11/2/2015
True or False?
Pain Assessment in the Elderly and Clients with Dementia
Pain is a normal part of aging?
November 5, 2015
Glen‐mary Christopher RN, BN, BA
Working together…for healthy people in healthy communities.
False
 Pain is never “normal”.  Acceptance of this myth can diminish a client’s quality of life by limiting ability to socialize, provide self‐care, and engage in meaningful activities.
 Fact: By diminishing pain by 25% functionality may improve by as much as 50%!
 Up to 80% of residents in LTC facilities experience persistent, daily pain.
Working together…for healthy people in healthy communities.
Working together…for healthy people in healthy communities.
Common sources of pain in older adults
 Peripheral vascular disease
 Diabetes
 Post‐stroke syndrome
 Pressure ulcers
 Oral/dental problems
 Contractures
 Degenerative joint disease
 Rheumatoid arthritis
 Fractures
 Osteoporosis
 Chronic cancer pain or treatment‐related pain syndromes such as chemotherapy‐induced peripheral neuropathy
Working together…for healthy people in healthy communities.
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11/2/2015
True or False?
False
Older adults can’t reliably report pain.
Working together…for healthy people in healthy communities.
Most, including those with mild to moderate cognitive impairment, can use a numeric rating scale Be sure all assistive devices are in place before assessing pain or using a pain scale
Use words other than “pain” when asking. Some clients will deny pain, but report having “aching”, “soreness”, or other sensations
Working together…for healthy people in healthy communities.
“When you can’t use your words, what else can you do?”
Pain is “what the client says it
is”!
-Margo McCaffery
What if the client can’t “say”?
“YOU ACT IT OUT!”
Roxanne Franklin
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11/2/2015
What are needs driven behaviours?
Disruptive, agitated, and aggressive behaviors that result from one or more unmet needs —
physical, psychological, emotional, or social.
Because …
Loss of ability to express needs in language causes the person to “communicate” through behavior.
The KEY to successfully interpreting and
managing these behaviours is… highly
individualized ASSESSMENT!
Consequences of under assessing pain in advanced dementia
‐Pain behaviors are not synonymous with mental health or emotional needs
‐Psychotropic drugs may mask pain behaviors without actually treating the pain (i.e. calling out or fidgeting behavior).
‐Elders are then prevented from communicating the source of their distress. ‐McAuliffe, et al. (2008)
Working together…for healthy people in healthy communities.
We have a moral and ethical imperative
Margaret Somerville, one of Canada’s best known ethicists states
“We all must recognize that intentionally leaving a patient in pain is a breach of fundamental human rights…”
What about neglecting
to assess for the presence of pain in the first place?
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11/2/2015
Behavioural Indicators
 Research shows that certain behaviours represent pain in non‐verbal clients:
 Non‐verbal vocal complaints (sighs, gasps, moans, groans, cries)
 facial grimacing – acknowledged indicators of pain are:
 Brow raising or lowering, cheek raising, eyelids tightening, nose wrinkling, lip corner pulling, chin raising, and lip puckering.
 bracing (clutching or holding onto furniture, equipment, or affected area during movement) rubbing (massaging affected area)
 restlessness
 verbal vocal complaints, such as "ouch" or "stop“
What to do?
Use a standardized, validated observational pain assessment tool – don’t use your own opinion!
• 2 excellent tools are:
• Pain Assessment in Advanced Dementia (PAINAD), and • Pain Assessment Checklist for Seniors with Limited Ability to Communicate© (PACSLAC)
Working together…for healthy people in healthy communities.
Guidelines for Serial Trial Intervention (STI)
a. Attempt first to elicit a self‐report from patient and, if unable, document why self‐report cannot be used.
b. Identify pathologic conditions or procedures that may cause pain.
c. List patient behaviors that may indicate pain. A behavioral pain assessment tool should be used.
d. Identify behaviors that caregivers and others knowledgeable about the patient think may indicate pain (proxy reporting)
e. Attempt an analgesic trial.
– Start low and titrate to effect (keep going until analgesic is effective or resident experiences unacceptable side effects)
Working together…for healthy people in healthy communities.
Planning Treatment
 Combine pharmacologic and non‐pharmacologic strategies
 Advocate for “rational polypharmacy”
 Watch out for drug‐drug interactions or other drugs that cause sedation (think: Gravol)
 Titrate according to the resident’s response  When pain is ongoing, treatment should be ATC (Around The Clock) NOT PRN
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11/2/2015
Documentation
 Chart every report of pain, the nursing assessment including pain scale rating (or PAINAD/PACSLAC scores), interventions taken, and outcome of interventions. Documentation allows the ongoing assessment of location and duration of pain, the use of analgesic and its effectiveness, and presence of side effects.
Working together…for healthy people in healthy communities.
PAINAD
Choosing A Tool
NRS/Faces/Verbal Descriptors
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PACSLAC
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11/2/2015
PACSLAC Graph
Questions, comments, or stories to share?
References
References
Algase, D., Beck, C., Kolanowski, A., Whall, A. Berent, S., Rickards, K., & Beattie, E. (1996).Need‐
driven dementia‐compromised behavior: An alternative view of disruptive behavior. American Journal of Alzheimer’s Disease, 11(6), 10‐19.
American Geriatrics Society (2012). Statement on the Use of Opioids in the Treatment of Persistent Pain in Older Adults. American Geriatrics Society (2009). Pharmacological Management of Persistent Pain in Older Persons. British Pain Society and British Geriatrics Society (2007). Guidance on the assessment of pain in older people.
Bruckenthal, P., Carrington, M., Reisner, L. (2009). Special issues in the management of chronic pain in older adults. Pain Medicine, 10(S2), s67‐s78. doi:10.1111/j.1526‐4637.2009.00667.x
Copp, L. (2006). An ethical responsibility for pain management. Journal of Advanced Nursing, 30th
Anniversary Edition, 1‐2.
D’Arcy, Yvonne. (2009). Overturning barriers to pain relief in older adults. Nursin2009. October, 32‐38.
Hadjistavropolous, T., Fitzgerald, T., & Marchildon, G. (2010). Practice guidelines for assessing pain in older persons with dementia residing in long‐term care facilites. Physiother Can. 62:104–
113.
Herr, K., Coyne, P., McCaffery, M., Manworren, R., & Merkel, S. (2011). Pain assessment in the patient unable to self‐report: position statement with clinical practice recommendations. Pain Management Nursing, 12(4), 230‐250. doi:10.1016/j.pmn.2011.10.002
Jovey, R. D. (2002). Managing pain: The Canadian healthcare professional’s reference. second edition. Healthcare & Financial Publisning, Toronto, ON.
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(6), 412‐419.
Librach, S. L. & Squires, B. P. (2002). The Pain Manual: Principles and Issues in Cancer Pain Management. Pegasus Healthcare International, Montreal, QC.
McAuliffe, L., Nay, R., O’Donnell, M., Fetherstonhaugh, D. (2009). Pain assessment in older people with dementia: literature review. Journal of Advanced Nursing 65(1), 2‐10. Morrison, S., & Siu, A. (1999). A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. Journal of Pain and Symptom Management, 19(4), 240‐247.
Scherder, E., van Manen, Femke. (2005). Pain in Alzheimer's disease: nursing assistants’ and patients’ evaluations. Journal of Advanced Nursing 52(2), 151‐158.
Working together…for healthy people in healthy communities.
Working together…for healthy people in healthy
communities.
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References
Schofield, P., O’Mahony, S., Collett, B., Potter, J. (2008). Introducing guidance for the assessment of pain in older adults. Journal of Community Nursing 22(12), 4‐8. Ottawa General Hospital. IV therapy guide. Seers, K., Watt‐Watson, J., & Bucknall, T. (2006). Challenges of pain management for the 21st
century. Journal of Advanced Nursing, 30th Anniversary Edition, 4‐5.
van Wilgen, C., Keizer, D. (2012). The sensitization model to explain how chronic pain exists without tissue damage. Pain Management Nursing, 13(1) pp 60‐65. doi:10.1016/j.pmn.2010.03.001
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