Assessing Pain in Older Adults - PowerPoint Presentation

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Assessing Pain in Older Adults

Houston Geriatric Education Center Evidence-Based Project

Sponsored

by HRSA funded – Greater Philadelphia GECSlide2

ObjectivesDescribe pain assessment techniques Review the PAIN-AD toolReview the NRS toolDiscuss the importance of re-assessment

Appreciate the need to document assessment findings regularly

Discuss pain management techniquesSlide3

General Facts About Pain-Fifth vital sign-Pain is Not a normal part of agingAlways something can be doneSlide4

Prevalence of Pain in Older AdultsPrevalence 25-50% of older community-dwelling (persistent type)50-75% of NH dwellers (persistent type)Cognitively intactSlide5

Prevalence of Pain in Older Adults with Cognitive Impairment40-70% of nursing home pts with dementia report painWhat is greatest risk for these patients?Slide6

Pain in Older Adults with Cognitive ImpairmentSlide7

Factors Contributing to the Under-Reporting of PainPain behaviors Cognitively intact – reporting? Assessed?Patient concerns Slide8

Hierarchy of Pain Assessment TechniquesPatient report Causes of pain (acute and chronic)

Pain behaviors

Surrogate report

Response to empirical therapy

IF ANY ARE PRESENT

Herr et al:, Assessment of Pain in Nonverbal Patients,

Pain Mgmt Nurs

, 2006Slide9

Indicators of PainBreathingNegative VocalizationFacial ExpressionBody LanguageConsolabilitySlide10

When to assess/observe for painAt admissionEvery shift (two times per 24 hours)After therapies (when should you see an effect?)Slide11

Numerical Rating ScaleVerbal scale-asks patients to rate pain on a scale from 0-100 is no pain10 is the worst pain they have ever had

Video Example of Using NRSSlide12
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Breathing0

Normal breathing = effortless, quiet, rhythmic (smooth) respirations

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Noisy labored breathing

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Cheyne

-Stokes respirations: rhythmic waxing and waning of breathing from very deep to shallow respirations with periods of apnea (no breathing)

Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale.

J Am Med Dir Assoc

. 2003;4:9-15.Slide14

Negative Vocalizations0

None; speech or vocalization has neutral or pleasant quality

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Low level speech with a negative or disapproving quality: muttering, mumbling, whining, grumbling, or swearing in a low volume with complaining, sarcastic or caustic tone; occasion

moan or groan

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Repeated troubled calling out: phrases or words being used over & over in tone that suggests anxiety, uneasiness, or distress

Crying: utterance of emotion accompanied by tears; may be sobbing or quiet weeping

Warden, et al,

J Am Med Dir Assoc

, 2003Slide15

Facial Expressions0

Smiling: upturned corners of the mouth, brightening of the eyes, look of pleasure/ contentment

Inexpressive: a neutral, at ease, relaxed, or blank look

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Sad: unhappy, lonesome, sorrowful, dejected look; may be tears in the eyes

Frightened: look of fear, alarm or heightened anxiety; eyes are wide open

Frown: downward turn of the corners of the mouth;

Increased facial wrinkling in the forehead and around the mouth may appear

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Facial grimacing: distorted, distressed look; brow is more wrinkled as is the area around mouth; eyes may be squeezed shut

Warden, et al,

J Am Med Dir Assoc

, 2003Slide16

Body Language0

Relaxed: calm, restful, mellow appearance; person seems to be “taking it easy”

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Distressed pacing: activity that seems unsettled

Fidgeting: restless movement; squirming about or wiggling in the chair may occur

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Rigid: stiffening of the body; arms and/or legs are tight & inflexible; trunk may appear straight and unyielding (exclude contractures)

Fists clenched: tightly closed hands; may be opened and closed repeatedly or held tightly shut

Knees pulled up: flexing legs & drawing knees toward chest

Pulling or pushing away

Striking out: hitting, kicking, grabbing, punching, biting

Warden et al.

J Am Med Dir Assoc

. 2003Slide17

Consolability0

No need to console: person appears content

1

Distracted or reassured by voice or touch: behavior stops when person is spoken to or touched,

with no indication that person is distressed

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Unable to console, distract or reassure: inability to sooth the person or stop a behavior with comforting words or actions

Warden et al.

J Am Med Dir Assoc

. 2003Slide18

Video ExampleClip One:Patient with dementia caseClip Two: Patient with dementia-particular attention to facial expressions and body languageBe mindful of one indicator being very strong, making for a stronger suspicion of pain.Slide19

Implementation Strategies Training recommendationsAware of limitationsOne piece of comprehensive assessment

Self-report elicited when possible

Aware of pt specific behaviors/atypical

Strategies for tool use

Serial observations

Observe during movement

System level support

Integrate with EMR

Institutional policies

Staff education

Herr et al.,

J Gerontol Nsg

, 2010Slide20

Pain ManagementFull assessment of pain ratingOver or under-reporting pain?more in-depth investigationPain history (cause)Family membersDepression screeningSlide21

Pain Management in Cognitively ImpairedDifferentiate - pain, depression & cognitive impairmentScheduled pain medications surgeryDelirium Slide22

Implications of Untreated PainDepressionPhysical functioningSocializationAppetiteQuality of lifeSlide23

Implications of Untreated PainAlso, cognitively impaired also exhibit:Resistance during caregivingMore moaning, groaning, grimacingPossible hitting, pushing awaySlide24

Non-pharmacological Treatment of PainOpiate, addiction, side effect fearsModify care practices Especially with cognitively impaired who need help with ADLsDistractionsHot/cold packsMassage

AcupunctureSlide25

Pharmacological Treatment of PainEducation side-effects dosage safetyNarcoticsAdjuvant therapyAnti-depressants

PolypharmacySlide26

Pain Medication GuidelinesWhen do we medicate? How do we medicate? Standardized ordersPre-medicate Slide27

Importance of Interdisciplinary Team in Pain ManagementRolesNurse (assessing and documenting pain)Social workerPTOT

Recreational therapist

Physician

Pharmacist

Imperative to education of patientSlide28

Importance of Follow-Up Documentation“patient had 8/10 PAIN-AD, 0.2mg Dilaudid IV (or morphine 5mg SL) administered”  30 minutes later the response should be addressed and measurable as documented by “patient’s pain improved to 3/10 on PAIN-AD” Slide29

ExamplesSlide30

Additional Resourcescompanion articlesNYU-Hartford Institute web sitewww.ConsultGeriRN.orgSlide31

Thank you!