Pain is a significant problem for many elderly adults, but remains poorly assessed and inadequately managed. Consequences of chronic pain include depression, impaired sleep, withdrawal, activity reductions, and lowered quality of life. Cognitive impairment represents a major barrier to effective pain assessment and management in the nursing home setting. Because dementia affects elders' memory and language skills, observational measures of pain are greatly needed to detect pain in this population. Pain assessment is a critical first step in effectively managing pain in this vulnerable population.
Objective: The purpose of this pilot study was to (1) examine the use of observational strategies to assess pain behaviors and (2) test the feasibility of using a naturalistic, activity-based protocol to exacerbate pain in elderly adults. Specifically, three research questions were addressed:
1. What is the prevalence and intensity of self-rated pain before, during, and after completing a standardized activity-based pain induction protocol? 2. What objective pain behaviors do participants exhibit while completing the activity protocol? 3. How does cognitive status influence self-reports of pain (presence and intensity) and objective pain behaviors? Design: A quasi-experimental design with repeated measures was used to assess pain before, during, and after an activity-based pain induction protocol.
Population, Sample, Setting, Years: The sample consisted of 14 participants with chronic pain drawn from 2 nursing homes in diverse regions of the United States. On average, the participants were about 84 years old; 7 were male and 7 were female. One half of the sample was considered to be cognitively intact (MMSE > 24) and ½ were cognitively impaired.
Concept or Variables Studied Together: Pain, pain behaviors, cognitive status.
Methods: Pain was assessed via self-report (e.g., pain presence, locations, and intensity) and observed pain behaviors (e.g., body movements and facial grimacing). Participants were asked to stand, sit, recline and walk in place for 1 minute segments to induce pain. Participants were videotaped during the study protocol. Informed consent was obtained from cognitively intact participants and legal proxies for study participation and videotaping.
Findings: The results indicated that 57% of the study participants verbally reported the presence of pain prior to the activity protocol. After each activity, the majority of participants reported pain, with walking eliciting the most intense pain. Further, the results indicated that 100% of the participants exhibited at least one pain behavior during the activity protocol. Analyses of the relationships between cognitive status, self-reported pain, and observed pain behaviors revealed no significant difference between those who were cognitively intact and those who were impaired. There was a trend, however, for cognitively impaired persons to report less pain and lower pain intensity than the intact participants. No differences in pain behaviors between the two groups emerged.
Conclusions: These findings support the use of observational strategies to assess pain in those who may be less able to verbally report its presence due to dementia. Moreover, the use of the activity-based protocol is a feasible way to induce measurable pain in elders, while at the same time being non-threatening and non-invasive.
Implications: The results of this study provide preliminary evidence to suggest that observation of pain behaviors may be a useful strategy for assessing pain in elders with and without cognitive impairment. This study, however, is limited by a small sample size. Further research is currently in progress to study this issue in a larger, more diverse population using a more refined activity protocol. If replicated, these findings may provide an important tool for assessing pain in this vulnerable population. The experience of chronic pain diminishes the health and quality of life for many elderly adults. Thus, attempts to improve pain assessment in elders with diminished cognitive capacity, with the long-term goal of improving pain management, are important in promoting health and functioning in this vulnerable population.
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