assessing pain in persons with impaired cognition and communication michael craine, ph.d. eastern...
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Assessing Pain in Persons with Impaired Cognition
and Communication
Assessing Pain in Persons with Impaired Cognition
and Communication
Michael Craine, Ph.D.Michael Craine, Ph.D.Eastern Colorado Eastern Colorado
Health Care SystemHealth Care System
Michael Craine, Ph.D.Michael Craine, Ph.D.Eastern Colorado Eastern Colorado
Health Care SystemHealth Care System
PolytraumaPolytrauma
• Two or more injuries to physical Two or more injuries to physical regions or organ systems, one of regions or organ systems, one of which may be life threatening.which may be life threatening.
• Results in Physical,Results in Physical,• Cognitive, Cognitive, • Psychological, Psychological, • or Psychosocial Impairmentsor Psychosocial Impairments• and Functional Disabilityand Functional Disability
VHA HANDBOOK 1172.1, 2005VHA HANDBOOK 1172.1, 2005
• Two or more injuries to physical Two or more injuries to physical regions or organ systems, one of regions or organ systems, one of which may be life threatening.which may be life threatening.
• Results in Physical,Results in Physical,• Cognitive, Cognitive, • Psychological, Psychological, • or Psychosocial Impairmentsor Psychosocial Impairments• and Functional Disabilityand Functional Disability
VHA HANDBOOK 1172.1, 2005VHA HANDBOOK 1172.1, 2005
PolytraumaPolytrauma• Traumatic Brain Injury frequently Traumatic Brain Injury frequently
occurs in polytrauma in occurs in polytrauma in combination with:combination with:
• Amputation,Amputation,• Auditory impairments,Auditory impairments,• Visual impairments,Visual impairments,• Spinal Cord Injury,Spinal Cord Injury,• Posttraumatic Stress Disorder and Posttraumatic Stress Disorder and
other mental health conditions other mental health conditions VHA HANDBOOK 1172.1, 2005VHA HANDBOOK 1172.1, 2005
• Traumatic Brain Injury frequently Traumatic Brain Injury frequently occurs in polytrauma in occurs in polytrauma in combination with:combination with:
• Amputation,Amputation,• Auditory impairments,Auditory impairments,• Visual impairments,Visual impairments,• Spinal Cord Injury,Spinal Cord Injury,• Posttraumatic Stress Disorder and Posttraumatic Stress Disorder and
other mental health conditions other mental health conditions VHA HANDBOOK 1172.1, 2005VHA HANDBOOK 1172.1, 2005
PolytraumaPolytrauma• Injuries often caused by an explosive blastInjuries often caused by an explosive blast• Primary blast injury– concussive overpressure to gas-Primary blast injury– concussive overpressure to gas-
containing organ systems: injury to lung, bowel, and containing organ systems: injury to lung, bowel, and inner ear, amputationinner ear, amputation
• Secondary blast injury – penetrating fragments and Secondary blast injury – penetrating fragments and other missiles can cause other missiles can cause head and soft tissue traumahead and soft tissue trauma
• Tertiary blast injury - displacement of the whole body by Tertiary blast injury - displacement of the whole body by combined pressure loads (shock wave and dynamic combined pressure loads (shock wave and dynamic overpressure)overpressure)
• Miscellaneous blast injuries - burns, crush, soft tissue, Miscellaneous blast injuries - burns, crush, soft tissue, fractures, and amputations fractures, and amputations VHA HANDBOOK 1172.1, 2005VHA HANDBOOK 1172.1, 2005
• Injuries often caused by an explosive blastInjuries often caused by an explosive blast• Primary blast injury– concussive overpressure to gas-Primary blast injury– concussive overpressure to gas-
containing organ systems: injury to lung, bowel, and containing organ systems: injury to lung, bowel, and inner ear, amputationinner ear, amputation
• Secondary blast injury – penetrating fragments and Secondary blast injury – penetrating fragments and other missiles can cause other missiles can cause head and soft tissue traumahead and soft tissue trauma
• Tertiary blast injury - displacement of the whole body by Tertiary blast injury - displacement of the whole body by combined pressure loads (shock wave and dynamic combined pressure loads (shock wave and dynamic overpressure)overpressure)
• Miscellaneous blast injuries - burns, crush, soft tissue, Miscellaneous blast injuries - burns, crush, soft tissue, fractures, and amputations fractures, and amputations VHA HANDBOOK 1172.1, 2005VHA HANDBOOK 1172.1, 2005
Polytrauma Brain InjuryPolytrauma Brain Injury
• 60% or more of polytrauma survivors 60% or more of polytrauma survivors have some degree of brain injury have some degree of brain injury VHA HANDBOOK 1172.1, 2005VHA HANDBOOK 1172.1, 2005
• Brain injury is the most frequent Brain injury is the most frequent problem treated at Polytrauma problem treated at Polytrauma Rehabilitation CentersRehabilitation Centers
• Injury to the brain primarily guides Injury to the brain primarily guides the course of rehabilitationthe course of rehabilitation
• 60% or more of polytrauma survivors 60% or more of polytrauma survivors have some degree of brain injury have some degree of brain injury VHA HANDBOOK 1172.1, 2005VHA HANDBOOK 1172.1, 2005
• Brain injury is the most frequent Brain injury is the most frequent problem treated at Polytrauma problem treated at Polytrauma Rehabilitation CentersRehabilitation Centers
• Injury to the brain primarily guides Injury to the brain primarily guides the course of rehabilitationthe course of rehabilitation
Polytrauma Rehabilitation CentersPolytrauma Rehabilitation CentersMajor Impairment Prevalence
BrainBrain 85.5%85.5%
Fracture-MaxillofacialFracture-Maxillofacial 30.1%30.1%
Fracture-ExtremityFracture-Extremity 25.9%25.9%
Soft Tissue-WoundsSoft Tissue-Wounds 21.0%21.0%
EyeEye 15.3%15.3%
EarEar 7.9%7.9%
Peripheral NervePeripheral Nerve 6.7%6.7%
Soft Tissue-BurnsSoft Tissue-Burns 4.7%4.7%AmputationAmputation 3.1%3.1%
Polytrauma Brain InjuryPolytrauma Brain Injury
http://www.neuroskills.com/ceumenu.shtml
Polytrauma Brain InjuryPolytrauma Brain Injury
• Brain Injury Symptoms include:Brain Injury Symptoms include:– Attention and Concentration DeficitAttention and Concentration Deficit
– Memory ProblemsMemory Problems
– Problems with New LearningProblems with New Learning
– Problems in Higher Order ReasoningProblems in Higher Order Reasoning
– Impaired Problem-solvingImpaired Problem-solving– Reduced Cognitive FlexibilityReduced Cognitive Flexibility
• Brain Injury Symptoms include:Brain Injury Symptoms include:– Attention and Concentration DeficitAttention and Concentration Deficit
– Memory ProblemsMemory Problems
– Problems with New LearningProblems with New Learning
– Problems in Higher Order ReasoningProblems in Higher Order Reasoning
– Impaired Problem-solvingImpaired Problem-solving– Reduced Cognitive FlexibilityReduced Cognitive Flexibility
Polytrauma and PainPolytrauma and Pain• Pain is a multidimensional Pain is a multidimensional
phenomenonphenomenon• Unpleasant sensory experienceUnpleasant sensory experience• Emotional sufferingEmotional suffering• Commonly associated with Commonly associated with
disability and emotional distressdisability and emotional distress• Pain is always subjectivePain is always subjective
• Pain is a multidimensional Pain is a multidimensional phenomenonphenomenon
• Unpleasant sensory experienceUnpleasant sensory experience• Emotional sufferingEmotional suffering• Commonly associated with Commonly associated with
disability and emotional distressdisability and emotional distress• Pain is always subjectivePain is always subjective
Polytrauma Pain AssessmentPolytrauma Pain Assessment
• Effective pain management requires Effective pain management requires a comprehensive assessment a comprehensive assessment
• Particular challenges are associated Particular challenges are associated with assessment and management of with assessment and management of pain in the cognitively-impaired pain in the cognitively-impaired veteran, and with efforts to balance veteran, and with efforts to balance optimal pain management with optimal pain management with rehabilitation goals rehabilitation goals VHA HANDBOOK 1172.1, 2005VHA HANDBOOK 1172.1, 2005
• Effective pain management requires Effective pain management requires a comprehensive assessment a comprehensive assessment
• Particular challenges are associated Particular challenges are associated with assessment and management of with assessment and management of pain in the cognitively-impaired pain in the cognitively-impaired veteran, and with efforts to balance veteran, and with efforts to balance optimal pain management with optimal pain management with rehabilitation goals rehabilitation goals VHA HANDBOOK 1172.1, 2005VHA HANDBOOK 1172.1, 2005
Polytrauma Pain AssessmentPolytrauma Pain Assessment
• Problems with attention, comprehension Problems with attention, comprehension and memory can affect patient reportand memory can affect patient report
• Neuropsychological and Neuropsychological and Speech/Language testing can be helpful Speech/Language testing can be helpful to define patient’s abilities to provide to define patient’s abilities to provide self-report and the best way of self-report and the best way of obtaining patient reportobtaining patient report
• Testing can identify specific deficits to Testing can identify specific deficits to consider when assessing painconsider when assessing pain
• Problems with attention, comprehension Problems with attention, comprehension and memory can affect patient reportand memory can affect patient report
• Neuropsychological and Neuropsychological and Speech/Language testing can be helpful Speech/Language testing can be helpful to define patient’s abilities to provide to define patient’s abilities to provide self-report and the best way of self-report and the best way of obtaining patient reportobtaining patient report
• Testing can identify specific deficits to Testing can identify specific deficits to consider when assessing painconsider when assessing pain
Cognitive Impairment and PainCognitive Impairment and Pain
• The inability to communicate well does not The inability to communicate well does not mean that a person is not experiencing painmean that a person is not experiencing pain
• Patients with difficulty in communication Patients with difficulty in communication due to cognitive impairment can suffer pain due to cognitive impairment can suffer pain and need to be assessed and need to be assessed
• Caregivers have difficulty knowing when Caregivers have difficulty knowing when these patients are in pain and when they these patients are in pain and when they are experiencing pain reliefare experiencing pain relief
• The inability to communicate well does not The inability to communicate well does not mean that a person is not experiencing painmean that a person is not experiencing pain
• Patients with difficulty in communication Patients with difficulty in communication due to cognitive impairment can suffer pain due to cognitive impairment can suffer pain and need to be assessed and need to be assessed
• Caregivers have difficulty knowing when Caregivers have difficulty knowing when these patients are in pain and when they these patients are in pain and when they are experiencing pain reliefare experiencing pain relief
Cognitive Impairment and PainCognitive Impairment and Pain
• Impaired patient is vulnerable to Impaired patient is vulnerable to under-treatment and over-treatmentunder-treatment and over-treatment
• Severe cognitive impairment is often Severe cognitive impairment is often associated with fewer complaints associated with fewer complaints (Parmalee, 1996)(Parmalee, 1996)
• Failure to report does not mean Failure to report does not mean absence of painabsence of pain
• Impaired patient is vulnerable to Impaired patient is vulnerable to under-treatment and over-treatmentunder-treatment and over-treatment
• Severe cognitive impairment is often Severe cognitive impairment is often associated with fewer complaints associated with fewer complaints (Parmalee, 1996)(Parmalee, 1996)
• Failure to report does not mean Failure to report does not mean absence of painabsence of pain
Assessment GuidelinesAssessment Guidelines
• Assessing Pain in the Patient with Impaired Assessing Pain in the Patient with Impaired Communication: A Consensus Statement Communication: A Consensus Statement from the VHA National Pain Management from the VHA National Pain Management Strategy Coordinating CommitteeStrategy Coordinating Committee
• VHA Pain Management WebpageVHA Pain Management Webpage
http://www1.va.gov/Pain_Management/http://www1.va.gov/Pain_Management/
• Assessing Pain in the Patient with Impaired Assessing Pain in the Patient with Impaired Communication: A Consensus Statement Communication: A Consensus Statement from the VHA National Pain Management from the VHA National Pain Management Strategy Coordinating CommitteeStrategy Coordinating Committee
• VHA Pain Management WebpageVHA Pain Management Webpage
http://www1.va.gov/Pain_Management/http://www1.va.gov/Pain_Management/
Assessment GuidelinesAssessment Guidelines
•Pain Assessment in the Non-verbal Pain Assessment in the Non-verbal Patient: Position Statement with Patient: Position Statement with Clinical Practice RecommendationsClinical Practice Recommendations
•American Society for Pain American Society for Pain Management NursingManagement Nursing
http://www.aspmn.org/http://www.aspmn.org/Organization/position_papers.htmOrganization/position_papers.htm
•Pain Assessment in the Non-verbal Pain Assessment in the Non-verbal Patient: Position Statement with Patient: Position Statement with Clinical Practice RecommendationsClinical Practice Recommendations
•American Society for Pain American Society for Pain Management NursingManagement Nursing
http://www.aspmn.org/http://www.aspmn.org/Organization/position_papers.htmOrganization/position_papers.htm
Assessment GuidelinesAssessment Guidelines
•Assessment guidelines are based on Assessment guidelines are based on studies in the elderly, children and studies in the elderly, children and persons who are intubated or persons who are intubated or unconsciousunconscious
•Younger adults with brain injuries and Younger adults with brain injuries and related pain assessment challenges have related pain assessment challenges have not been studiednot been studied
•Prevalence of pain after traumatic brain Prevalence of pain after traumatic brain injury has been estimated at 44% or injury has been estimated at 44% or moremore (Martelli et al, 2004; Sherman, et al, 2006) (Martelli et al, 2004; Sherman, et al, 2006)
•Assessment guidelines are based on Assessment guidelines are based on studies in the elderly, children and studies in the elderly, children and persons who are intubated or persons who are intubated or unconsciousunconscious
•Younger adults with brain injuries and Younger adults with brain injuries and related pain assessment challenges have related pain assessment challenges have not been studiednot been studied
•Prevalence of pain after traumatic brain Prevalence of pain after traumatic brain injury has been estimated at 44% or injury has been estimated at 44% or moremore (Martelli et al, 2004; Sherman, et al, 2006) (Martelli et al, 2004; Sherman, et al, 2006)
Recommendations for AssessmentRecommendations for Assessment
•Assess using multiple assessment Assess using multiple assessment strategies to identify presence and strategies to identify presence and intensity of painintensity of pain
•Patient’s report of painPatient’s report of pain•Reports of patient’s pain by surrogates, Reports of patient’s pain by surrogates,
caregiverscaregivers•Patient’s behaviorsPatient’s behaviors•Physiological parameters – Physiological parameters –
most useful in acute painmost useful in acute pain•Empirical analgesic trialsEmpirical analgesic trials
•Assess using multiple assessment Assess using multiple assessment strategies to identify presence and strategies to identify presence and intensity of painintensity of pain
•Patient’s report of painPatient’s report of pain•Reports of patient’s pain by surrogates, Reports of patient’s pain by surrogates,
caregiverscaregivers•Patient’s behaviorsPatient’s behaviors•Physiological parameters – Physiological parameters –
most useful in acute painmost useful in acute pain•Empirical analgesic trialsEmpirical analgesic trials
Patient’s Report of PainPatient’s Report of Pain
• Pain is a subjective experiencePain is a subjective experience• Best source of pain presence and Best source of pain presence and
pain intensity is patient reportpain intensity is patient report• But remember lack of report does But remember lack of report does
not mean lack of painnot mean lack of pain• Even persons with mild to moderate Even persons with mild to moderate
impairment can often learn to use impairment can often learn to use self-report methodsself-report methods (Chibnall, 2001; Ware et al, (Chibnall, 2001; Ware et al, 2006)2006)
• Pain is a subjective experiencePain is a subjective experience• Best source of pain presence and Best source of pain presence and
pain intensity is patient reportpain intensity is patient report• But remember lack of report does But remember lack of report does
not mean lack of painnot mean lack of pain• Even persons with mild to moderate Even persons with mild to moderate
impairment can often learn to use impairment can often learn to use self-report methodsself-report methods (Chibnall, 2001; Ware et al, (Chibnall, 2001; Ware et al, 2006)2006)
Patient’s Report of PainPatient’s Report of Pain
• Initially try different types of pain Initially try different types of pain intensity scales then consistently use intensity scales then consistently use one that patient prefersone that patient prefers
• Scale examples are 0-10 NRS, Wong-Scale examples are 0-10 NRS, Wong-Baker Faces, VAS, Verbal Descriptor Baker Faces, VAS, Verbal Descriptor Scales, vertical and horizontal Scales, vertical and horizontal thermometersthermometers
• Patients can improve in reporting skill Patients can improve in reporting skill with practicewith practice
• Initially try different types of pain Initially try different types of pain intensity scales then consistently use intensity scales then consistently use one that patient prefersone that patient prefers
• Scale examples are 0-10 NRS, Wong-Scale examples are 0-10 NRS, Wong-Baker Faces, VAS, Verbal Descriptor Baker Faces, VAS, Verbal Descriptor Scales, vertical and horizontal Scales, vertical and horizontal thermometersthermometers
• Patients can improve in reporting skill Patients can improve in reporting skill with practicewith practice
Patient’s Report of PainPatient’s Report of Pain
Wong-Baker FACES Pain Rating Scale
Numeric Rating Scale (NRS)
0 1 2 3 4 5 6 7 8 9 10No Pain Mild Moderate Severe Worst Possible
Patient’s Report of PainPatient’s Report of Pain
• Examples of scales can be found in Examples of scales can be found in the the Pain as the Fifth Vital Sign ToolkitPain as the Fifth Vital Sign Toolkit and and Pain Outcomes ToolkitPain Outcomes Toolkit
• VHA Pain Management WebpageVHA Pain Management Webpage
http://www1.va.gov/http://www1.va.gov/Pain_ManagementPain_Management
• Examples of scales can be found in Examples of scales can be found in the the Pain as the Fifth Vital Sign ToolkitPain as the Fifth Vital Sign Toolkit and and Pain Outcomes ToolkitPain Outcomes Toolkit
• VHA Pain Management WebpageVHA Pain Management Webpage
http://www1.va.gov/http://www1.va.gov/Pain_ManagementPain_Management
Patient’s Report of PainPatient’s Report of Pain•Ask the patient for a description Ask the patient for a description
of painof pain•““Pain is what the person says it is.” Pain is what the person says it is.”
(McCaffery and Pasero, 1999)(McCaffery and Pasero, 1999)• Inquire about:Inquire about:
– sensory – pain qualitysensory – pain quality– emotional – suffering, emotional – suffering,
anxiety, depressionanxiety, depression– behavioral components – activity, behavioral components – activity,
guardingguarding
•Ask the patient for a description Ask the patient for a description of painof pain
•““Pain is what the person says it is.” Pain is what the person says it is.” (McCaffery and Pasero, 1999)(McCaffery and Pasero, 1999)
• Inquire about:Inquire about:– sensory – pain qualitysensory – pain quality– emotional – suffering, emotional – suffering,
anxiety, depressionanxiety, depression– behavioral components – activity, behavioral components – activity,
guardingguarding
Patient’s Report of PainPatient’s Report of Pain• Focus assessment on specific Focus assessment on specific
concrete, here and now experience of concrete, here and now experience of painpain
• ““How much pain do you feel now?” Not How much pain do you feel now?” Not “how much pain have you had the “how much pain have you had the lately?”lately?”
• Compare report to experiences like Compare report to experiences like needle sticks that occur commonlyneedle sticks that occur commonly
• Focus assessment on specific Focus assessment on specific concrete, here and now experience of concrete, here and now experience of painpain
• ““How much pain do you feel now?” Not How much pain do you feel now?” Not “how much pain have you had the “how much pain have you had the lately?”lately?”
• Compare report to experiences like Compare report to experiences like needle sticks that occur commonlyneedle sticks that occur commonly
Report by SurrogatesReport by Surrogates
• Caregivers and family members can Caregivers and family members can provide information about painprovide information about pain
• Surrogates should be asked to describe Surrogates should be asked to describe specific behaviorsspecific behaviors
• Inquire about sensory, emotional and Inquire about sensory, emotional and behavioral componentsbehavioral components
• Surrogates can underestimate and Surrogates can underestimate and overestimate pain presence and overestimate pain presence and intensityintensity
• Caregivers and family members can Caregivers and family members can provide information about painprovide information about pain
• Surrogates should be asked to describe Surrogates should be asked to describe specific behaviorsspecific behaviors
• Inquire about sensory, emotional and Inquire about sensory, emotional and behavioral componentsbehavioral components
• Surrogates can underestimate and Surrogates can underestimate and overestimate pain presence and overestimate pain presence and intensityintensity
Observation of BehaviorsObservation of Behaviors
• Facial ExpressionsFacial Expressions• Verbalizations/VocalizationsVerbalizations/Vocalizations• Body movementsBody movements• Interpersonal behavior changeInterpersonal behavior change• Change in activity patternChange in activity pattern• Mental status change – anxiety, Mental status change – anxiety,
agitation, depression agitation, depression (American Geriatrics Society, 2002)(American Geriatrics Society, 2002)
• Facial ExpressionsFacial Expressions• Verbalizations/VocalizationsVerbalizations/Vocalizations• Body movementsBody movements• Interpersonal behavior changeInterpersonal behavior change• Change in activity patternChange in activity pattern• Mental status change – anxiety, Mental status change – anxiety,
agitation, depression agitation, depression (American Geriatrics Society, 2002)(American Geriatrics Society, 2002)
Observation of Pain BehaviorsObservation of Pain Behaviors
• Patients with cognitive impairment Patients with cognitive impairment may not show any specific behavior may not show any specific behavior associated with painassociated with pain
• Patients with severe impairment may Patients with severe impairment may appear stoic when they are actually appear stoic when they are actually displaying a frozen mask in response displaying a frozen mask in response to painto pain
• Patients with cognitive impairment Patients with cognitive impairment may not show any specific behavior may not show any specific behavior associated with painassociated with pain
• Patients with severe impairment may Patients with severe impairment may appear stoic when they are actually appear stoic when they are actually displaying a frozen mask in response displaying a frozen mask in response to painto pain
Observation of Pain BehaviorsObservation of Pain Behaviors
• Pain behaviors should be assessed Pain behaviors should be assessed at rest and during movementat rest and during movement
• Pain Behaviors have not been well-Pain Behaviors have not been well-examined in younger veterans with examined in younger veterans with cognitive impairmentcognitive impairment
• Pain behaviors should be assessed Pain behaviors should be assessed at rest and during movementat rest and during movement
• Pain Behaviors have not been well-Pain Behaviors have not been well-examined in younger veterans with examined in younger veterans with cognitive impairmentcognitive impairment
Physiological ParametersPhysiological Parameters
• Changes in vital signs can provide Changes in vital signs can provide some indication of acute distresssome indication of acute distress
• Not a good indicator of chronic Not a good indicator of chronic problemproblem
• Vital changes do not discriminate Vital changes do not discriminate pain from other sources of distresspain from other sources of distress
• Absence of physiologic indicators Absence of physiologic indicators does not mean absence of paindoes not mean absence of pain
• Changes in vital signs can provide Changes in vital signs can provide some indication of acute distresssome indication of acute distress
• Not a good indicator of chronic Not a good indicator of chronic problemproblem
• Vital changes do not discriminate Vital changes do not discriminate pain from other sources of distresspain from other sources of distress
• Absence of physiologic indicators Absence of physiologic indicators does not mean absence of paindoes not mean absence of pain
Empirical Analgesic TrialsEmpirical Analgesic Trials• Use in conjunction with other assessment strategiesUse in conjunction with other assessment strategies• Consider other sources of distress Consider other sources of distress
that could be masked by analgesic trialthat could be masked by analgesic trial• PTSD is very common in this population and should PTSD is very common in this population and should
receive receive specific treatmentspecific treatment
• PTSD can be present even in the instance of a loss PTSD can be present even in the instance of a loss of consciousness at time of injury (Bryant et al, 1999)of consciousness at time of injury (Bryant et al, 1999)
•
• Use in conjunction with other assessment strategiesUse in conjunction with other assessment strategies• Consider other sources of distress Consider other sources of distress
that could be masked by analgesic trialthat could be masked by analgesic trial• PTSD is very common in this population and should PTSD is very common in this population and should
receive receive specific treatmentspecific treatment
• PTSD can be present even in the instance of a loss PTSD can be present even in the instance of a loss of consciousness at time of injury (Bryant et al, 1999)of consciousness at time of injury (Bryant et al, 1999)
•
Empirical Analgesic TrialsEmpirical Analgesic Trials
• Consider impact of analgesic on Consider impact of analgesic on cognitive statuscognitive status
• Identify functional/behavioral Identify functional/behavioral indicators to determine efficacyindicators to determine efficacy
• Use an adequate titration schedule Use an adequate titration schedule (25% - 50%) to assure dose efficacy(25% - 50%) to assure dose efficacy
• Consider impact of analgesic on Consider impact of analgesic on cognitive statuscognitive status
• Identify functional/behavioral Identify functional/behavioral indicators to determine efficacyindicators to determine efficacy
• Use an adequate titration schedule Use an adequate titration schedule (25% - 50%) to assure dose efficacy(25% - 50%) to assure dose efficacy
Pain Assessment ToolsPain Assessment Tools
• Numerous tools have Numerous tools have been developedbeen developed
• Tools are designed for use with Tools are designed for use with elderly with dementia or childrenelderly with dementia or children
• No tools have been validated for No tools have been validated for polytrauma patients with cognitive polytrauma patients with cognitive impairmentimpairment
• All tools need further refinementAll tools need further refinement
• Numerous tools have Numerous tools have been developedbeen developed
• Tools are designed for use with Tools are designed for use with elderly with dementia or childrenelderly with dementia or children
• No tools have been validated for No tools have been validated for polytrauma patients with cognitive polytrauma patients with cognitive impairmentimpairment
• All tools need further refinementAll tools need further refinement
Pain Assessment ToolsPain Assessment Tools
• Noncommunicative Patient’s Pain Noncommunicative Patient’s Pain Assessment Instrument (NOPPAIN)Assessment Instrument (NOPPAIN)
• Checklist of Nonverbal Pain Indicators Checklist of Nonverbal Pain Indicators (CNPI)(CNPI)
• Discomfort in Dementia of Alzheimer’s Discomfort in Dementia of Alzheimer’s Type (DS-DAT)Type (DS-DAT)
• Pain Assessment Checklist for Seniors Pain Assessment Checklist for Seniors with Limited Ability to Communicate with Limited Ability to Communicate (PACSLAC)(PACSLAC)
• Doloplus 2Doloplus 2• OthersOthers
• Noncommunicative Patient’s Pain Noncommunicative Patient’s Pain Assessment Instrument (NOPPAIN)Assessment Instrument (NOPPAIN)
• Checklist of Nonverbal Pain Indicators Checklist of Nonverbal Pain Indicators (CNPI)(CNPI)
• Discomfort in Dementia of Alzheimer’s Discomfort in Dementia of Alzheimer’s Type (DS-DAT)Type (DS-DAT)
• Pain Assessment Checklist for Seniors Pain Assessment Checklist for Seniors with Limited Ability to Communicate with Limited Ability to Communicate (PACSLAC)(PACSLAC)
• Doloplus 2Doloplus 2• OthersOthers
Pain Assessment ToolsPain Assessment Tools
• There is no standardized tool based on There is no standardized tool based on nonverbal pain indictors that can be nonverbal pain indictors that can be recommended for broad adoption in recommended for broad adoption in clinical practice clinical practice (Herr et al, 2006)(Herr et al, 2006)
• State of the Art review of tools used State of the Art review of tools used with elderly with dementia is available with elderly with dementia is available at City of Hope Websiteat City of Hope Websitehttp://www.cityofhope.org/prc/elderly.asphttp://www.cityofhope.org/prc/elderly.asp
• There is no standardized tool based on There is no standardized tool based on nonverbal pain indictors that can be nonverbal pain indictors that can be recommended for broad adoption in recommended for broad adoption in clinical practice clinical practice (Herr et al, 2006)(Herr et al, 2006)
• State of the Art review of tools used State of the Art review of tools used with elderly with dementia is available with elderly with dementia is available at City of Hope Websiteat City of Hope Websitehttp://www.cityofhope.org/prc/elderly.asphttp://www.cityofhope.org/prc/elderly.asp
DocumentationDocumentation
• Only patient self-report of pain intensity Only patient self-report of pain intensity can be entered in CPRS can be entered in CPRS vital sign sectionvital sign section
• Pain tool scores cannot be substituted Pain tool scores cannot be substituted for patient self-report for patient self-report even if they provide a 0-10 number, even if they provide a 0-10 number, e.g. PAINADe.g. PAINAD
• All other pain assessment is documented All other pain assessment is documented in progress note with appropriate titlein progress note with appropriate title
• Only patient self-report of pain intensity Only patient self-report of pain intensity can be entered in CPRS can be entered in CPRS vital sign sectionvital sign section
• Pain tool scores cannot be substituted Pain tool scores cannot be substituted for patient self-report for patient self-report even if they provide a 0-10 number, even if they provide a 0-10 number, e.g. PAINADe.g. PAINAD
• All other pain assessment is documented All other pain assessment is documented in progress note with appropriate titlein progress note with appropriate title
Re-AssessmentRe-Assessment
• Pain assessment is an Pain assessment is an ongoing processongoing process
• Pain should be re-assessed Pain should be re-assessed regularly with other vital signsregularly with other vital signs
• Pain assessment should always Pain assessment should always occur after new interventions or occur after new interventions or changes in health statuschanges in health status
• Pain assessment is an Pain assessment is an ongoing processongoing process
• Pain should be re-assessed Pain should be re-assessed regularly with other vital signsregularly with other vital signs
• Pain assessment should always Pain assessment should always occur after new interventions or occur after new interventions or changes in health statuschanges in health status
Polytrauma PainPolytrauma Pain
• Treat the Person – Not the Pain! Treat the Person – Not the Pain! Dennis Turk, Ph.D.Dennis Turk, Ph.D.
• Always address pain in context of the Always address pain in context of the individual patientindividual patient
• This requires extra attention in cases This requires extra attention in cases of cognitive impairment and impaired of cognitive impairment and impaired communication.communication.
• Treat the Person – Not the Pain! Treat the Person – Not the Pain! Dennis Turk, Ph.D.Dennis Turk, Ph.D.
• Always address pain in context of the Always address pain in context of the individual patientindividual patient
• This requires extra attention in cases This requires extra attention in cases of cognitive impairment and impaired of cognitive impairment and impaired communication.communication.