Pain In Non-communicative Patients Research Articles

Pain in non-communicative older adults beyond dementia: a narrative review.

Aging is associated with an increased risk of developing pain, especially in the presence of concurrent chronic clinical conditions. Similarly, multimorbidity can affect the perception and ability of older adults to appropriately respond to and communicate pain, and there is a clinical heterogeneity in the processing of painful sensations in different neurological conditions. The present narrative review is aimed at assessing the prevalent diseases associated with poor communication and pain in older adults, together with the available diagnostic instruments for the clinical assessment of pain in such a vulnerable population. Dementia was the most described pathology identified in the current literature associated with poor communication in older adults affected by pain, along with Parkinson's disease and stroke. Notably, a common pattern of pain behaviors in these neurological disorders also emerged, indicating potential similarities in the clinical presentation and appropriate diagnostic workout. At the same time, there are many differences in the way patients express their pain according to their main neurological pathology. In addition to this, although a plethora of observation-based tools for pain in patients with dementia have been developed, there is no gold standard, and the clinical utility of such measurements is still largely unaddressed. Meanwhile, there is substantially no standardized observation-based tool for pain in non-communicative patients with Parkinson's disease, and only a few for stroke. Overall, the present narrative review provides an update on the prevalent diseases beyond dementia associated with a communicative disability and a painful condition in older adults.

Calibration trial of an innovative medical device (NEVVA© ) for the evaluation of pain in non-communicating patients in the intensive care unit.

Pain management is an essential and complex issue for non-communicative patients undergoing sedation in the intensive care unit (ICU). The Behavioral Pain Scale (BPS), although not perfect for assessing behavioral pain, is the gold standard based partly on clinical facial expression. NEVVA© , an automatic pain assessment tool based on facial expressions in critically ill patients, is a much-needed innovative medical device. In this prospective pilot study, we recorded the facial expressions of critically ill patients in the medical ICU of Caen University Hospital using the iPhone and Smart Motion Tracking System (SMTS) software with the Facial Action Coding System (FACS) to measure human facial expressions metrically during sedation weaning. Analyses were recorded continuously, and BPS scores were collected hourly over two 8 h periods per day for 3 consecutive days. For this first stage, calibration of the innovative NEVVA© medical device algorithm was obtained by comparison with the reference pain scale (BPS). Thirty participants were enrolled between March and July 2022. To assess the acute severity of illness, the Sequential Organ Failure Assessment (SOFA) and the Simplified Acute Physiology Score (SAPS II) were recorded on ICU admission and were 9 and 47, respectively. All participants had deep sedation, assessed by a Richmond Agitation and Sedation scale (RASS) score of less than or equal to -4 at the time of inclusion. One thousand and six BPS recordings were obtained, and 130 recordings were retained for final calibration: 108 BPS recordings corresponding to the absence of pain and 22 BPS recordings corresponding to the presence of pain. Due to the small size of the dataset, a leave-one-subject-out cross-validation (LOSO-CV) strategy was performed, and the training results obtained the receiver operating characteristic (ROC) curve with an area under the curve (AUC) of 0.792. This model has a sensitivity of 81.8% and a specificity of 72.2%. This pilot study calibrated the NEVVA© medical device and showed the feasibility of continuous facial expression analysis for pain monitoring in ICU patients. The next step will be to correlate this device with the BPS scale.

Nociceptive Response Is a Possible Marker of Evolution in the Level of Consciousness in Unresponsive Wakefulness Syndrome Patients.

The Nociception Coma Scale (NCS) and its revised version (NCS-R) were used to evaluate behavioral responses to pain in non-communicative patients. We hypothesized that if patients demonstrate changes to their NCS(-R) scores over time, their evolving behavioral abilities could indicate a forthcoming diagnostic improvement with the Coma Recovery Scale-Revised (CRS-R). Forty-three Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) patients were enrolled in the study. The patients were assessed weekly using the CRS-R and NCS(-R) for four consecutive weeks. The first assessment was within 10 days after hospitalization. The assessments were performed between 09:30 and 11:30 AM in a room with constant levels of humidity, light and temperature, as well as an absence of transient noise. Noxious stimuli were administered using a Newton-meter, with pressure applied to the fingernail bed for a maximum of 5 s unless interrupted by a behavioral response from subjects. Seventeen patients demonstrated improvements in their level of consciousness, 13 of whom showed significant behavioral changes through the NCS(-R) before being diagnosed with a Minimally Conscious State (MCS) according to the CRS-R. The behavioral changes observed using the NCS(-R) corresponded to a high probability of observing an improvement from VS/UWS to MCS. To characterize the increased likelihood of this transition, our results present threshold scores of ≥5 for the NCS (accuracy 86%, sensitivity 87%, and specificity 86%) and ≥3 for the NCS-R (accuracy 77%, sensitivity 89%, and specificity 73%). In conclusion, a careful evaluation of responses to nociceptive stimuli in DOC patients could constitute an effective procedure in assessing their evolving conscious state.

Pain and Associated Neuropsychiatric Symptoms in Patients Suffering from Dementia: Challenges at Different Levels and Proposal of a Conceptual Framework.

Old age is critically associated with multi-morbidity, chronic pain, and high risk for dementia. Recognizing and treating pain is very much dependent on language comprehension and production. Both may be impaired in dementia. Moreover, neuropsychiatric symptoms may interact with pain perception. The main aims of the present article were 1) to identify key areas for future research to elucidate the relation between pain and associated neuropsychiatric symptoms in dementia, and 2) to provide a conceptual framework for ameliorating the clinical process of recognizing, assessing, and managing pain in non-communicating patients with advanced dementia.

Validity and reliability of Italian version of the Non-Communicating Children's Pain Checklist: revised version

The Non-Communicating Children Pain Check List-Revised (NCCPC-R) is a clinical assessment tool used to assess and measure pain in children aged 3 to 18 years, with mental and intellectual disabilities, incapable to speak. Aim of our study was to test the validity and reliability of the Italian version of the NCCPC-R in children with cognitive impairment, in order to obtain a valid tool for pain assessment in these children. Prospective observational study. Pediatric Outpatient of Physical and Rehabilitative Medicine Department, and Pediatrics, Child Neurology and Psychiatry Department, Sapienza University, Rome. 55 non-communicating children, with severe intellectual disability, aged 3-18 years. The guidelines for "translation, adaptation, and validation of instruments or scales for cross-cultural healthcare research" were used to translate the scale, which was administered by the parents/caregivers twice for 2 consecutive days, in association with NRS (Numerical Rating Scale). The reliability of the scale was evaluated using the intra and inter-class correlation coefficient (ICCs); Cronbach alpha coefficient was used to test the internal validity of the scale; "Receiver Operating Characteristic" (ROC) curves were used to compare pain-free scores with pain scores, determining threshold scores; Pearson correlation between NCCPC-R and NRS values was measured. The InterCC between the first and the second interviewer at T0 was 0,97, the IntraCC of the first interviewer at T0-T1 was 0,89, showing a high correlation; the Cronbach alpha coefficient at T0 was 0,97, showing a high scale's validity. Pearson correlation between NRS and NCCPC-R values at T0 was 0,54 showing a medium level of agreement (P<0,0001). AUC (area under the curve) obtained by ROC curve at T0 was 0,807 (P=0,001), with sensitivity 95,2 and specificity 55,6, while a T1 AUC was 0,814 (P<0,001), with sensitivity 86,49, specificity 78,57. The Italian version of NCCPC-R scale could be used to asses pain in non-communicating patients with mental and intellectual disabilities, showing a good correlation when compared to the NRS. The use of NCCPC-R scale in daily life made parents/caregivers able to discriminate the presence/absence of pain in non-communicating children, based on the scores obtained with the questionnaire.

Measuring Acute Pain Over Time in the Critically Ill Using the Multidimensional Objective Pain Assessment Tool (MOPAT)

Background: A valid and reliable instrument is needed to assess acute pain in critically ill patients unable to self-report and who may be transitioning between critical care and other settings. Aim: To examine the reliability, validity, and clinical utility of the Multidimensional Objective Pain Assessment Tool (MOPAT) when used over time by critical care nurses to assess acute pain in non-communicative critically ill patients. Methods: Twenty-seven patients had pain assessed at two time points (T1 and T2) surrounding a painful event for up to 3 days. Twenty-one ICU nurses participated in pain assessments and completed the Clinical Utility Questionnaire. Results: Internal consistency reliability coefficient alphas for the MOPAT were .68 at T1 and .72 at T2. Inter-rater agreement during painful procedures or turning was 68% for the behavioral dimension and 80% for the physiologic dimension. Validity was evidenced by decreases (p < .001) in the MOPAT total and behavioral and physiologic dimension scores when comparing T1 and T2. Nurses found the tool clinically useful. Conclusion: The MOPAT can be used in the critical care setting as a helpful tool to assess pain in non-communicative patients. The MOPAT is unique in that the instrument can be used over time and across settings.

Assessing Pain Using the Variation Coefficient of Pupillary Diameter.

The VCPD allows for an objective assessment of pain in laboring women. It could allow for an easy assessment of pain in noncommunicating patients: newborns or very old patients, patients with serious psychological conditions, assessment during the immediate postoperative period, or in intensive care units.

ID 61 – Electrophysiological correlates of experimental pain perception

Objective Identify pain markers remains a major scientific and medical problem. In this view, we studied the dynamics of central and autonomic responses to tonic painful stimuli. Methods Twelve healthy subjects underwent 2 tonic painful (hand electrical stimulations and 10°C water immersion) and 2 non-painful (hand 15 °C water immersion and stressful cognitive) tests during 2 min. Continuous 128 electroencephalographic (EEG) derivations, pupillary, electrodermal conductance, heart rate and blood pressure were recorded, with pain ratings. Time–frequency analyses were applied to EEG and autonomic measures. Loreta® and BESA were used to estimate the location of EEG activities. Results A significant contralateral decrease in alpha power occurred in parietal-central regions during the 2 painful but not in non-painful conditions, with involvement of somatosensory, dorsolateral and anteromedial prefrontal cortices. Electrodermal conductance and pupil dilation showed large and reproducible variations during painful and stressful non-painful conditions, while cardiovascular responses were only responsive to the latter. Conclusions These results suggest a specific electrophysiological response to experimental pain, based on the combination of EEG-alpha power decrease with electrodermal and pupil autonomic responses. Key message This work highlighted a combination of non-invasive pain markers that may be tested in various clinical settings to detect pain in non-communicative patients.

Cortical responses to salient nociceptive and not nociceptive stimuli in vegetative and minimal conscious state.

Aims: Questions regarding perception of pain in non-communicating patients and the management of pain continue to raise controversy both at a clinical and ethical level. The aim of this study was to examine the cortical response to salient visual, acoustic, somatosensory electric non-nociceptive and nociceptive laser stimuli and their correlation with the clinical evaluation.Methods: Five Vegetative State (VS), 4 Minimally Conscious State (MCS) patients and 11 age- and sex-matched controls were examined. Evoked responses were obtained by 64 scalp electrodes, while delivering auditory, visual, non-noxious electrical and noxious laser stimulation, which were randomly presented every 10 s. Laser, somatosensory, auditory and visual evoked responses were identified as a negative-positive (N2-P2) vertex complex in the 500 ms post-stimulus time. We used Nociception Coma Scale-Revised (NCS-R) and Coma Recovery Scale (CRS-R) for clinical evaluation of pain perception and consciousness impairment.Results: The laser evoked potentials (LEPs) were recognizable in all cases. Only one MCS patient showed a reliable cortical response to all the employed stimulus modalities. One VS patient did not present cortical responses to any other stimulus modality. In the remaining participants, auditory, visual and electrical related potentials were inconstantly present. Significant N2 and P2 latency prolongation occurred in both VS and MCS patients. The presence of a reliable cortical response to auditory, visual and electric stimuli was able to correctly classify VS and MCS patients with 90% accuracy. Laser P2 and N2 amplitudes were not correlated with the CRS-R and NCS-R scores, while auditory and electric related potentials amplitude were associated with the motor response to pain and consciousness recovery.Discussion: pain arousal may be a primary function also in vegetative state patients while the relevance of other stimulus modalities may indicate the degree of cognitive and motor behavior recovery. This underlines the importance of considering the potential experience of pain also in patients in vegetative state and to appropriately assess a possible treatment also in those patients.

Assessment of Acute Pain Using Physiologic Variables in Non-communicative Patients: Nurses' Perspectives (S748)

•Provide a synopsis of selected literature of physiologic variables (i.e., diaphoresis, blood pressure, heart rate, and respiratory rate) as they relate to the assessment of acute pain in adult patients who cannot self-report.•Discuss acute care nurses' use of specific physiologic variables (i.e., diaphoresis, blood pressure, heart rate, and respiratory rate) to assess pain in patients unable to self-report, including their perceptions of what constitutes significant changes indicative of acute pain. Physiologic variables (PV) believed to indicate acute pain include diaphoresis and changes in blood pressure (BP), heart rate (HR), and respirations. Nurses report using PV to help determine if patients who cannot self-report are experiencing pain, but literature is lacking. To explore how nurses use PV and PV changes to assess pain in patients unable to self-report. Two focus groups were conducted with 13 nurses at an academic medical center to elicit their experiences and opinions using PV and changes in PV to assess acute pain in patients who can't self-report. Open-ended questions and systematic probes were used until saturation was reached. Data were organized and synthesized using content analysis. When nurses noted PV changes, they said they explore and rule out other causes before attributing them to pain. They reported that changes in respiratory rate, pattern, and depth are the first and most easily observed pain-related PV. Changes in systolic BP were more relevant than changes in diastolic BP and HR changes may also be relevant. Diaphoresis was considered a late sign of uncontrolled pain. Behavioral indicators of acute pain in non-communicative patients were deemed more important than physiologic indicators. Nurses recommended using PV to help assess acute pain and pain relief. PV may add important information to the assessment of acute pain in non-communicative patients and may be useful for evaluating pain and pain relief. Although PV changes can be explained by other factors, their complimentary role to behavioral indicators needs systematic exploration.

Acute Pain Evaluation with Algoplus®Scale in Cambodian Patients

Evaluation of acute pain in patients with language barriers is often difficult during humanitarian missions. Algoplus, a behavioral scale validated for acute pain evaluation in Caucasians with verbal communication difficulties, was tested during a clinical mission in Cambodia in patients admitted to hospital for acute pain. Patients (N = 33, 19 men and 14 women [38 ± 3 years old]) suffering from acute pain were admitted to Calmette Hospital, Phnom Penh, Cambodia during June 2010. Patients spoke Khmer only; a medical trainee who did no speak Khmer performed the Algoplus scale, and a bilingual Khmer pain specialist doctor asked the patient to score pain intensity on a numerical scale (0-10). The relevance of the scale and of each item (facial expression, complaints, look, body position, and atypical behavior yes/no) was studied. Internal consistency was assessed by Cronbach alpha analysis and convergent validity by correlation coefficient. The relationship between Algoplus items and pain intensity was analysed. Pain intensity (6.3 ± 2.2) and Algoplus scores (2.1 ± 1.2) are correlated (r = 0.61, P < 0.001): increases in Algoplus are correlated to increases in pain intensity. Internal consistency is 0.51, and scales comparison per item is significant for facial expression (P = 0.028) and complaints (P = 0.005), but not for the other items. This feasibility study shows that despite a correlation with pain intensity, Algoplus may underestimate acute pain in this population. It is, however, an interesting tool for future studies to explore facial expression and complaints as proxies of pain in non-communicative patients.

Aplicación de la Escala de conductas indicadoras de dolor (ESCID) en el paciente con trauma grave no comunicativo y ventilación mecánica

ObjectiveTo assess pain in non-communicative patients with severe trauma undergoing mechanical ventilation prior to, during and after tracheal suctioning, mobilization and wound care. Material and methodA prospective and observational study from October to December 2011 was performed. Study variables were ESCID scale and monitoring of vital signs (blood pressure, heart rate, and respiratory rate). Data were gathering 5minutes before, during and 15minutes after the 3procedures. The nursing evolutive report recorded pain assessment, administration and effectiveness of the analgesia. Descriptive analysis of variables included Student's T test/ANOVA for multivariate analysis with SPSS 17.0. ResultsA hundred eighty four observations: 46.8% tracheal suctioning, 38.5% mobilization and 14.7% wound care were performed in 29 patients. ESCID score was 0.4±1 before, 3.4±2.7 during and 0.4±1 after for wound care; 0.4±1.1 before, 3.6±2.2 during and 1.1±0.5 for tracheal suctioning; 0.5±1.1 before, 3±2.8 during and 0.2±0.8 after for mobilization. These increased significantly during the performance of the 3procedures before-during/during-after: P=.000. All the hemodynamic variables were significantly modified during mobilization and tracheal suctioning: before-during/during-after: P=.000, with the exception of the cures that only affected respiratory rate. 27% of the procedures received analgesia: 9% received it before, 15% during and 3.2% after, with more analgesia being required for the wound care (33.3%). The data collected in the nursing report on the evaluation of pain/effectiveness of the analgesia showed 20.66%. ConclusionAn increase on the ESCID score was observed while performing the procedures.

Adaptación y validación de la versión española de la escala de evaluación de dolor en personas con demencia avanzada: PAINAD-Sp

IntroductionPain in elderly people is considered a major concern in nursing home facilities affecting between 49% and 83% of the residents. Progression of Alzheimer's Disease causes more communication difficulties in patients with advanced dementia and therefore more problems to understand even the most simple pain evaluation scales. Identification and implementation of appropriate pain management strategies depends on an adequate pain assessment. Material and methodsThe main objective of the study was to validate the Spanish version of the PAINAD Scale (PAINAD-Sp) and to assess its applicability in Spanish Geriatric Nursing Homes. The 20 patients diagnosed with severe dementia from a Geriatric Centre in Spain were observed by five observers with different professional profiles for 5 minutes to each participant, and PAINAD-Sp Scale was administered simultaneously to a Visual Analogical Scale-VAS. Three different observational conditions were established: resting condition, during presumably pleasant activity and during presumable painful activity. ResultsCronbach's alpha ranged between 0.467 and 0.827 (average 0.692), and rose if Breathing item was deleted. Inter-rater reliability ranged between 0.587 and 0.956. Correlation between PAINAD-Sp Scale total measures and VAS was statistically significant (P<.05) in all measures and ranged from 0.517 to 0.868. ConclusionsFindings in the study showed that the scale is useful to measure pain in non communicative patients suffering from dementia. The scale maintains good levels of reliability for different healthcare professionals even when they have little training.

Measuring Pain in Non-Communicative Patients in the Inpatient Hospice Setting: Psychometric Evaluation of the Multidimensional Objective Pain Assessment Tool (MOPAT) (SA517-A)

Measuring Pain in Non-Communicative Patients in the Inpatient Hospice Setting: Psychometric Evaluation of the Multidimensional Objective Pain Assessment Tool (MOPAT) (SA517-A)

Pain Perception in Disorders of Consciousness: Neuroscience, Clinical Care, and Ethics in Dialogue

Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal of artificial nutrition and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329–38) and end-of-life decisions (J Neurol 2010 258, 1058–65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/UWS more respondents agreed with treatment withdrawal when they considered that VS/UWS patients did not feel pain (77%) as compared to those who thought VS/UWS did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments.

Validation francophone de la grille d’évaluation de la douleur-déficience intellectuelle – version postopératoire

The aim of the study was to test the validity of a French language version of the Non-Communicating Children's Pain Checklist - Postoperative Version (NCCPC-PV): grille d'évaluation de la douleur-déficience intellectuelle (GED-DI). We assessed the intensity of pain in 87 intellectually disabled surgical patients recruited in four Canadian and French hospitals in the pre- and post-operative settings using the GED-DI, a 100-mm visual analogue pain scale (VAS) and the Rosen sedation scale. The validity of the GED-DI was measured by the difference in scores between pre- and postoperative conditions. The checklist was made up of 30 items divided into seven subgroups. Items were rated from 0 to 3 for a total score ranging from 0 to 90 points. The mean (standard deviation) age of the patients was 17 (11) yr and the mean mental age 24.5 (24) months. The total GED-DI score was 6.1 (4.9) pre- and 13.4 (11.2) post-surgery (P<0.001). All subgroups had a higher score after surgery (P<0.001). The receiver operating characteristic (ROC) curves, comparing the absence of pain to mild pain scores and moderate to severe pain scores, showed a cutoff at 6 (mild pain) and 11 (moderate to severe pain). The French version of the NCCPC-PV can be used to assess pain in non-communicating patients with intellectual disabilities in a postoperative setting. It has good content validity, as the total pre-surgery score for the GED-DI was significantly lower than the postoperative score, and showed a good concurrent validity when compared to the VAS.

Portraits of the Invisible: Faces of Urban Dying Poor (746)

acute pain in noncommunicative patients in two settings’ acute care hospital and hospice inpatient unit. Research objectives. The purpose of this presentation is to report reliability, validity, and clinical utility data from the acute care setting. Methods. The study used a cross-sectional instrument-testing design with pain ratings before and after a pain-relieving intervention. The sample was comprised of 163 hospitalized palliative care patients with painful conditions who could not self-report any aspect of their pain. Independent MOPAT ratings before and after the intervention was performed by two study nurses (SNs) or by a SN and volunteer staff nurse (VSN). VSNs completed a Clinical Utility Questionnaire (CUQ) monthly during the study. Results. Preliminary analysis indicates that percent agreement between rater pairs was 72.386.6 for SN/SN and 69.4-84.5 for SN/VSN on the BEH subscale, and 78.4-81.3 for SN/SN and 74.4e79.9 for SN/VSN on the PHY subscale. Internal consistency reliability differed by whether patients were able to vocalize sounds or not, with higher alpha coefficients on BEH for those able to vocalize (0.84). VSNs had positive perceptions of the MOPAT, with higher CUQ scores if completed within 30 days of MOPATuse. Conclusion. The preliminary analysis suggests that the MOPAT performed reasonably well. More in-depth psychometric and clinical utility analyses are underway. Implications for research, policy, or practice. A psychometrically sound and clinically useful objective measure of acute pain may help in assessing pain in noncommunicative palliative care patients across settings.

Measuring Pain in Noncommunicative Palliative Care Patients in the Acute Care Setting: Psychometric Evaluation of the Multidimensional Objective Pain Assessment Tool (MOPAT) (745)

1.Describe the process for evaluating the reliability, validity, and clinical utility of a pain assessment instrument in noncommunicative palliative care patients.2.Articulate the potential clinical uses of a pain assessment instrument for noncommunicative palliative care patients. Background. Assessing pain in acutely ill palliative care patients who cannot self-report remains a major clinical challenge. Researchers have developed behavioral and physiologic measures for such patients, but focused on single settings with patients having varying levels of cognitive impairment and self-report capability. Our multisite study evaluates the reliability, validity, and clinical utility of the MOPAT, an objective behavioral (BEH) and physiologic (PHY) measure of acute pain in noncommunicative patients in two settings’ acute care hospital and hospice inpatient unit. Research objectives. The purpose of this presentation is to report reliability, validity, and clinical utility data from the acute care setting. Methods. The study used a cross-sectional instrument-testing design with pain ratings before and after a pain-relieving intervention. The sample was comprised of 163 hospitalized palliative care patients with painful conditions who could not self-report any aspect of their pain. Independent MOPAT ratings before and after the intervention was performed by two study nurses (SNs) or by a SN and volunteer staff nurse (VSN). VSNs completed a Clinical Utility Questionnaire (CUQ) monthly during the study. Results. Preliminary analysis indicates that percent agreement between rater pairs was 72.3-86.6 for SN/SN and 69.4-84.5 for SN/VSN on the BEH subscale, and 78.4-81.3 for SN/SN and 74.4–79.9 for SN/VSN on the PHY subscale. Internal consistency reliability differed by whether patients were able to vocalize sounds or not, with higher alpha coefficients on BEH for those able to vocalize (0.84). VSNs had positive perceptions of the MOPAT, with higher CUQ scores if completed within 30 days of MOPAT use. Conclusion. The preliminary analysis suggests that the MOPAT performed reasonably well. More in-depth psychometric and clinical utility analyses are underway. Implications for research, policy, or practice. A psychometrically sound and clinically useful objective measure of acute pain may help in assessing pain in noncommunicative palliative care patients across settings.

Assessment and detection of pain in noncommunicative severely brain-injured patients

Detecting pain in severely brain-injured patients recovering from coma represents a real challenge. Patients with disorders of consciousness are unable to consistently or reliably communicate their feelings and potential perception of pain. However, recent studies suggest that patients in a minimally conscious state can experience pain to some extent. Pain monitoring in these patients is hence of medical and ethical importance. In this article, we will focus on the possible use of behavioral scales for the assessment and detection of pain in noncommunicative patients.

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

Objectives To develop a clinically relevant and easy to use pain assessment tool for individuals with advanced dementia that has adequate psychometric properties. Design 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. Setting Inpatient dementia special care units in a Veterans Administration Medical Center. Participants 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. Measurements 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. Results 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. PAINAD and the 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. Conclusions 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. 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. PAINAD and the 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.