Pain Assessment In Advanced Dementia Research Articles

Development and Psychometric Evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale

To develop a clinically relevant and easy to use pain assessment tool for individuals with advanced dementia that has adequate psychometric properties. Instrument development study using expert clinicians and behavioral observation methods. Measurement of sensitivity of the instrument to detect the effects of analgesic medications in a quality improvement activity. Inpatient dementia special care units in a Veterans Administration Medical Center. Nineteen residents with advanced dementia who were aphasic or lacked the ability to report their degree of pain and six professional staff members. Additionally, data from medical records of 25 residents who were receiving pain medications as required (PRN) were collected. Based on the literature review, related assessment tools and consultation with expert clinicians, a five-item observational tool with a range of 0 to 10 was developed. The tool, Pain Assessment in Advanced Dementia (PAINAD), was compared with the Discomfort Scale and two visual analog scales (discomfort and pain) by trained raters/expert clinicians in the development study, and used for detection of analgesic efficacy in a quality improvement activity. Adequate levels of interrater reliability were achieved between dyads of the principal investigator with each clinical research rater and between two raters. PAINAD had satisfactory reliability by internal consistency with a one factor solution. PAINADthe Discomfort Scale-Dementia of Alzheimer Type (DS-DAT) were significantly correlated, providing evidence of construct validity. PAINAD detected statistically significant difference between scores obtained before and after receiving a pain medication. The PAINAD is a simple, valid, and reliable instrument for measurement of pain in noncommunicative patients. Since the patient population used for its development and testing was limited to a relatively small number of males, further research is needed before it can be universally recommended.

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

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.