Pain Assessment In Advanced Dementia Research Articles

Pericapsular Hip Block Guided by Ultrasonography in Elderly People with Hip Fracture in the Emergency Sector: Clinical Trial.

Objectives This study evaluated pain intensity in elderly subjects with hip fractures admitted to the emergency sector and undergoing preoperative pericapsular nerve group (PENG) block. Additionally, the degree of tolerable hip flexion was assessed. Methods A prospective, randomized, and controlled clinical trial with parallel groups. The control group consisted of elderly subjects with hip fractures undergoing standardized intravenous systemic analgesia. The intervention group consisted of elderly patients with hip fractures undergoing PENG block and standardized systemic analgesia. The groups were evaluated at rest and during movement using the Pain Assessment in Advanced Dementia (PAINAD) scale. We determined pain intensity and reduction, in addition to the degree of tolerable flexion of the fractured hip. All patient assessments occurred before the medication or block administration and at 45 minutes, 12, 24, and 36 hours postmedication or block. Results Preoperatively and 24 hours after PENG block, elderly subjects with hip fracture showed a significant reduction in pain at rest or movement compared to control patients ( p < 0.05), with 60% of patients assessed at rest demonstrating desirable pain reduction (≥50%) and only 13.3% of the control group achieving the desired pain reduction. During movement, after undergoing PENG block, 40% of subjects demonstrated the desired pain reduction and no patient from the control group. The intervention group also showed a significant improvement in the tolerable hip flexion group ( p < 0.05). Conclusion Preoperative PENG block in elderly subjects with hip fractures admitted to the emergency sector provided a significant reduction in pain compared with the control group.

The Challenges of Pain Assessment in Geriatric Patients With Dementia: A Review.

Pain in dementia patients is common, poorly measured, and undertreated. It is important to discuss the challenges in the pain assessment and management to find a possible solution for adequate pain management. The aim of this article is to discuss the challenges in the assessment of pain in geriatric patients with dementia. An extensive online database search was conducted via multiple websites using the following keywords: "dementia," "pain assessments," "pain assessment with dementia," "causes of pain with dementia," "pain assessments using recent technology," "geriatric," and "old age" to identify the relevant articles. Our inclusion criteria were articles that focused on pain in geriatric patients diagnosed with dementia, in English, published between January 2018 and January 2023, and available as free full text and those which were clinical trials, observational studies, review articles, systemic reviews, meta-analysis, or case series. The exclusion criteria were articles that did not have pain in geriatric patients diagnosed with dementia as their primary focus, involving geriatric or non-geriatric patients with major psychological distress, not in the English language, not published between January 2018 and January 2023, and not available as free full-text and those which were case reports and editorial articles. After manually excluding the articles that did not meet our inclusion criteria, we ended up with 38 articles. In conclusion, any instruments have been made for the pain assessment in patients with dementia. The two most common tools used to assess pain in this vulnerable population are the Pain Assessment in Advanced Dementia (PAINAD) and Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) scales. The utilization of new technology may offer promising solutions for the pain assessment in patients with dementia.

Prevalencia y características clínicas del dolor en pacientes con enfermedad crónica avanzada

ObjectivesDetermine pain prevalence and clinical characteristics in patients with advanced chronic disease and identify breakthrough pain frequency. DesignObservational, descriptive, cross-sectional study. LocationThree primary care teams and one intermediate care hospital. ParticipantsAll patients with advanced chronic disease. Main measurementsA semi-structured interview was performed to collect demographic, clinical, and specific variables of pain using validated scales. Patient location (home, nursing home or hospital) and advanced chronicity trajectory (organ failure, oncological disease, dementia, or multimorbidity) were recorded. Pain was assessed based on the Brief Pain Inventory (BPI) and, in cases of disabling dementia, using the Pain Assessment in Advanced Dementia (PAINAD). A statistical descriptive, comparative analysis between variables was performed using the R software. ResultsOf all patients selected, 223 (60.4%) were included. Prevalence of pain: 83.9% (n=187), with no differences based on location or trajectory. Significant differences in pain intensity based on location (P=.0046) (moderate-severe in patients at home, moderate in hospital patients, and mild in nursing home patients) and on trajectory (P<.0001) (moderate-severe in patients with organ failure and multimorbidity, moderate in patients with cancer, and mild in patients with dementia). Global functional impact of pain was mild-moderate, emotional impact was severe in 41.5% of patients (n=51), and breakthrough pain was observed in 8.6% (n=13). ConclusionsPain must always be explored and assessed in patients with advanced chronicity, since it was highly prevalent in all locations and trajectories, being particularly intense in patients at home with organ failure and multimorbidity. Breakthrough pain was found in non-oncological trajectories.

Multi-Center Validation of Pain Assessment in Advanced Dementia (PAINAD) Scale in Malaysia

The detection of pain in persons with advanced dementia is challenging due to their inability to verbally articulate the pain they are experiencing. Pain Assessment in Advanced Dementia (PAINAD) is an observer-rated pain assessment tool developed based on non-verbal expressions of pain for persons with severe dementia. This study aimed to perform construct validation of PAINAD for pain assessment in persons with severe dementia in Malaysia. This was a prospective cross-sectional study conducted from 27 April 2022 to 28 October 2022 in eight public hospitals in Malaysia. The PAINAD scale was the index test, and the Discomfort Scale—Dementia of the Alzheimer Type (DS-DAT) and Nurse-Reported Pain Scale (NRPS) were the reference tests for construct and concurrent validity assessment. Pain assessment for the study subjects was performed by two raters concurrently at rest and during activity. The PAINAD score was determined by the first rater, whereas the DS-DAT and NRPS were assessed by the second rater, and they were blinded to each other’s findings to prevent bias. PAINAD showed good positive correlations ranging from 0.325 to 0.715 with DS-DAT and NRPS at rest and during activity, with a p-value of &lt;0.05. It also demonstrated statistically significant differences when comparing pain scores at rest and during activity, pre- and post-intervention. In conclusion, the PAINAD scale is a reliable observer-rated pain assessment tool for persons with severe dementia in Malaysia. It is also sensitive to changes in the pain level during activity and at rest, pre- and post-intervention.

Psychometric evaluation of the Pain Assessment in Advanced Dementia scale in an acute general hospital setting.

People with dementia are at risk of unplanned hospital admissions and commonly have painful conditions. Identifying pain is challenging and may lead to undertreatment. The psychometric properties of the Pain Assessment in Advanced Dementia (PAINAD) scale, in medical inpatients with dementia have not been evaluated. A secondary data analysis from a longitudinal study of 230 people with dementia admitted to two acute general hospitals in London, UK. Internal consistency, inter-rater reliability, test-retest reliability, concurrent validity, construct validity and discriminant validity of PAINAD were tested at rest and in movement. This predominantly female (65.7%) sample had a mean age of 87.2 (Standard Deviation; SD=5.92) years. Inter-rater reliability showed an intra-class correlation (ICC) of 0.92 at rest and 0.98 in movement, test-retest reliability ICC was 0.54 at rest and 0.66 in movement. Internal consistency was 0.76 at rest and 0.80 in movement (Cronbach's α). Concurrent validity was weak between PAINAD and a self-rating level of pain (Kendall's Tau; τ=0.29; p>0.001). There was no correlation between PAINAD and a measure of behavioural and psychological symptoms of dementia, suggesting no evidence of convergent validity. PAINAD scores were higher during movement than rest, providing evidence of discriminant validity (z=-8.01, p<0.001). We found good inter-rater reliability and internal consistency. The test-retest reliability was modest. This study raises concerns about the validity of the PAINAD in general acute hospitals. This provides an insight into pain assessment in general acute hospitals which may inform further refinements of the PAINAD.

Classification of elderly pain severity from automated video clip facial action unit analysis: A study from a Thai data repository.

Data from 255 Thais with chronic pain were collected at Chiang Mai Medical School Hospital. After the patients self-rated their level of pain, a smartphone camera was used to capture faces for 10 s at a one-meter distance. For those unable to self-rate, a video recording was taken immediately after the move that causes the pain. The trained assistant rated each video clip for the pain assessment in advanced dementia (PAINAD). The pain was classified into three levels: mild, moderate, and severe. OpenFace© was used to convert the video clips into 18 facial action units (FAUs). Five classification models were used, including logistic regression, multilayer perception, naïve Bayes, decision tree, k-nearest neighbors (KNN), and support vector machine (SVM). Out of the models that only used FAU described in the literature (FAU 4, 6, 7, 9, 10, 25, 26, 27, and 45), multilayer perception is the most accurate, at 50%. The SVM model using FAU 1, 2, 4, 7, 9, 10, 12, 20, 25, and 45, and gender had the best accuracy of 58% among the machine learning selection features. Our open-source experiment for automatically analyzing video clips for FAUs is not robust for classifying pain in the elderly. The consensus method to transform facial recognition algorithm values comparable to the human ratings, and international good practice for reciprocal sharing of data may improve the accuracy and feasibility of the machine learning's facial pain rater.

Performance of Melatonin as Prophylaxis in Geriatric Patients with Multifactorial Risk for Postoperative Delirium Development: A Randomized Comparative Study.

Objective:Postoperative delirium is the worst patient outcome. Elderly patients undergoing orthopaedic procedures under general anaesthesia are highly liable to experience delirium. Several studies supported melatonin use for the prevention of delirium. This work evaluated the prophylactic efficiency of melatonin for postoperative delirium in patients with multifactorial risk for developing delirium as elderly undergoing orthopaedic trauma surgery under general anaesthesia.Methods:This double-blinded prospective randomized comparative study was conducted on 80 elderly patients subjected to orthopaedic interventions under general anaesthesia. Patients were randomized into group M (Melatonin group) and group NM (Non-melatonin group). Group M received 5 mg melatonin while group NM received placebo. The study drugs were given preoperatively and for the first 3 postoperative days. For the incidence of delirium, patients were evaluated using the Abbreviated Mental Test. The Pain Assessment in Advanced Dementia, sedation scores, and changes in hemodynamics were recorded.Results:The incidence of delirium was significantly lower postoperatively in M group (25%) relative to NM group (52.5%) (P < .001, OR = 2.3. 95% CI = −0.44, + 1.23). Abbreviated Mental Test scores at postanaesthesia care unit and day 0 showed a highly significant differences. However, Abbreviated Mental Test scores had no significant difference within the 3 postoperative days. Heart rate was significantly lower in M group after 50 minutes from the start of surgery. Mean blood pressure, Pain Assessment in Advanced Dementia, and sedation scores showed insignificant differences.Conclusion:Perioperative melatonin treatment could reduce the incidence of postoperative delirium in the studied population, and it could be considered a prophylactic medication.

Pain Assessment in Impaired Cognition (PAIC15) Instrument: Cutoffs Against Three Standards

Observational pain scales can help identify pain in persons with impaired cognition including dementia who may have difficulty expressing pain verbally. The Pain Assessment in Impaired Cognition-15 (PAIC15) observational pain scale covers 15 important items that are indicative of pain, but it is unclear how likely pain is for persons with each summed score (theoretical range 0-45). The goal of our study was to determine sensitivity and specificity of cut offs for probable pain on the PAIC15 against three possible standards. We determined cut offs against (1) self report when able, (2) the established Pain Assessment in Advanced Dementia (PAINAD) cut off of 2, and (3) observer’s overall estimate based on a series of systematic observations. We used data of 238 nursing home residents with dementia who were observed by their physician in training or nursing staff in the context of an evidence-based medicine (EBM) training study, with 137 residents assessed twice. The area under the ROC curve was excellent against the PAINAD cut off (□0.8) at both assessments, but acceptable or less than acceptable for the other two standards. Across standards and criteria for optimal sensitivity and specificity, cut offs at the PAIC15 could be 3 or 4. Guided by self report we recommend PAIC15 scores of 3 and higher to represent probable pain with sensitivity and specificity in the 0.5 to 0.7 range.

Invariance of the PAINAD Scale Between the Black and White Residents Living With Dementia.

The purpose of this study was to test the reliability and validity of the Pain Assessment in Advanced Dementia (PAINAD) and particularly consider whether or not this measure was invariant when used among the Black and White residents. Baseline data from an implementation study testing that included a sample of 553 residents, 30% of who were Black, from 55 nursing were included in this study. The Winsteps statistical program was used to perform the Rasch analysis and evaluate the reliability and validity of the measure based on internal consistency, infit and outfit statistics, mapping, and a differential item functioning (DIF) analysis. The AMOS statistical program was used for confirmatory factor analysis. The findings supported the reliability and validity of the PAINAD when used with these individuals and demonstrated that there was no evidence of invariance between the Black and White residents. All the items fit the model, but there was not a good spread of the items across the pain level of the participants. The majority of the participants (75%) were so low in pain signs or symptoms that they could not be differentiated. Based on the clinical practice and observations, it is recommended that additional items can be added to the measure such as observing the individual for evidence of resisting care, retropulsion when trying to stand, hitting or kicking when turning in bed, hitting or kicking when transferring from bed to chair, hitting or kicking when ambulating, or hitting or kicking when raising arms, less engagement with others, and decreased participation in the activities previously enjoyed.

Factors influencing the quality of life in patients with severe dementia.

A comprehensive understanding of the relevant factors involved in improving quality of life (QoL) is essential in patients with severe dementia; however, rating scales used in previous studies may not adequately reflect the factors that affect these patients. The purpose of this study was to identify factors that contribute to QoL using an evaluation scale suitable for patients with severe dementia. The current cross-sectional study was conducted at a hospital for recuperation in Hyogo prefecture in Japan. The measurement scales included the QoL in Late-Stage Dementia Japanese version (QUALID-J), Cognitive Test for Severe Dementia, Neuropsychiatric Inventory-Nursing Home (NPI-NH), Physical Self-Maintenance Scale (PSMS), Pain Assessment in Advanced Dementia (PAINAD), and Special Care Unit Environment Quality Scale (SCUEQS). Multiple regression analyses were performed. We assessed a total of 105 patients with severe dementia (80 women; aged 87.3 ± 6.3 years). Multiple regression demonstrated that the QUALID-J total score was significantly affected by the NPI-NH and PAINAD scores. Factors 1 (expression of comfort) and 2 (expression of discomfort) of the QUALID-J were significantly affected by the PSMS and PAINAD, and the NPI-NH and PAINAD scores, respectively. Our results indicate that behavioural and psychological symptoms of dementia and pain are important factors in influencing the QoL of patients with severe dementia.

Probable Pain on the Pain Assessment in Impaired Cognition (PAIC15) Instrument: Assessing Sensitivity and Specificity of Cut-Offs against Three Standards.

Observational pain scales can help to identify pain in persons with dementia who may have difficulty expressing pain verbally. The Pain Assessment in Impaired Cognition-15 (PAIC15) covers 15 items that indicate pain, but it is unclear how probable pain is, for each summed score (range 0–45). We aimed to determine sensitivity and specificity of cut-offs for probable pain on the PAIC15 against three standards: (1) self-report when able, (2) the established Pain Assessment in Advanced Dementia (PAINAD) cut-off of 2, and (3) observer’s overall estimate based on a series of systematic observations. We used data of 238 nursing home residents with dementia who were observed by their physician in training or nursing staff in the context of an evidence-based medicine (EBM) training study, with re-assessment after 2 months in 137 residents. The area under the ROC curve was excellent against the PAINAD cut-off (≥0.8) but acceptable or less than acceptable for the other two standards. Across standards and criteria for optimal sensitivity and specificity, PAIC15 scores of 3 and higher represent possible pain for screening in practice, with sensitivity and specificity against self-report in the 0.5 to 0.7 range. While sensitivity for screening in practice may be too low, a cut-off of 4 is reasonable to indicate probable pain in research.

Spanish adaptation and validation of the Pain Assessment Scale in Advanced Dementia (PAINAD) in patients with dementia and impaired verbal communication: cross-sectional study

ObjectivesThe aim of this study was to adapt and validate the Pain Assessment in Advanced Dementia (PAINAD) scale in Spanish.DesignCross-sectional observational study.SettingTwo health districts of Andalusian provinces, located in the...

Correlation between Biomarkers of Pain in Saliva and PAINAD Scale in Elderly People with Cognitive Impairment and Inability to Communicate.

The pain assessment in advanced dementia (PAINAD) appears to be a clinically useful tool. However, the salivary determination of tumor necrosis factor receptor type II (sTNF-RII) and secretory IgA (sIgA) as pain biomarkers is still incipient. The aim was to correlate the PAINAD score with sTNF-RII and sIgA biomarker levels in the saliva of patients with advanced dementia. In this regard, a cross-sectional study was conducted. The sample consisted of 75 elderly patients with a clinical diagnosis of dementia and a global deterioration scale (GDS) score of 5 to 7. The PAINAD scale was determined by a previously trained professional and the collection of salivary samples was performed using the passive secretion method. Human sTNF-RII and sIgA using ELISA kits. The results showed a correlation between the PAINAD scale (numeric, binary, and recoded) and sTNF-RII and sIgA (p < 0.001). No association between the sociodemographic and clinical variables and the PAINAD scale was found (p > 0.05). Between 97.3% and 96.2% of patients with pain on the PAINAD scale also showed pain based on the sTNF-RII levels; in all of them, sIgA levels did not fit the logistic models. Therefore, the correlation highlights the usefulness of this scale and confirms the usefulness of sTNF-RII and sIgA as biomarkers of pain.

Reliability and Feasibility of the Pain Assessment in Advanced Dementia Scale–Korean Version (PAINAD-K)

BackgroundThere is currently no observational instrument for assessing pain in aged patients who are unable to provide self-report in long-term care hospitals in Korea. AimsThe goal of this research was to culturally adapt and test the validity, reliability, and feasibility of the Korean version of the Pain Assessment in Advanced Dementia Scale. DesignThis was a methodologic study aiming to translate the Pain Assessment in Advanced Dementia Scale. Participants/SubjectsThe inpatients in a 270-bed LTC hospital in D metropolitan city were assessed pain levels. MethodsThe Pain Assessment in Advanced Dementia (PAINAD) Scale was used as an observation scale to assess 192 long-term care hospital patients, with observation durations of 1 and 5 minutes. ResultsThe interrater reliability (1 minute) for the scale showed substantial kappa agreement of .62, and scores for the 1- and 5-minute observations showed almost perfect agreement of .95. The criterion validity of the scale (1 minute) was high relative to the Face-Legs-Activity-Cry-Consolability (FLACC) Scale, and low compared with the numeric rating scale (NRS). Discriminant validity was established between patients with and without pain. The feasibility of the Pain Assessment in Advanced Dementia Scale–Korean Version (PAINAD-K) (1 minute) indicated low sensitivity of 41.3% and high specificity of 92.6%. ConclusionsTherefore, the PAINAD-K is a valid and reliable tool to determine the absence of pain in non-verbal aged patients.

466 - Reliability“and Validity Study of the Thai version of the Pain Assessment in Advanced Dementia”(PAINAD-Th)

Background: Dementia is a syndrome that affects multiple cognitive domains and causes functional decline. People with dementia (PwD) often experience pain, still could not report the symptom due to the decline in cognition that leads to communication problems. Therefore, pain in PwD is often underrecognized and undertreated. Many behavioral observation tools have been developed to help identify pain in PwD; the Pain Assessment in Advanced Dementia (PAINAD) scale is one of the recommended tools to evaluate pain in PwD. The PAINAD has been translated into many languages, yet not translated into Thai language. Since there is no pain assessment tool for PwD in Thailand.Objective: This study aimed to assess the reliability"and validity of the PAINAD in Thai version (PAINAD-Th) for measuring pain in people with"PwDMaterials and Methods: The cross-cultural translation including forward translation and back-translation of PAINAD-Th were performed, then the content validity was assessed by the expert committee. Enrolled participants were inpatients aged 60 years or over, and had dementia with Functional Assessment Staging Test (FAST) of at least 6 which represented moderately severe stage. A research assistant recorded 5-minute videos of the participants, the first video was during the activity that could provoke the pain and the second video was at rest. Two trained nurses independently rated the pain of the participants by observing the videos using the PAINAD-Th to examine the inter-rater reliability and the concurrent validity of the test against the reference standard which was the numeric rating scale (NRS) rated by the expert committee. The same rating process was reproduced one week apart to explore the test-retest reliability.Results: The content validity index of the PAINAD-Th was 1.00 and 0.93 (forward and back-translation, respectively)."The inter -rater and test-retest reliability showed an excellent intra-class correlation coefficient of"0.92 and 0.96, respectively. The concurrent validity was significantly correlated with the reference standard with an excellent intra-class correlation coefficient of"0.95.Conclusions: The PAINAD-Th is a promising tool for pain evaluation in PwD as it provides an excellent concurrent validity against the reference standard. Also, it has excellent content validity, inter-rater, and test-retest reliability.

468 - Can a Robotic Seal Called PARO Manage Chronic Pain in People with Dementia Living in Nursing Homes?

AbstractObjective: To evaluate the effect of interaction with a robotic seal (PARO) for pain management in nursing home residents living with dementia.Methods: Registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12618000082202), a pilot randomized controlled trial followed by semi-structured interviews were conducted between January 2018 and January 2019. Forty-three residents aged ?65 years living with dementia and chronic pain were recruited from three nursing homes in Australia. Participants were randomized to either a PARO group (individual, non-facilitated, 30-minute sessions, five days per week for six weeks) or a usual care group using a computer-generated random number. Observational pain behaviors were rated by researchers using the Pain Assessment in Advanced Dementia (PAINAD) scale and staff-rated pain levels were measured by the numeric rating scale. Medications regularly prescribed and as needed were quantified by the Medication Quantification Scale-III (MQS-III). Generalized estimating equation model and thematic analysis were used to analyze the data.Results: Participants in the PARO group had significantly lowered level of observed pain (-0.514, 95% confidence interval [CI] -0.774 to -0.254, p&lt;0.001) and used fewer PRN medications (-1.175, 95% CI - 2.205 to -0.145, p=0.025) than those in usual care after controlling for age, gender, cognitive function and medications at baseline. There were no significant differences in staff-rated pain levels and regularly scheduled medications between the two groups. Interviews also indicated that the PARO intervention may reduce the pain experience through distraction and reminiscence of previous positive memories. Limitations of weight, voice and characteristics of PARO were identified.Conclusions and Implications: PARO shows promise in reducing pain and medications for nursing home residents living with dementia and chronic pain. This intervention might be incorporated into daily practice as an alternative to manage pain in people with dementia. Care staff need to balance the benefits and limitations of incorporating social robots into their clinical practice and residents’ individualized preferences need to be considered. Larger randomized controlled trials with longer time frames are warranted to further test the use of PARO in long-term care settings.

Pain Incidence, Treatment, and Associated Symptoms in Hospitalized Persons with Dementia

BackgroundModerate to severe pain has been frequently reported in hospitalized older adults. Pain in hospitalized persons with dementia within the context of other common symptoms, functional decline, delirium, and behavioral and psychological symptoms of dementia (BPSD), has received little attention. AimsDescribe the incidence of pain, the pharmacologic management of pain, and the association of pain with physical function, delirium, and BPSD in hospitalized persons with dementia. DesignDescriptive, cross-sectional study. SettingSix medical units in three hospitals. ParticipantsBaseline data from 299 hospitalized persons with dementia enrolled in the Family-centered Function-focused Care (Fam-FFC) cluster randomized trial. MethodsDescriptive analyses of pain used the Pain Assessment in Advanced Dementia (PAINAD) scale and the use of medication for pain management. Linear regression analyses tested relationships between pain and:1) physical function (Barthel Index), 2) delirium severity (Confusion Assessment Method Severity Short Form) and 3) BPSD severity (Neuropsychiatric Inventory- Questionnaire). ResultsThe majority of the sample was female (61.9%), non-Hispanic (98%), and Black (53.2%), with a mean age of 81.58 (SD=8.54).Of the 299 patients, 166 (56%) received pain medication. Of the 108 individuals who demonstrated pain, 40% (n=43) did not receive pain medication. When controlling for age, gender, cognition, and comorbidities, pain was significantly associated with function, delirium severity, and BPSD severity. ConclusionsResults suggest that pain may be undertreated in hospitalized persons with dementia, and should be considered upon admission to optimize function, decrease delirium, and prevent or decrease BPSD.

Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study

BackgroundIntensive care (ICU) patients’ burn pain is difficult to assess, communicate and address, risking chronic pain syndromes and psychological morbidity. AimsTo understand how the introduction of validated pain tools (Critical Care Pain Observation Tool [CPOT], Numerical Rating Scale [NRS], Pain Assessment in Advanced Dementia [PAINAD]) affected clinical judgement processes, analgesia/sedation administration and the experience of burn-injured patients. MethodsConsecutive chart review compared type and amount of analgesia/sedation administered, ventilation time and length of ICU/hospital stay between consecutive burn patients pre- and 6-months post-intervention (n=70). Analysis of 36 qualitative interviews with ICU clinicians (n=12) and burn-injured adults (n=12) pre- and post-intervention was guided by Tanner's (2006) Clinical Judgement Model. ResultsOverall, there was a significant increase in morphine (P=0.04) and propofol (P=0.04) use and a trend towards increased paracetamol (P=0.06) use post-intervention. There was a trend towards greater Midazolam use for TBSA<20% (P=0.06), and significantly increased propofol use for TBSA≥20% (P=0.03). Ventilation time and ICU/hospital length of stay were unchanged.Qualitative analysis revealed complex clinical judgement dependent on the context of the patient's situation, unit culture, background beliefs of clinicians and in knowing the patient. Whilst the CPOT and NRS enhanced analytic reasoning and pain advocacy, the PAINAD appeared redundant. ConclusionsEffective pain assessment, management and advocacy are assisted by evidence-based assessment practices.

Nursing Education Intervention Effects on Pain Intensity of Nursing Home Residents with Different Levels of Cognitive Impairment: A Cluster-Randomized Controlled Trial.

PurposePain management in nursing homes is challenging and pain prevalence remains high. The objective of this study was to improve the pain situation of nursing home residents following a nursing-related educational intervention within a cluster-randomized controlled trial (2016–2018).ParticipantsClusters were nursing homes from one nursing home operator in Bavaria, Germany. Nursing home residents who were permanently registered in the facilities, at least 60 years of age, and who themselves or their legal guardians provided informed consent were included.InterventionIn addition to the implementation of pain nurses and pain care assistants, staff of the intervention group received an educational intervention in pain management, containing classroom (quality circles) and web-based training for nurses.MethodsBased on the Mini-Mental State Examination (MMSE), residents were either interviewed (MMSE 10–30) using self-report instruments or observed (MMSE 0–9) by proxy assessment. The primary outcome in residents able to self-report was maximum pain intensity according to Brief Pain Inventory (BPI); in those not able to self-report treatment-relevant pain above cut-off (≥2) on the Pain Assessment in Advanced Dementia (PAINAD).ResultsOut of 20 randomly selected clusters, 9 nursing homes from the control, and 6 nursing homes from the intervention group participated. Multilevel linear (n=347 residents, MMSE 10–30) and logistic regression (n=222 residents, MMSE 0–9) analyses were conducted. Maximum pain intensity was higher after intervention (B=1.32, p<0.01), decreased with a better quality of life (B=−0.07, p<0.001), and was lower when dementia diagnoses were present (B=−1.12, p<0.01). PAINAD scores before and after intervention did not differ significantly (OR=0.89, p=0.724), but chances to exhibit treatment-related pain were higher with decreasing MMSE (OR=0.94, p<0.05).ConclusionWhile no significant positive intervention effect was measured, findings suggest nurses’ raised awareness towards pain management. Overall results indicate that large-scale educational interventions seem to be less effective in complex nursing home settings without also including specific individual-based intervention measures.

Deficits in pain medication in older adults with chronic pain receiving home care: A cross-sectional study in Germany.

ObjectiveTo analyze the pattern and appropriateness of pain medications in older adults receiving home care.MethodsWe performed a prospective cross-sectional study in patients ≥65 years old having chronic pain and receiving home care in Berlin, Germany. Data on prescribed pain medications were collected using self-reported information, nursing documents, and medication plans during interviews at home. Pain intensity was determined with the numeric rating scale (NRS) and the Pain Assessment In Advanced dementia (PAINAD) scale. The Pain Medication Appropriateness Scale score (SPMAS) was applied to evaluate inappropriateness (i.e. a score ≤67) of pain medication.ResultsOverall 322 patients with a mean age of 82.1 ± 7.4 years (71.4% females) were evaluated. The average pain intensity scores during the last 24 hours were 5.3 ± 2.1 and 2.3 ± 2.3 on NRS and PAINAD scale (range 0–10, respectively). Sixty (18.6%) patients did not receive any pain medication. Among the treated patients, dipyrone was the most frequently prescribed analgesic (71.4%), while 50.8% and 19.1% received systemic treatment with opioids and non-steroidal anti-inflammatory drugs, respectively. The observed median SPMAS was 47.6 (range 0–100) with 58 (18.0%) of patients achieving appropriate values. Half of the patients were treated with scheduled, while 29.9% were only treated with on-demand medications. Cognitive status had no effect on appropriateness of pain treatment.ConclusionsWe observed substantial deficits in dosing patterns and appropriateness of pain medication in older adults with pain receiving home care. This applied to both patients with and without severe cognitive impairment.