"Pain Assessment of Adults with Cognitive Lim"
Pain Assessment of Adults with Cognitive Limitations Dana N. Rutledge, PhD, RN Lecturer in Nursing, California State University @ Fullerton Nancy E. Donaldson, DNSc, FAAN Director, Center for Research & Innovation in Patient Care, UCSF School of Nursing Diane S. Pravikoff, PhD, FAAN Director of Research/Professional Liaison Cinahl Information Systems Funding for the qualitative literature reviews from which this presentation comes was from Cinahl Information Systems. The reviews are found in The Online Journal of Clinical Information, a journal aimed at publishing qualitative (non-meta- analytic) systematic reviews of clinically and educationally relevant topics. Pain Assessment Required in all patients, regardless of cognitive status (JCAHO, 2002) Individualized Pain Assessment Pain assessment guidelines and tools Standardized in patients with normal cognition Adaptation based upon patient needs, characteristics For example, cognitive impairment Clinical significance Assessment of pain with a cognitively impaired post- operative patient Behavioral changes (e.g., agitation) in a patient with metastatic cancer or person with Alzheimer’s disease Cognitive Impairment Alterations in mental status affecting comprehension, memory, or communication Multiple causes Temporary (delirium; confusion) or long-lasting (dementia; developmental delay) Risk Factors for Cognitive Impairment Dementia (chronic) Delirium (acute onset) Previous history cognitive impairment; presence of fracture on admission, esp. hip; age over 80 years; use of neuroleptic meds; cancer, esp. terminal phases; dehydration; electrolyte imbalances, etc. Age (older) Pain Scales Often tested on non- cognitively impaired persons Variably useful with cognitively impaired persons Presentation Aim To discuss the clinical implications of the scientific evidence related to pain assessment/screening of persons with cognitive limitations or impairment Qualitative Integrative Reviews Evidence Literature (research studies, quality improvement and research utilization projects) Pain assessment in the cognitively impaired (Medline, CINAHL search terms: pain, pain measurement; mental disorders, delirium, confusion) Since 1994 (AHCPR clinical guidelines on cancer pain management; 1992 CPG on acute pain management) Reviews Rutledge, D.N., & Donaldson, N.E. (1998). Pain assessment and documentation. Part I. Overview and application in adults. The Online Journal of Clinical Innovations, 1(5), 1-37. Available at http://www.cinahl.com Rutledge, D.N., & Donaldson, N.E. (1998). Pain assessment and documentation. Part II. Special populations of adults. The Online Journal of Clinical Innovations, 1(6), 1-29. Available at http://www.cinahl.com Rutledge, D.N., Donaldson, N.E., & Pravikoff, D.S. (2002). Update. Pain Assessment and Documentation. Special Populations of Adults. The Online Journal of Clinical Innovations, 5(1), 1-49. Available at http://www.cinahl.com Findings Self report tools can be used for some persons with cognitive limitation Behavioral cues may give clues to presence/absence of pain Cues may be more likely during activity Cues are read most easily by caregivers who know the person’s normal behaviors Pain assessment can be driven by decision algorithms Impaired Sense of Pain Quality Common in late stage dementia, strokes Increased pain tolerance No complaints of pain, no appearance of pain, even in situations that are painful to most people (post-operative states, injuries) Implications I. Ways to assess/screen II. Behavior changes III. Effects of staffing IV. Use of a pain assessment algorithm V. Protection of persons who do not communicate pain I. Ways to Assess/Screen Screen – is pain present? Assess – gets at quality and other characteristics of pain For cognitively impaired, screening may be only level of information available to you Self Report Gold standard of pain assessment – self report Ask persons with cognitive limitations about Pain right now Pain or discomfort or aches or hurting Location of pain (or other terms) If patient able to self report, frequent monitoring of current pain Past pain may not be accurately remembered Inappropriate question - “tell me the level of the worst pain you’ve had in the last 24 hours.” More appropriate – “what is your usual level of pain?” Pain Assessment Tools Careful explanation Allow practice with tool May require several repetitions before success of use is useful for assessment purposes No Pain Mild Moderate Severe Pain Helpful Hints Use words besides “pain” Ache, discomfort, hurting Do not limit to one self report method Studies have shown that different tools can be understood by different people Have the person point or indicate on their own body where their pain/discomfort is Tools with Documented Success Structured Pain Interview (Weiner et al, 1998; 1999) 1. Do you have any pain or discomfort today? 2. Do you have some pain or discomfort every day or almost every day? What about any aching or soreness? 3. For how long have you had some pain or discomfort? < 3 months, 3-6 months, > 6 months Philadelphia Geriatric Center Pain Intensity Scale (Krulewich et al, 2000) In general, how much have you been bothered by pain over the past few weeks? How much are you bothered by pain right now? How much are you bothered by pain when it is at its worst? How many days a week does the pain get really bad? How much are you bothered by pain when it is at its least? How much has the pain interfered with your day- to-day activities? Pain extensity (Weiner et al, 1998; Wynn et al, 2000) The number of areas on a body map that a person identifies as having pain Have person point to parts of their own body where they are experiencing pain (may be less useful) Structured Pain Map Interview (Weiner et al, 1998) Done in the morning, prior to medication administration Ask persons to indicate the parts of their body that are painful at the present time by pointing to the corresponding location(s) on a pain map; place an X on the body part Using scoring template (body divided into 45 body surface areas), total # areas marked is the pain extensity score Pain Thermometer Vertical pain scale with pain descriptors No pain, little pain, MOST PAIN moderate pain, quite bad pain, very bad pain, pain is almost unbearable Person to select adjective on the scale that best describes their pain Visual and verbal cues NO PAIN II. Behavior Changes Subtle (or not so subtle) changes in behavior and vocalizations can indicate pain Behavioral observation tools available More useful in detecting changes in individual patients (for clinical use) that in detecting differences between patients (for research use) Often more helpful if used over time, across a variety of a person’s activities If aggressive behaviors are occurring, behavioral observation often elicits potential pain as a cause Discomfort Scale – Dementia of Alzheimer Type (DS-DAT) Easily administered, clinically useful Measures discomfort in non- communicative patients with cognitive disorders Observer must have full view of patient’s body and face Staff training in use necessary DS-DAT (Hurley et al, 1992; Miller et al, 1996) Noisy breathing Observation over a 5 Negative vocalization minute period Facial expression Scoring Content Frequency Sad Intensity Frightened Duration Frown Body language Tense Relaxed Fidgeting III. Effects of staffing Continuity among caregivers enhances their ability to detect changes in behaviors, thus enhancing the accuracy of their pain assessment Day-to-day caregiving such as bathing, ambulating IV. Use of a Pain Assessment Algorithm Serial use of several assessment tools found to be useful with persons with cognitive limitations Decisions made as attempts to use tools are made Stepped interventions when pain is suspected can also become part of an algorithm Sample Algorithm Initial screening: “are you having pain (discomfort, etc.)?” If yes, try a paper and pencil numeric rating scale to get an indication of level/intensity of pain If unsuccessful, try verbal questioning with adjectives (no pain, little pain, moderate pain, unbearable pain) If unsuccessful, try a colored thermometer with visual and verbal cues With any assessment, have the person point to where he/she is hurting With all, use behavioral assessment of cues, especially with activities When pain management strategies are used (e.g., analgesics, warm/cold compresses), reassess using successful method, or observe for change in behavioral cues (e.g., decreased aggression, facial grimacing) V. Patient Safety With cognitive impairment, patients are at risk to lose the protection that pain provides (e.g., avoidance of hot/cold) Always protect persons with cognitive limitations from potential harm Conclusion Pain assessment should be attempted with persons who have cognitive limitations Multiple methods can be tried Variable success can be expected across patients