Current Trends in Pain Research: Assessing Pain in Patients With Cognitive Impairments
RESEARCH CORNER Edited by Patricia Beat Reisinger, MS, CRRN, FNP-C
Introduction
As spinal cord injury (SCI) nurses we need to be aware of the cognitive impairments in relation to our SCI patient population. Cognitive impairments will be discussed in this article in the form of brain injury and dementia.
Twenty eight percent of patients with SCI have at least a minor brain injury with loss of consciousness, whereas 11.5% have a brain injury severe enough to demonstrate cognitive or behavioral changes (Go, De Vivo, & Richards, 1995). Fifteen percent of the US population over 85 years of age meets the criteria for dementia. Aging with SCI has been discussed in the literature at length in terms of physical wear and tear, but not specifically addressing dementia. Life expectancies for persons with SCI have extended into the sixth and seventh decades of life (Charlifue & Lammertse, 2003). This phenomenon is due to our improved health care and renal care for the person with SCI.
These small but significant percentages of persons with SCI and cognitive impairments have special needs. One of the most significant items to assess is pain. Chronic pain has been reported in nearly four out of five persons with SCI (Bryce & Ragnarson, 2003). Pain assessment and cognitive impairments in patients with SCI are a significant challenge to the SCI nurse.
This writer interviewed Michael Craine, PhD, director of the Interdisciplinary Pain Team, Supervisory Psychologist of Health Support Services Section, and SCI and Disorders Team Psychologist at the Denver Veterans Administration (VA) Medical Center in Denver, Colorado. Craine also codeveloped Assessing Pain in the Patient with Impaired Communication: A Consensus Statement from the Veterans Health Administration (VHA) National Pain Management Strategy Coordinating Committee (2004).
Pain is a subjective experience. A patient’s self-report of pain and pain intensity is the best source of information. Craine states that, in pain assessment research, there are groups within the VA system that are working to address the difficulty of assessing pain in persons with cognitive impairments. “We as clinicians rely on self report and tools, such as the zero to ten rating scale to specify the intensity of pain. But, persons who have cognitive impairment can have difficulty with the abstract reasoning skills that are needed to convert their personal subjective experience into a number on a zero to ten scale” (personal communication, February 17, 2005).
Assessment of Pain
Assessment of pain in the patient with cognitive impairments is a formidable challenge in the pain management field. Craine emphasizes a sequential pain assessment, which includes:
• Patient’s report of pain
• Reports of patients pain by family and friends
• Patient’s behaviors
• Physiological parameters (most useful in acute pain assessment)
Patient’s Report of Pain
Efforts should be made to get a self-report of pain from the patient; this requires communication through vocal or nonvocal communication of pain and its intensity. Several studies have demonstrated that elderly patients with mild to moderate cognitive impairment can respond reliably to measures of pain intensity (VHA National Pain Management Strategy Coordinating Committee, 2004). Persons with severe cognitive impairment tend to report fewer complaints (Parmalee,1996). Nevertheless, fewer verbal complaints do not necessarily mean less pain. Failure to report pain should not be assumed to mean the absence of pain.
Reports of Patient Pain by Family, Friends or Care Providers
This assessment technique is helpful in combination with selfreportof pain and observation of the patient’s behaviors. Craine states that family members tend to rate pain intensity higher for patients and care providers tend to rate pain intensity lower.
Observation of Patient Behaviors to Assess Pain
Craine states that when a patient is unable to use a self- report method, observation of behaviors from family members or consistent caregivers can provide valuable insight such as facial expressions, verbalizations, vocalizations, body movements, changes in interpersonal interactions, changes in activity patterns or routines, and mental status changes (American Geriatric Society, 2002). Facial expressions are the best indicator of emotions. Some patients with cognitive impairment display little or no specific behaviors associated with pain due to the disorganized nature of their behavior overall.
The observed behaviors should be assessed at rest and with movement. Craine states, “A person sitting quietly may not appear to have any pain, but with movement (or transfers). . . they may then begin to show guarding or grimacing” (personal communication, February 17, 2005). It is also important to consider potential causes of distressed behavior with facial expressions and body movements other than pain. Other causes would include: infections, constipation, bladder problems, and primary mood disorders in the individual with SCI and cognitive impairment.
Empirical Trials of Analgesics
Craine emphasized that this method of assessing pain is not to be used as a first line of pain assessment for patients with cognitive impairments, but should be used in combination with other pain assessment tools. There are no tested practice protocols and it is important to consider that a person with a brain injury or dementia is more sensitive to medications. Many analgesics can negatively alter cognitive status and this should be considered during the course of any trial. Other potential types of distressed behaviors are agitation; this can be worsened by the use analgesics.
Current Pain Assessment Tools
Most pain assessment tools can be used to elicit self-report of pain in the person with cognitive impairments. Craine states that assessment reliability is increased by referencing pain questions to the patient in the here and now. It is also important to try different methods while using the same scale repeatedly over time with a patient. Most clinicians are aware of the Numeric Pain Intensity Scale (0 to 10 scale), (U.S. Department of Health and Human Services [USDHHS], 1994) and the Wong-Baker Faces Scale, (Wong & Whaley, 1986). The patient’s ability to use self-report scales can improve with practice and the clinician can assist the patient by educating the patient to get the best assessment. It is also important for the clinician to remember that the report of pain as the fifth vital sign is completely a subjective report. The clinician should avoid interpreting the pain measurement for the patient.
Current Pain Assessment Tools for the Cognitively Impaired
Craine previously mentioned that the VA currently has several Web-based reference tools to help clinicians address these issues. These tools were developed by the Veterans Health Administration (VHA) National Pain Management Strategy Coordinating Committee (2004), VHA (2000), VHA National Pain Outcomes Workgroup (2003), and the VHA Health Services Research and Development Office (2005). These tools are available on the internet at the following Web sites: http://www.va.gov/Pain_Management/; http://www.vachronicpain.org; and http://www.measure mentexperts.org/news/2005/Winter/commentary_pain.asp
Future Pain Assessment Research
Craine states that the current VA groups that are working on pain assessment in persons with cognitive impairments have done an extensive scientific literature review. All of the current studies call for more research to develop reliable and valid instruments for assessing pain in this population. “The basic idea is that patients with impaired communication suffer pain and need to be assessed, but there is a lack of established reliable measures for the assessment of pain in these [persons]” (personal communication, February 17, 2005).
References
American Geriatric Society Panel on Persistent Pain in Older Persons (2002). The management of persistent pain in older persons. Journal of the American Geriatric Society, 50, 5205-5224.
Bryce, T. N., & Ragnarsson, K. T. (2003). Pain management in persons with spinal cord disorders. In V. W. Lin (Ed.), Spinal cord medicine (pp. 441-456). New York: Demos.
Charlifue, M. A., & Lammertse, D. (2003). Spinal cord injury and aging. In V.W. Lin (Ed.), Spinal cord medicine (pp. 829-838). New York: Demos.
Department of Veterans Affairs, National Veterans Administration Pain Outcomes Working Group (2003). VHA pain outcomes toolkit. Retrieved February 22, 2005 from: http://www.vachronicpain.org
Go, B. K., De Vivo, M. D., & Richards, J. S. (1995). The epidemiology of spinal cord injury. In S. L. Stover, J. A. DeLisa, & G. G. Whiteneck (Eds.), Spinal cord injury: Clinical outcomes from the model systems (pp. 21-51). Gaithersburg, MD: Aspen.
Parmalee, P. A. (1996). Pain in cognitively impaired older persons. Clinics in geriatric medicine, 12(3), 473-488.
US Department of Health and Human Services (1994). Management of cancer pain: Clinical practice guideline. (AHCPR Publication No. 94-0592). Rockville, MD: Author.
Veterans Health Administration National Pain Management Strategy Coordinating Committee (2004). Assessing pain in the patient with impaired communication: A consensus statement. Retrieved February 22, 2005 from: http://www.vachronicpain.org/.
Veterans Health Administration, Geriatrics and extended care strategic healthcare group (2000). Pain, the 5th vital sign: Toolkit. Retrieved February 22, 2005 from: http:// www.vachronicpain.org/Downloads/pain5thvitalsignv2.PDF
VHA Health Services Research and Development Office (2005). METRIC Newsletter, Winter 2005. Retrieved February 22, 2005 from: http://www.measurement experts.org/news/2005/Winter/commentary_pain.asp.
Wong, D., & Whaley, L. (1986). Clinical handbook of pediatric nursing (2nd ed.). St. Louis: C.V. Mosby.
Patricia Beat Reisinger, MS, CRRN, FNP-C is a nurse practitioner in the Outpatient SCI/D Program at Denver VA Medical Center as part of the Eastern Colorado Health Care System, Denver, Colorado.
The editor of Research Corner welcomes your input. Please email patricia.reisinger@med.va.gov with comments, questions, or suggestions.