Observing Pain in Individuals with Cognitive Impairment: A Pilot Comparison Attempt across Countries and across Different Types of Cognitive Impairment

Abstract

Facial expression is a key aspect in observational scales developed to improve pain assessment in individuals with cognitive impairments. Although these scales are used internationally in individuals with different types of cognitive impairments, it is not known whether observing facial expressions of pain might differ between regions or between different types of cognitive impairments. In a pilot study, facial responses to standardized experimental pressure pain were assessed among individuals with different types of cognitive impairments (dementia, mild cognitive impairment, Huntington’s disease, and intellectual disability) from different countries (Denmark, Germany, Italy, Israel, and Spain) and were analyzed using facial descriptors from the PAIC scale (Pain Assessment in Impaired Cognition). We found high inter-rater reliability between observers from different countries. Moreover, facial responses to pain did not differ between individuals with dementia from different countries (Denmark, Germany, and Spain). However, the type of cognitive impairment had a significant impact; with individuals with intellectual disability (all being from Israel) showing the strongest facial responses. Our pilot data suggest that the country of origin does not strongly affect how pain is facially expressed or how facial responses are being scored. However, the type of cognitive impairment showed a clear effect in our pilot study, with elevated facial responses in individuals with intellectual disability.

Measuring pain and nociception: Through the glasses of a computational scientist. Transdisciplinary overview of methods

“…The Facial Action Coding System [FACS; (Ekman et al, 2002)] provides a taxonomy of facial movements as physical expressions of emotions in general and specifically including pain. Based on this system, the facial expression of pain can be used as an indicator of perceived pain based on which this system is particularly useful in non-verbal populations, for example, people with (severe) dementia (Kunz et al, 2021;Lautenbacher et al, 2018). Because of the specificity using mimic is an invaluable tool to assess pain, although it only gives very rough estimates of the magnitude of the perceived pain.…”

Towards a Better Understanding on How Cognitive Impairment Affects Pain

“…In this Special Issue, we take an important step forward by tackling the complex topic of pain assessment in individuals with impaired cognition from several angles. The articles included in this Special Issue focus on pain outcomes and pain responses in varies types and pathologies of cognitive impairments, ranging from individuals with intellectual disabilities [ 1 , 2 , 3 ] to older adults with varying degrees of cognitive impairments [ 4 , 5 , 6 , 7 ] and more severe forms of dementia [ 8 ]. Moreover, about half of the articles have a clear clinical perspective, with investigations focused on the reliability [ 9 ] and clinical cut-off scores [ 8 ] of observational pain assessment scales as well as reflections on the pain management and pharmacological treatment of pain in younger and older individuals with cognitive impairments [ 1 , 7 ].…”

“…Moreover, about half of the articles have a clear clinical perspective, with investigations focused on the reliability [ 9 ] and clinical cut-off scores [ 8 ] of observational pain assessment scales as well as reflections on the pain management and pharmacological treatment of pain in younger and older individuals with cognitive impairments [ 1 , 7 ]. Other articles applied controlled experimental pain stimuli to compare pain sensitivity between different pathologies of cognitive impairments [ 2 , 4 ].…”

“…Across all articles, it becomes evident that pain is still often overlooked in individuals with cognitive impairments and that observational pain assessment tools are necessary to improve this situation in these vulnerable individuals. The articles included also show promising findings, namely that these observational pain assessment scales allow for a reliable pain assessment that is relatively consistent across different regions in Europe, across different language versions, and across different pathologies [ 3 , 4 , 8 , 9 ]. Moreover, it also becomes apparent across articles that cognitive impairment is not necessarily associated with a decrease in pain responsiveness to noxious stimuli; in contrast, several articles point to an increase in pain responses in individuals with cognitive impairments [ 2 , 4 , 5 ].…”

“…The articles included also show promising findings, namely that these observational pain assessment scales allow for a reliable pain assessment that is relatively consistent across different regions in Europe, across different language versions, and across different pathologies [ 3 , 4 , 8 , 9 ]. Moreover, it also becomes apparent across articles that cognitive impairment is not necessarily associated with a decrease in pain responsiveness to noxious stimuli; in contrast, several articles point to an increase in pain responses in individuals with cognitive impairments [ 2 , 4 , 5 ]. Two of the articles in this special suggest that this increase in pain sensitivity—either measured via experimental or clinical pain assessment methods—seems to be associated with poor executive functioning [ 5 , 6 ].…”