Abstract
BackgroundDespite experimental evidence suggesting that pain sensitivity is not impaired by cognitive impairment, observational studies in nursing home residents have observed an inverse association between cognitive impairment and resident-reported or staff-assessed pain. Under the hypothesis that the inverse association may be partially attributable to differential misclassification due to recall and communication limitations, this study implemented a missing data approach to quantify the absolute magnitude of misclassification of pain, pain frequency, and pain intensity by level of cognitive impairment.MethodsUsing the 2016 Minimum Data Set 3.0, we conducted a cross-sectional study among newly admitted US nursing home residents. Pain presence, severity, and frequency is assessed via resident-reported measures. For residents unable to communicate their pain, nursing home staff document pain based on direct resident observation and record review. We estimate a counterfactual expected level of pain in the absence of cognitive impairment by multiply imputing modified pain indicators for which the values were retained for residents with no/mild cognitive impairment and set to missing for residents with moderate/severe cognitive impairment. Absolute differences (∆) in the presence and magnitude of pain were calculated as the difference between documented pain and the expected level of pain.ResultsThe difference between observed and expected resident reported pain was greater in residents with severe cognitive impairment (∆ = -10.2%, 95% Confidence Interval (CI): -10.9% to -9.4%) than those with moderate cognitive impairment (∆ = -4.5%, 95% CI: -5.4% to -3.6%). For staff-assessed pain, the magnitude of apparent underreporting was similar between residents with moderate impairment (∆ = -7.2%, 95% CI: -8.3% to -6.0%) and residents with severe impairment (∆ = -7.2%, 95% CI: -8.0% to -6.3%). Pain characterized as “mild” had the highest magnitude of apparent underreporting.ConclusionsIn residents with moderate to severe cognitive impairment, documentation of any pain was lower than expected in the absence of cognitive impairment. This finding supports the hypothesis that an inverse association between pain and cognitive impairment may be explained by differential misclassification. This study highlights the need to develop analytic and/or procedural solutions to correct for recall/reporter bias resulting from cognitive impairment.
Highlights
Despite experimental evidence suggesting that pain sensitivity is not impaired by cognitive impairment, observational studies in nursing home residents have observed an inverse association between cognitive impairment and resident-reported or staff-assessed pain
This study addresses this research gap by asking the question: “What levels of pain would nursing home residents with moderate-to-severe cognitive impairment have documented in the absence of their cognitive impairment?” This question implicitly recognizes a counterfactual realty in which residents with cognitive impairment could be observed in the absence of their cognitive impairment
Data source and population We conducted a cross-sectional study among nursing home residents who were newly admitted to US nursing homes in 2016, as identified in the Minimum Data Set 3.0 (MDS 3.0) [16]
Summary
Despite experimental evidence suggesting that pain sensitivity is not impaired by cognitive impairment, observational studies in nursing home residents have observed an inverse association between cognitive impairment and resident-reported or staff-assessed pain. Pain assessment is inherently dependent on communication, either explicitly through verbal communication or via implicit signs and behaviors consistent with pain (e.g., moaning, flinching). For this reason, misclassification of pain may result from misreporting, or by unobserved or unrecognized signs of pain. Pain is commonly experienced by nursing home residents and is a critical metric of quality of care [2]. Pain affects measures of wellbeing [5] including depression, anxiety, sleep disturbance, social isolation, and immobility [6, 7]
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