People Living With Dementia: Dementia Characteristics and Family Caregiver Pain Assessment.

People living with dementia (PLWD) experience pain like other older adults, but with changes due to dementia, they rely more on family caregivers for pain assessment. Many different elements contribute to a pain assessment. Changes in characteristics of PLWD may be associated with changes in the use of these different pain assessment elements. The current study reports associations between PLWD's agitation, cognitive function, and dementia severity and the frequency with which family caregivers use pain assessment elements. In a sample of family caregivers (N = 48), statistically significant associations were found between worsening cognitive function and greater use of rechecking for pain after intervention (rho = 0.36, p = 0.013), and between lower cognitive scores on a subscale of dementia severity and asking others if they have noticed a behavior change in the PLWD (rho = 0.30, p = 0.044). Limited statistically significant associations suggest that, overall, family caregivers of PLWD do not use pain assessment elements more frequently with changes in characteristics of PLWD. [Journal of Gerontological Nursing, 49(7), 17-23.].

Caregiving self-efficacy and pain assessment by family caregivers of people living with dementia.

Like other older adults, people living with dementia (PLWD) experience pain, and the task of pain assessment often falls to family caregivers. In this study, we surveyed family caregivers of PLWD to determine the frequency with which they use different elements of pain assessment. We also determined correlations of family caregivers' characteristics (caregiving self-efficacy, relationship duration and type, mood, education level, and health literacy) with their use of the elements of pain assessment. Participants reported frequent use of many pain assessment elements. Statistically significant correlations were found between caregiving self-efficacy for obtaining respite and asking others about noticed behavior change (rho=.0.41, p=.007); and for responding to disruptive patient behaviors for multiple pain assessment elements including observing pain behaviors (rho=0.49, p<.001), asking others about noticed behavior change (rho=0.54, p<.001) and rechecking (rho=0.56, p<.001). Continued efforts are needed to describe pain assessments by family caregivers of PLWD.

International consensus-based policy recommendations to advance universal palliative care access from the American Academy of Nursing Expert Panels.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. On behalf of the Academy, these evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. Through improved palliative nursing education, nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative care nurses worldwide, nurses can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations. Part II herein provides a summary of international responses and policy options that have sought to enhance universal palliative care and palliative nursing access to date. Additionally, we provide ten policy, education, research, and clinical practice recommendations based on the rationale and background information found in Part I. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter.

Voices of African American Older Adults on the Implications of Social and Healthcare-Related Policies for Osteoarthritis Pain Care.

BACKGROUND: Chronic pain is a distressing symptom that older adults with osteoarthritis (OA) seek to minimize through management. Research consistently points out the disparities that older African Americans face when managing chronic pain conditions, but a major gap in the literature is how pain care policy at the federal, state, and local level protects or exposes older African Americans to disadvantaged care. AIMS: The purpose of this original research is to examine policy issues and care enhancement opportunities that emerge from the narratives and personal stories of older African Americans living with chronic OA pain. DESIGN: A secondary qualitative data analysis. METHODS: African Americans (≥50 years) with OA pain living in Louisiana were interviewed to gather global perspectives and specific information about how they manage OA pain. Narrative analytic techniques were applied to 18 individual, semistructured interviews. RESULTS: Three policy-related pain management issues and implications surfaced from the older African Americans' rich narratives: (1) "Access to and navigation of the healthcare system," (2) "Affordability of natural supplements, medications, and treatments," and (3) "Expansion of pain palliative care and community programs." CONCLUSIONS: African American older adults face numerous challenges in managing pain well. Navigating the healthcare system is an abiding issue, and perceived injustice in care was a common thread throughout the narratives. On the positive side, older African Americans also proposed practice- and policy-related solutions to counter the pain treatment challenges. Nurses are natural advocates for patients, and should work to change healthcare policies that unfairly marginalize ethnic/racial older adults' long-term ability to manage chronic pain.

A Paradigm Shift for Movement-based Pain Assessment in Older Adults: Practice, Policy and Regulatory Drivers.

BACKGROUND: The profession of nursing has been on the front line of pain assessment and management in older adults for several decades. Self-report has traditionally been the most reliable pain assessment method, and it remains a priority best practice in identifying the presence and intensity of pain. Although advances in technology, biomarkers, and facial cue recognition now complement self-report, it is still important to maximize self-report of pain and to gather understanding of the total pain experience directly from patients. Practices in pain assessment in older adults have evolved over the past 25 years, and current research and quality improvement studies seek not only to detect the presence of pain, but also to determine the best protocol for assessment and most important pain characteristics to assess. Increasing data are now supporting two emerging practices: (1) consistently assessing the impact of pain on function, and (2) measuring pain during movement-based activities rather than at rest. OBJECTIVE: The purpose of this article is thus to discuss the shifting paradigm for movement-based pain assessment in older adults, as well as the practice, policy, and regulatory drivers that support this practice change.

American Academy of Nursing Expert Panel consensus statement on nursing's roles in ensuring universal palliative care access.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.

Cannabidiol (CBD) Use by Older Adults for Acute and Chronic Pain.

Legalization of cannabidiol (CBD) products has ignited interest in clinical practice and research. One desired indication includes possible pain-relieving effects of CBD. The purposes of the current article are to (1) clarify terminology relevant to cannabinoids; (2) explain and understand the pharmacotherapeutics of CBD; (3) examine research of the current use of CBD by older adults for treating pain; (4) discuss safety considerations with using CBD products; and (5) provide best practice recommendations for clinicians as they advise their older adult patients. A review of the literature demonstrated mixed results on the efficacy of CBD in relieving pain in older adults. There is inconsistency in the labeling of over-the-counter CBD products that can result in safety issues and will require more federal quality control. Likewise, gaps in knowledge regarding safety and efficacy of CBD use in older adults are vast and require further research. [Journal of Gerontological Nursing, 47(7), 6-15.].

An integrated model of multimorbidity and symptom science.

BACKGROUND: Prevalence and complexity of persons with multiple chronic conditions (MCC), also known as multimorbidity, are shifting clinical practice from a single disease focus to one considering MCC and symptoms. Although symptoms are intricately bound to concepts inherent in MCC science, symptoms are largely ignored in multimorbidity research and literature. PURPOSE: Introduce an Integrated Model of Multimorbidity and Symptom Science. METHODS: Critical integrative review and synthesis process. FINDINGS: The model comprises three primary domains: 1. Contributing/ Risk Factors; 2. Symptom/Disease/Treatment Interactions; and 3. Patient Outcomes. DISCUSSION: The model highlights the multilevel nature of contributing factors and the recursive interactions among multiple etiologies, conditions, symptoms, therapies, and outcomes.

Patterns and Perceptions of Self-Management for Osteoarthritis Pain in African American Older Adults.

OBJECTIVE: To explore and describe older African Americans' patterns and perceptions of managing chronic osteoarthritis pain. METHODS: A convergent parallel mixed-methods design incorporating cross-sectional surveys and individual, semistructured interviews. SETTING: One hundred ten African Americans (≥50 years of age) with clinical osteoarthritis (OA) or provider-diagnosed OA from communities in northern Louisiana were enrolled. RESULTS: Although frequency varied depending on the severity of pain, older African Americans actively used an average of seven to eight self-management strategies over the course of a month to control pain. The average number of self-management strategies between high and low education and literacy groups was not statistically different, but higher-educated adults used approximately one additional strategy than those with high school or less. To achieve pain relief, African Americans relied on 10 self-management strategies that were inexpensive, easy to use and access, and generally perceived as helpful: over-the-counter (OTC) topicals, thermal modalities, land-based exercise, spiritual activities, OTC and prescribed analgesics, orthotic and assistive devices, joint injections, rest, and massage and vitamins. CONCLUSIONS: This is one of the first studies to quantitatively and qualitatively investigate the self-management of chronic OA pain in an older African American population that happened to be a predominantly higher-educated and health-literate sample. Findings indicate that Southern-dwelling African Americans are highly engaged in a range of different self-management strategies, many of which are self-initiated. Although still an important component of chronic pain self-management, spirituality was used by less than half of African Americans, but use of oral nonsteroidal anti-inflammatory drugs and opioids was relatively high.

Psychometric Evaluation of a Pain Intensity Measure for Persons with Dementia.

OBJECTIVE: The goal of this study was to conduct initial psychometric analyses of a seven-item pain intensity measure for persons with dementia (PIMD) that was developed using items from existing pain observational measures. DESIGN AND METHODS: We evaluated validity by examining associations with an expert clinician's pain intensity rating (ECPIR) and an established pain observation tool (Mobilization Observation Behaviour Intensity Dementia [MOBID]). We also examined correlations between the PIMD and known correlates of pain: depression, sleep disturbances, agitation, painful diagnoses, and caregiver pain reports. We examined the differences between PIMD scores for "at rest" and "during movement" observations. We assessed reliability by calculating Cronbach's alpha and estimating inter-rater reliability using intraclass correlations (ICCs). Finally, we examined whether six additional "recent changes in behavior" items improved the PIMD's ability to predict expert clinicians' pain ratings. SETTING: Sixteen nursing homes located in Alabama, Georgia, Pennsylvania, and New Jersey. PARTICIPANTS: One hundred ninety residents with moderate to severe cognitive impairment, mean age of 84 years, 49.5% female, and 70% white. RESULTS: PIMD during movement scores were highly correlated with the ECPIR and overall MOBID scores. As expected, there were large differences between at rest and during movement PIMD scores. Associations of PIMD with known correlates of pain were generally low and statistically nonsignificant. Internal consistency was supported with a Cronbach alpha of 0.72 and an inter-rater ICC of 0.82 for during movement PIMD scores. CONCLUSIONS: Initial evaluation of the PIMD supports its validity and reliability. Additional testing is needed to evaluate the tool's sensitivity to changes in pain intensity.

Developing a Pain Intensity Measure for Persons with Dementia: Initial Construction and Testing.

OBJECTIVE: The goal of this study was to identify a limited set of pain indicators that were most predicive of physical pain. We began with 140 items culled from existing pain observation tools and used a modified Delphi approach followed by statistical analyses to reduce the item pool. METHODS: Through the Delphi Method, we created a candidate item set of behavioral indicators. Next, trained staff observed nursing home residents and rated the items on scales of behavior intensity and frequency. We evaluated associations among the items and expert clinicians' assessment of pain intensity. SETTING: Four government-owned nursing homes and 12 community nursing homes in Alabama and Southeastern Pennsylvania. PARTICIPANTS: Ninety-five residents (mean age = 84.9 years) with moderate to severe cognitive impairment. RESULTS: Using the least absolute shrinkage and selection operator model, we identified seven items that best predicted clinicians' evaluations of pain intensity. These items were rigid/stiff body or body parts, bracing, complaining, expressive eyes, grimacing, frowning, and sighing. We also found that a model based on ratings of frequency of behaviors did not have better predictive ability than a model based on ratings of intensity of behaviors. CONCLUSIONS: We used two complementary approaches-expert opinion and statistical analysis-to reduce a large pool of behavioral indicators to a parsimonious set of items to predict pain intensity in persons with dementia. Future studies are needed to examine the psychometric properties of this scale, which is called the Pain Intensity Measure for Persons with Dementia.

Self-Reported Pain Interference and Analgesic Characteristics in Rural Older Adults.

BACKGROUND: Pain impacts the lives of millions of community-dwelling older adults. An important characteristic of pain is "pain interference" which describes the influence of pain on function. A description of pain interference is limited in rural settings where the number of older adults is expected to increase, and health disparities exist. AIMS: The purpose of this study was to describe pain interference and analgesic medication use, highlighting those that may be potentially inappropriate in a sample of rural community-dwelling older adults. DESIGN: This secondary analysis was from a cross sectional study. SAMPLE AND SETTINGS: Data were analyzed from a sample of 138 rural community-dwelling older adults. METHODS: Statistical analyses were performed on demographics, health characteristics, pain interference, and potentially inappropriate analgesic medication data. RESULTS: Pain interference with work activity was reported by 76% of older adults overall, with 23% reporting moderate and 4% extreme interference, and 41% reported sleep difficulty due to pain. Higher pain interference was significantly associated with higher body mass index, more health providers, and the daily use of non-steroidal anti-inflammatory drugs (NSAIDs). Older women experienced more sleep difficulties due to pain. Over-the-counter analgesics were used most frequently by rural older adults to manage pain. Of most risk was the daily use of NSAIDs, in which only 30% used medications to protect the gastrointestinal system. CONCLUSIONS: Older adults in rural settings experience pain interference and participate in independent-medicating behaviors that may impact safety.

ASPMN 2019 Position Statement: Pain Assessment in the Patient Unable to Self-Report.

Managing pain in those vulnerable populations who are unable to self-report or communicate is challenging due to difficulty recognizing pain presence and severity. As no valid and reliable objective measure of pain exists, the ASPMN supports assessment practice recommendations that gather relevant information to infer presence of pain and evaluate response to intervention. Nurses and other healthcare professionals must be advocates for those who are unable to speak for themselves regarding their pain experience.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement.

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

Psychometric Evaluation of the MOBID Dementia Pain Scale in U.S. Nursing Homes.

PURPOSE: The Mobilization-Observation-Behavior-Intensity-Dementia (MOBID) Pain Scale is an observational tool in which raters estimate pain intensity on a 0-10 scale following five standardized movements. The tool has been shown to be valid and reliable in northern European samples and could be useful in the United States (US) for research and clinical purposes. The goal of this study was to examine the validity and reliability of the MOBID among English-speaking nursing home residents in the US. DESIGN: Cross-sectional study. SETTINGS: Sixteen nursing homes in Pennsylvania, New Jersey, Georgia and Alabama. PARTICIPANTS: One hundred thirty-eight older adults with dementia and moderate to severe cognitive impairment. METHODS: Validity was evaluated using Spearman correlations between the MOBID overall pain intensity score and 1) an expert clinician's pain intensity rating (ECPIR), 2) nursing staff surrogate pain intensity ratings, and 3) known correlates of pain. We assessed internal consistency by Cronbach's alpha. RESULTS: MOBID overall scores were significantly associated with expert clinician's rating of current and worst pain in the past week (rho = 0.54, and 0.57; p < .001, respectively). Statistically significant associations also were found between the MOBID overall score and nursing staff current and worst pain intensity ratings as well as the Cornell Scale for Depression in Dementia (rho = 0.29; p < .001). Internal consistency was acceptable (α = 0.83). CONCLUSIONS AND CLINICAL IMPLICATIONS: Result of this study support the use of the MOBID in English-speaking staff and residents in the US. Findings also suggest that the tool can be completed by trained, nonclinical staff.

Relationships among pain intensity, pain-related distress, and psychological distress in pre-surgical total knee arthroplasty patients: a secondary analysis.

The current study aimed to examine the relationships between movement and resting pain intensity, pain-related distress, and psychological distress in participants scheduled for total knee arthroplasty (TKA). This study examined the impact of anxiety, depression, and pain catastrophizing on the relationship between pain intensity and pain-related distress. Data analyzed for the current study (N = 346) were collected at baseline as part of a larger Randomized Controlled Trial investigating the efficacy of TENS for TKA (TANK Study). Participants provided demographic information, pain intensity and pain-related distress, and completed validated measures of depression, anxiety, and pain catastrophizing. Only 58% of the sample reported resting pain >0 while 92% of the sample reported movement pain >0. Both movement and resting pain intensity correlated significantly with distress (rs = .86, p < .01 and .79, p < .01, respectively). About three quarters to two thirds of the sample (78% for resting pain and 65% for movement pain) reported different pain intensity and pain-related distress. Both pain intensity and pain-related distress demonstrated significant relationships with anxiety, depression, and catastrophizing. Of participants reporting pain, those reporting higher anxiety reported higher levels of distress compared to pain intensity. These findings suggest that anxious patients may be particularly distressed by movement pain preceding TKA. Future research is needed to investigate the utility of brief psychological interventions for pre-surgical TKA patients.

Evidence-Based Practice Guideline: Persistent Pain Management in Older Adults.

More individuals develop and endure constant or recurring pain in older adulthood. Although 40% of these individuals receive no treatment, many evidence-based treatments are available. Accurate assessment of pain, its impact on functioning, and preventing treatment-related harms lay the foundation of safe, effective pain control. Analgesic agents are often necessary, but require a delicate balance to prevent under-treatment, the unnecessary abandonment of therapy, or exposure to potentially serious adverse effects. Nondrug therapies must be better integrated into the treatment plan to ensure overall safety. Evidence-based approaches help older adults thrive and survive longer despite living with persistent pain. [Journal of Gerontological Nursing, 43(7), 20-31.].

Evidence-Based Practice Guideline : Acute Pain Management in Older Adults.

Acute pain is a prevalent problem in a growing segment of the older adult population and is often ineffectively managed despite the accumulation of evidence to guide assessment and support interventions in managing pain. Improvements in acute pain management in older adults are needed to provide consistent and quality pain assessment techniques and treatment therapies consistent with patient and/or family preferences. The current article briefly discusses ways to improve the pain experience and outcomes for older patients and families. [Journal of Gerontological Nursing, 43(2), 18-27.].

The state-of-"cultural validity" of self-report pain assessment tools in diverse older adults.

BACKGROUND: Pain continues to be a significant problem for older adults worldwide and a challenge for health care clinicians and researchers in assuring accurate identification and tailored treatment approaches. Attention has been devoted in recent years to development of pain assessment tools that are reliable and valid for use with older adults, including self-report scales and pain observation tools. METHODS AND DESIGN: This integrative review examines face, content, and construct validity relative to the research development, linguistic translation, and clinical implementation of self-report pain assessment tools in culturally diverse older adults. RESULTS: Many self-report pain assessment tools have not been tested and validated in many older adults of diverse cultures. As a result, self-report tools are limited in their accuracy and ability to capture the cultural distinctions that impact pain intensity ratings. CONCLUSION: The multiculturalism of health care and the use of existing pain assessment tools globally require that clinicians and researchers consider tool validity that incorporates the individual's cultural system in order to provide quality pain assessment. This article addresses one aspect of tool development and application across populations, the validation of self-report pain assessment tools for culturally diverse older adults. Recommendations for each the research and clinician are provided to assist in development, translation, and use of various self-report pain assessment tools.