Assessment of discomfort in advanced Alzheimer patients

Hurley, Ann C.; Volicer, Beverly J.; Hanrahan, Patricia; Houde, Susan Crocker; Volicer, Ladislav

doi:10.1002/nur.4770150506

Cited by 422 publications

(312 citation statements)

References 25 publications

(22 reference statements)

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“…[66] The DS-DAT demonstrates acceptable validity and reliability; however, its usefulness has been questioned because of the in-depth training required and because of lack of study of its sensitivity across settings and populations. [64] [88] Further, the DS-DAT is a measure of discomfort (e.g., validated with elevated temperature), and its validity as a pain measure is not clear.…”

Section: Observational Methodsmentioning

confidence: 99%

Assessment and measurement of pain in older adults

Herr

Garand

2001

Clinics in Geriatric Medicine

336

251

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Although the empirical base is still limited when providing clear directions for pain assessment and management in older adults, it is possible to identify recommendations for guiding practice based on consensus and a developing scientific base to support best practice activities. This article offers a brief overview of the epidemiology and consequences of pain, followed by a summary of issues and approaches relevant to pain assessment in older adults. Cohort specific recommendations for comprehensive pain assessment and measurement are then addressed. Prevalence and Consequences of Pain in Older AdultsOlder individuals frequently suffer from both acute and chronic painful diseases, have multiple diseases, and take numerous pain medications, [2] although relatively little investigative or clinical attention has been paid to the assessment of pain in the geriatric population, compared with the general population. This is surprising because populationbased figures indicate that the prevalence of pain is twofold higher in those over age 60 (250 per thousand), compared with those under age 60 (125 per thousand). [24] [79] [108] Further, prevalence estimates suggest that approximately 60% of community-dwelling older adults and up to 80% of elderly long-term care facility residents experience substantial pain.[24] [79] [108] Because pain is often remediable, [2] [25] it is thought that the high prevalence estimates of unrelieved pain in elderly persons may result from underrecognition, which in turn results in undertreatment. [65] [91] [120] The consequences of untreated pain can profoundly impact the older person's quality of life. In addition to physiologic risks associated with untreated pain (e.g., cough suppression with subsequent retention of pulmonary secretions), depression, [58] [39] [90] Therefore, it is imperative that health care professionals' knowledge and skills related to pain assessment in older adults be improved, and aggressive approaches to comprehensive pain assessment be adopted, to ensure and improve the quality of life of our senior citizens. Approaches to Pain Assessment with Older Adults Clinical AssessmentIn the clinical setting, accurate assessment of pain is critical for the identification of appropriate interventions and for evaluating the effectiveness of such interventions. Patients should be assessed regularly for the presence of pain and for improvement, deterioration, or complications attributable to pain treatment.[2] The frequency of the follow-up should be a function of the severity of the pain and the potential for adverse effects of treatment. Documentation of pain assessment formalizes the pain assessment process and is essential in the provision of individualized care from both a legal and professional perspective. [17] Inherent in the assessment of pain among older adults is the understanding of its potentially remediable components. For example, if a patient has acute pain, assessment should focus on the underlying pathology responsible for the pain stimulus. If th...

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Section: Observational Methodsmentioning

confidence: 99%

Assessment and measurement of pain in older adults

Herr

Garand

2001

Clinics in Geriatric Medicine

336

251

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“…Discomfort was assessed every 2 weeks until death or the end of the follow-up (6 months) using the validated Italian translation 23 of the Discomfort Scale-Dementia of Alzheimer Type (DS-DAT). 24 At the same time, data were collected about the patients' general condition; any changes in the treatment plan, along with the reasons for the change; DS-DAT scores; and CDs.…”

Section: Data Collectionmentioning

confidence: 99%

Critical Decisions for Older People With Advanced Dementia: A Prospective Study in Long-Term Institutions and District Home Care

Toscani¹,

Steen²,

Finetti³

et al. 2015

Journal of the American Medical Directors Association

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Objective. To describe and compare the decisions critical for survival or quality of life (CDs) made for patients with advanced dementia in nursing homes (NHs) and home care (HC) services.Design. Prospective cohort study with a follow-up of 6 months.Setting. Lombardy Region (NHs) and Reggio-Emilia and Modena Districts (HC), Italy.Participants. Patients (496 total; 315 in NHs and 181 in HC) with advanced dementia (Functional Assessment Staging Tool score >7) and expected survival >2 weeks.Measurements. At baseline, the patients' demographic data, date of admission and of dementia diagnosis, type of dementia, main co-morbidities, presence of pressure sores, ongoing treatments, and current prescriptions were abstracted from clinical records. At baseline and every 15 days thereafter, information regarding the patients' general condition and CDs (deemed critical by the doctor or team) was collected via interview with the doctor. For each CD, the physician reported the problem that led to the decision, the decision that was eventually made, the purpose of the decision, whether the decision had been discussed with and/or communicated to the family, who made the final decision, whether the decision was maintained after one week, whether it corresponded to what the doctor would have judged appropriate, and the expected survival of the patient (≤15 days).Results. For 267 of the 496 patients (53.8%; 60.3% in NHs and 42.5% at home), 644 CDs were made; for 95 patients, more than one CD was made. The problems that led to a CD were mainly infections (respiratory tract and other infections; 46.6%, 300/644 CDs); nutritional/hydration problems (20.6%; 133 CDs) and the worsening of a pre-existing disease (9.3%; 60 CDs). The most frequent type of decision concerned the prescription of antibiotics (overall 41.1%, 265/644; among NH patients 44.6%, 218/488; among HC patients, 30.2%, 47/156). The decision to hospitalize the patient was more frequently reported for HC than NH patients (25.5% vs. 3.1%). The most frequent purposes of the CDs in both settings were reducing symptoms or suffering (more so in NHs; 81.1 vs. 57.0% in HC) and prolonging survival (NH 27.5%; HC 23.1%; multiple purposes were possible). For 26 decisions (3.8%), the purpose was to ease death or not to prolong life. Conclusions.Decisions critical for the survival or quality of life of patients with advanced dementia were made for approximately half of the patients during a 6-month time frame, and such decisions were made more frequently in NHs than in HC. HC patients were more frequently hospitalized, and a sizeable minority of these patients were treated with the goal of prolonging survival. Italian patients with advanced dementia may benefit from the implementation of 5 palliative care principles, and HC patients may benefit from the implementation of measures to avoid hospitalizing patients near the end of life.

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“…The assessment of pain in older adults with cognitive impairment A number of behavioural scales have been developed to assess pain in older adults with cognitive impair-ment [36][37][38][39][40][41][42], and consistently include seven main indicators: physiological observation; facial expressions; body movements; verbalisations; and changes in interpersonal interactions, activity/routines and/or mental status. No single instrument can be recommended currently for general use [43].…”

Section: The Assessment Of Pain In the Older Populationmentioning

confidence: 99%

The assessment and management of peri‐operative pain in older adults

Schofield

2013

Anaesthesia

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SummaryA number of recent reports have highlighted the inadequate provision of pain relief for older inpatients. Despite the availability of numerous validated pain measures, pain remains poorly assessed in some cases and, particularly, in the cognitively impaired. Without proper assessment, patients may receive inadequate or inappropriate analgesia, both of which can worsen outcome. Most drugs and techniques that are used for analgesia in younger patients are also suitable for older patients, although dosages may have to be adjusted to avoid the side‐effects that are consequent upon age‐related changes in drug pharmacokinetics and pharmacodynamics, co‐morbidity, frailty, cognitive impairment and polypharmacy. This paper reviews current guidelines and methods of assessing pain in the older adult, and describes the use of, and problems with, mild, moderate, strong, adjuvant and local anaesthetic drugs in the older population for analgesia, advocating multimodal intervention to reduce dose‐related side‐effects, particularly of opioids.

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Assessment of discomfort in advanced Alzheimer patients

Cited by 422 publications

References 25 publications

Assessment and measurement of pain in older adults

Assessment and measurement of pain in older adults

Critical Decisions for Older People With Advanced Dementia: A Prospective Study in Long-Term Institutions and District Home Care

The assessment and management of peri‐operative pain in older adults

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