Objective: To develop a clinically relevant and easy to use pain assessment tool for individuals with advanced dementia of the Alzheimer type (AD) that has adequate psychometric properties. Clinical staff determined the need for this project to improve pain assessment and address a national initiative of "take 5" to assess pain routinely as the fifth vital sign. Nursing assistants provide 90% direct care to patients with AD, so if pain is to be assessed and brought to the attention of the licensed nurse for treatment, nursing assistants must be able to use an objective pain scale and record results accurately. 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. Population, Sample, Setting, Years: Inpatient Dementia Special Care Units in a Veterans Administration Medical Center. Nineteen residents with advanced AD 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 with advanced AD who were aphasic or lacked the ability to report their degree of pain who were receiving PRN pain medications were collected. Concept or Variables Studied Together or Intervention and Outcome Variable(s): Discomfort in advanced AD using the DS-DAT during concurrent validity testing and the Face, Legs, Activity, Cry, Consolability Scale (FLACC) used during the content validity phases of instrument development. Methods: Based on the literature review, related assessment tools and consultation with expert clinicians, a five-item observational tool with a range of 0-10 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. Findings: 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 DS-DAT were significantly correlated, providing evidence of construct validity. PAINAD detected statistically different scores before and after receiving a pain medication. Conclusions: The PAINAD is easy to use, valid, and reliable instrument for measurement of pain in non-communicative patients with advanced dementia. Implications: Numerous reports speak to unrecognized and untreated pain. Persons with advanced AD cannot report pain and are dependent on the observational skills of caregivers to detect pain. On January 1, 2001, the Joint Commission on Accreditation of Health Care Organizations established new pain standards requiring doctors and nurses to ask patients about their pain, measure it, and record it in their medical record for the first time ever. The PAINAD will enable clinicians to detect and treat pain, thereby improving quality of life in individuals with AD. Development and use of the PAINAD illustrates how a quality improvement project resulted in a research project that returned knowledge to clinicians at the bedside.
Supported by the Department of Veterans Affairs, Center for Excellence in Nursing Practice, Brigham and Women's Hospital, and School of Nursing, Bouve College of Health Sciences, Northeastern University, Boston, MA, and NIH (P30AG13846)
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