Observational pain assessment in older persons with dementia in four countries: Observer agreement of items and factor structure of the Pain Assessment in Impaired Cognition.

BACKGROUND: Recognition of pain in people with dementia is challenging. Observational scales have been developed, but there is a need to harmonize and improve the assessment process. In EU initiative COST-Action TD1005, 36 promising items were selected from existing scales to be tested further. We aimed to study the observer agreement of each item, and to analyse the factor structure of the complete set. METHODS: One hundred and ninety older persons with dementia were recruited in four different countries (Italy, Serbia, Spain and The Netherlands) from different types of healthcare facilities. Patients represented a convenience sample, with no pre-selection on presence of (suspected) pain. The Pain Assessment in Impaired Cognition (PAIC, research version) item pool includes facial expressions of pain (15 items), body movements (10 items) and vocalizations (11 items). Participants were observed by health professionals in two situations, at rest and during movement. Intrarater and interrater reliability was analysed by percentage agreement. The factor structure was examined with principal component analysis with orthogonal rotation. RESULTS: Health professionals performed observations in 40-57 patients in each country. Intrarater and interrater agreement was generally high (≥70%). However, for some facial expression items, agreement was sometimes below 70%. Factor analyses showed a six-component solution, which were named as follows: Vocal pain expression, Face anatomical descriptors, Protective body movements, Vocal defence, Tension and Lack of affect. CONCLUSIONS: Observation of PAIC items can be done reliably in healthcare settings. Observer agreement is quite promising already without extensive training. SIGNIFICANCE: In this international project, promising items from existing observational pain scales were identified and evaluated regarding their reliability as an alternative to pain self-report in people with dementia. Analysis on factor structure helped to understand the character of the items. Health professionals from four countries using four different European languages were able to rate items reliably. The results contributed to an informed reduction of items for a clinical observer scale (Pain Assessment in Impaired Cognition scale with 15 items: PAIC15).

Pain Assessment for Older Persons in Nursing Home Care: An Evidence-Based Practice Guideline.

Up to 80% of nursing home residents are affected by pain. Pain assessment aims to determine pain intensity, quality, and course of pain to underpin diagnostic decision making. In the nursing home population, pain assessment is frequently compromised by cognitive impairment. Characteristics of the nursing home setting, such as resident's age, staff skill mix, and overall aims of the care provided, also need to be taken into account. Therefore, an interdisciplinary evidence-based clinical practice guideline for pain assessment in the nursing home setting was developed. A systematic literature search was carried out covering publications between 2003 and 2015. Thirty-nine studies were included in the preparation of this guideline, supplemented by 12 international reference guidelines. Recommendations were subjected to a structured consensus-finding process with representatives from 37 scientific and professional organizations and patient representatives. The guideline underwent independent peer review before finalization. It comprises 62 recommendations that are grouped into 4 chapters: (1) context of pain assessment in nursing home care; (2) screening; (3) focused assessment; and (4) reassessment/monitoring of pain. Main recommendations stipulate that clinicians should assess the patient's ability to provide self-report of pain when screening for pain and that each resident should be screened for the presence of pain. A focused assessment of pain, performed during rest and activities, should include pain intensity, changed behaviors, general mobility, pain history, comorbidities, and pain medication. Pain should be re-assessed at regular intervals using the same instruments that were used for the focused assessment. Guideline development demonstrated that many aspects of pain assessment in older persons have not received adequate research attention so far. Available studies predominantly possess only low levels of evidence. Therefore, research into this area needs to be systematically developed to address questions of clinical relevance to support patient care.

Pain assessment in advanced dementia. Validity of the German PAINAD-a prospective double-blind randomised placebo-controlled trial.

Pain in combination with dementia is a common condition that makes pain recognition significantly more difficult. This results in undertreatment of pain in those suffering from dementia. The Pain Assessment in Advanced Dementia (PAINAD) scale currently represents one of the best approaches to pain detection in dementia. In a pilot study, strong inter-rater and retest reliability of the German version (PAINAD-G) was proven. However, the available data concerning the validity of this instrument were insufficient. The aim of the study was to validate the PAINAD-G scale by a double-blind randomised placebo-controlled trial in people with advanced dementia expected to be in pain. A second aim was to examine whether other observational tools (BISAD = Observation Instrument for Assessing Pain in the Elderly with Dementia) (German: Beobachtungsintrument für das Schmerzassessment bei alten Menschen mit Demenz, Checklist of Nonverbal Pain Indicators, Algoplus) were also able to demonstrate a significant difference between the study groups. Surprisingly, the study revealed no difference in "pain reduction" between those treated by oxycodone compared with those treated by placebo. Equally, none of the other 3 observational tools were able to demonstrate a significant difference between the study groups. However, correlations among the 4 observational tools were mostly moderate to high. A number of possible reasons for this observation, such as difficulties regarding sensitivity to change/responsiveness, consistence of the fundamental construct, influence of the early onset study, and efficacy of the analgesic in advanced dementia are discussed.

Pain assessment in elderly adults with dementia.

Chronic pain is highly prevalent in the ageing population. Individuals with neurological disorders such as dementia are susceptible patient groups in which pain is frequently under-recognised, underestimated, and undertreated. Results from neurophysiological and neuroimaging studies showing that elderly adults are particularly susceptible to the negative effects of pain are of additional concern. The inability to successfully communicate pain in severe dementia is a major barrier to effective treatment. The systematic study of facial expressions through a computerised system has identified core features that are highly specific to the experience of pain, with potential future effects on assessment practices in people with dementia. Various observational-behavioural pain assessment instruments have been reported to be both reliable and valid in individuals with dementia. These techniques need to be interpreted in the context of observer bias, contextual variables, and the overall state of the individual's health and wellbeing.