Pain Assessment for Individuals with Advanced Dementia in Care Homes: A Systematic Review

Pain is prevalent in older people, especially in those with advanced dementia who have communication impairments. Although pain is recognised to be present in this population, it is often under-assessed and ineffectively managed. The assessment of pain in advanced dementia is extremely challenging and complex, particularly in institutional settings such as care homes. This study systematically reviews the literature to examine and characterise the evidence for the use of pain assessment tools in care homes with individuals living with advanced dementia. Relevant publications were sourced from electronic bibliometric medical databases including AMED, CINAHL Plus, Medline, PsycINFO, EMBASE, TRIP Pro, Google Scholar, and HINARI. The database search was supplemented by screening citations and reference lists, in addition to a grey literature searches. The search identified 2221 studies, among which 26 were included in the review. The majority of the studies were observational, which created a rich source of data to create four major themes. The findings were informed and shaped by working with key stakeholders to develop a conceptual model that can contribute to developing evidence-based practice. This highlights the importance of a comprehensive, multi-disciplinary approach to pain assessment in this population, which is beyond the use of tools.

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Adoption of a Pain Assessment Tool in Older Homebound Patients With Dementia in a Housecall Practice: A Dissemination Study

Clinical Scholars Review ◽

10.1891/1939-2095.5.2.124 ◽

2012 ◽

Vol 5 (2) ◽

pp. 124-131 ◽

Cited By ~ 2

Author(s):

Jean-Claude K. Provost

Keyword(s):

Older Adults ◽

Pain Assessment ◽

Assessment Tool ◽

Selection Process ◽

Pain Scale ◽

Assessment Tools ◽

Advanced Dementia ◽

Pain Diagnosis

This article describes the steps of a pilot dissemination study toward adopting a pain assessment tool for older homebound adults with dementia. The chosen practice site had not previously used adequate pain assessment tools for older adults with dementia. After the selection process by a pain assessment tool committee, providers (N = 20) were asked to choose between three tools: pain assessment in advanced dementia (PAINAD), the Abbey Pain Scale, and DOLOPLUS-2/ DOLOSHORT. Providers voted to use the PAINAD (54%) for the following 2 weeks. A preintervention audit showed that without the use of a pain assessment tool, 97.7% of the charts did not have any documentation of a pain diagnosis nor an intervention. Postintervention using PAINAD, 91.3% of the charts had both (χ2[1] = 18.645, p < .001). The feedback obtained from providers (n = 10) after 2 weeks of testing the tool was unanimously positive. Many providers reported increased confidence in identifying pain and some changed their practice by placing pain assessment in the forefront of their encounter with their older clients with dementia. PAINAD was adopted as the pain assessment tool for this practice.

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Pain assessment and management in care homes: understanding the context through a scoping review

BMC Geriatrics ◽

10.1186/s12877-021-02333-4 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jan Pringle ◽

Ana Sofia Alvarado Vázquez Mellado ◽

Erna Haraldsdottir ◽

Fiona Kelly ◽

Jo Hockley

Keyword(s):

Cognitive Impairment ◽

Scoping Review ◽

Pain Assessment ◽

Care Home ◽

Nursing Home Residents ◽

Assessment Tools ◽

Care Staff ◽

Care Homes ◽

Cochrane Library ◽

Assessment And Treatment

Abstract Background Internationally, 2–5% of people live in residential or nursing homes, many with multi-morbidities, including severe cognitive impairment. Pain is frequently considered an expected part of old age and morbidity, and may often be either under-reported by care home residents, or go unrecognized by care staff. We conducted a systematic scoping review to explore the complexity of pain recognition, assessment and treatment for residents living in care homes, and to understand the contexts that might influence its management. Methods Scoping review using the methodological framework of Levac and colleagues. Articles were included if they examined pain assessment and/or management, for care or nursing home residents. We searched Medline, CINAHL, ASSIA, PsycINFO, EMBASE, Cochrane Library, and Google Scholar; reference lists were also screened, and website searches carried out of key organisations. Conversations with 16 local care home managers were included to gain an understanding of their perspective. Results Inclusion criteria were met by 109 studies. Three overarching themes were identified: Staff factors and beliefs - in relation to pain assessment and management (e.g. experience, qualifications) and beliefs and perceptions relating to pain. Pain assessment – including use of pain assessment tools and assessment/management for residents with cognitive impairment. Interventions - including efficacy/effects (pharmaceutical/non pharmaceutical), and pain training interventions and their outcomes. Overall findings from the review indicated a lack of training and staff confidence in relation to pain assessment and management. This was particularly the case for residents with dementia. Conclusions Further training and detailed guidelines for the appropriate assessment and treatment of pain are required by care home staff. Professionals external to the care home environment need to be aware of the issues facing care homes staff and residents in order to target their input in the most appropriate way.

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Pain Assessment and Management in Care Homes: Understanding the Internal and External Context Through a Scoping Review

10.21203/rs.3.rs-94536/v1 ◽

2020 ◽

Author(s):

Jan Pringle ◽

Jo Hockley ◽

Sofia Alvarado ◽

Erna Haraldsdottir ◽

Fiona Kelly

Keyword(s):

Scoping Review ◽

Pain Assessment ◽

Care Home ◽

Grey Literature ◽

Nursing Home Residents ◽

Care Staff ◽

Care Homes ◽

Cochrane Library ◽

Relevant Evidence ◽

Assessment And Treatment

Abstract Background: Internationally, 2-5% of people live in residential or nursing homes, many with multi-morbidities, including severe cognitive impairment. Pain is frequently considered an expected part of old age and morbidity, and may often be either under-reported by care home residents, or go unrecognized by care staff. We conducted a systematic scoping review to explore the complexity of pain recognition, assessment and treatment for residents living in care homes, and to understand the internal and external contexts that might influence its management.Methods: We conducted a scoping review using the methodological framework of Levac and colleagues. Articles were included if they examined pain assessment or management for care or nursing home residents. We searched Medline, CINAHL, ASSIA, PsycINFO, EMBASE, Cochrane Library, and Google Scholar; reference lists were screened, and website searches carried out of key organisations, to ensure relevant evidence was retrieved, including grey literature. As per the methodolocal framework, stakeholder evidence from 16 local care home managers was also accessed, to undertand their current perspectives.Results: Inclusion criteria were met by 109 studies. Three overarching themes were identified: staff variables and beliefs, pain assessment, and interventions. Evidence from the review indicated a lack of training and staff confidence in relation to pain assessment and management in care homes. This was particularly the case for residents with dementia, who cannot always verbalize their pain, and may resort to behavioral manifestations to try and communicate their distress.Conclusions: This review has highlighted that training and detailed guidelines for the appropriate assessment and treatment of pain are required by care home staff. Professionals external to the care home environment need to be aware of the issues facing care homes staff and residents in order to target their input in the most appropriate way. Internal and external contexts need further examination in order to integrate recognition and assessment of pain, and its management, to the benefit of residents.

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“A good death but there was all this tension around”- perspectives of residential managers on the experience of delivering end of life care for people living with dementia

BMC Geriatrics ◽

10.1186/s12877-021-02241-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jessica A. L. Borbasi ◽

Allison Tong ◽

Alison Ritchie ◽

Christopher J. Poulos ◽

Josephine M. Clayton

Keyword(s):

End Of Life ◽

End Of Life Care ◽

Aged Care ◽

Care Staff ◽

Care Homes ◽

Residential Aged Care ◽

Life Care ◽

Advanced Dementia ◽

Front Line ◽

Care Managers

Abstract Background End of life care for residents with advanced dementia in the aged care setting is complex. There is prolonged and progressive cognitive decline, uncertain disease trajectory, significant symptom burden and infrequent access to specialist palliative care. Residential aged care managers offer a unique perspective in understanding the experience of providing end of life care for residents with advanced dementia. They bring insight from the coalface to the broader policy context. The aim of this study was to describe the experience and perspectives of residential aged care managers on providing end of life care for residents living with dementia. Methods Focus groups and semi-structured interviews were conducted with residential or care managers from various care homes from one dementia specific aged care organisation in Australia. A comprehensive sampling strategy was used in participating care homes. Transcripts were analysed using thematic analysis. Results 20 residential or care managers from 11 aged care homes in two states of Australia participated in two focus groups (total 16 participants) or individual interviews (4 participants). Six themes were identified: laying the ground work to establish what families understand about dementia, playing the peacemaker in the face of unrealistic family demands and expectations, chipping away at denial and cultivating a path towards acceptance of death, recruiting general practitioners as allies, supporting and strengthening the front line, and dedication to optimal care is relentless but rewarding. Conclusion Aged care manager participants described provision of end of life dementia care as a rewarding but sometimes fraught experience requiring persistent personalisation of care and communication to enable family acceptance of the resident’s terminal condition. The findings suggest that continuous front line aged care staff skill development, iterative family discussions, and partnership building between aged care staff and general practitioners, are all required to promote optimal end of life dementia care in residential aged care settings.

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How hospitalized patients evaluate and report their pain together with nurses: A scoping review

Nordic Journal of Nursing Research ◽

10.1177/20571585211013480 ◽

2021 ◽

pp. 205715852110134

Author(s):

Bente Dale Malones ◽

Sindre Sylte Kallmyr ◽

Vera Hage ◽

Trude Fløystad Eines

Keyword(s):

Scoping Review ◽

Pain Assessment ◽

Health Professionals ◽

Clinical Care ◽

Hospitalized Patients ◽

Assessment Tools ◽

Post Surgery ◽

Reliable Assessment ◽

Scoping Reviews ◽

The Relationship

Pain assessment tools are often used by patients to report their pain and by health professionals to assess patients’ reported pain. Although valid and reliable assessment of pain is essential for high-quality clinical care, there are still many patients who experience inappropriate pain management. The aim of this scoping review is to examine an overview of how hospitalized patients evaluate and report their pain in collaboration with nurses. Systematic searches were conducted, and ten research articles were included using the PRISMA guidelines for scoping reviews. Content analysis revealed four main themes: 1) the relationship between the patient and nurse is an important factor of how hospitalized patients evaluate and report their post-surgery pain, 2) the patient’s feelings of inconsistency in how pain assessments are administered by nurses, 3) the challenge of hospitalized patients reporting post-surgery pain numerically, and 4) previous experiences and attitudes affect how hospitalized patients report their pain. Pain assessment tools are suitable for nurses to observe and assess pain in patients. Nevertheless, just using pain assessment tools is not sufficient for nurses to obtain a comprehensive clinical picture of each individual patient with pain.

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R7 Perceptions of Behavioral Pain Assessment Tools and Pain Outcomes in Non-verbal Patients: A Pilot Survey

Pain Management Nursing ◽

10.1016/j.pmn.2020.02.061 ◽

2020 ◽

Vol 21 (2) ◽

pp. 220

Author(s):

Kelly D. Allred ◽

Patrick Healy

Keyword(s):

Pain Assessment ◽

Assessment Tools ◽

Pilot Survey ◽

Pain Outcomes

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Self-report pain assessment tools for cognitively intact older adults: Integrative review

International Journal of Older People Nursing ◽

10.1111/opn.12170 ◽

2017 ◽

Vol 13 (2) ◽

pp. e12170 ◽

Cited By ~ 6

Author(s):

Youjeong Kang ◽

George Demiris

Keyword(s):

Older Adults ◽

Pain Assessment ◽

Assessment Tools ◽

Self Report ◽

Integrative Review ◽

Cognitively Intact

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Reliability of three linguistically and culturally validated pain assessment tools for sedated ICU patients by ICU nurses in Finland

Scandinavian Journal of Pain ◽

10.1515/sjpain-2017-0139 ◽

2018 ◽

Vol 18 (2) ◽

pp. 165-173 ◽

Cited By ~ 1

Author(s):

Sanna-Mari Pudas-Tähkä ◽

Sanna Salanterä

Keyword(s):

Intensive Care ◽

Internal Consistency ◽

Pain Assessment ◽

Assessment Tools ◽

Endotracheal Suctioning ◽

Icu Patients ◽

Rater Reliability ◽

Intensive Care Patients ◽

Video Recordings ◽

Test Retest Reliability

Abstract Background and aims: Pain assessment in intensive care is challenging, especially when the patients are sedated. Sedated patients who cannot communicate verbally are at risk of suffering from pain that remains unnoticed without careful pain assessment. Some tools have been developed for use with sedated patients. The Behavioral Pain Scale (BPS), the Critical-Care Pain Observation Tool (CPOT) and the Nonverbal Adult Pain Assessment Scale (NVPS) have shown promising psychometric qualities. We translated and culturally adapted these three tools for the Finnish intensive care environment. The objective of this feasibility study was to test the reliability of the three pain assessment tools translated into Finnish for use with sedated intensive care patients. Methods: Six sedated intensive care patients were videorecorded while they underwent two procedures: an endotracheal suctioning was the nociceptive procedure, and the non-nociceptive treatment was creaming of the feet. Eight experts assessed the patients’ pain by observing video recordings. They assessed the pain using four instruments: the BPS, the CPOT and the NVPS, and the Numeric Rating Scale (NRS) served as a control instrument. Each expert assessed the patients’ pain at five measurement points: (1) right before the procedure, (2) during the endotracheal suctioning, (3) during rest (4) during the creaming of the feet, and (5) after 20 min of rest. Internal consistency and inter-rater reliability of the tools were evaluated. After 6 months, the video recordings were evaluated for testing the test-retest reliability. Results: Using the BPS, the CPOT, the NVPS and the NRS, 960 assessments were obtained. Internal consistency with Cronbach’s alpha coefficient varied greatly with all the instruments. The lowest values were seen at those measurement points where the pain scores were 0. The highest scores were achieved after the endotracheal suctioning at rest: for the BPS, the score was 0.86; for the CPOT, 0.96; and for the NVPS, 0.90. The inter-rater reliability using the Shrout-Fleiss intraclass correlation coefficient (ICC) tests showed the best results after the painful procedure and during the creaming. The scores were slightly lower for the BPS compared to the CPOT and the NVPS. The test-retest results using the Bland-Altman plots show that all instruments gave similar results. Conclusions: To our knowledge, this is the first time all three behavioral pain assessment tools have been evaluated in the same study in a language other than English or French. All three tools had good internal consistency, but it was better for the CPOT and the NVPS compared to the BPS. The inter-rater reliability was best for the NVPS. The test-retest reliability was strongest for the CPOT. The three tools proved to be reliable for further testing in clinical use. Implications: There is a need for feasible, valid and reliable pain assessment tools for pain assessment of sedated ICU patients in Finland. This was the first time the psychometric properties of these tools were tested in Finnish use. Based on the results, all three instruments could be tested further in clinical use for sedated ICU patients in Finland.

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