Pain Assessment in Elderly Patients with Severe Dementia

Abstract

The purpose of this study was to assess the reliability and validity of facial expressions as pain indicators in patients with severe dementia. Based on interviews with patients who could report pain, we defined characteristics of decubitus ulcers associated with reports of pain during dressing changes. We then evaluated 9 patients who had ulcers with these characteristics but were unable to communicate verbally because of severe dementia. We videotaped their facial expressions before and during their decubitus ulcer dressing change. We showed the videotape segments, in random order, to 8 medical students and 10 nurses. The 18 viewers were asked to infer the presence or absence of pain based on their observations of the patients' facial expressions and vocalizations. The dressing change of decubitus ulcers extending beyond the subcutaneous tissue, covering an area of at least 9 cm(2), and with a moist surface, was always reported as painful by study patients able to report (95% confidence interval of 69-100%). The intraclass correlation coefficient for the answers of the 18 viewers evaluating each videotape segment for the presence of pain was 0.64. Sensitivity, specificity, and positive and negative predictive values of viewers' ratings of facial expressions and vocalizations as a measure of the presence of pain were: 0.70, 0.83, 0.90, and 0.81. The intraclass correlation coefficient for the answers rating pain intensity was only 0.10, indicating only slight agreement beyond chance. Assuming dressing changes of ulcers reported as painful by communicative patients are also painful in non-verbal severely demented patients, clinician observations of facial expressions and vocalizations are accurate means for assessing the presence of pain, but not its intensity, in patients unable to communicate verbally because of advanced dementia.

Pain behaviors observed during six common procedures: Results from Thunder Project II*

“…Puntillo and colleagues (8) also noted a significant relationship between the number of behavioral indicators of pain and nurses' ratings of their postoperative patients' pain intensity. Thus, there is a growing body of evidence to support the frequently observed clinical observation that patients with pain respond behaviorally more often than patients without pain (38). An extension of this evidence is our documentation of the specificity of behavioral responses.…”

“…These findings may cue clinicians into equating behavioral activity with degree of overall patient discomfort, especially in patients who are unable to self-report (38,43). These are the patients who are most at risk of experiencing unrelieved pain during a procedure because they cannot communicate verbally with their care providers.…”

Palliative Care for the Older Adult

“…48 The traditional signs of facial grimacing are accurate for the presence of pain but not its intensity. 49 Physician assessment of pain has been found to be accurate in mildly to moderately demented patients but less so in severely demented people. 50 Caregiver assessment of pain in one study had a 67% correlation with self-reported pain in patients with cognitive impairment (mean MMSE 15.7).…”

Les échelles d’hétéroévaluation de la douleur chronique à l’épreuve du quotidien en gériatrie

“…Keywords Elderly · Cognitive impairment · Pain assessment · Behavourial scale La douleur physique chronique est souvent sous-évaluée et n'est pas assez traitée [6] chez les personnes âgées présentant des difficultés à s'exprimer oralement [3,8,10]. L'importance des déficits sensoriels et cognitifs rend les outils d'autoévaluation inadaptés pour cette population.…”