Try This Pain Assessment Scale For People With Dementia
Try This Pain Assessment Scale For People With Dementia
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By Ann Horgas, PhD, RN, FGSA, FAAN, and Lois Miller, PhD, RN, FGSA
Pain Assessment
in People with
Dementia
Ed Eckstein
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Web Video
A Closer Look
Get more information on why its important for
nurses to screen for pain in patients with dementia, as well as why the PAINAD scale is a good
tool for doing so.
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Why Assess for Pain in
Patients with Advanced
Dementia?
here is growing recognition of the problem of pain in
older adults, the effects of pain on everyday function
and quality of life, and the difficulties of assessing and
managing pain in patients with dementia. Indeed, among
older adults with dementia who are in long-term care, the
prevalence of pain or potentially painful conditions is
high, with estimates ranging from 43% to 71%.2 Yet pain
is underdiagnosed and undertreated in this population.3
Older adults with advanced dementia cannot report
pain because of cognitive and verbal deficits (losses of
memory and judgment, confusion, and attention and language deficits). Instead, such patients may express pain
or discomfort through a number of behaviors, including
restless physical movements and various distressed vocalizations such as moaning and yelling. Furthermore, pain
can be exacerbated by the movement that occurs with
activities of daily living, such as bathing, dressing, and
transferring. During such activities, pain may be exhibited by other behaviors, such as resisting care, clenching
fists, grabbing the caregiver, guarding, and becoming
rigid. In addition to causing needless suffering, unrelieved pain in people with dementia can have serious
consequences, including declines in physical function,
diminished appetite, irritability, reduced participation in
social activities, and depression.2 (To see a discussion of
the need for ongoing assessment of pain in older adults,
go to http://links.lww.com/A254.
)
the patients own report of pain. (See Using PainRating Scales with Older Adults, June); to watch
the portion of the online video discussing those
scales, go to http://links.lww.com/A252. )
The PAINAD scales value is twofold. First, in
combination with other assessments (for example,
monitoring known sources of pain such as acute or
chronic conditions), the PAINAD scale can assure
the clinician that behaviors are (or are not) pain
related. Second, because behaviors that might indicate pain are not the same in all people with dementia, its useful to evaluate a patients actions in a
consistent manner using a single tool. This helps the
provider to recognize the patients unique behavioral
patterns and thereby detect changes. Its important
to remember that pain profiles will differsome
people may exhibit behaviors indicative of pain that
are not included on the PAINAD scale. Some behaviors not included are changes in interpersonal interactions (becoming withdrawn, decreasing social
interactions), changes in activity patterns (such as in
sleeping or eating), and changes in mental status (increased confusion). Its therefore important for clinicians to recognize a patients pain profile, which will
aid in the timely treatment of underlying conditions. (See Why Assess for Pain in Patients with
Advanced Dementia? at left.2,3)
ADMINISTERING THE PAINAD SCALE
An important first step for clinicians in assessing pain
in people with dementia is becoming aware of its
possible indicators; some commonly ignored behaviors in this population indicate pain. Regular use of
the PAINAD scale, along with other recommended
assessments (such as monitoring any behavioral
changes and attempting to obtain the patients report
of pain4), will increase nurses confidence in using this
tool, even though a range of behavioral cues may
indicate pain in patients with severe dementia. (To
watch the portion of the online video in which
nurses use the PAINAD scale with a patient, go to
http://links.lww.com/A253. )
Mr. Chasens pain is scored twice with the PAINAD
scale. His nurse observes him first at rest, before
breakfast, sitting in his wheelchair. She notes that his
breathing is normal and assigns a score of 0 to this
item. He remains quiet and calm, and his face is inexpressive, so she assigns a 0 to three indicators: vocalizations, consolability, and facial expression. But his
shoulders and upper body appear tense, and he fidgets with his clothes. For this, he earns a score of 1 in
the body language category.
Later in the morning, Mr. Chasens nurse observes
him as he is being transferred back to bed. (Although
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Remember . . .
its appropriate for nurses to use the PAINAD scale
while providing care, its not recommended in certain
instances. For example, when a nurse assists in a
transfer, it may be difficult for her or him to observe
and score the patients facial expression.) During the
transfer his breathing appears occasionally labored,
and he has short periods of hyperventilation; therefore, his nurse gives him a score of 1 in the breathing
category. He moans softly several times, earning a
score of 1 in the vocalizations category. His face
remains inexpressive, so he is given a score of 0 in the
facial expressions category, but he receives a score of
2 in body language after he violently strikes out with
clenched fists as the nurses transfer him. Finally,
because hes not reassured or distracted when a nurse
touches him on the arm and speaks softly to him, he
receives a score of 2 in consolability.
Challenges that may arise. It may be difficult to
determine whether a particular behavior is related
to pain or to something else, such as anxiety or
being too cold. Some behaviors may be inconsistent
or very subtle; detecting subtle changes may require
nurses to get to know the patient better by observing her or him at different times over the course of
several days. (For a more in-depth discussion, see
Behaviors Associated with Dementia, A New Look
at the Old, July 2005.)
SCORING AND INTERPRETING THE RESULTS
Using the definitions provided in the tool, raters assign
a score (ranging from 0 to 2) for each of the five areas
assessed. These five scores are then totaled; the final
score will range from 0 to 10, with 0 indicating no
pain and 10 indicating severe pain. No interpretation
of the intermediate scores is provided. Any item
scored as 1 or 2 indicates that the person is in some
type of pain or discomfort and should be followed up
with additional assessments.
The creators of the PAINAD scale have given no
specific guidance on the treatment of pain according
to each score. The soundness of using a 0-to-10
behavioral scale to rate the severity of pain has not
been established.5 At the most general level, a score
of 1 would indicate mild pain and a score of 10
would indicate severe pain. Mild pain (a total score
of 1 or 2) warrants comfort measures (such nonpharmacologic approaches as repositioning or distraction, or a mild analgesic such as acetaminophen);
moderate-to-severe pain (a total score of 5 to 10)
warrants stronger analgesia, such as an opioid, as
well as comfort measures.
The American Society for Pain Management
Nursings Task Force on Pain Assessment in the
Nonverbal Patient recommends a comprehensive,
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Watch It!
o to http://links.lww.com/A251 to see how nurses assess
older adults for pain. To watch a nurse use the Pain
Assessment in Advanced Dementia scale, go to
http://links.lww.com/A253. Then watch the health care team
plan preventive strategies.
View the video in its entirety and then apply for CE credit
at www.nursingcenter.com/AJNolderadults; click on the How
to Try This series link. All videos are free and in a downloadable format (not streaming video) that requires Windows
Media Player.
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Score
Breathing independent
of vocalization
Normal
Negative vocalization
None
Facial expression
Smiling or inexpressive
Facial grimacing.
Body language
Relaxed
Consolability
No need to console
BREATHING
1. Normal breathing is characterized
by effortless, quiet, rhythmic
(smooth) respirations.
2. Occasional labored breathing is
characterized by episodic bursts of harsh,
difficult or wearing respirations.
3. Short period of hyperventilation is
characterized by intervals of rapid, deep
breaths lasting a short period of time.
4. Noisy labored breathing is characterized by
negative sounding respirations on
inspiration or expiration. They may be loud,
gurgling, or wheezing. They appear
strenuous or wearing.
5. Long period of hyperventilation is
characterized by an excessive rate and
depth of respirations lasting a
considerable time.
6. Cheyne-Stokes respirations are
characterized by rhythmic waxing and
waning of breathing from very deep to
shallow respirations with periods of apnea
(cessation of breathing).
NEGATIVE VOCALIZATION
1. None is characterized by speech or
vocalization that has a neutral or
pleasant quality.
2. Occasional moan or groan is characterized by
mournful or murmuring sounds, wails or
laments. Groaning is characterized by louder
than usual inarticulate involuntary sounds,
often abruptly beginning and ending.
3. Low level speech with a negative or
disapproving quality is characterized by
muttering, mumbling, whining, grumbling,
or swearing in a low volume with a
complaining, sarcastic or caustic tone.
4. Repeated troubled calling out is
characterized by phrases or words being
used over and over in a tone that suggests
anxiety, uneasiness, or distress.
Total**
Reprinted from Journal of the American Medical Directors Association, 4(1), 9-15. Warden, V., Hurley, A.C., & Volicer, L. Development and psychometric
evaluation of the pain assessment in advanced dementia (PAINAD) Scale.
Copyright (2003), with permission from American Medical Directors Association.
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Mr. Chasen, continued. Over a period of several
weeks, the nurses loosely followed the World Health
Organizations three-step analgesic ladder for the
treatment of cancer painnonopioids as the first
step, followed by mild opioids and then stronger opioids. Once Mr. Chasen was receiving 15 mg of longacting morphine twice daily, he began to wheel
himself around the nursing home again. His aggressive behaviors stopped, and his hands and arms
relaxed. He was assessed with the PAINAD scale
once a day, and his caregivers learned to monitor his
behaviors in relation to the time since his previous
cortisone injection. They moved his legs more slowly
and with greater gentleness when providing care. If
he resisted and pushed the caregivers away, they
stopped what they were doing and allowed him to
remain in bed. There was a standing order for extra
analgesia at such times, after which they would
approach him again.
CONSIDER THIS
What evidence shows that the PAINAD scale identifies patients in pain? There are several published
tools for assessing pain in people with dementia.
The PAINAD scale is one of the most appropriate
for use in people with advanced dementia because
the behavioral indicators reflect those seen in this
population. According to the original study on the
PAINAD scale, it was moderately reliable and valid
for measuring behaviors related to pain in the people studied (in that case, elderly, white, male veterans with advanced dementia).1
Reliability. The PAINAD scale has moderate internal consistency (Cronbachs coefficients ranging
from 0.30 to 0.83).1 This indicates that the five
behaviors assessed are moderately associated with
one another when the instrument is used in people
with advanced dementia. With an objective measure of pain, interrater reliability (the extent to
which two or more raters agree when using the
tool) is very important. Interrater reliability for
the PAINAD scale was assessed during different
activities (pleasant versus unpleasant ones), and
reliability coefficients were moderately high during
pleasant (r = 0.93 to 0.97) and unpleasant (r = 0.82
to 0.90) activities.
Validity. Establishing the validity of an observational tool for pain, such as the PAINAD scale, is
difficult because people with dementia can neither
verify what their behaviors mean nor respond to
other tools for concurrent validity (other instruments measuring pain) and divergent validity (other
instruments measuring similar, yet different conditions such as depression). The PAINAD scale, like
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more detailed assessments of changes in usual activities and behaviors, may be more applicable for people with mild dementia.
Ann Horgas is associate professor and associate dean for
research at the University of Florida College of Nursing in
Gainesville. Lois Miller is a professor at the Oregon Health
and Science University School of Nursing in Portland. The
authors of this article have no significant ties, financial or
otherwise, to any company that might have an interest in the
publication of this educational activity. Contact author: Ann
Horgas, [email protected].
How to Try This is a three-year project funded by a grant
from the John A. Hartford Foundation to the Hartford
Institute for Geriatric Nursing at New York Universitys
College of Nursing in collaboration with AJN. This initiative
promotes the Hartford Institutes geriatric assessment tools,
Try This: Best Practices in Nursing Care to Older Adults:
www.hartfordign.org/trythis. The series will include articles
and corresponding videos, all of which will be available for
free online at www.nursingcenter.com/AJNolderadults.
Nancy A. Stotts, EdD, RN, FAAN (nancy.stotts@nursing.
ucsf.edu), and Sherry A. Greenberg, MSN, GNP-BC (sherry@
familygreenberg.com), are coeditors of the print series. The articles and videos are to be used for educational purposes only.
Routine use of Try This tools or approaches may require
formal review and approval by your employer.
REFERENCES
1. Warden V, et al. Development and psychometric evaluation
of the Pain Assessment in Advanced Dementia (PAINAD)
scale. J Am Med Dir Assoc 2003;4(1):9-15.
2. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr
Soc 2002;50(6 Suppl):S205-S224.
3. Horgas AL, Tsai PF. Analgesic drug prescription and use in
cognitively impaired nursing home residents. Nurs Res
1998;47(4):235-42.
4. Herr K, et al. Pain assessment in the nonverbal patient:
position statement with clinical practice recommendations.
Pain Manag Nurs 2006;7(2):44-52.
5. Herr K, et al. Tools for assessment of pain in nonverbal
older adults with dementia: a state-of-the-science review.
J Pain Symptom Manage 2006;31(2):170-92.
6. Hadjistavropoulos T, et al. An interdisciplinary expert consensus statement on assessment of pain in older persons.
Clin J Pain 2007;23(1 Suppl):S1-S43.
7. Talerico KA, et al. Psychosocial approaches to prevent and
minimize pain in people with dementia during morning
care. Alzheimers Care Quarterly 2006;7(3):163-74.
8. Miller LL, et al. Development of an intervention to reduce
pain in older adults with dementia: challenges and lessons
learned. Alzheimers Care Quarterly 2005;6(2):154-67.
9. Horgas AL, et al. Assessing pain in persons with dementia:
relationships among the non-communicative patients pain
assessment instrument, self-report, and behavioral observations. Pain Manag Nurs 2007;8(2):77-85.
10. Zwakhalen SM, et al. The psychometric quality and clinical
usefulness of three pain assessment tools for elderly people
with dementia. Pain 2006;126(1-3):210-20.
11. Costardi D, et al. The Italian version of the pain assessment
in advanced dementia (PAINAD) scale. Arch Gerontol
Geriatr 2007;44(2):175-80.
12. Schuler MS, et al. Psychometric properties of the German
Pain Assessment in Advanced Dementia Scale (PAINAD-G)
in nursing home residents. J Am Med Dir Assoc 2007;
8(6):388-95.
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