Topics in Geriatrics: Pain Assessment in Nonverbal Older Adults with Dementia

**Geriatric Wiki Assignment**

**Topics in Geriatrics: Pain Assessment in Nonverbal Older Adults with Dementia**

Older adults with
dementia cannot always communicate when and where they have pain, making it
impossible for patients in this population to use the gold standard self-reported
pain measures. For patients in this population, it is imperative that
clinicians use behavioral observation and changes in function to screen for
pain. It is estimated the older adults with dementia also have painful
conditions in addition to cognitive impairment with a prevalence of 49-83%1.
Thus, the purpose of this publication is to provide a resource for clinicians
assessing pain in older adults with dementia or other cognitive impairments
that are unable to communicate.

**Objectives:**

1.      Learn
the various ways to assess pain in older adults with dementia.

2.      Learn
when and how to administer and score pain assessments used in older adults with
dementia.

3.      Learn
about the evidence behind each pain assessment tool.

4.      Provide
access to the various pain assessment tools for older adults with dementia.

**Pain**
Assessment Tools

**1.**
Pain
Assessment in Advanced Dementia (PAINAD) scale2 http://dementiapathways.ie/\_filecache/04a/ddd/98-painad.pdf

a.       Uses
5 indicators:

i.
breathing:
labored breathing or hyperventilating

ii.
vocalization:
moaning or crying

iii.
facial
expression: frowning or grimacing

iv.
body
language: clenching fists or pushing away caregivers

v.
consolability:
an inability to be comforted

b.      Fast
and easy; can be administered in 5 minutes or less through observation

c.       Each
item is scored on 0-2 scale; when all 5 items are totaled a patient’s, score
can range from 0 (no pain) to 10 (severe pain).

d.      Internal
consistency: 0.50–0.67 0.69–0.74 Interrater reliability: r = 0.82–0.97
0.75–0.81 Test-retest: r = 0.90 (P!.001) Time interval: morning/ evening skift
scores r = 0.88 (interval: 15 d) r = 0.89 1

**2.**
Checklist
for Nonverbal Pain Indicators (CNPI)1 https://kentuckyonehealth.org/documents/Nursing/CNPI.pdf

**http://prc.coh.org/pdf/Assess%20Cog%209-09.pdf**

a.       6
items: nonverbal vocalizations, facial grimacing or wincing, bracing, rubbing,
restlessness, vocal complaints. Items scored on dichotomous scale: present (1)
or absent (0) at rest and on movement Total score range 0–121

b.      Common
obvious behaviors observed by direct observation

c.       internal
consistency: 0.54–0.64 Interrater reliability: r= 0.62–0.82 Percent agreement:
74%–94% r= 0.45–0.69 Test-retest: 34%–41% ; r= 0.23–0.661

d.      In
long-term care: Sensitivity: 55% Specificity: 85% Convergent validity1

**3.**
Pain
Assessment Checklist for Seniors with Severe Dementia (PACSLAC)1 https://geriatricpain.org/sites/geriatricpain.org/files/wysiwyg\_uploads/pacslac\_checklist\_with\_sm\_logo.pdf

a.       60
items, four dimensions: Facial expression (N = 13) Activity/body movements (N =
20) Social/ personality/ mood (N = 12) Physiologic/eating/ sleeping/vocal (N = 15)
Score range 0–60

b.      Internal
consistency: Retrospective data: 0.85 Total tool: 0.62–0.84 Subscales:
0.12–0.76 Interrater reliability: 0.92 Test-retest: Good intrarater
reliabilities

c.       Can
be completed in 5 minutes

d.      Item
reduction and subscale revisions needed

e.       Preferred
by nurses over PAINAD

**Who**
should I use these pain assessment tools with?

**PAINAD**
scale3: **nonverbal adults with severe dementia; has**
not been tested in adults with mild dementia

o
**When:**

 §  Admission

§  Every
8 hours

§  One
hour following pain intervention

§  Anytime
a change in status is reported

o
**How**

§  Observe
the older adult for 3-5 minutes during activity/with movement (such as bathing,
turning, transferring).

§  For
each item included in the PAINAD, select the score (0, 1, 2) that reflects the
current state of the behavior.

§  Add
the score for each item to achieve a total score. Total scores range from 0 to
10 (based on a scale of 0 to 2 for five items).

§  After
each use, compare the total score to the previous score received. An increased
score suggests an increase in pain, while a lower score suggests pain is
decreased.

§  CNA
should report any changes or scores to the nurse for follow-up assessment

**CNPI**
scale4: **cognitively impaired older** **adults living in LTC facilities**

o
Acute care settings require further
investigation

o   The Checklist of Non-Verbal Pain Indicators has been
shown to be a reliable and valid assessment tool in older adults with acute or
chronic pain, in critical care units and adults with dementia.4

o
**When**

§  Admission

§  Every
8 hours

§  One
hour following pain intervention

§  Anytime
a change in status is reported

o
**How5**
:

§  Instructions for use: Observe the patient at rest and
with movement. 0 = behavior not observed 1 = behavior is observed (even
briefly) during either while at rest or with activity 2 = behavior is observed
BOTH while at rest and during activity Add the “With Movement” and “At Rest”
columns to come up with a total score. For example: Total score of 0 would
indicate no indicators were observed with either movement or at rest A total
score of 5 would be reached if all indicators of pain were observed, but only
with movement A total score of 10 would be reached if all indicators of pain
were observed both at rest and with activity

**PACSLAC**
scale6: **adults with severe dementia in acute**
settings, LTC settings

o
**When:**

 §  Admission

§  Every
8 hours

§  One
hour following pain intervention

§  Anytime
a change in status is reported

o
**How:**

§  Use
during activity or movement

§  Total
the score at each use

§  Compare
previous scores

**References**

1.      Bjoro, Karen, and Keela Herr. “Assessment Of Pain In The
Nonverbal And/or Cognitively Impaired Older Adult.” *Current*
Therapy in Pain*, 2008, pp. 237–262.,*
doi:10.1016/b978-1-4160-4836-7.00005-5.

2.      Ann Horgas, and Lois Miller. “Pain Assessment in People with
Dementia.” *American Journal of Nursing*, vol. 108, no. 7, July 2008, pp. 62–70., doi:10.1097/01.NAJ.0000325648.01797.fc.

Warden,
V, Hurley AC, Volicer, V. (2003). Development and psychometric evaluation of
the Pain Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc,
4:9-15. Developed at the New England Geriatric Research Education &
Clinical Center, Bedford VAMC, MA.

4.      Nygaard
HA. Jarland M. (2006). The Checklist of Nonverbal Pain Indicators (CNPI):
testing of reliability and validity in Norwegian nursing homes. Age &
Ageing. 35(1):79-81

5.      Feldt
KS. (2000) The checklist of nonverbal pain indicators. Pain Management Nursing,
1(1):13-21.

6.      Fuchs-Lacelle,
S. & Hadjistavropoulos, T. (2004). Development and preliminary validation
of the pain assessment checklist for seniors with limited ability to
communicate (PACSLAC). Pain Management Nursing, 5(1), 37-49.