The Serial Trial Intervention (STI) is a research-based, systematic process used to assess and proactively treat pain in moderately to severely cognitively impaired adults who are unable to communicate effectively with providers.  Oftentimes, individuals with dementia use behaviors rather than specific verbal complaints to express the presence of a symptom or need.  These behaviors are frequently viewed negatively because of the impact on others.  When basic care such as feeding, toileting, or positioning does not resolve behaviors like calling out, crying, or aggression, a trial of analgesia may be helpful.  The STI serves as a guideline for analgesic use when other approaches, including non-pharmacological treatments, have not been effective.

Observational pain tools such as the PACSLAC or the PAINAD are essential to the documentation and monitoring of the STI. 

Serial Trial Intervention Steps

STEP 1: Physical

Begin with a physical assessment to look for bodily causes of discomfort (consider infection, dehydration, metabolic imbalance, history of painful sites, positioning needs, temperature, toileting needs, hunger, etc.).  If a problem is identified, appropriate treatment(s) are initiated that target the identified problem.  All assessment findings and interventions should be documented and care planned appropriately.  If the behavior continues, or if there was a negative physical assessment, proceed to Step 2. 

STEP 2: Affective

Conduct an affective needs assessment to determine emotional causes of distress (recent loss, environment change, decreased family visits, anniversaries, etc.).  If you identify a problem, initiate appropriate treatment(s) such as increased social interaction or activities or spiritual care visits.  All assessment findings and interventions should be documented and care planned appropriately.  If the behavior continues, or if there was a negative affective assessment, proceed to Step 3. 

STEP 3: Trial of Non-Pharmacological Comfort Treatments

Trial a series of non-pharmacological interventions such as distraction, gentle physical touch (e.g., applying lotion), warm/cold packs, or graduated physical activity.  All interventions and responses should be appropriately documented and care planned.  If they are ineffective, based on objective behavioral pain-assessment tools, proceed to Step 4. 

STEP 4: Trial of Analgesics

Trial a prescribed, scheduled analgesic for 2-3 weeks.  See Analgesic Trial document for more detail.  Document and care plan the trial secondary to noted behaviors.  If the trialed analgesic/s are ineffective, proceed to Step 5.

STEP 5: Consultation, consider Trial Psychotropic

A behavioral consultation is the next step.  If the recommendations from the consultation are reasonably implemented and documented as ineffective, repeat the series beginning at Step 1 or trial a prescribed PRN psychotropic to be given, documenting carefully using observational behavioral assessment tools.

Documentation

Documentation of manifested behaviors of concern as well as STI process is imperative.  Appropriate NANDA nursing diagnoses related to concerns of the affective (emotional) domain may be:

  1. Impaired Comfortold man
  2. Social Isolation
  3. Hopelessness
  4. Relocation Stress Syndrome
  5. Anxiety
  6. Defensive Coping
  7. Adult Failure to Thrive
  8. Fear
  9. Grieving
  10. Complicated Grieving
  11. Spiritual Distress

When pain has been identified as the causative factor of behavior changes, as evidenced by a successful analgesic trial, or improved positive behaviors following analgesic administration, appropriate nursing diagnoses may be impaired comfort, acute pain, or chronic pain.  Some facilities may find it helpful to use a documentation tool to note assessment findings and trialed interventions.  In this case, the tool PDF iconDocumenting Use of Serial Trial Intervention may prove to be helpful.

PDF iconSerial Trial Intervention - PDF Version

Reference

Kovach CR, Noonan PE, Schlidt AM, Reynolds S, Wells T. The Serial Trial Intervention: an innovative approach to meeting needs of people with dementia.  J Gerontol Nurs. 2006;32:18-36.