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

Abstract

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 nonintervention 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.

Ultrasound‐guided femoral nerve blocks are not superior to ultrasound‐guided fascia iliaca blocks for fractured neck of femur

“…Pain scores were recorded, by nursing staff blinded to the block allocation, immediately prior to the delivery of the blocks and at 20 min post‐administration of the final block. For participants with cognitive impairment who could not provide their own verbal pain score out of 10, the PAINAD scale was used to measure pain providing a comparable score to the Numeric Pain Rating Scale from 0 to 10 . The cognitive function of participants was assessed using the Glasgow Coma Scale (GCS) and Abbreviated Mental Test 4 (AMT‐4).…”

“…For participants with cognitive impairment who could not provide their own verbal pain score out of 10, the PAINAD scale was used to measure pain providing a comparable score to the Numeric Pain Rating Scale from 0 to 10. 23 The cognitive function of participants was assessed using the Glasgow Coma Scale (GCS) and Abbreviated Mental Test 4 (AMT-4). Demographic data was also collected on participants including age and gender.…”

The effectiveness of interventions to improve pain assessment and management in people living with dementia: A systematic review and meta‐analyses

“…Ten articles were excluded because the intervention did not focus on nurses or other health professionals to improve pain assessment and management in dementia care. One article (Fry et al., 2018) studied people with cognitive impairment; however, the intervention was for the population of people living with dementia. The article, assessed according to the inclusion criteria, was included after discussion by authors.…”

“…(2018). Pain reduction was measured postintervention (Chen & Lin, 2016; Fry et al., 2018; Liu & Lai, 2017; Pieper et al., 2018; Rostad et al., 2018; Sandvik et al., 2014), including reduction in pain‐related behaviours (Chen & Lin, 2016; Liu & Lai, 2017; Pieper et al., 2018) and reduction in dementia‐related agitation (Chen & Lin, 2016; Rostad et al., 2018).…”

Emergency department pain management in older patients

“…In a qualitative study, PAINAD was found by ED nurses to be preferable to other observational pain assessment tools like Abbey pain scale, Doloplus 2 and pain assessment check list for seniors with limited ability to communicate 49 . PAINAD is quick and simple to use, gives a score out of 10 and assesses both physiological and psychological pain sequelae 50 …”