Assessing Pain in the Cognitively Impaired Elderly

Click the tabs below to see responses from different professionals.

In your clinical experience, what measures do you rely on to assess pain in the cognitively impaired elderly person? 

Kyle Stein, MA:

Kyle Stein is an elder protective service caseworker currently working at Ethos, Inc. in Boston, MA.

The first thing I would do with a cognitively impaired client is conduct a Mini-Mental Status Exam in order to evaluate the extent to which my client can communicate with me. I would also try to gather information from my client’s primary care physician, nurse, home health aid, or primary care giver to understand the medical conditions of my elderly client as well as the severity of his or her conditions.
Next I’ll try to use industry standard measures such as pain scales with numbers, faces, or colors to assess pain. I’ve found that cognitively impaired elders sometimes have a difficult time describing their pain. Often clients will over or underestimate their pain – the use of scales may help the client quantify his or her pain. I’ll also ask about the frequency/severity of pain from a day to day, medication compliance, things that may impact pain such as weather, and if the client has discussed his or her pain with their primary care giver. Most often, I’ll discuss the findings of my assessment with the elderly person’s primary care physician, nurse, or care giver.

It is essential when assessing pain in a cognitively impaired elderly to communicate with those who care for the patient such as their nurses, physical therapist, and occupational therapist. They will provide beneficial information about any changes in behavior of the patient or other observations. Additionally, these people will also be able to work with you to take measures to assure for the clients safety such as keeping medications in lock boxes, setting up a medication regime, obtaining an Alzheimer’s Association bracelet, and making sure that appliances aren’t left on.

In your clinical experience, what measures do you rely on to assess pain in the cognitively impaired elderly person? 

Anne Marie Kelly, RN, BSN:

Anne Marie Kelly, RN, C, BSN, BC, CHPN, is a Pain Management Educator and Consultant, Catholic Memorial Home, Fall River, MA. 

First, let me say that there is no “magic bullet” for the assessment of pain in the cognitively impaired elderly. My sense is that everyone is waiting for the perfect tool that is valid and reliable, that will pinpoint when there is pain and where that is. My belief is that we have to forge ahead with what we have now, because currently the only reliable method of assessing pain is self report, and among patients who cannot self report we have to rely on what we know currently works best.

There is ongoing research examining the various assessment tools that currently exist because this is such an important issue. At the University of Iowa Geriatric Education Center, Keela A. Herr, RN, Ph.D., Professor and Chair, Adult Gerontological Nursing, and her colleagues, are working on grant sponsored research in this area and report their findings on their website and in scholarly publications. Also, standards and position papers on treatment of cognitively impaired elders are available online from the American Geriatrics Society, the Gerontological Society of America, and the American Society for Pain Management Nursing.

While we are waiting for something better, we must rely on both the assessment tools that we deem best for the individual patient, as well as our tried and true method of careful behavioral observation recorded over time. This can be painstaking work. It is always important to establish a patient’s baseline behavior. New facilities or clinicians need to know patients’ usual behaviors and what behavioral signs mean, including how the experience of pain is displayed. The person who spends the most time with the patient is the best person to observe this and pass on the information to the rest of the team. It is important to get a report from all shifts of caretakers. This may be a family member, nurse’s aide, or home care worker, or all of the caretakers if many are involved around the clock.

All new behaviors do not correlate with pain. The elderly person may be hungry or uncomfortable. But if pain is being considered the first thing to review is their diagnosis, and what are likely sources of pain. For example, is this a patient with osteoarthritis or metastatic cancer? Some behaviors may provide good clues. Does the patient grimace and groan whenever they are turned in bed? Is the patient holding on to a knee or their side when they walk, or rubbing their back?

If pain is thought to be the cause of the behavioral change, a trial of slowly increased analgesics over time is a good way to start. Treatment with an analgesic can start during the assessment. If there is no change a psychotropic medication may be considered, but this treats the behavior, not the pain if it exists. Then, depending on the patient’s course, further diagnostic studies may need to be performed to try to find a pain source.

In your clinical experience, what measures do you rely on to assess pain in the cognitively impaired elderly person? 

Ilona Kopits MD, MPH:

Ilona Kopits MD, MPH is a geriatrics fellow at Boston Medical Center’s Geriatrics Section, Boston, MA.

In order to assess pain in a cognitively impaired elder, it is crucially important to have a discussion with the patient’s primary care giver, or someone who sees the patient regularly such as a day nurse. The care giver can provide valuable information about changes in behavior. For example, the care giver will know if the patient is not getting out of bed, or walking, or perhaps not eating as much or as often. Care givers will also have insights into which types of treatments seem to be helping, hurting, or causing side effects. Additionally, the primary care giver is most often the person that is giving the patient his or her medications. A clinician is dependent on primary care givers not only for successful assessment but also successful treatment of pain.

A thorough exam is the next step in pain assessment. Often clinicians will rely on scales with numbers, faces, or colors for a patient to rate his or her pain. Although cognitively impaired patient s can often differentiate between mild and severe pain, in my experience, these patients are unable to rate their pain on any kind of scale because following the command, “Rate your pain” is too difficult a task. Instead of using a scale, you can examine the patient in terms of maneuver. You may ask a patient to try to get up and walk across a room, for example. The way I examine a patient depends on the type of pain that they have experienced. For patients with musculoskeletal pain, I may ask them or help them to flex joints and move around. For other patients I may try strength checking. It is also important to consider any underlying issues such as osteoporosis when conducting an exam. A patient experiencing new onset back pain may actually be suffering from a vertebral fracture due to osteoporosis.

Another way to assess for pain is to look at vital signs. If a patient’s heart rate is up that might indicate that he or she is experiencing pain. For the most part, however, a discussion with the primary care giver and a thorough exam is the most reliable method for assessing pain in a cognitively impaired elder.