Developing a pain assessment tool for people with cognitive impairment and dementia

Abstract

Pain is the most common symptom experienced by orthopaedic and trauma patients, many are older, may have dementia and/or experience cognitive impairment during hospitalisation. There is a direct correlation between the severity of cognitive impairment and under treatment of pain (Herr 2011). Uncontrolled pain and high pain scores are associated with complications, such as a chest infection, thrombosis, pressure ulcers and a longer hospital stay, greater disability and functional decline (Berry and Dabl 2000, Herr 2011, Scott et al 2011).Recognising pain and its assessment is a key role of nurses and is central to effective pain management (Coker et al 2008; Kumar and Allcock 2008). Pain rating scales ask the patient about their pain using simply worded questions to assess pain and are considered the most accurate way to assess pain (Kumar and Allcock 2008, Herr 2011). This assessment process requires the patient to communicate effectively by reporting and describing their pain. People with cognitive impairment and dementia may have problems with communication, remembering and describing pain making assessment of their pain a challenge. A number of observational behavioural pain assessment tools have been devised to overcome these communication problems (Herr 2011), but they are not used in everyday clinical practice (Manias 2012). This paper will explore the issues of assessing pain when patients have cognitive impairment and/or dementia and describe a practice development project developing a behavioural pain assessment tool for patients with cognitive impairment.A participatory action research approach was used following the identification of the problem of assessing pain in patients with cognitive impairment by a group of clinicians, including physiotherapists and trauma nurses. This approach includes as many stake holders as possible and involves a series of steps of planning, activity and evaluation. Consultation and participation occurred at each step. The stake holders included medical, therapy and nursing therapy staff (included nurse specialists, matrons, staff nurses, student nurses and non-registered nurses). A steering group was formed that met regularly. Workshops were also used to ensure as many staff as possible were involved in the project. A review of the literature identified many established behavioural pain assessment tools, which were examined by participants and three were chosen to be trialled. These were The Abbey (Abbey et al 2000), the Pain Assessment IN Advanced Dementia (PAINAD) (Warden et al 2004) and the Checklist of Non-verbal Pain Intensity (Feldt 2000). Each of the tools were used in everyday practice over a six week period and then evaluated by the nurses on the trauma wards. This also enabled comparisons to be made between the different assessment tools. The three pain assessment tools did help highlight the possibility of pain in many patients, but we also discovered problems with each tool including the format, some content and a failure to identify pain occasionally. In some cases members of the patient?s family informed staff of their pain (Gregory 2012). These observations support the importance of knowing the person to be able to identify changes in behaviour (McAucliffe et al 2008) and the family should be involved to assist in identifying pain behaviours.Evaluation of the pain assessment tools and their limitations by the clinical staff led to the development of a new behavioural pain assessment tool. It was agreed to incorporate aspects from the Abbey and PAINAD plus an additional section for the family of the patient to add pain behaviour information about that individual (Gregory 2012). The behavioural pain assessment tool has been named the Bolton Pain Assessment Tool (BPAT).The BPAT is now being tested for its usefulness by clinical staff within trauma units prior to further validation research including exploring the perception of how families feel about being involved in pain assessment.