Anne Marie Kelly, RN, C, BSN, BC, CHPN, is a pain management educator and consultant, and a staff member at Catholic Memorial Home, Fall River, MA.

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Questions

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Evelyn Corsini:

Please describe the patients you have in mind when you talk about the cognitively impaired elder.

Anne Marie Kelly, RN: The population I am discussing here refers to cognitively impaired older adults who cannot reliably self-report pain. The inability of this population to communicate pain due to cognitive issues is a major barrier for them being adequately assessed and treated for pain. This is a growing concern as older adults represent the fastest growing segment of the total population. Previous studies have suggested that cognitively impaired elders have substantial pain that is under-treated. Statistics indicate there is a high prevalence of dementia in older adults due to Alzheimer’s disease, cerebrovascular disesases, and other disabilities that make assessment and management of pain difficult in this population.

Assessing pain adequately is the key to effective treatment. This poses a great challenge for caregivers when assessing an older adult who has no verbal or cognitive skills. In 2002, the American Geriatrics Society (AGS) published clinical practice guidelines, entitled The Management of Persistent Pain in Older Persons, which includes the assessment and management of pain in cognitively impaired older adults. In March 2006, The American Society for Pain Management Nursing will publish a position paper entitled Pain Assessment in the Non-verbal Patient. Ongoing research and education is needed in this segment of the population to achieve optimal pain management and provide adequate interventions.

EC: How do you assess pain in the cognitively impaired elder?

AMK: A multifaceted approach is recommended which includes family/caregiver input, direct observation, and evaluation of response to treatment. No objective assessment strategy is sufficient by itself. Pasero & McCaffery, 2005, and the American Geriatrics Association, 2002, recommend the following procedure when assessing pain in those who cannot self-report:

1. Document the reason a self-report cannot be elicited.

2. Identify pathological conditions/diagnoses that may cause pain, such as, chronic pain etiologies (arthritis, neuropathies), musculoskeletal and neurological disorders, acute problems (urinary tract infection, pneumonia, pressure ulcer).

3. List the behaviors indicative of pain. Behavioral assessment scales may be used, however, keep in mind that a behavioral score is not the same as a pain intensity rating. Behavioral assessment tools may be helpful to identify the presence of pain. Critique of existing nonverbal pain assessment tools indicate that there is no current tool, although some have potential, which has strong reliability and validity in clinical practice for persons with advanced dementia. (www.cityofhope.org/prc/elderly.asp)

4. Identify behaviors that caregivers and others knowledgeable about the patient may indicate pain. Some of the behaviors typically considered pain related can include facial grimacing, agitation, irritability, groaning, changes in appetite or usual activities, or unmet comfort needs (hunger, thirst, or fatigue).

5. Attempt an analgesic trial.

Pain assessment in older adults who cannot self-report should include:

1. a search for potential cause of pain/discomfort (history, physical exam)

2. direct observation of behaviors (at rest and during movement)

3. reports from family members and caregivers (nurses, CNAs, and other healthcare professionals who know the person best)

4. evaluation of the response to treatment for pain

Direct observation includes noting changes in behavior, such as sudden withdrawal in someone who is usually active, or someone quiet becoming agitated, or observing someone holding a body part. Little research supports the use of vital sign changes as physiologic indicators for identifying pain. Absence of increased vital sounds does not indicate absence of pain. The best pain reporters are caregivers and those who are most familiar with the patient’s usual behaviors and his/her response to pain. If a condition or procedure is usually painful then assume pain is present in a cognitively-impaired person and treat the pain the same as you would for any other person. If you assume pain is present, begin an analgesic trial and monitor the response to treatment.

EC: What medications can be used for pain control?

AMK: An empiric analgesic trial should be initiated if there are pathological conditions likely to cause pain or if pain behaviors continue once basic comfort needs have been attended to. Begin an analgesic trial appropriate to the estimated intensity of pain and titrate to comfort. For mild to moderate pain, a non-opioid analgesic may be given (e.g. acetaminophen ATC). If behaviors improve, assume pain was the cause and continue the analgesic. Adding appropriate non-pharmacological interventions can help with pain relief. If behaviors continue, consider a low-dose short-acting opioid (hydrocodone, oxycodone, morphine) and observe response and monitor for side effects. In older adults, start with low doses and titrate slowly.

Following a reasonable analgesic trial, more aggressive treatment approaches or psychiatric evaluation may be needed if behaviors do not improve. The use of psychotropic drugs for treating pain behaviors, prior to an analgesic trial, will not treat the pain and can produce more side effects. Use of non-pharmacologic interventions, such as exercise, relaxation, music, heat, cold, massage, distraction, are helpful in relieving pain in combination with analgesics.

EC: What are some myths about pain and cognitively impaired elders?

AMK: A common myth is that persons who are cognitively impaired are less sensitive to pain. There is no research available that substantiates this myth. Another myth is that old age and pain go hand in hand. Older adults may develop conditions or diseases that cause pain, but age in itself does not produce pain. Older adults often fear being labeled as a complainer and will not report pain, or they fear the side effects of pain medications. Many believe their pain cannot be managed and they must live with it.

EC: Where are there good resources for people who want to learn more about this topic?

AMK: Some organizations such as the American Geriatrics Society, www.americangeriatrics.org , the American Society for Pain Management Nursing, www.aspmn.org, and the American Pain Society, www.americanpainsociety.org contain helpful guidelines on their websites.

References:

American Geriatrics Society Panel on Persistent Pain in Older Persons (2002). Clinical Practice Guideline. The management of persistent pain in older persons. JAGS, 50(6), S205-S224.

Herr, K., Decker, S., & Bjoro, K (2003). State of the art review of tools for assessment of pain in nonverbal older adults. Retrieved from www.cityofhope.org/prc/elderly.asp

Herr, K., Decker, S (2004). Assessment of pain in older adults with severe cognitive impairment. Annals of Long Term care, 12(4), 46-52.

Pasero, C., McCaffery, M., (2005). No self-report means no pain-intensity rating. American Journal of Nursing, 105(3.10), 50-5.