# Presentation: 158496

## Assessing Pain in Persons with  Impaired Cognition and Communication

- Michael Craine, Ph.D.
- Eastern Colorado Health Care System

## Polytrauma

- Two or more injuries to physical regions or organ systems, one of which may be life threatening.
- Results in Physical,
- Cognitive,
- Psychological,
- or Psychosocial Impairments
- and Functional Disability    VHA HANDBOOK 1172.1, 2005

## Polytrauma

- Traumatic Brain Injury frequently occurs in polytrauma in combination with:
- Amputation,
- Auditory impairments,
- Visual impairments,
- Spinal Cord Injury,
- Posttraumatic Stress Disorder and other mental health conditions  VHA HANDBOOK 1172.1, 2005

## Polytrauma

- Injuries often caused by an explosive blast
- Primary blast injury– concussive overpressure to gas-containing organ systems: injury to lung, bowel, and inner ear, amputation
- Secondary blast injury – penetrating fragments and other missiles can cause head and soft tissue trauma
- Tertiary blast injury - displacement of the whole body by combined pressure loads (shock wave and dynamic overpressure)
- Miscellaneous blast injuries - burns, crush, soft tissue, fractures, and amputations  VHA HANDBOOK 1172.1, 2005

## Polytrauma Brain Injury

- 60% or more of polytrauma survivors have some degree of brain injury VHA HANDBOOK 1172.1, 2005
- Brain injury is the most frequent problem treated at Polytrauma Rehabilitation Centers
- Injury to the brain primarily guides the course of  rehabilitation

## Slide 6

| Polytrauma Rehabilitation Centers |  |
| --- | --- |
| Major Impairment Prevalence |  |
| Brain | 85.5% |
| Fracture-Maxillofacial | 30.1% |
| Fracture-Extremity | 25.9% |
| Soft Tissue-Wounds | 21.0% |
| Eye | 15.3% |
| Ear | 7.9% |
| Peripheral Nerve | 6.7% |
| Soft Tissue-Burns | 4.7% |
| Amputation | 3.1% |

## Polytrauma Brain Injury

- http://www.neuroskills.com/ceumenu.shtml

## Polytrauma Brain Injury

- Brain Injury Symptoms include:
*Attention and Concentration Deficit*
*Memory Problems*
*Problems with New Learning*
*Problems in Higher Order Reasoning*
*Impaired Problem-solving*
*Reduced Cognitive Flexibility**	**	**	**	*

## Polytrauma and Pain

- Pain is a multidimensional phenomenon
- Unpleasant sensory experience
- Emotional suffering
- Commonly associated with disability and emotional distress
- Pain is always subjective

## Polytrauma Pain Assessment

- Effective pain management requires a comprehensive assessment
- Particular challenges are associated with assessment and management of pain in the cognitively-impaired veteran, and with efforts to balance optimal pain management with rehabilitation goals   VHA HANDBOOK 1172.1, 2005

## Polytrauma Pain Assessment

- Problems with attention, comprehension and memory can affect patient report
- Neuropsychological and Speech/Language testing can be helpful to define patient’s abilities to provide self-report and the best way of obtaining patient report
- Testing can identify specific deficits to consider when assessing pain

## Cognitive Impairment and Pain

- The inability to communicate  well does not mean that a person is not experiencing pain
- Patients with difficulty in communication due to cognitive impairment can suffer pain and need to be assessed
- Caregivers have difficulty knowing when these patients are in pain and when they are experiencing pain relief

## Cognitive Impairment and Pain

- Impaired patient is vulnerable to under-treatment and over-treatment
- Severe cognitive impairment is often associated with fewer complaints (Parmalee, 1996)
- Failure to report does not mean absence of pain

## Assessment Guidelines

- Assessing Pain in the Patient with Impaired Communication: A Consensus Statement from the VHA National Pain Management Strategy Coordinating Committee
- VHA Pain Management Webpage
- 	http://www1.va.gov/Pain_Management/

## Assessment Guidelines

- Pain Assessment in the Non-verbal Patient: Position Statement with Clinical Practice Recommendations
- American Society for Pain Management Nursing
- 	http://www.aspmn.org/Organization/position_papers.htm

## Assessment Guidelines

- Assessment guidelines are based on studies in the elderly, children and persons who are intubated or unconscious
- Younger adults with brain injuries and related pain assessment challenges have not been studied
- Prevalence of pain after traumatic brain injury has been estimated at 44% or more (Martelli et al, 2004; Sherman, et al, 2006)

## Recommendations for Assessment

- Assess using multiple assessment strategies to identify presence and intensity of pain
- Patient’s report of pain
- Reports of patient’s pain by surrogates, caregivers
- Patient’s behaviors
- Physiological parameters – most useful in acute pain
- Empirical analgesic trials

## Patient’s Report of Pain

- Pain is a subjective experience
- Best source of pain presence and pain intensity is patient report
- But remember lack of report does not mean lack of pain
- Even persons with mild to moderate impairment can often learn to use self-report methods (Chibnall, 2001; Ware et al, 2006)

## Patient’s Report of Pain

- Initially try different types of pain intensity scales then consistently use one that patient prefers
- Scale examples are 0-10 NRS, Wong-Baker Faces, VAS, Verbal Descriptor Scales, vertical and horizontal thermometers
- Patients can improve in reporting skill with practice

## Patient’s Report of Pain

- Wong-Baker FACES Pain Rating Scale

**Numeric Rating Scale (NRS)**
- 	0     1     2     3     4     5     6     7     8     9     10
- 	No Pain    Mild        Moderate         Severe      Worst Possible

## Patient’s Report of Pain

- Examples  of scales can be found in the _Pain as the Fifth Vital Sign Toolkit_ and _Pain Outcomes Toolkit_
- VHA Pain Management Webpage
- 	http://www1.va.gov/Pain_Management

## Patient’s Report of Pain

- Ask the patient for a description of pain
- “Pain is what the person says it is.” (McCaffery and Pasero, 1999)
- Inquire about:
*sensory – pain quality*
*emotional – suffering, **anxiety, depression*
*behavioral components – activity, guarding*

## Patient’s Report of Pain

- Focus assessment on specific concrete, here and now experience of pain
- “How much pain do you feel now?” Not “how much pain have you had the lately?”
- Compare report to experiences like needle sticks that occur commonly

## Report by Surrogates

- Caregivers and family members can provide information about pain
- Surrogates should be asked to describe specific behaviors
- Inquire about sensory, emotional and behavioral components
- Surrogates can underestimate and overestimate pain presence and intensity

## Observation of Behaviors

- Facial Expressions
- Verbalizations/Vocalizations
- Body movements
- Interpersonal behavior change
- Change in activity pattern
- Mental status change – anxiety, agitation, depression (American Geriatrics Society, 2002)

## Observation of Pain Behaviors

- Patients with cognitive impairment may not show any specific behavior associated with pain
- Patients with severe impairment may appear stoic when they are actually displaying a frozen mask in response to pain

## Observation of Pain Behaviors

- Pain behaviors should be assessed at rest and during movement
- Pain Behaviors have not been well-examined in younger veterans with cognitive impairment

## Physiological Parameters

- Changes in vital signs can provide some indication of acute distress
- Not a good indicator of chronic problem
- Vital changes do not discriminate pain from other sources of distress
- Absence of physiologic indicators does not mean absence of pain

## Empirical Analgesic Trials

- Use in conjunction with other assessment strategies
- Consider other sources of distress that could be masked by analgesic trial
- PTSD is very common in this population and should receive specific treatment
- PTSD can be present even in the instance of a loss of consciousness at time of injury (Bryant et al, 1999)

## Empirical Analgesic Trials

- Consider impact of analgesic on cognitive status
- Identify functional/behavioral indicators to determine efficacy
- Use an adequate titration schedule (25% - 50%) to assure dose efficacy

## Pain Assessment Tools

- Numerous tools have been developed
- Tools are designed for use with elderly with dementia or children
- No tools have been validated for polytrauma patients with cognitive impairment
- All tools need further refinement

## Pain Assessment Tools

- Noncommunicative Patient’s Pain Assessment Instrument (NOPPAIN)
- Checklist of Nonverbal Pain Indicators (CNPI)
- Discomfort in Dementia of Alzheimer’s Type (DS-DAT)
- Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)
- Doloplus 2
- Others

## Pain Assessment Tools

- There is no standardized tool based on nonverbal pain indictors that can be recommended for broad adoption in clinical practice (Herr et al, 2006)
- State of the Art review of tools used with elderly with dementia is available at City of Hope Website
- 	http://www.cityofhope.org/prc/elderly.asp

## Documentation

- Only patient self-report of pain intensity can be entered in CPRS vital sign section
- Pain tool scores cannot be substituted for patient self-report even if they provide a 0-10 number, e.g. PAINAD
- All other pain assessment is documented in progress note with appropriate title

## Re-Assessment

- Pain assessment is an ongoing process
- Pain should be re-assessed regularly with other vital signs
- Pain assessment should always occur after new interventions or changes in health status

## Polytrauma Pain

- Treat the Person – Not the Pain! 			*Dennis Turk, Ph.D.*
- Always address pain in context of the individual patient
- This requires extra attention in cases of cognitive impairment and impaired communication.