The role of the CNA Pain Assessment Tool (CPAT) in the pain management of nursing home residents with dementia.

Implementation and testing of the CPAT in two hundred fifteen dementia residents of three regional skilled nursing facilities. To examine the effect of incorporating the CPAT into an AMDA long-term care pain management clinical practice guideline on nursing home residents with dementia. To evaluate changes in CPAT scores after treatment for pain. A non-randomized pre and post intervention design was used. Main outcome measures of the number of falls, episodes of distressed behavior and rates of antipsychotic usage were compared pre and post CPAT/AMDA guideline implementation. CPAT score changes were calculated after pain management. Falls and verbally aggressive behavior were reduced post intervention but did not achieve statistical significance. Antipsychotic usage declined significantly post intervention. CPAT scores declined significantly after treatment for pain. The implementation of a CPAT/AMDA guideline in skilled nursing facilities may reduce falls, verbally aggressive behaviors and antipsychotic usage in residents with dementia. The CPAT is useful in evaluating the effects of pain treatment in nursing home residents with dementia.

Pain assessment in nursing home residents with dementia: psychometric properties and clinical utility of the CNA Pain Assessment Tool (CPAT).

OBJECTIVES: To examine the psychometric properties and clinical utility of the CPAT, an instrument to assess pain in nursing home residents with dementia. DESIGN: Instrument development and testing. SETTING: Three regional skilled nursing facilities. PARTICIPANTS: One hundred forty-five residents of 3 skilled nursing facilities. MEASUREMENTS: The inter-rater reliability, test-retest reliability, construct validity, and criterion validity of the CPAT was measured after initial CNA training. Measurement of inter-rater reliability and test-retest reliability was repeated after modified CNA training. Internal consistency (Cronbach's alpha) was calculated for all reliability measures. The clinical utility/feasibility of the CPAT was measured by means of a practicality survey. RESULTS: The CPAT was found to have acceptable levels of both interrater reliability (ICC=0.71) and test-retest reliability (ICC=0.67). Construct validity as measured by a paired t test was statistically significant (P=.043). Criterion validity as measured by Spearman's rank correlation coefficient was also statistically significant (P=.048). Internal consistency was acceptable for all measures as calculated by Cronbach's alpha, which ranged from 0.72 to 0.84. As determined by a practicality survey, the CPAT was shown to be a clinically useful and feasible instrument. CONCLUSION: This study provides evidence that the CPAT is a reliable and valid pain assessment instrument when used in nursing home residents with dementia. It has also been shown to be a tool with suitable clinical utility and feasibility. Further study is warranted to ascertain if its use will lead to improved resident function and quality of life and whether the results of this study are reproducible in other dementia populations. The CPAT's ability to quantify pain and measure treatment response has not been determined.

Evidence-based review of interventions to improve palliation of pain, dyspnea, depression.

This review of the guideline developed by the Clinical Efficacy Subcommittee of the American College of Physicians and the accompanying systematic review offers clinicians evidence-based recommendations for palliative care. Seriously ill patients should be assessed for pain, dyspnea, and depression. Clinicians should use therapies of proven effectiveness to manage pain, depression, and dyspnea, including opioids in patients with unrelieved dyspnea and oxygen for short-term relief of hypoxemia. Clinicians should ensure that advance care planning, including completion of advance directives, occurs.

Use of the certified nursing assistant pain assessment tool (CPAT) in nursing home residents with dementia.

The purpose of this study was to develop a pain assessment tool utilized by certified nursing assistant (CNA) direct-care providers for nursing home residents with dementia and to examine the impact of such a tool on their function, behavior, or medication use. In the first phase, 41 items from an observational pain assessment tool were correlated with an objective pain "gold standard"; 12 statistically significant items were retained and used in the CNA pain assessment tool. Symmetry analysis was then conducted to determine if this resulted in any significant change in resident function, behavior, or medication use. This failed to detect significant change in these characteristics. A pain assessment tool utilized by CNA direct-care providers can be developed for use in nursing home residents with dementia. Further study is required to determine whether the use of such a tool will improve their function or quality of life.

To PEG or not to PEG: a review of evidence for placing feeding tubes in advanced dementia and the decision-making process.

Percutaneous endoscopic gastrostomy (PEG) has evolved into a common low-risk procedure in current medical practice. Clinical evidence supporting the use of tube feedings in patients with advanced dementia is clearly lacking, yet PEG procedures continue to be performed in a large number of these cases. In fact, multiple studies have shown that feeding tubes seldom are effective in improving nutrition, maintaining skin integrity by increased protein intake, preventing aspiration pneumonia, minimizing suffering, improving functional status, or extending life. The decision-making process is complicated, however, and involves the clinician considering such issues as advance directives, ethical considerations, legal/financial concerns, emotional factors, cultural background, religious beliefs, and the need for a family meeting incorporating all of these principles.