Pain in Cognitively Impair.PDBؼn'RCH1DTGP@ @J@@@9a@;@=@=@ >@ >)@ >k@ B'@ HHH@J@LOOPPain in Cognitively ImpairedBؼؽUnfiledPain in Cognitively Impairedw@w@/%/%   bb@  Try This Dementia Series Volume 1, Number 7, Fall 2004 Series Editor: Marie Boltz, APRN, MSN, GNP Communication Difficulties: Assessment and Interventions By: Della Frazier-Rios, RN, MS and Cora Zembrzuski, APRN, MSN, CS, PhD (cand.) WHY: .+9O,: J8O Z !X ! q ! N*+X*+ ND GGCora Zembrzuski, APRN, MSN, CS, PhD (cand.) GG4(GG4:GG4L^f^sn rs~6ttAssessing Pain in Persons with DementiaII Ann Horgas,,< LP\hDl>~    dd tt:vv wy   ,0 @ P{`cd:vdd est    ,d   r!- r.;S `B;S *Rdr *br38_  & & )  O r  ra r *  * r* >MML LMbp_QQQ PQ6J J mu lm&ll 4PRDTT T rd x v  PERMISSION is hereby granted to reproduce, post, download, and/or distribute this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org. E-mail notification of usage to: hartford.ign@nyu.edu.  '7' * "#W5$ 7        &  4  B P eferences Feldt, K. S. (2000) The checklist of nonverbal pain indicators (CNPI). Pain Management Nursing, 1(1): 13-21. Herr, K. (2002). Chronic pain: Challenges and assessment strategies. Journal of Gerontological Nursing, 28 (1), 20-27. Herr KA, Mobily PR. Comparison of selected pain assessment tools for use with the elderly. Applied Nursing Research. 1993;6:39-46. Horgas, A. L., & Tsai, P. F. (1998). Analgesic drug prescription and use in cognitively impaired nursing home residents. Nursing Research, `Z 47, 235-242. Kovach, C., Weissman, D., Griffie, J., Matson, S., & Muchka, S. (1999). Assessment and treatment of discomfort for people with late-stage dementia. Journal of Pain and Symptom Management, 18: 412-419. Weiner, D.K., Hanlon, J.T. (2001). Pain in nursing home residents: Management strategies. Drugs & Aging, 18:13-29. pK > nw   s J GS&h(h  Rd2t     V Date: ______________ Patient ID: __________ Hospital Day ________ F6HFb t YZZ Z ZZ[Z   0>N ^n   *ad r rbb yz Rj *Rj/OO6(:JN$`NrNN$ !:"" #O(* /1  68 <> ,BD <HIL\"(6l(B6~BH6KMKXZ fh uw ~   *(8H^n  6:, BR6h z      , *$4J6`HJ rPR vx  * *(:8 HXHn"# /1 IL  * *KK KLKK2,LM.Z Z * z '>N^".n sa~ sa s b    A series provided by The Hartford Institute for Geriatric Nursing and the Alzheimers Association www.hartfordign.org&wU5UUc23"||t !1! (*+28563HGVMXHHarie Boltzh_nG``NPdI (<< Facial Grimaces/ Winces=T <  *)8(HXh*, xTry This Dementia Series Volume 1, Number 2, Fall 2003 Series Editor: Marie Boltz, APRN, MSN, GNP Assessing Pain in Persons with Dementia By: Ann Horgas, RN, PhD WHY: There is no evidence that persons with dementia physiologically experience less pain than do other older adults. Rather than being less sensitive to pain, cognitively- impaired elders: may fail to interpret sensations as painful, are often less able to recall their pain, and may not be able to verbally communicate it to their care providers. As such, cognitively impaired older adults are often under-treated for pain (Horgas & Tsai, 1998). As with all older adults, those with dementia are at risk for multiple sources and types of pain, including chronic pain from conditions such as osteoarthritis and acute pain. Untreated pain in cognitively impaired older adults can: delay healing, disturb sleep and activity patterns reduce functioning reduce quality of life prolong hospitalization Target Population: Older patients who, because of cognitive impairments, may not be able to be assessed for pain using standardized pain assessment instruments. Thus, beginning with the individuals entry into the hospital, whether through planned or emergent entry, interpreting behaviors and assessing pain is essential. Best Tools: Currently, there are few valid and reliable tools available specifically to measure pain in older adults with dementia. We recommend the following: Use a standardized tool to assess pain, if possible. Many persons with dementia can respond to pain measures such as the Verbal Descriptor Scale (Herr, 2002; see also Try This on pain assessment). This tool measures pain intensity by asking participants to select a word that best describes their present pain (e.g., no pain to worst pain imaginable). This measure has been found to be a reliable and valid measure of pain intensity, and is reported to be the easiest to complete and the most preferred by older adults (Herr & Mobily, 1993). Use an observational tool to measure the presence of pain in persons with dementia. The Checklist for Nonverbal Pain Behaviors (Feldt, 2000) is designed to assess pain behaviors in post-operative patients. This measure has high inter-rater reliability (93% agreement; Kappa = .63 to .82) and is positively associated with self-reports of pain. The presence of pain indicators is scored as a 1, and the total number of indicators are summed for those occurring at rest, with movement, and overall. The relationship between scores on this tool and pain intensity ratings has not yet been established; i.e., there are no clear cutoff scores to indicate pain severity. Instead, the presence of any of the behavioral indicators listed may be indicative of pain, and warrants further investigation, treatment, and monitoring by the practitioner. Ask family or usual caregivers as to whether the patients current behavior (i.e. crying out, restlessness) is different from their customary behavior. This change in behavior may signal pain. If pain is suspected, consider a time-limited trial of a mild analgesic agent, such as acetaminophen. Thoroughly investigate behavior changes in persons with dementia and, once other causes have been ruled out, initiate a trial of analgesic. Observe closely for changes in expression, behavior, and movement consistent with alleviation of pain (Kovach et al., 1999; Weiner & Hanlon, 2001). Strengths and Limitations: Pain is a subjective experience and there are no definitive, universal tests for pain. For patients with dementia, it is particularly important to know the patient and to consult with family and close contacts. Barriers to Pain Management in Persons with Dementia: There are many barriers to effective pain management in this population. Some common myths are: (a) pain is a normal part of aging (b) if a person doesnt say they have pain, they must not be experiencing it, and (c) that strong analgesics (e.g., opioids) must be avoided in elderly. A more effective approach to pain management in persons with dementia is to assume that they do have pain if they have conditions and/or medical procedures that are typically associated with pain. That is, to take a proactive approach in listening and observing for pain and taking steps to alleviate it. Checklist of Nonverbal Pain Indicators Date: ______________ Patient ID: __________ Hospital Day ________ Write a 0 if the behavior was not observed, and a 1 if the behavior occurred even briefly during activity or rest. With MovementRestVocal complaints: Non-verbal Expression of pain, not in words: moans groans grunts cries gasps sighs2. Facial Grimaces/ Winces Furrowed brow narrowed eyes tightened lips jaw drop clenched teeth distorted expressions3. Bracing Clutching or holding onto side rails bed tray table, or affected area during movement,Restlessness Constant or intermittent shifting of position rocking intermittent or constant hand motions inability to keep stillRubbing Massaging affected areaIn addition, record Verbal complaints Vocal complaints: Verbal Words expressing discomfort or pain: "ouch," "that hurts" cursing during movement, exclamations of protest (e.g., stop; thats enough)Subtotal Scores Total Score  Feldt, K. S. (1996). Treatment of pain in cognitively impaired versus cognitively intact post hip fractured elders. (Doctoral dissertation, University of Minnesota, 1996). Dissertation Abstracts International, 57-09B, 5574. Feldt, K.S. (2000). Checklist of Nonverbal Pain Indicators. Pain Management Nursing, 1 (1), 13-21. PERMISSION is hereby granted to reproduce, post, download, and/or distribute this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org. E-mail notification of usage to: hartford.ign@nyu.edu. References Feldt, K. S. (2000) The checklist of nonverbal pain indicators (CNPI). Pain Management Nursing, 1(1): 13-21. Herr, K. (2002). Chronic pain: Challenges and assessment strategies. Journal of Gerontological Nursing, 28 (1), 20-27. Herr KA, Mobily PR. Comparison of selected pain assessment tools for use with the elderly. Applied Nursing Research. 1993;6:39-46. Horgas, A. L., & Tsai, P. F. (1998). Analgesic drug prescription and use in cognitively impaired nursing home residents. Nursing Research, 47, 235-242. Kovach, C., Weissman, D., Griffie, J., Matson, S., & Muchka, S. (1999). Assessment and treatment of discomfort for people with late-stage dementia. Journal of Pain and Symptom Management, 18: 412-419. Weiner, D.K., Hanlon, J.T. (2001). Pain in nursing home residents: Management strategies. Drugs & Aging, 18:13-29. A series provided by The Hartford Institute for Geriatric Nursing and the Alzheimers Association www.hartfordign.org +(-/ E!c!$$%%%#DI!$SH1't+-#!89999:S=>> >>< + GHF+ .LM&MK & % Q RR4P) (c  c  '7' nw   sU5UU J' p8x4 4EnS&L+e"4ND 'G ,-(,-?,. ,.,./H,.,4Y,.,/0/V,. /s,./,.&,/x,1,1 ,./. /,.  "#W5$ GS&h(h  c23"Iiwg#)EQ.. $`` b @      ` }  r3