General Guidelines for Pain Assessment in Older Adults with Cognitive Impairment
- Take into account the older adult’s history, interview information and results of physical examinations.
- Use assessment approaches that include both self-report and observational measures when possible.
- For self-reporting tools, the Numeric Rating Scale (NRS) and the Pain Thermometer should be attempted with older adults whose cognitive functioning ranges from intact to mildly or moderately impaired. The Faces Pain Scale-Revised (FPS-R) is an alternate tool that is preferred by some older adults, particularly African-Americans and Asians.
- For observational tools, the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) is recommended as a screening tool to monitor older adults for development of behaviors that may be pain-related. If pain-related behaviors have been determined, the Pain Assessment in Advanced Dementia (PAINAD) is recommended for monitoring directly observable behaviors on a regular basis in older adults with chronic pain.
- Understand that all observational tools seek to document behaviors that may be pain related. Scores generated from these instruments do not represent pain intensity, and must be interpreted at the Pain assessment during a movement (such as transferring, bathing, dressing, and ambulating) is more likely to identify an underlying persistent pain problem than observation at rest.
- Pain assessment during a movement (such as transferring, bathing, dressing, and ambulating) is more likely to identify an underlying persistent pain problem than observation at rest.
- Attempt an analgesic trial to help determine if pain is the cause of behavior that may be pain-related. If the use of analgesic medications leads to a reduction of potential behavioral indicators of pain, continue to treat the behaviors as if they are pain related.
- A comprehensive pain assessment should also include evaluations of impact of pain on related aspects of the older adult’s functioning (e.g. associated symptoms, sleep disturbance, appetite changes, physical activity changes, concentration, and relationships with others).
- Among persons with dementia, it would be important to solicit the assistance of a knowledgeable informant (hands-on caregivers, involved family/friends) to accomplish this goal and identify typical pain behaviors for the individual older adult.
- Several instruments contain items that need to be assessed over time (e.g., changes in sleeping, eating). A tool that screens for changes in behavior, such as the PACSLAC, can be helpful in monitoring these changes.
Specific Recommendations Following the Selection of Suitable Assessment Tools
- Use an individualized approach collecting baseline scores for each individual older adult.
- Solicit the assistance of knowledgeable informants when collecting observational data.
- When assessment tools are used to monitor pain levels over time, they must be used under similar circumstances each time the pain tool is completed (e.g., getting dressed in the morning or toileting before going to bed).
Adapted from: Pain Management Nursing. 2011 Dec;12(4):230-50. Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations. Herr K1, Coyne PJ, McCaffery M, Manworren R, Merkel S.