Practice Guidelines for Assessing Pain in Older Persons with Dementia Residing in Long-Term Care Facilities

Abstract

Purpose: Frail patients with dementia most frequently present with musculoskeletal pain and mobility concerns; therefore, physiotherapy interventions for this population are likely to be of great benefit. However, physiotherapists who work with older adults with dementia confront a considerable challenge: the communication impairments that characterize dementia make it difficult to assess pain and determine its source. For an effective physiotherapy programme to be implemented, valid pain assessment is necessary. This paper is intended to provide practice guidelines for pain assessment among older persons with dementia. Summary of Key Points: Over the last several years, there has been tremendous research progress in this area. While more research is needed, several promising assessment methodologies are available. These methodologies most often involve the use of observational checklists to record specific pain behaviours. Recommendations: We encourage the ongoing and regular evidence-based pain assessment of older persons with dementia, using standardized procedures. Without regular and systematic assessment, pain problems will often go undetected in this population. Given the need for systematic pain assessment and intervention for long-term care populations with mobility concerns and muculoskeletal pain problems, we call for increased involvement of physical therapists in long-term care facilities.Key Words: Alzheimer's disease, assessment, dementia, long-term care, older adults, painHadjistavropoulos T, Dever Fitzgerald T, Marchildon GP. Practice guidelines for assessing pain in older persons with dementia residing in long-term care facilities. Physiother Can. 2010;62:104-113. RÉ SUMÉObjectif : Les patients de santé fragile atteints de dé mence sont les plus sujets aux douleurs musculosquelettiques et aux problè mes de mobilité . Par consé quent, les interventions en physiothé rapie apporteront sans doute de grands bienfaits à cette clientè le. Toutefois, les physiothé rapeutes travaillant auprè s des personnes â gé es atteintes de dé mence doivent faire face à un dé fi de taille : la dé gradation des capacité s de communication caracté risant la dé mence fait en sorte qu'il est difficile d'é valuer la douleur et d'en dé terminer la source. Pour qu'un programme efficace de physiothé rapie puisse ê tre mis en oeuvre, une é valuation valide de la douleur doit ê tre ré alisé e. Cette documentation tente de proposer des directives de pratique pour l'é valuation de la douleur chez les personnes â gé es atteintes de dé mence. Ré sumé des points clé s : Au cours des derniè res anné es, des progrè s considé rables ont é té ré alisé s au chapitre de la recherche dans ce secteur. Mê me si plus de recherche est né cessaire, plusieurs mé thodes d'é valuation prometteuses sont disponibles. Ces mé thodologies font souvent appel à l'utilisation de listes de vé rification des observations comprenant la consignation de comportements douloureux particuliers. Recommandations : Nous encourageons l'é valuation continue ...

Discrepancy between stimulus response and tolerance of pain in Alzheimer disease

“…After each stimulus the subject was asked to rate the pain on a horizontally held colored analog scale (CAS), which is the pain rating tool recommended in patients with mild to moderate dementia. 14,15 The participants' ability to understand the scale had been tested at baseline and all were able to understand and explain the scale correctly.…”

Case report: A patient with dementia presenting with hip fracture in the emergency department – Challenges of acute pain assessment

“…Weiner et al (1998) evaluated a numeric 0-10 pain scale; they found that older people with dementia who had major difficulties comprehending the scale tended to have MMSE scores closer to 13/30. Although MMSE scores can be used to determine the likelihood that self-reports of pain will be valid, it has been recommended that self-report measures always be attempted, regardless of the level of cognitive functioning (AGS, 2002;Hadjistavropoulos et al, 2007), because there are patients with low MMSE scores who can self-report pain (Hadjistavropoulos et al, 2010).…”

Assessment and Measurement of Pain in Adults in Later Life

“…When gathering self-report from older adults, providers should prompt simple and concrete questions (eg, “Does this hurt?”). 27 A common mistake made by providers when obtaining self-report is to ask “How are you doing?” or “Are you comfortable?” to solicit a response about pain. Questions about general well-being should not be substituted for pain assessment because these may elicit socially desirable answers and may not elicit any information about pain.…”

“…Assessment completed over time should use the same pain self-report tool and assessor when possible, and conduct pain assessment under similar situations (eg, during movement). 27 Reassessment should always occur: Upon transitions of care/settings—discharge and admissionAfter initial report of pain, regardless of intervention administrationAt each new report of pain (eg, breakthrough pain)After any intervention (pharmacologic, including analgesic trials in nonverbal older adults, and nondrug) has been provided to determine efficacy in reducing pain intensity and/or improving pain-related disability. If a medication is given, reassess at predetermined intervals: (1) at the onset of action of analgesic effect, (2) during the peak analgesic effect, and (3) at the time when medication levels are lowest (ie, generally 4–6 hours after administration).…”