WHY: Pain in older adults is very often undertreated, and it may be especially so in older adults with severe dementia. Changes in a patient’s ability to communicate verbally present special challenges in treating pain, since self-report is considered the gold standard of pain assessment. As with all older adults, those with dementia are at risk for multiple sources and types of pain, including chronic pain from conditions such as osteoarthritis and acute pain from surgery, injury, and infection. Untreated pain in cognitively impaired older adults can delay healing, disturb sleep and activity patterns, reduce function, reduce quality of life, and prolong hospitalization

BEST TOOLS: The best tool for use in this population is a comprehensive pain assessment (Horgas, 2017) that includes self-report and objective measures of pain. Reid and colleagues (2015) provide a comprehensive protocol and geriatric pain assessment form. For patients with dementia, The American Society for Pain Management Nursing’s Task Force on Pain Assessment in the Nonverbal Patient (Herr, Coyne, et al., 2006) recommends a comprehensive, hierarchical approach to pain assessment that incorporates the following steps:

• Ask older adults with dementia about their pain. Even older adults with mild to moderate dementia can respond to simple questions about their pain. 
• Use a standardized tool to assess pain intensity, such as the numerical rating scale (NRS) (0-10) or a verbal descriptor scale (VDS) (Herr, Coyne, et al., 2006). The VDS asks participants to select a word that best describes their present pain (e.g., no pain to worst pain imaginable) and may be more reliable than the NRS in older adults with dementia.
• Use an observational tool to measure the presence of pain in older adults with dementia. Choose one and use it consistently to assess change over time.
• Ask family or usual caregivers as to whether the patient’s current behavior (e.g., crying out, restlessness) is different from their customary behavior. This change in behavior may signal pain. 
• If pain is suspected, consider a time-limited trial of an appropriate type and dose of an analgesic agent. Thoroughly investigate behavior changes to rule out other causes. Use self-report and observational pain measures to evaluate the pain before and after administering the analgesic.

TARGET POPULATION: Older adults with cognitive impairment who cannot be assessed for pain using standardized pain assessment instruments. Pain assessment in older adults with cognitive impairment is essential for both planned or emergent hospitalization. 

VALIDITY AND RELIABILITY: PAINAD: The PAINAD has an internal consistency reliability ranging from 0.50 (for behavior assessed at rest) to 0.67 (for behaviors assessed during unpleasant caregiving activities). Interrater reliability is high (r = 0.82 - 0.97). The PAINAD scale is reported to have moderate to high concurrent validity, depending on whether the patient was at rest or involved in pleasant or unpleasant activities (r = 0.76 to 0.95).MOBID-2: The MOBID-2 has demonstrated high inter- and intra-rater and test-retest reliability (Sandvik et al., 2014).  Internal consistency reliability was also high, with Cronbach’s alpha ranging from 0.82 - 0.84 (Husebo et al., 2010). Importantly, the MOBID-2 has demonstrated sensitivity to pain treatment and, to date, is the only behavioral measure to establish this important dimension of pain treatment (Husebo, Osetlo, & Strand, 2014). 

STRENGTHS AND LIMITATIONS: Pain is a subjective experience and there are no definitive, universal tests for pain. For patients with dementia, it is particularly important to know the patient and to consult with family and usual caregivers.

BARRIERS to PAIN MANAGEMENT in OLDER ADULTS with DEMENTIA: There are many barriers to effective pain management in this population. Some common myths are: pain is a normal part of aging; if a person doesn’t verbalize that they have pain, they must not be experiencing it; and that strong analgesics (e.g., opioids) must be avoided. There are also some barriers to using observational tools to assess pain in this population. Some of the PAINAD scale behaviors, such as breathing and consolability, may be difficult to assess. The MOBID-2 requires assessment during movement and caregiver must be trained in use of the tool.

SUMMARY: An effective approach to pain management in older adults with dementia is to assume that they do have pain if they have conditions and/or medical procedures that are typically associated with pain. Take a proactive approach in pain assessment and management. The use of a standardized pain assessment tool is important in measuring pain. It enables health care providers to document their assessment, measure change in pain, evaluate treatment effectiveness, and  communicate to other health care providers, the patient, and the family

MORE ON THE TOPIC:

Herr, K., Coyne, P.J., Manworren, R., McCaffery, M., Merkel, S., Peolosi-Kelly, J., Wild, L., & American Society for Pain Management Nursing. (2006). Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Management Nursing, 7(2), 44-52.

Horgas, A.L. (2017). Pain assessment in older adults. Nursing Clinics of North America, 52(3), 375-385.

Horgas, A.L. (2017). Pain management in older adults. Nursing Clinics of North America, 52(4), e1-e7.

Husebo, B.S., Strand, L.I., Moe-Nilssen, R., Husebo, S.B., & Ljunggren, A.E. (2010). Pain in older adults with severe dementia. Psychometric properties of the Mobilization-Observation-Behaviour-Intensity-Dementia (MOBID-2) Pain Scale in a clinical setting. Scandinavioal Journal of Caring Sciences, 24(2), 380-391.

Husebo, B.S., Ostelo, R., & Strand, L.I. (2014). The MOBID-2 pain scale: Reliability and responsiveness to pain in patients with dementia. European Journal of Pain, 18(10), 1419-1430. 

Reid, M.C., Eccleston, C., & Pillemer, K. (2015). Management of chronic pain in older adults. BMJ, 350, h532.

Sandvik, R.K., Selbaek, G., Seifert, R., Aarsland, D., Ballard, C., Corbett, A., & Husebo, B.S. (2014). Impact of a stepwise protocol for treating pain on pain intensity in nursing home residents with dementia: A cluster randomized trial. European Journal of Pain, 18(10), 1490-1500.

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.

Zwakhalen, S.M., van der Steen, J.T., & Najim, M.D. (2012). Which score most likely represents pain on the observational PAINAD pain scale for patients with dementia? Journal of the American Medical Director Association, 13, 384-389.