1. Assessing Pain in Older Adults
Houston Geriatric Education Center Evidence-Based Project
Sponsored by HRSA funded – Greater Philadelphia GEC

2. Objectives Describe pain assessment techniques Review the PAIN-AD tool
Review the NRS tool
Discuss the importance of re-assessment
Appreciate the need to document assessment findings regularly
Discuss pain management techniques

3. General Facts About Pain
-Fifth vital sign
-Pain is Not a normal part of aging
Always something can be done

4. Prevalence of Pain in Older Adults
25-50% of older community-dwelling (persistent type)
50-75% of NH dwellers (persistent type)
Cognitively intact

5. Prevalence of Pain in Older Adults with Cognitive Impairment
40-70% of nursing home pts with dementia report pain
What is greatest risk for these patients?

6. Pain in Older Adults with Cognitive Impairment
Many studies show that as cognitive impairment increases, less documentation and less pain medication given. None of these studies are in hospices. Feldt and Morrison are acute care and the rest in NHs. Even if hospice does better job with pain medicine, concern about those with cognitive impairment.

7. Factors Contributing to the Under-Reporting of Pain
Pain behaviors
Cognitively intact – reporting? Assessed?
Patient concerns
Nurses in particular are often unaware of what pain behaviors may be or how to properly assess them.
If the patient does not report his pain, then the nurses have a tendency not to ask about pain or properly screen a patient for pain.
Pain reports by patients are often ignored. Not a normal part of aging.

8. Hierarchy of Pain Assessment Techniques
Patient report
Causes of pain (acute and chronic)
Pain behaviors
Surrogate report
Response to empirical therapy
IF ANY ARE PRESENT
5 things you should look at, start with patient report (GOLD STANDARD) and the rest don’t have to be done in any order. We are going to focus on PAIN BEHAVIORS.
Numerical Rate Scale – advanced dementia usually means someone MMSE <11 and not self-reporters, however someone with dementia may be able to self-report and one must ALWAYS attempt to get a self-report on the NRS 1-10point scale just as in ESAS as well. There are people with varying levels of cognitive impairment – may feel it is easier to say “severe pain” or “debilitating” rather than a numerical scale.
Herr et al:, Assessment of Pain in Nonverbal Patients, Pain Mgmt Nurs, 2006

9. Indicators of Pain Breathing Negative Vocalization Facial Expression
Body Language
Consolability
Body language-tense, fidgeting when sitting up
Consolability-harder to assess, can you comfort them/distract them with comforting thoughts? Can they even be distracted or are they in too much pain?

10. When to assess/observe for pain
At admission
Every shift (two times per 24 hours)
After therapies (when should you see an effect?)
At rest and with movement.
The difference between direct observation and observation over time (seeing changes in behavior from normal – requires observing patient over time)
Watch patient during movement if possible
Observing behaviors are usually better to answer “IF” the patient has pain rather than “HOW BAD” the pain is
Do the behaviors reflect physical pain or something else?

11. Numerical Rating Scale
Verbal scale-asks patients to rate pain on a scale from 0-10
0 is no pain
10 is the worst pain they have ever had
Video Example of Using NRS
Start video at 2:48- 3:38 for role play of nurse using NRS
3:39 starts use of FACES scale, not important to HGEC EBP

12. No really good pain observational tool that measures INTENSITY – because it does not equal 1-10 numerical score. Still a disconnect and a judgment that the nurse/HHA makes. Does it reflect physical pain or psychological pain? Risk/benefit of this tool – rather treat for pain than not!
There are some measures – over 15 measures have been developed with data to support that they are reliable and valid. One type includes items – is there a change in routine or a change in sleep pattern? Changes you see could be related to dying process. The other type is a direct observational tool – appropriate because our patients may only be in hospice for less than 5 days.

13. Breathing
Normal breathing = effortless, quiet, rhythmic (smooth) respirations 1
Noisy labored breathing 2
Cheyne-Stokes respirations: rhythmic waxing and waning of breathing from very deep to shallow respirations with periods of apnea (no breathing)
Walk through 5 items/domains…
Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4:9-15.

14. Negative Vocalizations
None; speech or vocalization has neutral or pleasant quality 1
Low level speech with a negative or disapproving quality: muttering, mumbling, whining, grumbling, or swearing in a low volume with complaining, sarcastic or caustic tone; occasion moan or groan 2
Repeated troubled calling out: phrases or words being used over & over in tone that suggests anxiety, uneasiness, or distress
Crying: utterance of emotion accompanied by tears; may be sobbing or quiet weeping
Warden, et al, J Am Med Dir Assoc, 2003

15. Facial Expressions
Smiling: upturned corners of the mouth, brightening of the eyes, look of pleasure/ contentment
Inexpressive: a neutral, at ease, relaxed, or blank look 1
Sad: unhappy, lonesome, sorrowful, dejected look; may be tears in the eyes
Frightened: look of fear, alarm or heightened anxiety; eyes are wide open
Frown: downward turn of the corners of the mouth; Increased facial wrinkling in the forehead and around the mouth may appear 2
Facial grimacing: distorted, distressed look; brow is more wrinkled as is the area around mouth; eyes may be squeezed shut
Warden, et al, J Am Med Dir Assoc, 2003

16. Body Language
Relaxed: calm, restful, mellow appearance; person seems to be “taking it easy” 1
Distressed pacing: activity that seems unsettled
Fidgeting: restless movement; squirming about or wiggling in the chair may occur 2
Rigid: stiffening of the body; arms and/or legs are tight & inflexible; trunk may appear straight and unyielding (exclude contractures)
Fists clenched: tightly closed hands; may be opened and closed repeatedly or held tightly shut
Knees pulled up: flexing legs & drawing knees toward chest
Pulling or pushing away
Striking out: hitting, kicking, grabbing, punching, biting
Warden et al. J Am Med Dir Assoc. 2003

17. Consolability
No need to console: person appears content 1
Distracted or reassured by voice or touch: behavior stops when person is spoken to or touched, with no indication that person is distressed 2
Unable to console, distract or reassure: inability to sooth the person or stop a behavior with comforting words or actions
Warden et al. J Am Med Dir Assoc. 2003

18. Video Example Clip One: Clip Two: Patient with dementia case
Patient with dementia-particular attention to facial expressions and body language
Be mindful of one indicator being very strong, making for a stronger suspicion of pain.
Clip One- 18:55-older male with dementia being moved by nursing assistants
19:45-21:03 description of how to rate using PAIN-AD-example score of “9”
Clip Two- 23:00 particular attention to facial expression and body language 24:50-observations of video

19. Implementation Strategies
Training recommendations
Aware of limitations
One piece of comprehensive assessment
Self-report elicited when possible
Aware of pt specific behaviors/atypical
Strategies for tool use
Serial observations
Observe during movement
System level support
Integrate with EMR
Institutional policies
Staff education
Herr et al., J Gerontol Nsg, 2010

20. Pain Management Full assessment of pain rating
Over or under-reporting pain?
more in-depth investigation
Pain history (cause)
Family members
Depression screening
9:53 in video-example of care plan meeting for pain with nurse, social worker, physical therapist-shows interdisciplinary approach to pain management plan
Talks about addiction, pain history, exercise, keeping a pain diary

21. Pain Management in Cognitively Impaired
Differentiate - pain, depression & cognitive impairment
Scheduled pain medications
surgery
Delirium

22. Implications of Untreated Pain
Depression
Physical functioning
Socialization
Appetite
Quality of life
Pain and depression are very often interrelated, and if at least one is treated, the patient’s quality of life immediately improves.

23. Implications of Untreated Pain
Also, cognitively impaired also exhibit:
Resistance during caregiving
More moaning, groaning, grimacing
Possible hitting, pushing away

24. Non-pharmacological Treatment of Pain
Opiate, addiction, side effect fears
Modify care practices
Especially with cognitively impaired who need help with ADLs
Distractions
Hot/cold packs
Massage
Acupuncture

25. Pharmacological Treatment of Pain
Education
side-effects
dosage
safety
Narcotics
Adjuvant therapy
Anti-depressants
Polypharmacy

26. Pain Medication Guidelines
When do we medicate?
How do we medicate?
Standardized orders
Pre-medicate
Important to note that cognitively impaired can’t tell you when/if it’s going to hurt or when to stop doing something that hurts.

27. Importance of Interdisciplinary Team in Pain Management
Roles
Nurse (assessing and documenting pain)
Social worker PT OT
Recreational therapist
Physician
Pharmacist
Imperative to education of patient
See care plan meeting video clip at 9:53 for interdisciplinary approach between nurses, social worker and physical therapist discussion

28. Importance of Follow-Up Documentation
“patient had 8/10 PAIN-AD, 0.2mg Dilaudid IV (or morphine 5mg SL) administered” 
30 minutes later the response should be addressed and measurable as documented by “patient’s pain improved to 3/10 on PAIN-AD”

29. Examples
CASE 1: with movement and position change pt had mild moaning. Did request for roxanol, spoke to nurse, Helen and facility MD to approve of orders for roxanol. Flacc 4/10 with position change only, at rest pt seems pain free. Family report they notice pt keeps touching head as if she is having pain.
CASE 2: pt states "my stomach hurts", unable to describe

30. Additional Resources companion articles
NYU-Hartford Institute web site

31. Thank you!