Journal of Pain and Symptom Management
Volume 31, Issue 2 , Pages 170-192 , February 2006

Tools for Assessment of Pain in Nonverbal Older Adults with Dementia: A State-of-the-Science Review

  • Keela Herr, PhD, RN, FAAN

      Affiliations

    • Corresponding Author InformationAddress reprint requests to: Keela Herr, PhD, College of Nursing, 452 NB, The University of Iowa, 50 Newton Road, Iowa City, IA 52242, USA.
    • ,
  • Karen Bjoro, RN, MSN, PhDc
    • ,
  • Sheila Decker, PhD, APRN-BC

,Accepted 6 July 2005.

References 

  1. Hebert LE, Scherr PA, Bienias JL, Bennett DA, Evans DA. Alzheimer disease in the US population: prevalence estimates using the 2000 census. Arch Neurol. 2003;60:1119–1122
  2. Feldt KS, Ryden MB, Miles S. Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture. J Am Geriatr Soc. 1998;46:1079–1085
  3. Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain Symptom Manage. 1995;10:591–598
  4. Parmelee PA. Pain in cognitively impaired older persons. Clin Geriatr Med. 1996;12:473–487
  5. Won AB, Lapane KL, Vallow S, et al. Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. J Am Geriatr Soc. 2004;52:867–874
  6. Young DM. Pain in institutionalized elders with chronic dementia. PhD dissertation. Iowa City, IA: The University of Iowa, 2001.
  7. Morrison RS, Magaziner J, McLaughlin MA, et al. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103:303–311
  8. Landi F, Onder G, Cesari M, et al. Pain and its relation to depressive symptoms in frail older people living in the community: an observational study. J Pain Symptom Manage. 2005;29:255–262
  9. Williamson GM, Schulz R. Pain, activity restriction, and symptoms of depression among community-residing elderly adults. J Gerontol. 1992;47:P367–P372
  10. Brummel-Smith K, London MR, Drew N, et al. Outcomes of pain in frail older adults with dementia. J Am Geriatr Soc. 2002;50:1847–1851
  11. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003;58:76–81
  12. Schuler M, Njoo N, Hestermann M, Oster P, Hauer K. Acute and chronic pain in geriatrics: clinical characteristics of pain and the influence of cognition. Pain Med. 2004;5:253–262
  13. Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am Geriatr Soc. 1990;38:409–414
  14. Roy R, Thomas MR. A survey of chronic pain in an elderly population. Can Fam Physician. 1986;32:513–516
  15. Hartikainen SA, Mantyselka PT, Louhivuori-Laako KA, Sulkava RO. Balancing pain and analgesic treatment in the home-dwelling elderly. Ann Pharmacother. 2005;39:11–16
  16. Herrick C, Steger-May K, Sinacore DR, et al. Persistent pain in frail older adults after hip fracture repair. J Am Geriatr Soc. 2004;52:2062–2068
  17. Jakobsson U, Rahm Hallberg I, Westergren A. Pain management in elderly persons who require assistance with activities of daily living: a comparison of those living at home with those in special accommodations. Eur J Pain. 2004;8:335–344
  18. Ferrell BR, Schaffner M. Pharmacoeconomics and medical outcomes in pain management. Semin Anesth. 1997;16:152–159
  19. Sengstaken EA, King SA. The problems of pain and its detection among geriatric nursing home residents. J Am Geriatr Soc. 1993;41:541–544
  20. Hall-Lord ML, Larsson G, Steen B. Pain and distress among elderly intensive care unit patients: comparison of patients' experiences and nurses' assessments. Heart Lung. 1998;27:123–132
  21. Kaasalainen SJ, Robinson LK, Hartley T, et al. The assessment of pain in the cognitively impaired elderly: a literature review. Perspectives. 1998;22:2–8
  22. Weiner D, Peterson B, Keefe F. Chronic pain-associated behaviors in the nursing home: resident versus caregiver perceptions. Pain. 1999;80:577–588
  23. Werner P, Cohen-Mansfield J, Watson V, Pasis S. Pain in participants of adult day care centers: assessment by different raters. J Pain Symptom Manage. 1998;15:8–17
  24. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic assessment of geriatric drug use via epidemiology. JAMA. 1998;279:1877–1882
  25. Morrison RS, Siu AL. A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. J Pain Symptom Manage. 2000;19:240–248
  26. Teno JM, Kabumoto G, Wetle T, Roy J, Mor V. Daily pain that was excruciating at some time in the previous week: prevalence, characteristics, and outcomes in nursing home residents. J Am Geriatr Soc. 2004;52:762–767
  27. Teno JM, Weitzen S, Wetle T, Mor V. Persistent pain in nursing home residents. JAMA. 2001;285:2081
  28. Horgas AL, Tsai PF. Analgesic drug prescription and use in cognitively impaired nursing home residents. Nurs Res. 1998;47:235–242
  29. McNeill JA, Sherwood GD, Starck PL. The hidden error of mismanaged pain: a systems approach. J Pain Symptom Manage. 2004;28:47–58
  30. Sullivan LW, Eagel BA. Leveling the playing field: recognizing and rectifying disparities in management of pain. Pain Med. 2005;6:5–10
  31. Green CR, Baker TA, Smith EM, Sato Y. The effect of race in older adults presenting for chronic pain management: a comparative study of black and white Americans. J Pain. 2003;4:82–90
  32. Green CR, Ndao-Brumblay SK, Nagrant AM, Baker TA, Rothman E. Race, age, and gender influences among clusters of African American and white patients with chronic pain. J Pain. 2004;5:171–182
  33. Parmelee PA, Smith B, Katz IR. Pain complaints and cognitive status among elderly institution residents. J Am Geriatr Soc. 1993;41:517–522
  34. Porter FL, Malhotra KM, Wolf CM, et al. Dementia and response to pain in the elderly. Pain. 1996;68:413–421
  35. Stein WM, Ferrell BA. Pain in the nursing home. Clin Geriatr Med. 1996;12:601–613
  36. Weiner D, Peterson B, Keefe F. Evaluating persistent pain in long term care residents: what role for pain maps?. Pain. 1998;76:249–257
  37. Huffman JC, Kunik ME. Assessment and understanding of pain in patients with dementia. Gerontologist. 2000;40(5):574–581
  38. LaChapelle DL, Hadjistavropoulos T, Craig KD. Pain measurement in persons with intellectual disabilities. Clin J Pain. 1999;15:13–23
  39. Scherder EJ. Low use of analgesics in Alzheimer's disease: possible mechanisms. Psychiatry. 2000;63:1–12
  40. Gibson SJ, Farrell M. A review of age differences in the neurophysiology of nociception and the perceptual experience of pain. Clin J Pain. 2004;20:227–239
  41. Gibson SJ, Helme RD. Age-related differences in pain perception and report. Clin Geriatr Med. 2001;17:433–456
  42. Gibson SJ, Voukelatos X, Ames D, Flicker L, Helme RD. An examination of pain perception and cerebral event-related potentials following carbon dioxide laser stimulation in patients with Alzheimer's disease and age-matched control volunteers. Pain Res Manag. 2001;6:126–132
  43. Helme RD, Meliala A, Gibson SJ. Methodologic factors which contribute to variations in experimental pain threshold reported for older people. Neurosci Lett. 2004;361:144–146
  44. Feldt KS. The checklist of nonverbal pain indicators (CNPI). Pain Manag Nurs. 2000;1:13–21
  45. Weiner D, Pieper C, McConnell E, Martinez S, Keefe F. Pain measurement in elders with chronic low back pain: traditional and alternative approaches. Pain. 1996;67:461–467
  46. Hadjistavropoulos T, LaChapelle DL, MacLeod FK, Snider B, Craig KD. Measuring movement-exacerbated pain in cognitively impaired frail elders. Clin J Pain. 2000;16:54–63
  47. Asplund L, Norberg A, Adolfsson R, Waxman HM. Facial expressions in severely demented patients—a stimulus-response study of four patients with dementia of the Alzheimer's type. Int J Geriatr Psychiatry. 1991;6:599–606
  48. Feldt KS, Warne MA, Ryden MB. Examining pain in aggressive cognitively impaired older adults. J Gerontol Nurs. 1998;24:14–22
  49. Kovach CR, Weissman DE, Griffie J, Matson S, Muchka S. Assessment and treatment of discomfort for people with late-stage dementia. J Pain Symptom Manage. 1999;18:412–419
  50. Marzinski LR. The tragedy of dementia: clinically assessing pain in the confused nonverbal elderly. J Gerontol Nurs. 1991;17:25–28
  51. AGS Panel on Persistent Pain in Older Persons . The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50:S205–S224
  52. Dirks JF, Wunder J, Kinsman R, McElhinny J, Jones NF. A Pain Rating Scale and a Pain Behavior Checklist for clinical use: development, norms, and the consistency score. Psychother Psychosom. 1993;59:41–49
  53. Richards JS, Nepomuceno C, Riles M, Suer Z. Assessing pain behavior: the UAB Pain Behavior Scale. Pain. 1982;14:393–398
  54. Cohen-Mansfield J, Lipson S. Pain in cognitively impaired nursing home residents: how well are physicians diagnosing it?. J Am Geriatr Soc. 2002;50:1039–1044
  55. Cohen-Mansfield J. Relatives' assessment of pain in cognitively impaired nursing home residents. J Pain Symptom Manage. 2002;24:562–571
  56. Ferrell BR, Cohen MZ, Rhiner M, Rozek A. Pain as a metaphor for illness: impact of cancer pain on family caregivers. Oncol Nurs Forum. 1991;18:1303–1309
  57. Madison JL, Wilkie DJ. Family members' perceptions of cancer pain. Comparisons with patient sensory report and by patient psychologic status. Nurs Clin North Am. 1995;30:625–645
  58. Yeager KA, Miaskowski C, Dibble S, Wallhagan M. Differences in pain knowledge and perception of the pain experience between outpatients with cancer and their family caregivers. Oncol Nurs Forum. 1995;22:1235–1241
  59. Cohen-Mansfield J, Creedon M. Nursing staff members' perceptions of pain indicators in persons with severe dementia. Clin J Pain. 2002;18:64–73
  60. Fisher SE, Burgio LD, Thorn BE, et al. Pain assessment and management in cognitively impaired nursing home residents: association of certified nursing assistant pain report, Minimum Data Set pain report, and analgesic medication use. J Am Geriatr Soc. 2002;50:152–156
  61. Manfredi PL, Breuer B, Meier DE, Libow L. Pain assessment in elderly patients with severe dementia. J Pain Symptom Manage. 2003;25:48–52
  62. Mentes JC, Teer J, Cadogan MP. The pain experience of cognitively impaired nursing home residents: perceptions of family members and certified nursing assistants. Pain Manag Nurs. 2004;5:118–125
  63. Shega JW, Hougham GW, Stocking CB, Cox-Hayley D, Sachs GA. Pain in community-dwelling persons with dementia: frequency, intensity, and congruence between patient and caregiver report. J Pain Symptom Manage. 2004;28:585–592
  64. American Medical Directors Association . The management of chronic pain in long-term care settings. Columbia, MD: American Medical Directors Association; 2003;
  65. Herr K, Bjoro K, Steffensmeier J, Rakel B. Evidence-based practice guideline: Acute pain management in older adults. Iowa City: The University of Iowa, Research Dissemination Core, 2006.
  66. Herr KA, Garand L. Assessment and measurement of pain in older adults. Clin Geriatr Med. 2001;17:457–478
  67. Herr K, Titler M, Sorofman B, et al. Research-based protocol: Acute pain management in the elderly. Iowa City: The University of Iowa, Research Dissemination Core; 2000;
  68. Abbey JA, Piller N, DeBellis A, et al. The Abbey Pain Scale. A 1-minute numerical indicator for people with late-stage dementia. Int J Palliat Nurs. 2004;10:6–13
  69. Hurley AC, Volicer BJ, Hanrahan PA, Houde S, Volicer L. Assessment of discomfort in advanced Alzheimer patients. Res Nurs Health. 1992;15:369–377
  70. Lefebvre-Chapiro S, The Doloplus Group . The Doloplus 2 scale—evaluating pain in the elderly. Eur J Palliat Care. 2001;8:191–194
  71. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. Practice applications of research. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23:293–297
  72. Snow AL, Weber JB, O'Malley KJ, et al. NOPPAIN: a nursing assistant-administered pain assessment instrument for use in dementia. Dement Geriatr Cogn Disord. 2004;17:240–246
  73. Fuchs-Lacelle S, Hadjistavropoulos T. Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Manag Nurs. 2004;5:37–49
  74. Villanueva MR, Smith TL, Erickson JS, Lee AC, Singer CM. Pain assessment for the dementing elderly (PADE): reliability and validity of a new measure. J Am Med Dir Assoc. 2003;Jan/Feb:1–8
  75. 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;Jan/Feb:9–15
  76. Decker SA, Perry AG. The development and testing of the PATCOA to assess pain in confused older adults. Pain Manag Nurs. 2003;4:77–86
  77. Breu LM, McGrath PJ, Camfield C, Rosmus C, Finley GA. Preliminary validation of an observational pain checklist for persons with cognitive impairments and inability to communicate verbally. Dev Med Child Neurol. 2000;42:609–616
  78. Kaasalainen S, Crook J. A comparison of pain-assessment tools for use with elderly long-term-care residents. Can J Nurs Res. 2003;35:58–71
  79. Simons W, Malabar R. Assessing pain in elderly patients who cannot respond verbally. J Adv Nurs. 1995;22:663–669
  80. Burns N, Grove SK. The practice of nursing research. Conduct, critique, & utilization. 4th ed.. Philadelphia, PA: Saunders; 2001;
  81. Jacobson SF. Evaluating instrument for use in clinical nursing research. In:  Frank-Stromberg MA,  Olson SJ editor. Instruments for clinical health care research. Boston, MA: Jones and Bartlett Publishers; 1997;p. 3–19
  82. Norbeck JS. What constitutes a publishable report of instrument development?. Nurs Res. 1985;34:380–382
  83. Kovach CR, Noonan PE, Griffie J, Muchka S, Weissman DE. Use of the assessment of discomfort in dementia protocol. Appl Nurs Res. 2001;14:193–200
  84. Kovach CR, Noonan PE, Griffie J, Muchka S, Weissman DE. The assessment of discomfort in dementia protocol. Pain Manag Nurs. 2002;3:16–27
  85. Miller J, Neelon V, Dalton J, et al. The assessment of discomfort in elderly confused patients: a preliminary study. J Neurosci Nurs. 1996;28:175–182
  86. The Doloplus Group . Behavioral pain assessment scale for elderly subjects presenting with verbal communication disorders. Available from www.doloplus.com/versiongb/index.htmRetrieved June 10, 2003
  87. Baiardi J, Parzuchowski J, Kosik C, et al. Examination of the reliability of the FLACC Pain Assessment tool with cognitively impaired elderly. Annual National Conference of Gerontological Nurse Practitioners. Chicago, IL, 2002.
  88. Snow AL. Personal communication, April 24, 2004.
  89. Scherder E, Oosterman J, Swaab D, et al. Recent developments in pain in dementia. BMJ. 2005;330:461–464
  90. Scherder EJ, Sergeant JA, Swaab DF. Pain processing in dementia and its relation to neuropathology. Lancet Neurol. 2003;2:677–686
  91. Herr K, Decker S. Assessment of pain in older adults with severe cognitive impairment. Ann Long Term Care. 2004;12:46–52

PII: S0885-3924(05)00611-1

doi: 10.1016/j.jpainsymman.2005.07.001

Journal of Pain and Symptom Management
Volume 31, Issue 2 , Pages 170-192 , February 2006

Article Tools