patients who present to the ED with a cognitive impairment as they are frequently unable to self-report their level of pain, which can have a negative impact on pain management. This paper aims to review how cognitive impairment influences pain assessment in elderly adults who present to the ED with an injury due to a fall. A literature search of EMBASE, ProQuest, PubMed, Science Direct, SciFinder and the Curtin University Library database was conducted using keyword searches to generate lists of articles which were then screened for relevance by title and then abstract to give a final list of articles for full-text review. Further articles were identified by snowballing from the reference lists of the full-text articles. The literature reports that ED staff commonly use visual or verbal analogue scales to assess pain, but resort to their own intuition or physiological parameters rather than using standardised observational pain assessment tools when self-report of pain is not attainable due to cognitive impairment. While studies have found that the use of pain assessment tools improves the recognition and management of pain, pain scores are often not recorded for elderly patients with a cognitive impairment in the ED, leading to poorer pain management in this patient group in terms of time to analgesic administration and the use of strong opioids. All healthcare professionals involved in the care of such patients, including pharmacists, need to be aware of this and strive to ensure analgesic use is guided by appropriate and accurate pain assessment in the ED.

Low back pain in older adults: risk factors, management options and future directions

Low back pain (LBP) is one of the major disabling health conditions among older adults aged 60 years or older. While most causes of LBP among older adults are non-specific and self-limiting, seniors are prone to develop certain LBP pathologies and/or chronic LBP given their age-related physical and psychosocial changes. Unfortunately, no review has previously summarized/discussed various factors that may affect the effective LBP management among older adults. Accordingly, the objectives of the current narrative review were to comprehensively summarize common causes and risk factors (modifiable and non-modifiable) of developing severe/chronic LBP in older adults, to highlight specific issues in assessing and treating seniors with LBP, and to discuss future research directions. Existing evidence suggests that prevalence rates of severe and chronic LBP increase with older age. As compared to working-age adults, older adults are more likely to develop certain LBP pathologies (e.g., osteoporotic vertebral fractures, tumors, spinal infection, and lumbar spinal stenosis). Importantly, various age-related physical, psychological, and mental changes (e.g., spinal degeneration, comorbidities, physical inactivity, age-related changes in central pain processing, and dementia), as well as multiple risk factors (e.g., genetic, gender, and ethnicity), may affect the prognosis and management of LBP in older adults. Collectively, by understanding the impacts of various factors on the assessment and treatment of older adults with LBP, both clinicians and researchers can work toward the direction of more cost-effective and personalized LBP management for older people.

Pain assessment tools for older adults with dementia in long-term care facilities: a systematic review

AIM

The aim of this review is to document pain assessment tools used primarily for older adults in long-term care facilities and compare self-report and observer-rated tools.

METHODS

A literature search was conducted in Ovid MEDLINE^®, Embase, Cochrane and PsycINFO. Keywords included 'dementia', 'pain management' and 'managing pain'.

RESULTS

Of 1033 references, 23 articles were selected for inclusion. Six tools were self-rated and 18 tools were administered by an observer. 13 studies evaluated the reliability/validity of their scales; four studies compared different scales against each other.

CONCLUSION

Self-report should be the first-line approach when possible, with observational assessment used as a supplementary tool. Reliable observational tools have been shortened, and shown to maintain high reliability/validity, and positive psychometric properties.

Assessment and Measurement of Pain in Adults in Later Life

Pain in aging adults is a global health problem requiring a proactive and consistent assessment approach. Pain assessment is critical to detecting pain and developing a collaborative and adaptive pain management plan. Getting health providers to assess and measure pain even in older adults who are communicative and can self-report remains a challenge. Self-report is the best method for identifying pain. Using a validated pain assessment scale is key to evaluate pain intensity. This article discusses techniques to obtain self-report and describe appropriate self-report pain tools for a focused pain assessment and reassessment in adults in later life.

Initial testing of a behavioural pain assessment tool within trauma units

Pain is common in trauma patients who may be older and also may have cognitive impairment leading to reduced communication about their pain. A number of observational pain assessment tools are available and have been found to have limited clinical usefulness. The Bolton Pain Assessment Tool (BPAT) was developed following a trial of three established tools and includes a section to involve family and/or close carers in the pain assessment process. The aim of this paper is to present the findings of initial testing of BPAT. BPAT was used and evaluated by clinical staff in four trauma units in the UK. Forty-six staff evaluations were completed and 98% indicated it was easy to use; it took between one and two minutes to complete by 69.5% and led to pain management interventions by 93.5% of the respondents. It was rated highly by the clinical staff, but the involvement of families and close carers in the assessment process was different at each unit, with one unit not involving the family/close carer. There remains the need for a simple and practical way of assessing pain. This initial testing of the clinical feasibility of BPAT suggests that it is easy to use and helps to identify pain, but further testing of its reliability and validity is required.

Oral health-related quality of life in mild Alzheimer: patient versus caregiver perceptions

PURPOSE

To compare perceptions on oral health-related quality of life (OHRQoL) between Alzheimer disease (AD) patients and their caregivers by using the Geriatric Oral Health Assessment Index (GOHAI). Correlation between GOHAI and prostheses quality was also performed.

METHODS

GOHAI was applied to 16 AD elders and their caregivers. GOHAI index was compared to objective measures of AD patients' prostheses quality, rated by a researcher. Data were submitted to Wilcoxon signed rank and McNemar tests (α = 5%). Kappa correlations verified the concordance for GOHAI scores between AD patients and caregivers. Spearman's correlation was used to explore concordance between GOHAI scores and prostheses quality indices.

RESULTS

Total GOHAI scores from AD patients and caregivers were similar (P = 0.262). Overall Kappa was good (0.62). There were no correlations between GOHAI scores and prostheses quality.

CONCLUSION

AD patients assess and self-report their OHRQoL similarly to their main caregiver.

Pain intensity among institutionalized elderly: a comparison between numerical scales and verbal descriptors

AbstractOBJECTIVECorrelating two unidimensional scales for measurement of self-reported pain intensity for elderly and identifying a preference for one of the scales.METHODA study conducted with 101 elderly people living in Nursing Home who reported any pain and reached ( 13 the scores on the Mini-Mental State Examination. A Numeric Rating Scale - (NRS) of 11 points and a Verbal Descriptor Scale (VDS) of five points were compared in three evaluations: overall, at rest and during movement.RESULTSWomen were more representative (61.4%) and the average age was 77.0±9.1 years. NRS was completed by 94.8% of the elderly while VDS by 100%. The association between the mean scores of NRS with the categories of VDS was significant, indicating convergent validity and a similar metric between the scales.CONCLUSIONPain measurements among institutionalized elderly can be made by NRS and VDS; however, the preferred scale for the elderly was the VDS, regardless of gender.

Pain in Community-Dwelling Older Adults with Dementia: Results from the National Health and Aging Trends Study

OBJECTIVES

To report prevalence, correlates, and medication management of pain in community-dwelling older adults with dementia.

DESIGN

Cross-sectional.

SETTING

In-person interviews with self- or proxy respondents living in private residences or non-nursing home residential care settings.

PARTICIPANTS

Nationally representative sample of community-dwelling Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study 2011 wave.

MEASUREMENTS

Dementia status was determined using a modified previously validated algorithm. Participants were asked whether they had had bothersome and activity-limiting pain over the past month. A multivariable Poisson regression model was used to determine the relationship between bothersome pain and sociodemographic and clinical characteristics.

RESULTS

Of the 7,609 participants with complete data on cognitive function, 802 had dementia (67.2% aged ≥80, 65.0% female, 67.9% white, 49.7% proxy response, 32.0% lived alone, 18.8% lived in residential care); 670 (63.5%) participants with dementia experienced bothersome pain, and 347 (43.3%) had pain that limited activities. These rates were significantly higher than in a propensity score-matched cohort without dementia (54.5% bothersome pain, P < .001, 27.2% pain that limited activity, P < .001). Proxies reported slightly higher rates of pain than self-respondents, but differences were statistically significant only for activity-limiting pain (46.6% proxy vs 40.1% self, P = .03). Correlates of bothersome pain included arthritis, heart and lung disease, less than high school education, activity of daily living disability, depressive and anxiety symptoms, and low energy. Of those reporting pain, 30.3% stated that they rarely or never took any medications for pain.

CONCLUSION

Community-living older adults with dementia are at high risk of having pain. Creative interventions and programs are needed to manage pain adequately in this vulnerable population.

Non-opiate pharmacotherapy options for the management of pain in older adults

Pain is highly prevalent, costly, and disabling in later life, especially when undertreated. In this article, we aim to describe the risks and benefits of non-opioid medication options for the management of pain in adults aged 65 years and older in order to provide additional options in a practitioner's tool box when designing a pain management regimen for an older adult. Non-opiate pharmacologic therapies, such as acetaminophen, nonsteroidal anti-inflammatory drugs, topicals, and antidepressants have an important role in pain management of older adults. When designing a pain regimen, taking an individualized approach that considers the patient's functional status, comorbidities, and treatment goals will maximize pain management.

Everyday cognition in prodromal Huntington disease

OBJECTIVE

Assessment of daily functions affected by cognitive loss in prodromal Huntington's disease (HD) is necessary in practice and clinical trials. We evaluated baseline and longitudinal sensitivity of the Everyday Cognition (ECog) scales in prodromal HD and compared self- and companion-ratings.

METHOD

Everyday cognition was self-assessed by 850 participants with prodromal HD and 768 companions. We examined internal structure using confirmatory factor analysis (CFA) on baseline data. For longitudinal analysis, we stratified participants into Low, Medium, and High disease progression groups. We examined ECog scores for group differences and participant-and-companion differences using linear mixed effects regression (LMER). Comparison with the Total Functional Capacity (TFC) scale was made.

RESULTS

CFA revealed good fit of a 5-factor model having a global factor (total score), and subfactors (subscales) of memory, language, visuospatial perception, and executive function. At study entry, participants and companions in the Medium and High groups reported significantly worsened everyday cognition as well as significant functional decline over time. Losses became more pronounced and participant and companion ratings diverged as individuals progressed. TFC showed significant functional loss over time in the High group but not in the Medium group.

CONCLUSIONS

Disease progression is associated with reduced self- and companion-reported everyday cognition in prodromal HD participants who are less than 13 years to estimated motor onset. Our findings suggest companion ratings are more sensitive than participants' for detecting longitudinal change in daily cognitive function. ECog appears more sensitive to specific functional changes in the prodrome of HD than the TFC.