Assessing Pain in Cognitively Impaired Nursing Home Residents: The State of the Science and the State We're In

Abstract

The challenge of accurately assessing pain in persons with advanced dementia, particularly those who are noncommunicative, is well known, and the need for reliable, valid assessment methods has been well documented. 1 Huffman JC Kunik ME Assessment and understanding of pain in patients with dementia. Gerontologist. 2000; 40: 574-581 Crossref PubMed Scopus (85) Google Scholar , 2 Sengstaken EA King SA The problems of pain and its detection among geriatric nursing home residents. J Am Geriatr Soc. 1993; 41: 541-544 PubMed Google Scholar , 3 Cohen-Mansfield J Lipson S Pain in cognitively impaired nursing home residents: How well are physicians diagnosing it?. J Am Geriatr Soc. 2002; 50: 1039-1044 Crossref PubMed Scopus (90) Google Scholar In this issue are two examples of progress being made in the quest for evidence-based pain assessment tools to use with this population. In their article, Warden, Hurley, and Volicer 4 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 Abstract Full Text Full Text PDF PubMed Scopus (732) Google Scholar present a refined pain assessment measure, the Pain Assessment in Advanced Dementia Scale (PAINAD scale) based upon some of their earlier work. 5 Hurley AC Volicer BJ Hanrahan P et al. Assessment of discomfort in advanced Alzheimer patients. Res Nurs Health. 1992; 15: 369-377 Crossref PubMed Scopus (387) Google Scholar This tool reflects the authors’ response to the need for a measure that is easy to use and does not require extensive staff training. Also in this issue, Villanueva and colleagues 6 Villanueva MR Smith TL Erickson JS et al. Pain Assessment for the Dementing Elderly (PADE): Reliability and Validity of a New Measure. J Am Med Dir Assoc. 2003; 4: 1-8 Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar present the Pain Assessment for the Dementing Elderly scale (PADE scale) that, like the PAINAD scale, builds on reports in the literature that stress the significance of facial characteristics, body posture, breathing patterns, and vocalizations as expressions of pain, and the importance of assessing pain during movement. Each of the studies in this issue addressed other critical components of a pain management program for residents with severe dementia. Warden and colleagues included response to treatment in their study and demonstrated that PAINAD scores decreased with analgesic administration. The PADE study used nursing home (NH) staff rather than research assistants to test their pain measure. Such testing is critical to ensure that use of the tool is feasible for general use. Clearly, progress is being made in instrumentation as researchers continue to build on and expand existing measures and methods. However, as authors of both studies in this issue state, limitations remain. The PAINAD was tested on a small number of male veterans and may not be valid for women or other males. Race/ethnicity was not identified in the PAINAD study and was limited to white patients in the PADE study, again making generalizations to non-white patients impossible. Finally, the persistent challenge of separating pain symptoms from agitation and other behavioral manifestations attributable to non-pain causes was recognized as a focus for further study.