Effectiveness of a Multi-component Delirium Prevention Program Implemented on General Medicine Hospital Units: an Interrupted Time Series Analysis.

BACKGROUND: Delirium is among the most prevalent harmful events in hospitals that is associated with an elevated risk for severe outcomes such as functional decline, falls, longer length of stay, and increased mortality. OBJECTIVE: To evaluate the impact of the implementation of a multi-component delirium program on the prevalence of delirium and the incidence of falls among patients staying on general medicine inpatient hospital units. DESIGN: A pre-post intervention study using retrospective chart abstraction and interrupted time series analysis. COHORT: Patients were selected from adult patients that stayed at least 1 day on one of the five general medicine units in a large community hospital in Ontario, Canada. A total of 16 random samples of 50 patients per month for 8 consecutive months pre-intervention (October 2017 to May 2018) and 8 months post intervention (January 2019 to August 2019) were selected for a total of 800 patients. There were no exclusion criteria. INTERVENTION: The delirium program included multiple components: education of staff and hospital leadership, twice per day bed-side screen for delirium, non-pharmacological and pharmacological prevention, and intervention strategies and a delirium consultation team. MEASUREMENT: Delirium prevalence was assessed using the evidence-based delirium chart abstraction method, CHART-del. Demographic data as well as fall incidence were also collected. RESULT: Our evaluation showed that the implementation of a multicomponent delirium program led to a reduction in delirium prevalence and fall incidences. The reduction in both delirium and falls was the largest for patients in the ages between 72 and 83 years old and varied across inpatient units. CONCLUSION: A multi-component delirium program to improve the prevention, recognition, and management of delirium reduces the prevalence of delirium and fall incidence among patients in general medicine units.

The impact of psychiatric and medical comorbidity on the risk of mortality: a population-based analysis.

BACKGROUND: As life expectancy increases, more people have chronic psychiatric and medical health disorders. Comorbidity may increase the risk of premature mortality, an important challenge for health service delivery. METHODS: Population-based cohort study in Ontario, Canada of all 11 246 910 residents aged ⩾16 and <105 on 1 April 2012 and alive on 31 March 2014. Secondary analyses included subjects having common medical disorders in 10 separate cohorts. Exposures were psychiatric morbidity categories identified using aggregated diagnosis groups (ADGs) from Johns Hopkins Adjusted Clinical Groups software® (v10.0); ADG 25: Persistent/Recurrent unstable conditions; e.g. acute schizophrenic episode, major depressive disorder (recurrent episode), ADG 24: Persistent/Recurrent stable conditions; e.g. depressive disorder, paranoid personality disorder, ADG 23: Time-limited/minor conditions; e.g. adjustment reaction with brief depressive reaction. The outcome was all-cause mortality (April 2014-March 2016). RESULTS: Over 2 years' follow-up, there were 188 014 deaths (1.7%). ADG 25 conferred an almost threefold excess mortality after adjustment compared to having no psychiatric morbidity [adjusted hazard ratio 2.94 (95% CI 2.91-2.98, p < 0.0001)]. Adjusted hazard ratios for ADG 24 and ADG 23 were 1.12 (95% CI 1.11-1.14, p < 0.0001) and 1.31 (95% CI 1.26-1.36, p < 0.0001). In all 10 medical disorder cohorts, ADG 25 carried significantly greater mortality risk compared to no psychiatric comorbidity. CONCLUSIONS: Psychiatric disorders, particularly those graded persistent/recurrent and unstable, were associated with excess mortality in the whole population, and in the medical disorder cohorts examined. Future research should examine whether service design accounting for psychiatric disorder comorbidity improves outcomes across the spectrum of medical disorders.

All together: Integrated care for youth with type 1 diabetes.

OBJECTIVE: We describe the implementation and evaluation of an integrated, stepped care model aimed to identify and address the concerns of adolescents with type 1 diabetes (T1D) associated with diabetes-related quality of life (DRQoL), emotional well-being, and depression. RESEARCH DESIGN AND METHODS: The care model with 4 steps: (1) Systematic identification and discussion of concerns salient to adolescents; (2) Secondary screening for depressive symptoms when indicated; (3) Developing collaborative treatment plans with joint physical and mental health goals; and (4) Psychiatric assessment and embedded mental health treatment; was implemented into an ambulatory pediatric diabetes clinic and evaluated using quantitative and qualitative methods. RESULTS: There were 236 adolescents (aged 13-18 years) with T1D that were enrolled in the care model. On average adolescents identified three concerns associated with their DRQoL and 25% indicated low emotional well-being. Fifteen adolescents received a psychiatric assessment and embedded mental health treatment. Both adolescents and caregivers were appreciative of a broader, more holistic approach to their diabetes care and to the greater focus of the care model on adolescents, who were encouraged to self-direct the conversation. Parents also appreciated the extra level of support and the ability to receive mental health care for their adolescents from their own diabetes care team. CONCLUSION: The initial findings from this project indicate the acceptability and, to limited extent, the feasibility of an integrated stepped care model embedded in an ambulatory pediatric diabetes clinic led by an interdisciplinary care team. The care model facilitated the identification and discussion of concerns salient to youth and provided a more holistic approach.

Using Person-Reported Outcomes (PROs) to Motivate Young People with Diabetes.

PURPOSE OF REVIEW: This manuscript describes how person-reported outcomes (PROs) can be utilized in care for young people with diabetes in the context of motivation. RECENT FINDINGS: The use of person-reported outcome measures (PROMS) in clinical care is feasible and acceptable, and helps focus the clinical encounter on life domains important to the person with diabetes. Results with regard to impact on self-management and glycemic outcomes are limited. Motivation is an important factor for self-management. Based on self-determination theory, autonomy-supportive, person-centered, and collaborative communication by diabetes care providers is associated with better outcomes. PROMs can facilitate this conversation. Understanding of youth motivation for maintaining or improving self-management behaviors requires a person-centered approach. PROMs can be used to facilitate an autonomy-supportive and person-centered conversation in clinical care. Training diabetes care providers in autonomy-supportive, person-centered conversation skills to discuss PROs might help to tap into youth's motivation, but further research is needed.

Screening preschool children with toothache: validation of the Brazilian version of the Dental Discomfort Questionnaire.

BACKGROUND: The Dental Discomfort Questionnaire (DDQ) is an observational instrument intended to measure dental discomfort and/or pain in children under 5 years of age. This study aimed to validate a previously cross-culturally adapted version of DDQ in a Brazilian children sample. METHODS: Participants included 263 children (58.6% boys, mean age 43.5 months) that underwent a dental examination to assess dental caries, and their parent that filled out the cross-culturally adapted DDQ on their behalf. Exploratory factor analysis (principal component analysis form) and psychometric tests were done to assess instrument's dimensionality and reliability. RESULTS: Exploratory factor analysis revealed a multidimensional instrument with 3 domains: 'eating and sleeping problems' (Cronbach's alpha 0.81), 'earache problems' (alpha 0.75), and 'problems with brushing teeth' (alpha 0.78). The assessment had excellent stability (weighted-kappa varying from 0.68 to 0.97). Based on the factor analysis, the model with all 7 items included only in the first domain (named DDQ-B) was further explored. The items and total median score of the DDQ-B were related to parent-reported toothache and the number of decayed teeth, demonstrating good construct and discriminant validities. CONCLUSIONS: DDQ-B was proven a reliable pain assessment tool to screen this group of Brazilian children for caries-related toothache, with good psychometric properties.

An Integrated Care Model to Support Adolescents With Diabetes-related Quality-of-life Concerns: An Intervention Study.

BACKGROUND: Our aim in this study was to determine whether participating in an integrated stepped care model for adolescents with type 1 diabetes (T1D) would lead to improvements in overall quality of life (QoL), diabetes-related quality of life (DRQoL) and glycated hemoglobin (A1C) levels compared with usual care. METHODS: A nonrandomized, 2-group, pre/post, delayed-intervention design was used for this study. The Mind Youth Questionnaire (MY-Q) was used to assess QoL and DRQoL. Adolescents attending the diabetes clinic using the stepped care model formed the intervention group (n=77). These adolescents completed the MY-Q, and the identified concerns were discussed and addressed with them by their care team as part of the care model. Adolescents attending a pediatric diabetes clinic on another site completed the MY-Q as a comparison group (n=39), results were not shared with their care team, and they received the standard care. RESULTS: There were 116 adolescents between 13 to 17 years of age, who completed the MY-Q on 2 occasions. Baseline data were obtained on the first occasion, and, on the second occasion, an average of 12 months later, there was a follow-up assessment. At follow-up, adolescents in the intervention group had a significantly higher overall QoL and reported significantly fewer concerns on DRQoL domains than those in the comparison group. Participation in the intervention group, however, did not lead to improvements in A1C. CONCLUSION: This study shows that implementing an integrated stepped care model within an interprofessional pediatric diabetes clinic can lead to the improvement of adolescents' overall QoL and DRQoL.

Improving the Prevention, Detection, and Management of Delirium in Adult Inpatients; an Interprofessional Consultative Team Pilot Project.

Delirium is a common, often preventable fluctuating state of cognition associated with increased morbidity and mortality. This report describes the implementation of an interprofessional consultative Delirium Team formed to improve the prevention, detection, and management of delirium in a community hospital. Team members consulted refered inpatients with delirium to establish a care plan and provide recommendations for pharmacological and non-pharmacological management. The team also offered delirium-related education to unit staff, patients, and caregivers. Consultations were initially completed by the team Nurse Practitioner or Occupational Therapist, and complex patients were discussed with the team Geriatrician and Psychiatrist at rounds to optimize specialist input. Of the 160 patients managed by the team over the 8-month study period, two-thirds of referred patients did not require specialist consultation for their delirium management. Strategies most often recommended by experts for managing delirium were related to medical management, social/cognitive engagement, and functional mobility. Two-thirds of all recommendations made by the team were implemented. Barriers and facilitators to implementation and improving unit staff adherence are further described. The consultative Delirium Team is a promising model that should be further explored for managing an aging population in a capacity-limited medical system.

Effectiveness of Interprofessional Consultation-Based Interventions for Delirium: A Scoping Review.

BACKGROUND: Interprofessional geriatric consultation teams and multicomponent interventions are established models for delirium care. They are combined in interprofessional consultative delirium team interventions; however, insight into this novel approach is lacking. OBJECTIVE: To describe the effectiveness and core components of consultation-based interventions for delirium. METHOD: Ovid MEDLINE, EMBASE, PsycINFO, CINAHL, and ProQuest. Data on core intervention components, outcomes, facilitators, and barriers were extracted. RESULTS: 10 studies were included. Core intervention components were systematic delirium screening, ongoing consultation, implementation of non-pharmacologic and pharmacological interventions, and staff education. Of the included studies, 1/6 found a significant reduction in delirium incidence, 1/2 a reduction in delirium duration, and 2/3 found a reduction in falls. Facilitators and barriers to implementation were discussed. CONCLUSION: There was consistency in team structure and core components, however intervention operationalization and effectiveness varied widely. There is some evidence that this model is effective for reducing delirium and its sequelae.

An observational study evaluating the impact on prostate patient outcomes and experiences when radiation therapists use a standard grading system tool to assess and document treatment-related toxicities and interventions.

BACKGROUND/PURPOSE: Men undergoing radiation therapy (RT) treatment for prostate cancer (PC) often experience acute urinary, bowel, sexual, and hormonal toxicities. Timely screening, management, and documentation of these toxicities is an integral part of clinician practice, ensuring patients receive the care they require. Various screening tools, completed by either the patient or the clinician, are available, which allow clinicians to collect and respond to these toxicity outcomes; however there is a paucity of literature regarding the effective use and timing of these tools during RT treatment. This study aims to evaluate the feasibility of conducting comprehensive toxicity screening and symptom management using a toxicity screening tool in one of the busiest RT departments in Canada. Specifically, the use of a toxicity screening tool and its effect on the quality of toxicity documentation, operational impact, and patient reported outcomes (PRO). METHODS: 90 consented patients were allocated to either the structured or non-structured arm. Patients in the structured arm were assessed weekly by radiation therapists for 13 toxicities across four domains (bladder, bowel, hormonal, and sexual), using an in-house developed structured questionnaire, known as the Grid, to complete the National Cancer Institute's Common Toxicity Criteria for Adverse Events v3 (CTCAEv3). Patients in the non-structured arm were assessed and had free text clinical documentation charted according to current department policy. The Expanded Prostate Cancer Index Composite (EPIC), a PRO tool to evaluate patient function and bother after prostate cancer treatment, was completed by all study patients on a weekly basis. Statistical analysis compared documentation completeness, EPIC scores, patient satisfaction, and operational impact between study arms, as well as evaluated optimal timing of toxicity assessments. RESULTS: Assessment of the non-structured arm for completeness revealed an inconsistent and insufficient amount of documentation for the bladder and bowel domains. As for both the sexual and hormonal domains, documentation was largely absent. There was no difference in EPIC scores and patient satisfaction scores between the structured arm and the non-structured arm. Evaluation of the timing of PROs showed significant week to week change for the bladder and bowel toxicities, but not the sexual and hormonal toxicities. Finally, the use of the Grid revealed no significant impact on daily operations, only increasing average treatment times by seven seconds, and did not create any additional workload for the oncologists. CONCLUSIONS: Use of the Grid increased documentation completeness without negatively impacting clinical flow or operations, despite the fact that PROs were not improved. Based on EPIC PRO scores, bladder and bowel toxicities should be evaluated on a weekly basis during RT treatment, while sexual and hormonal toxicities need only be evaluated monthly.

Integrated Community Collaborative Care for Seniors with Depression/Anxiety and any Physical Illness.

BACKGROUND: We report on the feasibility and effectiveness of an integrated community collaborative care model in improving the health of seniors with depression/anxiety symptoms and chronic physical illness. METHODS: This community collaborative care model integrates geriatric medicine and geriatric psychiatry with care managers (CM) providing holistic initial and follow-up assessments, who use standardized rating scales to monitor treatment and provide psychotherapy (ENGAGE). The CM presents cases in a structured case review to a geriatrician and geriatric psychiatrist. Recommendations are communicated by the CM to the patient's primary care provider. RESULTS: 187 patients were evaluated. The average age was 80 years old. Two-thirds were experiencing moderate-to-severe depression upon entry and this proportion decreased significantly to one-third at completion. Qualitative interviews with patients, family caregivers, team members, and referring physicians indicated that the program was well-received. Patients had on average six visits with the CM without the need to have a face-to-face meeting with a specialist. CONCLUSION: The evaluation shows that the program is feasible and effective as it was well received by patients and patient outcomes improved. Implementation in fee-for-service publicly funded health-care environments may be limited by the need for dedicated funding.

The Collaborative Care Model for Patients With Both Mental Health and Medical Conditions Implemented in Hospital Outpatient Care Settings.

With the increased concern regarding the negative impact that care in silos has on patients and the health care system, there is growing interest in integrated models of care especially for individuals with co-occurring physical and mental health conditions. Although generally applied in a community setting, we adapted and implemented an evidence-based integrated model of care, the collaborative care model (CCM) in an adult and a pediatric hospital-based outpatient clinic. Enrolment was criteria based and management was measurement driven. The model is team based and consists of new roles for its members including the patient, the care manager, the primary care clinician, and the psychiatric consultant. A key role was that of the care manager who worked with the patient and engaged primary care. The care manager also organized team-based treatment planning in systematic case reviews that contributed to the care plan. Support for training of the new and changes in roles is underscored. In this communication we comment on our initial experience of applying the CCM to the hospital outpatient setting.

Dental Discomfort Questionnaire: its use with children with a learning disability.

This study investigated whether the behaviors from the Dental Discomfort Questionnaire (DDQ) could help identify toothaches in children with a learning disability, who have a limited capacity to self-report. The objectives were to examine whether the behaviors from the DDQ occur more often in children with a learning disability who have caries and a toothache than in children who do not have caries and a toothache; and secondly, to examine whether two additional items increase the specificity and sensitivity of the DDQ to recognize a toothache, in this particular population of children with a learning disability. The DDQ was completed by a convenience sample of 58 parents on behalf of their children: 31% girls, aged between 6 and 13 years (mean = 7.5, SD = 2.7). Of the total group, 26% (n = 15) suffered from a toothache and 43% (n = 25) had carious teeth. Children with caries and a toothache had a significantly higher mean DDQ score and displayed more toothache-related behaviors (e.g., problems with chewing, problems with brushing teeth) than children without caries or toothache. The DDQ seems to be a functional and easy-to-use instrument to alert parents to the presence of a toothache in this specific group of children with a learning disability.

Children's Behavioral Pain Cues: Implicit Automaticity and Control Dimensions in Observational Measures.

Some pain behaviors appear to be automatic, reflexive manifestations of pain, whereas others present as voluntarily controlled. This project examined whether this distinction would characterize pain cues used in observational pain measures for children aged 4-12. To develop a comprehensive list of cues, a systematic literature search of studies describing development of children's observational pain assessment tools was conducted using MEDLINE, PsycINFO, and Web of Science. Twenty-one articles satisfied the criteria. A total of 66 nonredundant pain behavior items were identified. To determine whether items would be perceived as automatic or controlled, 277 research participants rated each on multiple scales associated with the distinction. Factor analyses yielded three major factors: the "Automatic" factor included items related to facial expression, paralinguistics, and consolability; the "Controlled" factor included items related to intentional movements, verbalizations, and social actions; and the "Ambiguous" factor included items related to voluntary facial expressions. Pain behaviors in observational pain scales for children can be characterized as automatic, controlled, and ambiguous, supporting a dual-processing, neuroregulatory model of pain expression. These dimensions would be expected to influence judgments of the nature and severity of pain being experienced and the extent to which the child is attempting to control the social environment.

Dental Discomfort Questionnaire: assessment of dental discomfort and/or pain in very young children.

OBJECTIVE: To present and analyse the Dental Discomfort Questionnaire (DDQ) for very young children and to assess the possible differences in pain-related behaviours displayed by children with or without reported toothache, and by children with or without decayed teeth. METHODS: Based on parental interviews of toddlers referred to a dental care practice 12 pain-related behaviours were identified which formed the DDQ. The DDQ was filled out by parents on behalf of their children (n = 146; mean age 47 months). Two-third (n = 94) of the children were referred to a special dental care centre and one-third (n = 52) were controls from a day care centre. RESULTS: The results show that the 12 items of the DDQ seem to measure one dimension. However, four items do not correlate with the presence of reported toothache, when these items are removed the DDQ-8 has a satisfactory reliability. All eight behaviours from the DDQ-8 occur significantly more often in children with decayed teeth and toothache than in children without decayed teeth or toothache. Especially behaviours concerning eating or brushing teeth are found to be more often present in children with decayed teeth and toothache. CONCLUSIONS: It seems useful to take the child behaviour into account in assessing toothache. The DDQ has shown to be a reliable instrument, which could be helpful in the future for both parents and dentists in identifying toothache in young children.

Format guidelines to make them vivid, intuitive, and visual: use simple formatting rules to optimize usability and accessibility of clinical practice guidelines.

AIM: We present simple formatting rules derived from an extensive literature review that can improve the format of clinical practice guidelines (CPGs), and potentially increase the likelihood of being used. METHODS: We recently conducted a review of the literature from medicine, psychology, design, and human factors engineering on characteristics of guidelines that are associated with their use in practice, covering both the creation and communication of content. The formatting rules described in this article are derived from that review. RESULTS: The formatting rules are grouped into three categories that can be easily applied to CPGs: first, Vivid: make it stand out; second, Intuitive: match it to the audience's expectations, and third, Visual: use alternatives to text. We highlight rules supported by our broad literature review and provide specific 'how to' recommendations for individuals and groups developing evidence-based materials for clinicians. CONCLUSION: The way text documents are formatted influences their accessibility and usability. Optimizing the formatting of CPGs is a relatively inexpensive intervention and can be used to facilitate the dissemination of evidence in healthcare. Applying simple formatting principles to make documents more vivid, intuitive, and visual is a practical approach that has the potential to influence the usability of guidelines and to influence the extent to which guidelines are read, remembered, and used in practice.

Pain assessment in children: validity of facial expression items in observational pain scales.

OBJECTIVES: Assessing pain in young children requires astute judgment by observers. Multidimensional observational scales for pediatric pain contribute by providing behavioral cues believed to characterize pain in children; yet, few measurement items have undergone rigorous psychometric evaluation. This is the case with facial expression, which has been widely recognized as the most sensitive and specific nonverbal indicator of pain. The criteria for identifying facial expressions of pain differ substantially across scales and are frequently inconsistent with empirical descriptions. MATERIALS AND METHODS: The present study compared observer ratings of children's (aged 1 to 6 y, inclusive) videotaped postoperative pain reactions using the facial activity items from 6 widely used pediatric pain assessment scales and an anatomically based and empirically validated measure, the Child Facial Coding System. We hypothesized that facial expression items that did not correspond to empirical descriptions would lead to less reliable and divergent pain estimates. Intercoder reliability, criterion validity (empirical and convergent), content validity, and face validity were examined. RESULTS: Findings supported hypotheses and indicated that variation in cues proposed for assessing facial expression led to widely ranging scores that could be insensitive to differences in children's pain intensity. DISCUSSION: The facial items varied considerably in coder judgment reliability as well as criterion (empirical and convergent), content, and face validity. Observational scales should provide behavioral cues that correspond to empirical descriptions of the facial expression of pain.

Children's coping with pain during dental care.

OBJECTIVES: The purpose of this study was (i) to assess the coping strategies of 11-year-old children when dealing with pain at the dentist, (ii) to determine the extent to which the level of the children's dental fear and their experience with pain at the dentist are related to their ability to cope and their choice of strategies, and (iii) to analyse the possible differences between subsamples concerning dental caries. METHODS: The coping strategies were investigated using the Dental Cope Questionnaire (n = 597); the level of dental fear was assessed using the Children's Fear Survey Schedule (CFSS-DS); a question is asked whether a child had experienced pain at the dentist in the past and dental caries was assessed using the DMFS index. RESULTS: The results show that 11-year olds use a variety of coping strategies. Internal strategies are used most frequently, external coping strategies are used less frequently, and destructive strategies are hardly used. The subjects rate internal and external strategies as effective. Children with pain experience and fearful children use more coping strategies, with fearful children using more internal strategies. Reported pain and anxiety were related to the dental status. CONCLUSIONS: The use and choice of coping strategies seems to be at least partly determined by the level of dental fear and the child's experience with pain.

Assessment of pain by the child, dentist, and independent observers.

PURPOSE: The objective of this study was to analyze the assessment of pain and distress by the child, dentist, and independent observers during a dental injection and study the relationship between the different assessments. METHODS: The amount of pain experienced by the child during local anesthesia was reported independently by the child to both the dentist and parent on a 4-point scale running from "no pain" to "a lot of pain." The dentist and observers also gave a score for the pain experienced on a 4-point scale. The amount of distress experienced by the child during local anesthesia was assessed by the dentist and observers using a 6-point scale (from "relaxed" to "out of contact"). RESULTS: The dentists' pain assessment was the lowest. A substantial correlation was found between the child's self-reported pain and the pain as assessed by independent observers. There was a moderate correlation between the amount of distress and pain intensity as reported by the child during the anesthesia phase. CONCLUSIONS: Observation of a child in a videotaped procedure is apparently the most reliable method to accurately assess pain behavior and to discriminate pain from distress. A combination of the child's report and video observation is advised to assess pain in young children.

The cross-cultural process of adapting observational tools for pediatric pain assessment: the case of the Dental Discomfort Questionnaire.

BACKGROUND: A rigorous cross-cultural adaptation process of an existing instrument could be the best option for measuring health in different cultures, instead of developing a new tool, and prior to psychometric and validation testing. The Dental Discomfort Questionnaire (DDQ), a validated instrument for assessing toothache in young children, has not been cross-culturally adapted so far. This study aimed to explore the detailed phases of the cross-cultural adaptation process of a pain assessment tool, presenting the example of the DDQ Brazilian-Portuguese adapted version. METHODS: The study design was based on the universalist approach, which consists of a sequential analysis to assess the relevant phases of a cross-cultural process before testing the measures of the instrument: conceptual, item, semantic, and operational equivalences. Systematic information was gathered from the literature, expert discussions, translations, and pre-testing through cognitive interviews with Brazilian population. RESULTS: Detailed description of the three major phases for a cross-cultural adaptation process was given. Notes of the changes done in the structure of the presented instrument (DDQ) were specifically pointed out at each phase. Conceptual and item analyses showed that there are similarities in the DDQ construct between the original and Brazilian cultures that require minor modifications. Translations and back-translations allowed the development of the preliminary Brazilian-Portuguese version of the DDQ, which was tested and underwent other minor changes to improve its comprehensibility. CONCLUSIONS: Describing the phases was important to show how changes are made in a cross-cultural adaptation process of an instrument. This also could help researchers in adapting similar pediatric pain assessment tools to different cultures. A Brazilian-Portuguese version of the DDQ was presented.

Pain in the elderly: validity of facial expression components of observational measures.

OBJECTIVES: Assessing pain in elderly persons, who have diminished capacity to communicate verbally, requires use of observational scales that focus upon nonverbal behavior. Facial expression has been recognized as providing the most specific and sensitive nonverbal cues for pain. This study examined the validity of facial expression components of 6 widely used pain assessment scales developed for elders with dementia. Descriptions of the facial expression of pain vary widely on these scales. METHODS: The detailed, anatomically based, objectively coded, and validated Facial Action Coding System was used as a criterion index to provide a definitive description of the facial expression of pain. Thirty elderly inpatients with clinically significant pain in the back or hip, the majority of whom had cognitive impairments, provided videotaped reactions to physical activities. Participants' facial expressions were videotaped during 4 randomly ordered physical activities and coded by a qualified Facial Action Coding System coder. Three 6-second clips indicative of mild, moderate, and severe pain intensities were selected for study for each participant. The 90 clips were coded by 5 raters using the facial expression components of the following observational scales: Doloplus-2, Mahoney, Abbey, pain assessment checklist for seniors with limited ability to communicate, noncommunicative patient's Pain Assessment Instrument, and Pain Assessment in Advanced Dementia. RESULTS: Overall, scales that provided specific descriptions using the empirically displayed facial actions associated with pain yielded greater sensitivity, interjudge reliability, and validity as indices of pain. DISCUSSION: Facial expression items on observational scales for assessing pain in the elderly benefit from adherence to empirically derived descriptions. Those using the scales should receive specific direction concerning cues to be assessed. Observational scales that provide descriptors that correspond to how people actually display facial expressions of pain perform better at differentiating intensities of pain.