E ffectiveness of a Behavior Assessment Tool to Identify Pain in Patients With Dementia

1. Effectiveness of a Behavior Assessment Tool to Identify Pain in Patients With Dementia Amy Brown, Vanessa Gonzales-Lopez, Jessica Hull, Marijo Johnson and Tai Blake Ferris State University, Big Rapids

2. Introduction • Assessing pain in person’s with dementia can prove difficult. Often Times pain can be left untreated as a result. • “Pain can be prevalent in 26-83% of nursing home patients and patients with dementia can be under-treated secondary to their inability to self-report pain” (Warden, Hurley & Volicer, 2003, p. 9).

3. Goal • To explore the literature and gain insight as to: • What Pain assessment are available? • The accuracy of pain assessments in patients with dementia. • Are patients with dementia being inadequately treated for pain due to the assessment approach.

4. Article Number 1Evaluation of a Behavioral Assessment Tool for the Individual Unable to Report Self PainHutchinson, Tucker, Kim & Gilder (2006)

5. Review of Article Number 1 • Control Group: Physicians and Nurses w/ standardized number scale (57 controls) • Variable Group: Physicians and Nurses w/ the PAINAD scale (27 variables) • Location: Post Operative Unit • Data collection: Amount of parenteral morphine equivalent • Results: Patients were treated more frequently and had less incidence of unknown pain documented than with the general numeric scale.

6. Analysis of Article Number 1 • The purpose includes the population and is written in a clear, concise statement. • Variables were identified in the introduction segment • Propositional study using quantitative research to look at pain, which is subjective in nature, utilizing a methodological approach. • Samples identified through the mini mental exam and diagnosis of dementia on a post-op unit • Results were cause and effect • Sample Sizes were small and PAINAD had previously been validated using small samples • Data was collected by the nurses and physicians through structured observation.

7. Descriptive statistics: Parenteral Morphine Equivalent (PME) and unknown pain • PME was higher in the variable group • Level of Evidence: VI • Evidence was reported in an objective manner • Less reports of unknown pain than with using the general numeric scale of 0-10

8. Article Number 2 Pain in Older Persons with Severe dementia. Psychometric Properties or the Mobilization-Observation-Behavior-Intensity-Dementia (MOBID-2) Pain Scale in a Clinical Setting Husebo, Strand, Moe-Nilssen, Husebo & Ljunggren (2009)

9. Review of Article Number 2 • Purpose: Validate the reliability of the MOBID-2 pain assessment tool and validate reliability from previous studies • Location: Nursing Home • Participants: Residents with severe dementia

10. Analysis of Article Number 2 • Informed consent was gained from participants or legal guardians • Participants decided based on age and diagnosis of severe dementia based on MMSE (Mini Mental) • Purpose statement was a clear statement but utilized technical terminology which made a hard read • Included a non-comprehensive literature review and short-comings of other similar studies • Methodological study appropriate for research questions presented • Two different nurses to assess pain

11. No control group but sampling was purposeful as each participant was evaluated prior to the study. • Participants chosen based on inclusion and exclusion criteria • Cross sectional study was used • Table with data was available for view but demographics were not • Small sample size, limits results • This research was designed to validate reliability of the tool. • The instrument was clearly discussed • Descriptive Statistics: Reliability and Validity of results obtained, clearly depicted in text and tables and do correlate • Measures of central tendency were included • Inferential Statistics: Inter-rater and test re-test reliability were high

12. Information throughout the article is not presented clearly • Relies very heavily on stats and technical language to explain results • Pain Assessment Tool is not clearly described • Fails to address short term conditions but states application of behavioral issues • Not enough evidence for application in clinical practice • Level of Evidence: VI

13. Article Number 3 Development and Psychometric Evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale Warden, Hurley, Volicer, (2003)

14. Review of Article Number 3 • Purpose: To find a time efficient and easy to understand tool to assess pain in patients that were unable to self report pain. • Control Group: Nurses trained to assess patient with dementia using the PAINAD scale • Location: Hospital dementia unit • Participants: Patients with advanced dementia • Results: PAINAD is effective to measure “pain intensity in patients who are unable to self-report pain and also recognizes good construct validity and reliability” (Warden, et al., 2003, p. 12).

15. Analysis of Article Number 3 • Hospitals IRB approved the study • Informed consent was obtained from the participants responsible parties. • An informal meeting was held to discuss the study • Purpose statement was clear and easy to understand • Extensive literature review was included along with assessments of other tools • Methodological study to evaluate the effectiveness, accuracy and ease of use of the PAINAD tool. • Participants needed to be aphasic, with a diagnosis of dementia and someone responsible for their decision making.

16. Sample size was small and two participants had deceased before the study was completed. • Assessment was completed with the patient at rest, during pleasurable activities and during activities that were more likely to cause pain. • Descriptive Statistics: Difficult to understand and the tables provided did provide more understanding • The demographics were briefly discussed, did not represent the population, and were not included in the table. • Demographics were briefly discussed, did not include the entire population and were not included in the tables • Results were all objective

17. Article Number 4 Pain Assessments in Persons with dementia: Relationship between Self-Report and Behavioral Observation Horgas, Elliott & Marsiske, (2009)

18. Review of Article Number 4 • Purpose: To determine if behavioral indicators correlate with self reported pain, therefore showing a correlation between behaviors and pain. • Control Group: Nurses trained to use PAINAD • Location: Variety of living situations • Participants: Cognitively impaired elderly adults as well as cognitively intact elderly adults, that met the following 5 criteria: • “English speaking, 65 years of age and older, be able to stand up from a chair and have osteoarthritis in their lower body” (Horgas et al., 2009, p. 127)

19. Result: Patients with dementia experienced the same amount of pain, but were less likely to verbalize. Several concepts were gained including: • Self reported pain is not a good indicator of pain in persons with dementia, assessment of pain during movement is supported, number of pain reports is linked to intensity, analgesic pain meds need to be evaluated in cognitively impaired patients.

20. Analysis of Article Number 4 • Purpose was a clear, concise statement • Clearly stated hypothesis: that pain would be underreported by cognitively impaired participants, therefore behavioral indicators would be similar for both groups despite amount of pain reported • Study questions were clear • A quasi-experimental, correlational design was used, which is appropriate to answer the research questions and draw conclusions • Target population was clearly identified as well as a comparison population.

21. Subjects were chosen from 17 facilities within central Florida and were interviewed for eligibility and cognitive status. • Pain interview was conducted prior to the study being completed to evaluate participants standings • Individual RN’s were used to assess the patients activity • Descriptive statistics that were used in the study included pain rating and number of behavioral pain indicators observed, as well as demographics, which were appropriate for the research study and clearly presented using graphs and tables. • Variability of the statistics was discussed. • Demographics not representative of the overall population • Level of Evidence: VI

22. Application of Evidence • Use of PAINAD assessment tool could be incorporated into almost any clinical setting. • A behavioral assessment tool for pain would be helpful in clinical practice • Both could prevent under-assessment of pain and ensure adequate pain management for all patients.

23. Conclusion • Evidence clearly demonstrates the need to assess patients in a holistic manner • The above studies lend reliability to the use of behavioral assessment tools to assist with identifying pain in cognitively impaired people • It is not clear whether or not this is a “better” approach to pain assessment than the numerical rating scale, but does attest to reliability of behavioral indicators to assist with the assessment of pain • Given the fact that people with dementia may or may not be able to self-report pain, it is imperative to assess the person reviewing behaviors, verbal indicators and a comprehensive review of diagnosis • People have a basis right to pain management, further studies will be helpful to determine the best approach to assess pain in the nonverbal or cognitively impaired patient • Assessing behaviors as part of a comprehensive pain assessment is supported as reliable in the above literature and should be incorporated into the comprehensive pain assessment for the cognitively impaired or nonverbal patient

24. References • Cervo, F.A., Bruckenthal, P., Chen, J.J., Bright-Long, L.E., Fields, S. Zhang, G. & Strongwater, I. (2009). Pain assessment in Nursing home resident with dementia: Psychometric properties and clinical utility of the CNA pain assessment tool (CPAT). Journal of the American Medical Directors Association, 10(9), 505-510. Doi: 10.1016/j.jamda.2009.05.011 • Horgas, A.L. (2010). Try this: best practices in nursing care to older adults. Assessing pain in older adults with dementia. MEDSURG Nursing, 19(3), 199-200. • Horgas, A.L., Elliott, A.F., & Marsiske, M. (2009). Pain assessment in persons with dementia: relationship between self-report and behavioral observation. Journal of the American Geriatrics Society, 57, 126-139. Doi:10.1111/j.1532-5415.2008.02071.x • Horgas, A. & Miller, L. (2008). Pain assessment in people with dementia. American Journal of Nursing, 108(7), 62-71. • Husebo, B.S., Strand, L.I., Moe-Nilssen, R., Husebo, S.B., & Ljunggren, A.E. (2010). Pain in older persons with severe dementia. Psychometric properties of the Mobilization-Observation-Behaviour-Intensity-Dementia (MOBID-2) Pain Scale in a clinical setting. Scandinavian Journal of Caring Sciences, 24, 380-391. Doi: 10.1111/j.1471-6712.2009.00710.x

25. Hutchison, R.W., Tucker, W.F., Kim, S. & Gilder, R. (2006). Evaluation of a behavioral assessment tool for the individual unable to self-report pain. American Journal of Hospice and Palliative Care, 23(4), 328-331. Doi: 10.1177/1049909106290244 • Lane, P., Kuntupis, M., MacDonald, S., McCarthy, P., Panke, J.A., Warden, V., & Volicer, L. (2003). A pain assessment tool for people with advanced Alzheimer’s and other progressive dementias. Home Health Nurse, 21(1), 32-37. • Leone, A.F., Standoli, F., & Hirth, V. (2009). Implementing a pain management program in long-term care facility using a quality improvement approach. Journal of the American Medical Director’s Association, 10(1), 67-73. Doi:10.1016/j.jamda.2008.08.003 • Smith, M. (2005). Pain assessment in nonverbal adults with advanced dementia. Perspectives in Psychiatric Care, 41(3), 99-113. • Warden, V., Hurley, A.C., & Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. Journal of the American Medical Directors Association, 4(1), 9-15. Doi: 10.1097/01.JAM.0000043422.31640.F7