Assessing Pain in Persons with Impaired Cognition and Communication

1. Assessing Pain in Persons with Impaired Cognition and Communication Michael Craine, Ph.D. Eastern Colorado Health Care System

2. Polytrauma • Two or more injuries to physical regions or organ systems, one of which may be life threatening. • Results in Physical, • Cognitive, • Psychological, • or Psychosocial Impairments • and Functional DisabilityVHA HANDBOOK 1172.1, 2005

3. Polytrauma • Traumatic Brain Injury frequently occurs in polytrauma in combination with: • Amputation, • Auditory impairments, • Visual impairments, • Spinal Cord Injury, • Posttraumatic Stress Disorder and other mental health conditions VHA HANDBOOK 1172.1, 2005

4. Polytrauma • Injuries often caused by an explosive blast • Primary blast injury– concussive overpressure to gas-containing organ systems: injury to lung, bowel, and inner ear, amputation • Secondary blast injury – penetrating fragments and other missiles can cause head and soft tissue trauma • Tertiary blast injury - displacement of the whole body by combined pressure loads (shock wave and dynamic overpressure) • Miscellaneous blast injuries - burns, crush, soft tissue, fractures, and amputations VHA HANDBOOK 1172.1, 2005

5. Polytrauma Brain Injury • 60% or more of polytrauma survivors have some degree of brain injury VHA HANDBOOK 1172.1, 2005 • Brain injury is the most frequent problem treated at Polytrauma Rehabilitation Centers • Injury to the brain primarily guides the course of rehabilitation

7. Polytrauma Brain Injury http://www.neuroskills.com/ceumenu.shtml

8. Polytrauma Brain Injury • Brain Injury Symptoms include: • Attention and Concentration Deficit • Memory Problems • Problems with New Learning • Problems in Higher Order Reasoning • Impaired Problem-solving • Reduced Cognitive Flexibility

9. Polytrauma and Pain • Pain is a multidimensional phenomenon • Unpleasant sensory experience • Emotional suffering • Commonly associated with disability and emotional distress • Pain is always subjective

10. Polytrauma Pain Assessment • Effective pain management requires a comprehensive assessment • Particular challenges are associated with assessment and management of pain in the cognitively-impaired veteran, and with efforts to balance optimal pain management with rehabilitation goals VHA HANDBOOK 1172.1, 2005

11. Polytrauma Pain Assessment • Problems with attention, comprehension and memory can affect patient report • Neuropsychological and Speech/Language testing can be helpful to define patient’s abilities to provide self-report and the best way of obtaining patient report • Testing can identify specific deficits to consider when assessing pain

12. Cognitive Impairment and Pain • The inability to communicate well does not mean that a person is not experiencing pain • Patients with difficulty in communication due to cognitive impairment can suffer pain and need to be assessed • Caregivers have difficulty knowing when these patients are in pain and when they are experiencing pain relief

13. Cognitive Impairment and Pain • Impaired patient is vulnerable to under-treatment and over-treatment • Severe cognitive impairment is often associated with fewer complaints (Parmalee, 1996) • Failure to report does not mean absence of pain

14. Assessment Guidelines • Assessing Pain in the Patient with Impaired Communication: A Consensus Statement from the VHA National Pain Management Strategy Coordinating Committee • VHA Pain Management Webpage http://www1.va.gov/Pain_Management/

15. Assessment Guidelines • Pain Assessment in the Non-verbal Patient: Position Statement with Clinical Practice Recommendations • American Society for Pain Management Nursing http://www.aspmn.org/Organization/position_papers.htm

16. Assessment Guidelines • Assessment guidelines are based on studies in the elderly, children and persons who are intubated or unconscious • Younger adults with brain injuries and related pain assessment challenges have not been studied • Prevalence of pain after traumatic brain injury has been estimated at 44% or more (Martelli et al, 2004; Sherman, et al, 2006)

17. Recommendations for Assessment • Assess using multiple assessment strategies to identify presence and intensity of pain • Patient’s report of pain • Reports of patient’s pain by surrogates, caregivers • Patient’s behaviors • Physiological parameters – most useful in acute pain • Empirical analgesic trials

18. Patient’s Report of Pain • Pain is a subjective experience • Best source of pain presence and pain intensity is patient report • But remember lack of report does not mean lack of pain • Even persons with mild to moderate impairment can often learn to use self-report methods(Chibnall, 2001; Ware et al, 2006)

19. Patient’s Report of Pain • Initially try different types of pain intensity scales then consistently use one that patient prefers • Scale examples are 0-10 NRS, Wong-Baker Faces, VAS, Verbal Descriptor Scales, vertical and horizontal thermometers • Patients can improve in reporting skill with practice

20. Patient’s Report of Pain Wong-Baker FACES Pain Rating Scale Numeric Rating Scale (NRS) 0 1 2 3 4 5 6 7 8 9 10 No Pain Mild Moderate Severe Worst Possible

21. Patient’s Report of Pain • Examples of scales can be found in the Pain as the Fifth Vital Sign Toolkit and Pain Outcomes Toolkit • VHA Pain Management Webpage http://www1.va.gov/Pain_Management

22. Patient’s Report of Pain • Ask the patient for a description of pain • “Pain is what the person says it is.” (McCaffery and Pasero, 1999) • Inquire about: • sensory – pain quality • emotional – suffering, anxiety, depression • behavioral components – activity, guarding

23. Patient’s Report of Pain • Focus assessment on specific concrete, here and now experience of pain • “How much pain do you feel now?” Not “how much pain have you had the lately?” • Compare report to experiences like needle sticks that occur commonly

24. Report by Surrogates • Caregivers and family members can provide information about pain • Surrogates should be asked to describe specific behaviors • Inquire about sensory, emotional and behavioral components • Surrogates can underestimate and overestimate pain presence and intensity

25. Observation of Behaviors • Facial Expressions • Verbalizations/Vocalizations • Body movements • Interpersonal behavior change • Change in activity pattern • Mental status change – anxiety, agitation, depression (American Geriatrics Society, 2002)

26. Observation of Pain Behaviors • Patients with cognitive impairment may not show any specific behavior associated with pain • Patients with severe impairment may appear stoic when they are actually displaying a frozen mask in response to pain

27. Observation of Pain Behaviors • Pain behaviors should be assessed at rest and during movement • Pain Behaviors have not been well-examined in younger veterans with cognitive impairment

28. Physiological Parameters • Changes in vital signs can provide some indication of acute distress • Not a good indicator of chronic problem • Vital changes do not discriminate pain from other sources of distress • Absence of physiologic indicators does not mean absence of pain

29. Empirical Analgesic Trials • Use in conjunction with other assessment strategies • Consider other sources of distress that could be masked by analgesic trial • PTSD is very common in this population and should receive specific treatment • PTSD can be present even in the instance of a loss of consciousness at time of injury (Bryant et al, 1999)

30. Empirical Analgesic Trials • Consider impact of analgesic on cognitive status • Identify functional/behavioral indicators to determine efficacy • Use an adequate titration schedule (25% - 50%) to assure dose efficacy

31. Pain Assessment Tools • Numerous tools have been developed • Tools are designed for use with elderly with dementia or children • No tools have been validated for polytrauma patients with cognitive impairment • All tools need further refinement

32. Pain Assessment Tools • Noncommunicative Patient’s Pain Assessment Instrument (NOPPAIN) • Checklist of Nonverbal Pain Indicators (CNPI) • Discomfort in Dementia of Alzheimer’s Type (DS-DAT) • Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) • Doloplus 2 • Others

33. Pain Assessment Tools • There is no standardized tool based on nonverbal pain indictors that can be recommended for broad adoption in clinical practice (Herr et al, 2006) • State of the Art review of tools used with elderly with dementia is available at City of Hope Website http://www.cityofhope.org/prc/elderly.asp

34. Documentation • Only patient self-report of pain intensity can be entered in CPRS vital sign section • Pain tool scores cannot be substituted for patient self-report even if they provide a 0-10 number, e.g. PAINAD • All other pain assessment is documented in progress note with appropriate title

35. Re-Assessment • Pain assessment is an ongoing process • Pain should be re-assessed regularly with other vital signs • Pain assessment should always occur after new interventions or changes in health status

36. Polytrauma Pain • Treat the Person – Not the Pain! Dennis Turk, Ph.D. • Always address pain in context of the individual patient • This requires extra attention in cases of cognitive impairment and impaired communication.