Transcript Assessing Pain in Older Adults Powerpoint

Assessing Pain in
Older Adults
Houston Geriatric Education Center Evidence-Based Project
Sponsored by HRSA funded – Greater Philadelphia GEC
Objectives
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Describe pain assessment techniques
Review the PAIN-AD tool
Review the NRS tool
Discuss the importance of re-assessment
Appreciate the need to document assessment
findings regularly
• Discuss pain management techniques
General Facts About Pain
• -Fifth vital sign
• -Pain is Not a normal part of aging
• Always something can be done
Prevalence of Pain in Older
Adults
• Prevalence
– 25-50% of older community-dwelling
(persistent type)
– 50-75% of NH dwellers (persistent type)
• Cognitively intact
Prevalence of Pain in Older Adults
with Cognitive Impairment
• 40-70% of nursing home pts with dementia
report pain
• What is greatest risk for these patients?
Pain in Older Adults with
Cognitive Impairment
Cognitive impairment
Less Pain Documented
Less Analgesic Ordered
Less Analgesic Given
Bernabei et al, 1998
Feldt & Miles, 1998
Horgas & Tsai, 1998
Morrison &Sui, 2000
Scherder et al, 1999
Sengstaken & King, 1993
Won et al, 1999
Factors Contributing to the
Under-Reporting of Pain
• Pain behaviors
• Cognitively intact – reporting? Assessed?
• Patient concerns
Hierarchy of Pain Assessment Techniques
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Patient 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, 2006
Indicators of Pain
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Breathing
Negative Vocalization
Facial Expression
Body Language
Consolability
When to assess/observe for pain
• At admission
• Every shift (two
times per 24 hours)
• After therapies
(when should you
see an effect?)
Numerical Rating Scale
• Verbal scale-asks patients to rate pain on a
scale from 0-10
• 0 is no pain
• 10 is the worst pain they have ever had
• Video Example of Using NRS
Breathing
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Normal breathing = effortless, quiet,
rhythmic (smooth) respirations
Noisy labored breathing
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.
Negative Vocalizations
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None; speech or vocalization has neutral or
pleasant quality
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
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, 2003
Facial Expressions
0
Smiling: upturned corners of the mouth, brightening of
the eyes, look of pleasure/ contentment
Inexpressive: a neutral, at ease, relaxed, or blank look
1
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
2
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, 2003
Body Language
0
Relaxed: calm, restful, mellow appearance; person seems to
be “taking it easy”
1
Distressed pacing: activity that seems unsettled
Fidgeting: restless movement; squirming about or wiggling
in the chair may occur
2
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. 2003
Consolability
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No need to console: person appears content
Distracted or reassured by voice or touch:
behavior stops when person is spoken to or
touched, with no indication that person is
distressed
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. 2003
Video Example
• Clip One:
– Patient with dementia case
• Clip Two:
– Patient with dementia-particular attention to
facial expressions and body language
Be mindful of one indicator being very strong,
making for a stronger suspicion of pain.
Implementation Strategies
• Training recommendations
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Aware of limitations
One 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, 2010
Pain Management
• Full assessment of pain rating
• Over or under-reporting pain?
– more in-depth investigation
• Pain history (cause)
• Family members
• Depression screening
Pain Management in Cognitively
Impaired
• Differentiate - pain, depression & cognitive
impairment
• Scheduled pain medications
– surgery
• Delirium
Implications of Untreated Pain
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Depression
Physical functioning
Socialization
Appetite
Quality of life
Implications of Untreated Pain
• Also, cognitively impaired also exhibit:
– Resistance during caregiving
– More moaning, groaning, grimacing
– Possible hitting, pushing away
Non-pharmacological Treatment
of Pain
• Opiate, addiction, side effect fears
• Modify care practices
– Especially with cognitively impaired who need
help with ADLs
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Distractions
Hot/cold packs
Massage
Acupuncture
Pharmacological Treatment of
Pain
• Education
– side-effects
– dosage
– safety
• Narcotics
• Adjuvant therapy
– Anti-depressants
• Polypharmacy
Pain Medication Guidelines
• When do we medicate?
• How do we medicate?
– Standardized orders
– Pre-medicate
Importance of Interdisciplinary
Team in Pain Management
• Roles
– Nurse (assessing and documenting pain)
– Social worker
– PT
– OT
– Recreational therapist
– Physician
– Pharmacist
• Imperative to education of patient
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”
Examples
Additional Resources
• companion articles
• NYU-Hartford Institute web site
– www.ConsultGeriRN.org
Thank you!