Doloplus-2, a valid tool for behavioural pain assessment?

Chronic pain interference assessment tools for children and adults who are unable to self-report: A systematic review of psychometric properties

AIM

To identify and evaluate psychometric properties of assessment tools for assessing pain interference in children, adolescents, and adults with chronic pain and the inability to self-report.

METHOD

The protocol was registered with PROSPERO (CRD42022310102). A search was run in MEDLINE, Embase, and PsycInfo (29th March 2022) to identify articles reporting psychometric properties of pain interference assessment tools for children, adolescents, and adults with chronic pain and the inability to objectively self-report pain. Retrieved studies were reviewed by two authors (MGS, LCF) and study quality was assessed using COSMIN.

RESULTS

Psychometric properties of 10 pain interference tools were assessed from 33 studies. The Paediatric Pain Profile (PPP) had low-quality evidence for content validity and internal consistency with children and adolescents who are unable to self-report. No tools for adults had evidence for content validity and internal consistency. No tool had evidence for all nine psychometric properties.

INTERPRETATION

The PPP is recommended for pain interference assessment in children and adolescents with chronic pain and the inability to self-report. Few tools are available for adults. Three tools for children (Patient-Reported Outcome Measurement Information System Pediatric Proxy Pain Interference Scale; Bath Adolescent Pain Questionnaire for Parents; modified Brief Pain Inventory-Proxy [mBPI]) and three tools for adults (Doloplus-2; Patient-Reported Outcome Measurement Information System Pain Interference Scale-proxy; Brief Pain Inventory-proxy) are promising but require further investigation.

Studies on Reliability and Measurement Error of Measurements in Medicine - From Design to Statistics Explained for Medical Researchers

Reliability and measurement error are measurement properties that quantify the influence of specific sources of variation, such as raters, type of machine, or time, on the score of the individual measurement. Several designs can be chosen to assess reliability and measurement error of a measurement. Differences in design are due to specific choices about which sources of variation are varied over the repeated measurements in stable patients, which potential sources of variation are kept stable (ie, restricted), and about whether or not the entire measurement instrument (or measurement protocol) was repeated or only part of it. We explain how these choices determine how intraclass correlation coefficients and standard errors of measurement formulas are built for different designs by using Venn diagrams. Strategies for improving the measurement are explained, and recommendations for reporting the essentials of these studies are described. We hope that this paper will facilitate the understanding and improve the design, analysis, and reporting of future studies on reliability and measurement error of measurements.

Psychometric properties of pain measurements for people living with dementia: a COSMIN systematic review

PURPOSE

Detecting pain in older people with dementia is challenging. Consequentially, pain is often under-reported and under-treated. There remains uncertainty over what measures should be promoted for use to assess pain in this population. The purpose of this paper is to answer this question.

METHODS

A search of clinical trials registered on the ClinicalTrial.gov and ISRCTN registries was performed to identify outcome measures used to assess pain in people with dementia. Following this, a systematic review of published and unpublished databases was performed to 01 November 2021 to identify papers assessing the psychometric properties of these identified measures. Each paper and measure was assessed against the COSMIN checklist. A best evidence synthesis analysis was performed to assess the level of evidence for each measure.

RESULTS

From 188 clinical trials, nine outcome measures were identified. These included: Abbey Pain Scale, ALGOPLUS, DOLOPLUS-2, Facial Action Coding System, MOBID-2, self-reported pain through the NRS or VAS/thermometer or Philadelphia Geriatric Pain Intensity Scale, PACSLAC/PACSLAC-2, Pain Assessment in Advanced Dementia (PAINAD), and Checklist for non-verbal pain behavior (CNPI). From these, 51 papers (5924 people with dementia) were identified assessing the psychometric properties of these measures. From these, there was strong- and moderate-level evidence to support the use of the facial action coding system, PACSLAC and PACSLAC-II, CNPI, DOLOPLUS-2, ALGOPLUS, MOBID, and MOBID-2 tools for the assessment of pain with people living with dementia.

CONCLUSION

Whilst these reflect measurement tools used in research, further consideration on how these reflect clinical practice should be considered.

PROSPERO REGISTRATION

CRD42021282032.

Are Chronic Pain Patients with Dementia Being Undermedicated?

In dementia, neuropathological changes alter the perception and expression of pain. For clinicians and family members, this knowledge gap leads to difficulties in recognizing and assessing chronic pain, which may consequently result in persons with dementia receiving lower levels of pain medication compared to those without cognitive impairment. Although this situation seems to have improved in recent years, considerable geographical variation persists. Over the last decade, opioid use has received global attention as a result of overuse and the risk of addiction, while the literature on older persons with dementia actually suggests undertreatment. This review stresses the importance of reliable assessment and the regular evaluation and monitoring of symptoms in persons with dementia. Based on current evidence, we concluded that chronic pain is still undertreated in dementia.

Interrater Variability in Pain Assessment of Long-term Care Residents with Dementia

PURPOSE

People with dementia are at great risk of their pain being undetected. In long-term care facilities, certified nursing assistants are on the front-line to detect whether a resident with dementia is experiencing pain, but research on certified nursing assistants' abilities to accurately assess pain are scarce. This study aims to examine certified nursing assistants' pain assessment skills using a simulated standardized video context.

DESIGN

A cross-sectional study was conducted.

METHODS

Fifty certified nursing assistants and 40 individuals with no professional experience in the field of care (controls) watched the same video of an older adult woman with dementia experiencing pain. Afterwards, they completed visual analog scales (pain intensity, affective distress), an observational pain assessment scale (Algoplus), and a set of questionnaires.

RESULTS

In both groups, pain intensity assessment and empathic reaction scores showed important interrater variability. Moreover, certified nursing assistants and controls did not differ in detecting the presence of pain or assessing its intensity. But certified nursing assistants displayed lower empathic reactions and dispositions. Certified nursing assistants pain assessment scores decreased with experience and expertise.

CONCLUSIONS

The practice of pain assessment is challenging for certified nursing assistants in long-term care facilities. Their professional status does not prevent inter-personal inconsistency and tends to lower their empathic dispositions. Personal determinants may interfere with their assessment behaviors and must be considered to enhance pain management for residents with dementia.

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.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

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.

Pain in Advanced Stages of Dementia: The Perspective of Medical Students

Background and objective: The number of studies related to medical students' attitude toward pain is limited. The aim of our study was, thus, to assess the medical students' knowledge of pain assessment and treatment in advanced stages of dementia in order to improve the existing curriculum in this area. Material and methods: We analyzed the medical students' knowledge about pain in advanced dementia based on a short questionnaire. The research was anonymous. The questionnaire was completed by 147 students. Results: The students most often suggested that pain in patients with advanced dementia could be manifested via body language and facial expression (107 students-72.8% and 100 students-68.0%, respectively). Vocalization was the third most frequently reported pain manifestation (84-57.1%). Other groups of pain symptoms (changes in activity patterns, changes in interpersonal interactions, and mental status changes) were indicated less often (p < 0.0001). Only five students (3.4%) listed the DOLOPLUS behavioral pain scale as an assessment tool for patients with advanced dementia, and 16 (10.9%) indicated observational scale elements or a necessity to observe the patient. Still, 110 students (74.5%) correctly characterized pain treatment in patients with advanced dementia. Conclusions: To the best of our knowledge, our study is pioneering in defining the deficits of medical students' knowledge on pain assessment and treatment in patients with advanced dementia. We highlighted knowledge gaps in the area of pain assessment which might make medical students incapable of proper pain treatment. Following the International Association for the Study of Pain considerations regarding the need for excellence in pain education, these results can contribute to the improvement of existing medical curricula in Poznan University of Medical Sciences to include pain management in dementia in a more "patient-centered" way in order to increase future staff's competency and to assure a better quality of care.

Palliative care for older people: the psychiatrist's role

In this overview we discuss the palliative psychiatric care of older people towards the end of life. We briefly consider ethics, dementia care, delirium, depression, anxiety, grief and physician-assisted suicide. We also discuss hope, dignity, spirituality and existentialism. We hope that this article will encourage clinicians to reflect on the effects of terminal illnesses on the mental health of dying people and the current provision of palliative psychiatric care.

LEARNING OBJECTIVES

•

DECLARATION OF INTEREST

None.

Advances in the pharmacological management of acute and chronic pain

Effective management of acute and chronic pain is an important aspect of nursing practice. Relieving patients' pain requires nurses to have an understanding of the latest evidence-based approaches, which will enable them to assess pain, implement appropriate management strategies and monitor their effectiveness. This article outlines the developments in evidence-based guidelines and recommendations for the pharmacological management of acute and chronic pain, including migraine, and in the use of analgesics such as opioids. It also discusses pain management in specific groups such as children and young people, and older people.

Objectively measuring pain using facial expression: is the technology finally ready?

Currently, clinicians observe pain-related behaviors and use patient self-report measures in order to determine pain severity. This paper reviews the evidence when facial expression is used as a measure of pain. We review the literature reporting the relevance of facial expression as a diagnostic measure, which facial movements are indicative of pain, and whether such movements can be reliably used to measure pain. We conclude that although the technology for objective pain measurement is not yet ready for use in clinical settings, the potential benefits to patients in improved pain management, combined with the advances being made in sensor technology and artificial intelligence, provide opportunities for research and innovation.

Geriatric Basics for the Neurohospitalist

Due to the increasing age of the population, neurohospitalists are more frequently caring for old and very old people. Fundamental definitions and topics related to geriatric medicine are therefore of particular importance. In this review, common issues encountered in geriatric patients hospitalized on the neurology service are discussed. Focus is put on the geriatric assessment, multiprofessional diagnostic and therapeutic procedures, geriatric syndromes, pharmacotherapy of the aged, delirium, pain, and palliative management as they are relevant for the neurohospitalist. In addition, ethical questions are addressed.

Measurement properties, feasibility and clinical utility of the Doloplus-2 pain scale in older adults with cognitive impairment: a systematic review

Background

The Doloplus-2 is a pain assessment scale for assessing pain in older adults with cognitive impairment. It is used in clinical practice and research. However, evidence for its measurement properties, feasibility and clinical utility remain incomplete. This systematic review synthesizes previous research on the measurement properties, feasibility and clinical utility of the scale.

Method

We conducted a systematic search in three databases (CINAHL, Medline and PsycINFO) for studies published in English, French, German, Dutch/Flemish or a Scandinavian language between 1990 and April 2017. We also reviewed the Doloplus-2 homepage and reference lists of included studies to supplement our search. Two reviewers independently reviewed titles and abstracts and performed the quality assessment and data abstraction.

Results

A total of 24 studies were included in this systematic review. The quality of the studies varied, but many lacked sufficient detail about the samples and response rates. The Doloplus-2 has been studied using diverse samples in a variety of settings; most study participants were in long-term care and in people with dementia. Sixteen studies addressed various aspects of the scale’s feasibility and clinical utility, but their results are limited and inconsistent across settings and samples. Support for the scale’s reliability, validity and responsiveness varied widely across the studies. Generally, the reliability coefficients reached acceptable benchmarks, but the evidence for different aspects of the scale’s validity and responsiveness was incomplete.

Conclusion

Additional high-quality studies are warranted to determine in which populations of older adults with cognitive impairment the Doloplus-2 is reliable, valid and feasible. The ability of the Doloplus-2 to meaningfully quantify pain, measure treatment response and improve patient outcomes also needs further investigation.

Trial registration

PROSPERO reg. no.: CRD42016049697 registered 20. Oct. 2016.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0643-9) contains supplementary material, which is available to authorized users.

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.

Associations between Pain and Quality of Life in Severe Dementia: A Norwegian Cross-Sectional Study

Background/Aims

Many variables influence the quality of life in older adults with dementia. We aim to quantify how the relationship between pain and quality of life in nursing home residents with severe dementia can be explained by neuropsychiatric symptoms, depressive symptoms, and activities of daily living.

Methods

This article presents cross-sectional baseline data from a cluster randomised controlled trial.

Results

The total and direct effects of pain on quality of life were statistically significant. Both neuropsychiatric and depressive symptoms partially mediated the relationship between pain and quality of life. Activities of daily living acted as a mediator only when modelled together with depressive symptoms.

Conclusion

Pain, neuropsychiatric symptoms, and depressive symptoms appear to be important factors that influence the quality of life for nursing home residents with severe dementia. Therefore, multidimensional interventions may be beneficial for maintaining or improving quality of life in this population.

Pain relief management following proximal femoral fractures: Options, issues and controversies

The majority of proximal femoral fractures occur in the elderly population. Safe and adequate pain relief is an integral part of the overall management of hip fractures. Inherent difficulties in the assessment of pain in elderly need to be taken into account and unique considerations should be made regarding the effective analgesia due to different elderly physiology, and their response to trauma and subsequent surgery. The pain management should start as soon as possible and special emphasis should be paid to contemporary methods of regional anaesthesia whilst a multimodal approach should be adopted in the perioperative period. The present review summarises the contemporary treatment options and controversies pertaining to the management of pain in elderly patients with proximal femoral fractures.

Nursing assistants: "he seems to be ill" - a reason for nurses to take action: validation of the Early Detection Scale of Infection (EDIS)

BACKGROUND

Signs and symptoms of infection in frail elderly are atypical, causing delay in diagnosis and treatment. To improve communication between healthcare staff of signs and symptoms of infection we developed an instrument, using qualitative data from observations by nursing assistants when they suspected infection. The aim of this study was to assess the validity of nursing assistants observations by developing and testing the instrument for early detection of infection in elderly nursing home residents.

METHODS

The early detection of infection (EDIS) instrument was based on data from focus interviews with nursing assistants. Over one year the nursing assistants used EDIS to document episodes of suspected early signs and symptoms of infection in 204 nursing home residents. Two physicians classified documented episodes as "no infection", "possible infection", and "infection". The content validity of the 13 items of the EDIS was established to explore the relationships between the items. The construct validity was used to explore the relationship between the items and the presence or absence of infection. The predictive value of the developed model was evaluated by the percentage of correct classifications of the observed cases. Generalized linear model (ordinal multinomial distribution and logit link) was used.

RESULTS

Of the 388 events of suspected infection, 20 % were assessed as no infection, 31 % as possible infection and 49 % as infection. Content validity analysis showed that 12/13 of the items correlated significantly with at least one other statement. The range in number of significant inter-correlations was from 0 ("pain") to 8 ("general signs and symptoms of illness"). The construct validity showed that the items "temperature" , "respiratory symptoms" and "general signs and symptoms of illness" were significantly related to "infection", and these were also selected in the model-building. These items predicted correct alternative responses in 61 % of the cases.

CONCLUSION

The validation of EDIS suggests that the observation of "general signs and symptoms of illness", made by nursing assistants should be taken seriously in detecting early infection in frail elderly. Also, the statement "He/She is not as usual" should lead to follow-up.

Assessment of discomfort in patients with cognitive failure in palliative care

OBJECTIVE

When cognitive impairment precludes patients' report of symptoms, it becomes necessary to use other means. The purpose of our study was to evaluate the validity of the method currently in use on our service.

METHOD

Two members of the team simultaneously assessed the patient and independently recorded whether the patient showed signs of discomfort, and a third questioned patients with cognitive failure who maintained some ability to respond if something was bothering them.

RESULTS

Some 200 assessments were made of 116 patients. The kappa coefficient of agreement was 0.615. The sensitivity was 17% and specificity 99%. The positive predictive value was 88%, and the negative predictive value was 73%.

SIGNIFICANCE OF RESULTS

Due to the low sensitivity of this method, it cannot be recommended as a screening tool.

Pain Assessment Strategies in Home Care and Nursing Homes in Mid-Norway: A Cross-sectional Survey

The prevalence of pain ranges from 27.8% to 86.5% in nursing homes and 42% to 50% in home care. Pain assessment is the first step toward effective pain management. The aim of this study was to explore the use of pain assessment strategies (verbal, numeric, and observation rating scales and standardized questions) in home care and nursing homes. The study was a descriptive cross-sectional survey. Health care providers who were responsible for the patients' medications replied to a questionnaire. In-home care and nursing homes in 11 randomly selected municipalities in Mid-Norway were included. Three hundred ninety-two individuals were included in this study (70% response rate): 271 (69%) from nursing homes and 121 (31%) from home care. The respondents working in home care had a higher educational level than those in working in nursing homes. Pain assessment instruments were not used frequently in nursing homes and home care. Verbal and numeric rating scales were used significantly more frequently in home care than in nursing homes. Registered nurses (RNs) in nursing homes used standardized questions significantly more often than did RNs in home care. RNs and social educators in home care self-reported less competence in treating the patients' total pain experience than did those in nursing homes. Workplace (working in home care) and regular training in the use of pain assessment tools explained more than 20% of the variation in the use of pain assessment tools. Regular training in the use of pain assessment tools is needed for health care workers in home care and nursing homes.

Instruments for assessing pain in persons with severe dementia

Through an integrative literature review involving the CINAHL, Cochrane, Embase, LILACS, PsycINFO, PubMed databases, tools available in the literature for assessing pain in individuals with severe dementia were identified along with versions validated for use in Brazil. We found 1501 relevant articles which, after selection of abstracts and full reading, yielded a final sample of 33 articles. The analysis enabled the identification of 12 instruments: ABBEY PAIN SCALE; ADD; CNPI; CPAT; DOLOPLUS-2; MOBID and MOBID-2; MPS; NOPPAIN; PACSLAC; PADE; PAINAD and PAINE. Despite the wide variety of tools for assessing pain in individuals with severe dementia worldwide, it was observed that only four are available in Portuguese, of which two are culturally adapted for Brazilian Portuguese (NOPPAIN and PACSLAC) and two validated for Portuguese of Portugal (DOLOPLUS and PAINAD), pointing to the need for further validation of instruments for use in Brazil.

Pain and distress in advanced dementia: choosing the right tools for the job

OBJECTIVE

There is a concern that pain is under-recognized in dementia. However, there may be other causes of distress. We wished to evaluate the utility of a distress tool and a pain tool.

METHODS

Nursing home residents with advanced dementia were observed using pain (Pain Assessment in Advanced Dementia scale (PAINAD)) and distress (Disability Distress Assessment Tool (DisDAT)) assessment tools. Those in pain were treated. Reassessment occurred at one and three months.

RESULTS

From 79 participants, 13 were assessed as being in pain. Psychosocial factors explained the behaviour of a false positive group. Both tools showed a significant decrease in pain following intervention (p = 0.008). Behaviours were similar in both groups.

CONCLUSIONS

Both tools are useful. However, the pain tool also picks up distress, which is not caused by pain. It could potentially lead to false ascriptions of pain. The distress tool picks up a broader array of signs, which may be useful both in practice and in research.

Challenges in pain assessment in cognitively intact and cognitively impaired older adults with cancer

PURPOSE/OBJECTIVES

To describe approaches to pain assessment in cognitively intact and cognitively impaired older adults with cancer.

DATA SOURCES

MEDLINE literature search, personal reference collection, and clinical experience.

DATA SYNTHESIS

A systematic and comprehensive pain assessment is the cornerstone of effective treatment strategies. Determining the effect of pain on older adults' ability to function is as important as rating pain intensity. Evidence-based recommendations exist to guide practice.

CONCLUSIONS

The undertreatment of pain in older adults persists despite a plethora of published guidelines addressing pain assessment and management. Unrelieved pain affects recovery from illness and all aspects of life. Systematic and ongoing assessment is elementary to effective pain management, yet assessments frequently are neither completed nor documented. Because pain is subjective and individual responses to pain interventions vary widely and are unpredictable, assessment is vital to comprehensive pain care in all clinical settings. Reliable and validated pain assessment tools for cognitively intact and cognitively impaired older adults are available to guide practice.

IMPLICATIONS FOR NURSING

Pain assessment is a core competency for nurses in all clinical settings. Comprehensive, individualized, and ongoing assessment provides the information necessary so that clinicians can develop interventions to relieve patients' pain and improve their quality of life. Nurses have the knowledge, skills, and tools to adequately screen and comprehensively assess pain in older adult patients, including those with cognitive impairment. By using this knowledge, nurses can change systems and practices, have a significant effect on improving pain care, and increase quality of life and function of older adults with pain.

[Problems of pain measurement and pain therapy in the elderly]

Due to complex physical and psychological changes in aging, pain measurement and therapeutic treatment of older and geriatric patients present a special challenge. Nevertheless, even for this category of patients, good treatment results are achievable if age-related particulars and problems are consistently heeded and accounted for. That includes adverse sensory and cognitive effects as much as multimorbidity and the polypharmacy that is frequently related to it. An essential prerequisite for adequate pain therapeutic care in elderly patients is consistent pain measurement. While numerical and verbal scales have also proven their usefulness for patients in advanced age who are not cognitively impaired, instruments must be applied for older people with communicative and/or cognitive restrictions with which the observed behavior of those involved can be surveyed in a multidimensional way.

Validation of Doloplus-2 among nonverbal nursing home patients--an evaluation of Doloplus-2 in a clinical setting

BACKGROUND

Pain measurement in nonverbal older adults is best based on behavioural observation, e.g. using an observational measurement tool such as Doloplus-2. The purposes of this study were to examine the use of Doloplus-2 in a nonverbal nursing home population, and to evaluate its reliability and validity by comparing registered nurses' estimation of pain with Doloplus-2 scores.

METHOD

In this cross-sectional study, Doloplus-2 was used to observe the pain behaviour of patients aged above 65 years who were unable to self-report their pain. Nurses also recorded their perceptions of patient pain (yes, no, don't know) before they used Doloplus-2. Data on demographics, medical diagnoses, and prescribed pain treatment were collected from patient records. Daily life functioning was measured and participants were screened using the Mini Mental State Examination.

RESULTS

In total, 77 nursing home patients were included, 75% were women and the mean age was 86 years (SD 6.6, range 68-100). Over 50% were dependent on nursing care to a high or a medium degree, and all were severely cognitively impaired. The percentage of zero scores on Doloplus-2 ranged from 17% (somatic reactions) to 40% (psychosocial reactions). Cronbach's alpha was 0.71 for the total scale. In total, 52% of the patients were judged by nurses to be experiencing pain, compared with 68% when using Doloplus-2 (p = 0.01). For 29% of the sample, nurses were unable to report if the patients were in pain.

CONCLUSIONS

In the present study, more patients were categorized as having pain while using Doloplus-2 compared with nurses' estimation of pain without using any tools. The fact that nurses could not report if the patients were in pain in one third of the patients supports the claim that Doloplus-2 is a useful supplement for estimating pain in this population. However, nurses must use their clinical experience in addition to the use of Doloplus-2, as behaviour can have different meaning for different patients. Further research is still needed about the use of Doloplus-2 in patients not able to self-report their pain.

Paramedic assessment of pain in the cognitively impaired adult patient

Background

Paramedics are often a first point of contact for people experiencing pain in the community. Wherever possible the patient's self report of pain should be sought to guide the assessment and management of this complaint. Communication difficulty or disability such as cognitive impairment associated with dementia may limit the patient's ability to report their pain experience, and this has the potential to affect the quality of care. The primary objective of this study was to systematically locate evidence relating to the use of pain assessment tools that have been validated for use with cognitively impaired adults and to identify those that have been recommended for use by paramedics.

Methods

A systematic search of health databases for evidence relating to the use of pain assessment tools that have been validated for use with cognitively impaired adults was undertaken using specific search criteria. An extended search included position statements and clinical practice guidelines developed by health agencies to identify evidence-based recommendations regarding pain assessment in older adults.

Results

Two systematic reviews met study inclusion criteria. Weaknesses in tools evaluated by these studies limited their application in assessing pain in the population of interest. Only one tool was designed to assess pain in acute care settings. No tools were located that are designed for paramedic use.

Conclusion

The reviews of pain assessment tools found that the majority were developed to assess chronic pain in aged care, hospital or hospice settings. An analysis of the characteristics of these pain assessment tools identified attributes that may limit their use in paramedic practice. One tool - the Abbey Pain Scale - may have application in paramedic assessment of pain, but clinical evaluation is required to validate this tool in the paramedic practice setting. Further research is recommended to evaluate the Abbey Pain Scale and to evaluate the effectiveness of paramedic pain management practice in older adults to ensure that the care of all patients is unaffected by age or disability.