PAIN MANAGEMENT

Pain Management In Elderly Patients With Dementia

Pain Management In Elderly Patients With Dementia

Introduction

The role of discomfort, both emotional and physical, is well known and accepted as an antecedent to behavioral disturbances among people with dementia (Hall & Buckwalter, 1987; Teri & Logsdon, 2000; Volicer & Hurley, 2000). The loss of ability to process, understand, and describe internal and external experiences regularly leads to behavioral expressions of distress, particularly as the disease progresses (Kovach, Weissman, Griffie, Matson, & Muchka, 2000; Volicer, 2001). Like other aging individuals, those with dementia are likely to have one or more chronic health conditions that cause pain, which, in turn, contributes to unnecessary discomfort, dysfunctional behavior, and diverse behavioral symptoms, and potential worsening of comorbid conditions. As a result, pain is an important factor to assess in older adults with dementia.

Nurses, and other allied healthcare providers that provide day-to-day care, are in key positions to facilitate accurate assessment and adequate treatment of pain, particularly among individuals in late-stage dementia who lack the ability to process their experiences and communicate needs verbally. No matter what the care setting—home, nursing home, or inpatient unit—both advanced practice and generalist nurses regularly play pivotal roles in managing complex patient care problems like pain assessment in advanced dementia. Through direct care, supervisory, educational, consultation, and interdisciplinary roles, nurses may positively influence care practice. Enhanced awareness of methods to accurately depict the pain experiences of nonverbal individuals with advanced dementia are critically important to effective care, treatment, and management across the healthcare continuum.

This review of literature highlights factors related to pain assessment among older adults with advanced dementia who are unable to communicate verbally. Background factors, including rates of pain among older adults as a group, common barriers to pain assessment among elderly, and problems inherent to usual pain assessment methods, are briefly reviewed to provide a framework for understanding pain assessment in advanced dementia. Specific problems created by dementia are then reviewed, including the need for pain definitions and methods that address the unique needs of those who are unable to communicate verbally (alternatively called nonverbal and noncommunicative throughout this paper). Seven assessment methods are reviewed, including brief discussion of items and psychometric properties. Conclusions related to possible future steps to further strengthen assessment scales and their use in practice are offered.

Articles describing pain assessment methods that did not rely on verbal report were identified as part of a larger literature review related to pain measurement among older adults (Smith, 2002: p24). Computerized literature searches of four databases (i.e., MEDLINE, CINAHL, PubMed, and EMB Reviews) used various combinations of search terms related to pain and older adults, and limited searches to older adults, research, and to a lesser extent, review articles. Narrower searches using combinations of dementia and pain focused on pain assessment methods. Assessment tools developed for use with cognitively impaired and nonverbal individuals were identified, reviewed, and included here. In addition to computerized literature searches, additional resources related to pain assessment in advanced dementia were identified via professional colleagues ...