Fast Fact and Concept #126: Pain Assessment in the Cognitively Impaired

Author(s): L. Scott Wilner, MD and Robert Arnold, MD.

The inability of cognitively impaired patients to communicate information about pain places them at high risk for inadequate pain control. Two common risk groups in palliative care include:

a) Patients with underlying brain pathology—e.g. dementia, Parkinson’s disease, stroke, developmental abnormalities; and

b) Patients receiving sedating medication—e.g. ICU patients receiving sedative/hypnotics to control anxiety/agitation from mechanical ventilation.

Recommended strategies to assess pain in these patients include the following:

• Ask the patient—many patients who appear cognitively impaired may still be able to provide useful information concerning pain;
• Interview the caregivers and family—patterns of particular behaviors may have developed that indicate pain (e.g. placing a hand on the forehead for headache);
• Review the medical record for known pain-inducing pathology (e.g. diabetic with painful neuropathy that was manifest when the patient was cognitively intact);
• Complete a physical examination and directed laboratory studies to assess for common pain-inducing problems (e.g. fracture, UTI)

In addition to these measures, clinicians should use a validated pain rating system for the cognitively impaired. Such rating systems focus the following observational items:

• facial expression
• body posture
• vocalizations
• appetite
• interactivity

Representative examples of pain rating scales for the cognitively impaired, along with background information concerning validation studies and clinical experience can be found at: http://www.healthcare.uiowa.edu/igec/tools/categoryMenu.asp?categoryID=7.

Doloplus-2 scale www.doloplus.com (1997)

• Assessment of Discomfort in Dementia Protocol (1999)
• Pain assessment in advanced dementia (2003).
• Checklist of nonverbal pain indicators (2000)
• Pain assessment for the dementing elderly (2003)
• Pain assessment for seniors with limited ability to communicate (2004)
• Abbey pain scale (2004)

To date, there are no trials comparing these different instruments. Thus, clinicians should choose one tool and use it consistently to ensure uniformity among health care providers and across shifts.

References

1. Closs SJ, Barr B, Briggs M, et al. A Comparison of Five Pain Assessment Scales for Nursing Home Residents with Varying Degrees of Cognitive Impairment. J Pain and Symptom Manage. March, 2004; 27(3); 196-205.
2. Feldt K. The Checklist of Nonverbal Pain Indicators (CNPI). Pain Manage Nursing. March, 2000; 1(1): 13-21.
3. Frampton M. Experience assessment and management of pain in people with dementia. Age and Ageing. 2003; 32(3): 248-251.

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Wilner LS and Arnold R. Fast Facts and Concepts #126: Pain assessment in the cognitively impaired. November 2004. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 11/2004

Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Pain>evaluation; dementia

Keyword(s): Pain>evaluation

Specific Disease and Organ System Category(s): Dementia