Pain Assessment in Persons With Cognitive Impairment

Pain can be difficult to assess in cognitively impaired individuals because their self-reports of pain can be inaccurate or difficult to obtain. ^[1] Thus, behavioral observation–based assessment is optimal in these patients. Common pain behaviors are as follows: ^[2]

• Facial expressions: Frowning, grimacing, distorted expression, rapid blinking

• Verbalizations/vocalizations: Sighing, moaning, calling out, asking for help, verbal abuse

• Body movements: Rigid, tense, guarding, fidgeting, increased pacing/rocking, mobility changes such as inactivity or motor restlessness

• Changes in interpersonal interactions: Aggressive, resisting care, disruptive, withdrawn

• Changes in activity patterns: Appetite change, sleep change, sudden cessation of common routines

• Mental status change: Crying, increased confusion, irritability, distress

Pain can also manifest physiologically. Such indicators are as follows: ^[2]

• Increased heart rate

• Increased blood pressure

• Increased breathing rate

• Diaphoresis

• Pupil dilatation

In persons with cognitive impairments, pain indicators may present as behaviors that are characteristic of other unmet needs. ^[2] For example, some indicators may in fact indicate hunger, thirst, overstimulation, understimulation, depression, or anxiety, among others.

Pain can be difficult to assess in cognitively impaired individuals because their self-reports of pain can be inaccurate or difficult to obtain. Thus, behavioral observation–based assessment is optimal in these patients. Common pain behaviors are as follows: ^[2]

• Facial expressions: Frowning, grimacing, distorted expression, rapid blinking

• Verbalizations/vocalizations: Sighing, moaning, calling out, asking for help, verbal abuse

• Body movements: Rigid, tense, guarding, fidgeting, increased pacing/rocking, mobility changes such as inactivity or motor restlessness

• Changes in interpersonal interactions: Aggressive, resisting care, disruptive, withdrawn

• Changes in activity patterns: Appetite change, sleep change, sudden cessation of common routines

• Mental status change: Crying, increased confusion, irritability, distress

Pain can also manifest physiologically. Such indicators are as follows: ^[2]

• Increased heart rate

• Increased blood pressure

• Increased breathing rate

• Diaphoresis

• Pupil dilatation

In persons with cognitive impairments, pain indicators may present as behaviors that are characteristic of other unmet needs. ^[2] For example, some indicators may in fact indicate hunger, thirst, overstimulation, understimulation, depression, or anxiety, among others.

Elderly patients

Elderly patients tend to underreport pain. In addition, many symptoms of aging may create communication barriers and challenges when complex pain-assessment tools are used. ^[3] Conditions such as dementia are the leading causes of impaired cognition in elderly patients. ^[4] To account for this, the clinician should allow ample time for the examination, appraise for communication impairments, use pain-assessment tools that elderly patients find easy to use, and be aware of any behavioral changes (see Pain-Assessment Tools). ^[5] Patient self-report of pain should be attempted in mild to moderate cognitively impaired patients. ^[6]

Infants and children

Infants and children may have a limited capacity for communication. In addition, young pediatric patients may be challenged by complex assessment tools. To account for this, the clinician should keep the patient’s developmental stage in mind during the assessment. For example, in infants, the physician should focus on reflexes and crying. In toddlers, the physician should watch for pursed lips, widening of eyes, rocking, rubbing, biting, hitting, kicking, and running away. However, studies have shown that children ages 5-7 are capable of accurately self reporting their own pain using the Wong-Baker FACES scale. ^[7] The clinician should choose age-appropriate pain-assessment tools (see Pain-Assessment Tools). ^[5]

Other

Many conditions can lead to cognitive impairments, and these can affect many demographics equally. Examples of such conditions include head trauma, speech deficits, memory deficits, language barriers that disrupt the ability to report pain, intubation, unconsciousness, and delirium. In these cases, the clinician should assess pain on a case-by-case basis.

Pain is a highly subjective internal stressor. A pain assessment can be used to collect details such as physiological indicators, behavior indicators, and self-reported accounts.

Physiological

Pain can cause the body to release increased levels of catecholamines and stress hormones, ^[8] which can then result in tachycardia, hypertension, and diaphoresis. In addition, pain causes alterations in capillary size that can result in an increased need for oxygen and decreased perfusion. ^[8] However, confirmation of these nonspecific physical manifestations are not enough to diagnose the presence of pain, since these physiologic measures can be influenced by medication and pathological conditions. ^[8]

Behavioral

Another method for pain assessment is behavioral observation–based, which is the best practice for noncommunicative patients. The following are common pain behaviors: ^[9]

• Facial expressions: Frowning, grimacing, distorted expression, rapid blinking

• Verbalizations/vocalizations: Sighing, moaning, calling out, asking for help, verbal abuse

• Body movements: Rigid, tense, guarding, fidgeting, increased pacing/rocking, mobility changes such as inactivity or motor restlessness

• Changes in interpersonal interactions: Aggressive, resisting care, disruptive, withdrawn

• Changes in activity patterns: Appetite change, sleep change, sudden cessation of common routines

• Mental status change: Crying, increased confusion, irritability, distress

Self-report

The most reliable method for pain assessment is a self-report. Any description of pain or results from a verbal scale is considered the criterion standard for pain assessment. The most common assessment tool is a numeric rating scale (NRS; see image below), in which the patient rates pain based on a scale from 0-10, with 0 being “no pain at all” and 10 being the “worst imaginable pain.” ^[5] In addition, a pain history should be taken to further expand the clinician’s assessment of the pain.

The following is an example of a pain history tool, using the OLD CARTS mnemonic: ^[10]

• Onset: When did the pain start? How did it start?

• Localization: Where is the pain?

• Describe the pain (eg, burning, aching, stabbing, shooting, throbbing)

• Characteristics: How intense is the pain?

• Aggravating: What makes the pain worse?

• Relieving factors: What relieves the pain? Have you received any treatments? What are they? Any adverse affects of the treatment?

• Time course: What is the time course of the pain?

• Symptoms related to pain: How does the pain affect certain activities (eg, sleep, physical functions, ability to work, mood, social life, sex life)?

Performance-based functional assessments are also necessary because they measure pain impact on the patient's daily functioning. These assessments include the "get-up and go test" and range of motion tests. ^[6]

When assessing pain in patients with cognitive impairments, the physician should use an appropriate pain-assessment tool based on the development of the patient. For the cognitively impaired, a Mini-Mental State Exam (MMSE) may be helpful in determining the pain-assessment tool to use. ^[6]

Pain scales for elderly patients

The physician should have various pain-assessment tools that elderly patients find easy to use. Once the physician has chosen a pain-assessment tool, the same tool should be used for every reassessment of pain in an individual patient.

The following are self-report pain-assessment tools that are suitable for elderly patients: ^[11]

• Verbally administered 0-10 scale: 0 is "no pain at all" and 10 is "the worst possible pain"

• Visual analog scale: A horizontal or vertical line that is 10 cm long; the patient points to the level of pain, and the clinician marks and records the length

  Visual Analog Scale.

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• Verbal descriptor scale: The patient uses word to describe the level of pain: no pain, mild, moderate, or severe pain

• Faces pain scale: An 8-point scale that shows a progression of facial expressions of pain; the patient picks the face that represents his or her level of pain

  FACES Pain Rating Scale. Image courtesy of the US Department of Veterans Affairs.

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• Pain thermometer: Words that describe pain correspond to a point on the thermometer

  Pain thermometer.

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• McGill Pain Questionnaire: Patients locate pain on a body drawing and then use words to describe the level of pain

Behavioral pain-assessment tools for elderly patients include the following: ^[11]

• The Assessment of Discomfort in Dementia Protocol (ADD)

• Checklist of Nonverbal Pain Indicators (CNPI)

• Doloplus 2

• Nursing Assistant-Administered Instrument to Assess Pain in Demented Individual (NOPPAIN)

• The Pain Assessment Scale for Seniors with Severe Dementia (PACSLAC)

• The Pain Assessment in Advanced Dementia Scale (PAINNAD)

Pain scales for children/infants

When assessing pain in children or infants, the child’s developmental stage should be in mind. Children may not be able to communicate pain effectively, so it is important that the clinician take a self-report and behavioral pain assessment, when possible.

Pain-assessment methods that are appropriate in newborns, infants, and toddlers include the following: ^[11]

• Neonatal Facial Coding System (NFCS)

• PAIN: Pain Assessment Inventory for Neonates

• Cries

• Objective Pain Scale

• FLACC (faces, legs, activity, cry, and consolability)

Pain-assessment methods that are appropriate in preschool-aged children include the following: ^[11]

• CFCS: Child Facial Coding System

• CHEOPS: Children’s Hospital of Eastern Ontario Pain Scale

• Poker Chip Tools

• Pain Thermometer

• Numeric Rating Scale

• FACES

• OUCHER

Pain-assessment methods that are appropriate in school-aged children and adolescents include the following: ^[11]

• FACES

• Facial Affective Scale

• OUCHER

• VAS: Visual Analog Scale

• CAS: Colored Analogue Scale

• Numeric Rating Scale

• Word Graphic Rating Scales

• Verbal Numeric Scale

Other pain scales

While some of the scales mentioned above can be used in any unconscious patient, many pain-assessment tools are appropriate. For such patients, it is vital to gather as much information as possible through observation and information given by a caregiver because the patient’s cognition may be seriously impaired.

Pain-assessment tools for cognitively impaired patients include the following:

• Pain Assessment and Intervention Notation (PAIN): Evaluates for grimacing, frowning, wincing, drawn around mouth and eyes, wrinkled forehead, teary eyes, crying

• Pain Behavior Assessment Tool (PBAT): Evaluates for grimace, frown, wince, eyes closed, eyes wide open with eyebrows raised, looking away in opposite direction of pain, grin, smile, mouth wide open to expose teeth and tongue, clenched teeth

• Behavioral Pain Scale (BPS): Assesses facial behavior and assigns a numerical value: Relaxed, partially tightened, fully tightened, grimacing

The American Society of Pain has recommended the following protocol to assess pain: ^[12]

• Obtain a self-report of pain whenever possible

• Assess potential causes of Pain: The clinician should consider pathological causes of pain and any procedure known to cause pain

• Observe patient behavior: Pain may manifest behaviorally (see Behavioral)

• Address any pain history from family, significant others, and caregivers

• Attempt pharmacological and nonpharmacological treatment options

• Reassessment: The Agency for Health Care Policy and Research states that reassessment should be performed within 30 minutes of parenteral drug administration, within 1 hour of oral drug administration, and upon each report of new or unchanged pain ^[5]

Pharmacological treatment

The following pharmacological treatment guidelines should be followed: ^[9]

• Pain should be treated rapidly

• Use scheduled dosing when pain is chronic and/or when the patient is unable to ask for medication

• Administer medication to pain level and assess verbal, behavioral, and functional response to medication

• When administering the medication, it is best to start with a lower dose and gradually increase the dose to alleviate the pain

• Be watchful of any adverse effects of the medication (see Other considerations); make changes if any occur, including changing the dosage or route, trying a different drug, and/or adding a drug that may counteract the side effects

A broad spectrum of pain medications are. One useful tool is the World Health Organization (WHO) pain relief ladder, which suggests the type of medication according to the severity of pain (see image below).

The following are the available pain medication categories: ^[5]

• Nonopioid analgesics: Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)

• Opioid analgesics: Mu opioid agonists and agonist-antagonist opioids

• Adjuvant analgesics: A large group of drugs prescribed for reasons other than pain but that have analgesic properties (eg, antiepileptic drugs, tricyclic antidepressants, local anesthetics)

Pharmacological treatment

Nonpharmacological treatment options should be administered in conjunction with analgesic. Some examples of this type of pain treatment are as follows: ^[9]

• Physical exercise

• Acupuncture

• Heat

• Cold

• Massage

• Relaxation

• Patient pain education

Other considerations

There are many pain-assessment tools; however, it is pertinent that the clinician is aware that these are relatively new tools that have not undergone extensive testing.

Unrelieved pain can cause tremendous discomfort to the patient and further exacerbate cognitive impairment, potentially resulting in sleep disruptions, disorientation, and exhaustion. Ultimately, untreated pain can affect all areas of life, such as social, physical, mental, and emotional well-being.

It is important that the patient population be considered when the treatment options are chosen. The benefits should outweigh the risk. When a pharmacological approach to pain management is chosen, the potential adverse effects of the medication (eg, sedation, impairment of cognition and balance, gastrointestinal bleeding, constipation) should be considered. ^[9] Opioids and NSAIDs can impair cognition. However, all opioids cause constipation and risk of addiction. As a result, the clinician should take note that the patient may have limited a capacity to report such symptoms. NSAIDs also increase the risk of gastric bleeding, ulceration, and cardiac events.

Nonpharmacological interventions are only as effective as the patient’s compliance. As a result, educating staff and family members about pain management can help increase the inclination toward compliance.

It is important to take a self-report of pain whenever possible.

Use appropriate pain-assessment tools for specific patient populations.

The clinician should take notice of behavioral details when trying to assess pain, but these characteristics may not be attributed to pain.

Once a treatment plan has been prescribed, it is important to evaluate and reassess pain and take note of any changes in behavior.

When prescribing medications, it is best practice to start with a low dosage and slowly titrate the medication.

The clinician should take note of any adverse effects of medications and make appropriate changes.

Pain education to the patient’s support group is an important part of pain management.