1. THE VALUE OF CNAs IN RECOGNIZING PAIN IN COGNITIVELY IMPAIRED NURSING HOME RESIDENTS April 8, 2009 The Empire Quality Partnership Teleconference Achieving Goals V - Assessment and Management of Residents' Pain EDWARD CISEK, PhD SUSAN ROSENDAHL-MASELLA, PhD

2. 2 Presentation Overview Pain and Dementia Facts Our Project Preliminary Findings (Phase 1)  Focus Groups  Observational Pain Assessment Tools

3. 3 The Facts SOURCE: URGENT ALERT: 2009 ALZHEIMER’S FACTS AND FIGURES http://www.alz.org/national/documents/report_alzfactsfigures2009.pdf A NEW CASE EVERY 70 SECONDS SIXTH LEADING CAUSE OF DEATH 148 BILLION DOLLARS IN ANNUAL COSTS 9.9 MILLION UNPAID CAREGIVERS 5.3 MILLION PEOPLE HAVE ALZHEIMER’S BY MID-CENTURY SOMEONE WILL DEVELOP ALZHEIMER’S EVERY 33 SECONDS BY 2010, THERE WILL BE NEARLY A HALF MILLION NEW CASES OF ALZHEIMER’S EACH YEAR BY 2050, THERE WILL BE NEARLY A MILLION NEW CASES EACH YEAR

4. 4 The Facts (cont.) 25 to 33% of nursing home residents are known to have moderate pain on a daily basis Leong & Nuo (2007); Sawyer et al. (2006); Smalbrugge et al. (2007); Teno et al. (2001) 49 to 83% of nursing home residents have substantial pain that is underdetected and/or undertreated Buchanan et al. (2002); Miller et al. (2003); Proctor & Hirdes (2001); Teno et al. (2002)

5. 5 More Facts... As mental impairment increases, reporting of pain decreases Parmelee et al. (1993) Weiner, Peterson, Logue, & Keefe (1998) There were no differences in the number or type of pain-causing conditions between those who were cognitively intact and those who were cognitively impaired yet pain complaints and reported pain intensity decreased with increasing cognitive impairment Parmelee (1996) (N = 871 nursing home residents); Hadjistavropoulos et al. (2007)

6. 6 More Facts... (cont.) Undertreatment of Pain  Cognitively Impaired Nursing Home Residents (N=38) All 38 residents exhibited aggressive behaviors 60% had at least one diagnosis known to cause pain NO PAIN MEDICATIONS given in previous month Feldt et al. (1998)  Hospitalized Advanced Dementia Patients with Hip Fractures (N=59 cognitively intact/N=38 cognitively impaired patients) Given less morphine than cognitively intact patients (1/3 the morphine equivalent) Over ¾ were without standing orders for analgesia Morrison & Siu (2000)

7. 7 New York State Department of Health Dementia Grants Program Schervier is Recipient of 3-year Research and Training Grant Assessment, Detection and Treatment of Pain in Nursing Home Residents with Advanced Dementia: Development of an Evidence-Based Best Practice

8. 8 New York State Department of Health Dementia Grants Program (cont.) Consortium  SCHERVIER NURSING CARE CENTER—LEAD FACILITY Paulette Sansone, PhD, LMSW Edward Cisek, PhD and Susan Rosendahl-Masella, PhD Susan Caccappolo, MSSW, LCSW Joseph Scarpa, MD and Louis Harris, DPT  RAVAZZIN CENTER FOR SOCIAL WORK RESEARCH ON AGING Michael Phillips, DSW  CABRINI CENTER FOR NURSING AND REHABILITATION Jeffrey Nichols, MD and Mary Devlin  ST. CABRINI NURSING HOME Jeffrey Nichols, MD and Barbara Gaughan

9. 9 New York State Department of Health Dementia Grants Program (cont.) Overview of Project  Primary Goals Identification of appropriate tools to assess pain in residents with advanced dementia Improvement of nursing home staff’s knowledge and attitudes regarding pain Implementation of organizational changes to the nursing home to aid in more accurate assessment and treatment of pain

10. 10 New York State Department of Health Dementia Grants Program (cont.) Project Phases  Phase 1 Conduct further tests of the psychometric properties of existing tools designed for the assessment of pain in residents with dementia PAINAD (Warden, Hurley, & Volicer, 2003) CNPI (Feldt, 2000) Doloplus-2 Scale (Wary & Doloplus, 1999)

11. 11 New York State Department of Health Dementia Grants Program (cont.)  Phase 2 Provide information to residents’ families regarding behavioral indicators of pain Develop and implement brief education program for nursing home physicians, nurses and CNAs Design and introduce a structured assessment and tracking process for the reporting and treatment of residents’ pain

12. 12 New York State Department of Health Dementia Grants Program (cont.)  Phase 3 Develop a comprehensive education and training manual for all nursing homes in NYS regarding pain in residents with advanced dementia Produce a step-by-step guide for implementing the best practice for identifying and tracking pain TRAINING MANUAL Step-by

13. 13 Assessment of Pain THE GOLD STANDARD  Resident Self-Report “Pain is whatever the patient says it is, ….” McCaffery (1968) Although cognitively impaired residents may be able to answer yes or no questions about whether they have pain, they may have difficulty identifying the location of their pain or describing temporal variations in their pain Stolee et al. (2005) Complex pain measures that require abstract thinking or discrimination may be too difficult for cognitively impaired residents to use reliably Parmelee (1994)

14. 14 Pain in cognitively impaired nursing home residents is difficult to detect particularly when communication is limited + Underreporting and inadequate assessment of pain ________________________________ NEED TO IMPROVE METHODS OF DETECTING AND MANAGING PAIN

15. 15 Residents with Cognitive Impairment: Guiding Principles for the Assessment of Pain Self-Report  Attempt to obtain with residents having mild to moderate cognitive impairment  As dementia progresses, the ability to self- report decreases and eventually self-report is NO LONGER POSSIBLE 2006 American Society of Pain Management Nursing http://www.medscape.com/viewarticle/533939; 2002 American Geriatrics Society

16. 16 Residents with Cognitive Impairment: Guiding Principles for the Assessment of Pain (cont.) Searches for Potential Causes of Pain/ Discomfort  Consider chronic pain conditions E.g., arthritis, low back pain, neuropathies  Musculoskeletal and neurologic disorders are most common Observation of Resident Behaviors

17. 17 Focus Groups Four Focus Groups (2 CNA, 2 Nurse) Questions  How do you know when a person with advanced dementia is experiencing pain?  What do you do when you recognize a resident is in pain?  Do you think some kind of form would help you to better communicate a resident’s pain to a nurse/doctor?

18. 18 CNA Focus Groups How do you know when a person with advanced dementia is experiencing pain?  Grimacing  Facial Expressions  Moaning/Crying  Less Movement  Shifting Positions  Holding Body Part  Less Talkative/Withdrawn  Agitation/Behavior Problems  Change in ADL Ability  Change of Appetite  Attempts to Verify Behavior is Pain-Related

19. 19 CNA Focus Groups (cont.) CNAs reported behavioral pain indicators consistent with American Geriatrics Society Guidelines  Facial Expressions  Verbalizations, Vocalizations  Body Movements  Changes in Interpersonal Interactions  Changes in Activity Patterns or Routines  Mental Status Change http://www.americangeriatrics.org/products/positionpapers/JGS5071.pdf

20. 20 CNA Focus Groups (cont.) What do you do when you recognize a resident is in pain?  Verbal report to nurse  Follow-up with nurse Nurses report that they rely on CNAs to report pain

21. 21 CNA Focus Groups (cont.) Do you think some kind of form would help you to better communicate a resident’s pain to a nurse/doctor?  Written form would reinforce and provide back-up to their verbal reports  Form can be used to track pain over time

22. 22 Psychometric Properties of Pain Assessment Tools: Reliability Sample  55 long term care residents with severe to very severe dementia Results  Intra-rater reliability (24-48 hrs.) ranged from.56 to.67 across three pain measures  Internal consistency ranged from.61 to.87

23. 23 Psychometric Properties of Pain Assessment Tools: Validity Sample  46 cognitively intact short-term rehabilitation patients Results  Correlations between CNA ratings of patient’s pain and patient’s self-report of pain were.31,.50 &.58, all of which are statistically significant IOWA PAIN THERMOMETER Herr and Mobily (1993) Used with permission of Keela Herr, PhD, RN, FAAN, AGSF, College of Nursing, The University of Iowa No pain Slight pain Mild pain Severe pain Moderate pain Extreme pain Pain as bad as it could be

24. 24 Conclusions Nurses rely on CNAs as source of pain information CNAs can identify most behavioral signs of pain CNAs recognize their role in communicating pain to nurses CNA report of residents’ pain to nurses is primarily verbal Written documentation can reinforce verbal reports When given tools to measure pain, CNAs appear to be reliable reporters CNAs are a gold mine of information

25. 25 Questions How often should pain be measured? How should pain assessment and reporting be integrated into nursing home practice? How will CNAs react to the added responsibility of pain assessment?

26. 26 Contact Information Susan Rosendahl-Masella: Susan_Rosendahl-Masella@bshsi.org (718) 548-1700 ext. 337 Edward Cisek: Ed_Cisek@bshsi.org (718) 548-1700 ext. 336

27. 27 Pain Assessment Tools for Residents with Dementia Attempt Self Report (Faces Pain Scale, Numeric Rating and Verbal Descriptor Scales) Abbey Pain Scale ADD Protocol (Assessment of Discomfort in Dementia) CNPI (Checklist of Nonverbal Pain Indicators) Doloplus-2 Scale DS-DAT (Discomfort Scale – Dementia of the Alzheimer’s Type) FLACC (Faces, Leg, Activity, Cry, Consolability) NOPPAIN (The Non-Communicative Patient’s Pain Assessment Instrument) PACSLAC (Pain Assessment Checklist for Seniors with Limited Ability to Communicate) PADE (Pain Assessment for the Dementing Elderly) PAINAD (Pain Assessment for Advanced Dementia) RaPID (Rating Pain in Dementia) Palliative Care Dementia Consortium (2008) http://www.scherviercares.org/resources.html

28. 28 References and Online Resources

29. 29 Source: http://consultgerirn.org/uploads/File/trythis/assessingPain.pdf

30. 30 Acknowledgments Bon Secours New York Health System James T. Higgins, CEO Schervier Center for Research in Geriatric Care Paulette Sansone Susan Caccappolo Yvette Rondeau Mike Phillips, Ravazzin Center Karen Wilson, VP of Nursing, Nurses, CNAs and all the staff at Schervier Nursing Care Center Beth Dichter and the NYSDOH Empire Quality Partnership