Abstract
BackgroundCommunication skills are known to decrease with advancing cognitive impairment. Analgesic treatment in long-term care may be deficient due to the residents’ impaired ability to communicate their pain and needs. Undertreated pain frequently leads to rising BPSD in residents with cognitive impairment, resulting in a treatment with antipsychotics. Aim of this study was the analysis of differences in assessment and pharmacological treatment of pain in nursing home residents relative to their cognitive state and ability to articulate pain.MethodsData stems from the baseline of a non-experimental pre-post-study in 12 Austrian nursing homes. Residents’ pain prevalence in relation to pain assessment and cognitive decline was assessed, data on medical diagnoses and prescriptions were retrieved from the nursing homes’ documentation (n = 425). Residents were first divided into two groups: Residents with MMSE ≥ 18 were selected into group CUS (cognitively unimpaired/slightly impaired), residents with MMSE ≤ 17 were selected into group CI (cognitively moderately to severely impaired). CI residents were then sub-grouped according to their ability to communicate pain via the Verbal Rating Scale (VRS) (i.e. group CI-V, group CI-NV). Pain behavior of CI residents was assessed with a modified German version of PAINAD. Group differences were tested with ANOVA and H-test, 95 % confidence intervals were calculated and associations were tested with log-binomial regression.ResultsPain prevalence in CI residents irrespective of their ability to communicate pain was 80 % and exceeded the CUS group prevalence significantly by 14 %. CI residents had significantly less analgesic prescriptions. Furthermore, CI residents have a significantly higher risk of getting no analgesics when in pain than CUS residents (CI-V: RR =2.6, CI-NV: RR =3.4). Use of antipsychotics was high in all groups (49 – 65 %) with more prescriptions in the cognitively impaired group.ConclusionResults point toward an underuse of pain medication in cognitively impaired residents, especially those unable to communicate pain verbally. The implementation of standardized pain assessments adapted to the cognitive abilities of residents may foster the recognition of pain, warrant optimized pain management, reduce inadequate medication and consequently raise the chance of equally effective pain treatment regardless of cognitive state.
Highlights
Communication skills are known to decrease with advancing cognitive impairment
Since cognitive impairment is common in many nursing home residents [9, 10], assessment and management of pain is demanding for physicians and nurses due to ambiguity in communication leading to the reasonable assumption that pain in persons with cognitive decline is both under-diagnosed and under-treated [11,12,13]
cognitively moderately – severely impaired (CI)-V and cognitively moderately – severely impaired/not verbally communicating (CI-NV) residents had a higher classification in the level of care than cognitively unimpaired (CUS) residents
Summary
Communication skills are known to decrease with advancing cognitive impairment. Analgesic treatment in long-term care may be deficient due to the residents’ impaired ability to communicate their pain and needs. Undertreated pain frequently leads to rising BPSD in residents with cognitive impairment, resulting in a treatment with antipsychotics. Since cognitive impairment is common in many nursing home residents [9, 10], assessment and management of pain is demanding for physicians and nurses due to ambiguity in communication leading to the reasonable assumption that pain in persons with cognitive decline is both under-diagnosed and under-treated [11,12,13]. There is evidence that persons with advanced cognitive decline either receive pain treatment, notably opioids, less frequently or in lower insufficient doses as compared to their cognitively fit counterparts [12, 15,16,17,18,19], whereas only few studies have reported a possible overuse of analgesics, paracetamol, in patients with cognitive impairment [20]. Various numerical and visual scales are available for self-reported experience of pain, all of them lacking soundness in persons with cognitive impairment due to their subjection on memory, abstract thinking and speech comprehension [28]
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