Pain Assessment in Clients with Dementia

Knowing the telltale signs of pain and using a pain assessment can help ensure that patients’ needs are not overlooked when they have difficulty communicating.

John V. Rider PhD, OTR/L MSCS, Amanda Godfrey OTD-S and Connor Wallace OTD S

As the life expectancy increases, dementia and other age-related disorders that affect cognition and communication will also increase. Pain is a major concern for people with dementia. The pain of people with dementia is common, hard to measure, and can have a significant impact on their quality of life and ability to function independently.

⁷ Rehabilitation clinicians and occupational therapists need to be aware of the severity of pain in this population. They should also ensure that all rehabilitation settings are evaluating and addressing pain levels.

Too Often Overlooked

Studies show that pain is not adequately treated in patients with cognitive impairments. According to studies, pain is not adequately treated among patients with cognitive disabilities. ^2,8 Patients with cognitive impairments have a decreased ability to verbally and visually communicate their pain. ^9-11 The main reason for this is that these individuals report their pain less frequently, less spontaneously and with a lower intensity. ^12,

Untreated pain can lead to psychological problems such as depression, sleep disorders, impaired function, decreased socialization, and further cognitive decline. ⁵ Therapists should therefore use different forms of pain assessment depending on the stage and severity of cognitive impairment.

What to Look for

Self-reporting is the gold standard for pain assessment because pain is a subjective experience. This can be done in standardized or nonstandardized formats. As cognitive and language abilities decrease, a tool that allows an observer to assess the patient should be added in addition. Occupational therapists can also conduct routine neuropsychological testing of cognitive status in order to determine when self-reporting is not reliable. People with cognitive or language impairments, for example, may experience pain but be unable to communicate it to their caregivers or healthcare providers. Documenting and observing pain behaviors can help identify clients who may be in pain, and begin appropriate treatment. Here is a list that occupational therapists, rehabilitation clinicians, and other healthcare professionals should document in order to achieve the proper goals and interventions for pain management.

Behavioral Pain Indicators*

• Face expressions: grimacing (grimacing), frowning (grimacing), rapid blinking (rapid blinking), tightly closing the eyes, etc.
• Vocalizations and verbalizations (moaning or sighing loudly, grunting or groaning), chanting. Calling out. Noisy breathing. Asking for help.
• Body Movements (restricting movement, fidgeting, pacing, rocking, guarding, gait, balance or mobility changes)
• Changes in interpersonal interaction (aggression, combativeness and resisting care; decreasing social interactions; inappropriate social interactions; disruptive behavior, withdrawal, verbal abuse, etc.)
• Changes in routines or activity patterns (refusal of food, changes in appetite, sleep patterns changing, sudden discontinuation of daily routines, increased wandering etc.)
• Mental status changes: (crying or increased confusion; irritability and distress; changes in attention, etc.)
• Changes in physiology (eg, heart rate, blood-pressure, sweating).

* Adapted by the AGS Panel for Persistent pain in Older Persons ¹⁴

Even if a person has cognitive impairment, it is important to take their pain reports seriously. Pain expression can also be subtler than the behavioral pain indicators above, and may take on other forms in dementia patients. For a complete clinical picture, observe pain behaviors during functional activities such as transferring, walking, repositioning or dressing and when at rest.

Rehabilitation clinicians may be the only healthcare professionals to observe clients during functional activities. They are often the first to notice pain behavior indicators. The typical behavioral pain indicators are often absent or hard to interpret in dementia patients, as some symptoms may manifest in a mute expression or withdrawn and quiet behavior. ¹³ Therapists should collaborate with family members, caregivers and other team member to better understand the baseline behaviors of these individuals. Any subtle changes in routine behavior can indicate pain.

Assessing Pain in Early Dementia

If the client is in the early stages, and has the cognitive abilities and communication skills to communicate pain verbally or visually, it may be appropriate for them to self-report pain. As part of the evaluation, clinicians must also be on the lookout for pain-related behaviors. To ensure accurate documentation and understanding of pain, occupational therapy and rehabilitation clinicians must:

• Simple scales can be used with both verbal and visual content
• Repeat the instructions and questions
• Give adequate time to respond
• Individualize your approach to the client’s neuropsychological deficits
• When assessing pain, try to minimize distractions and recognize the role that the environment plays.

Assessment of Pain in the Middle and Later Stages of Dementia

In the later stages of dementia it may be difficult to get a self-reported report, so behavioral indicators can be used. It is important to ask family members and caregivers about their history to recognize any changes in behavior. There are three behavioral domains that have been accepted by many as mirroring pain states on observer rating scales. ²

• Facial reactions (grimacing, closing the eyes, etc.)
• Vocalizations
• Body posture or movement (repeatedly moving or repositioning yourself when seated or lying down, holding one body part or another, rubbing an area repeatedly, etc.)

Any of these behaviors could indicate pain. Clinicians must pay attention to the triggers (movement, lying versus sitting, trying to swallow or a particular activity).

In addition to experimental methods, clinical applications have not yet been widely adopted. In clinical studies, for example, the use of brain imaging, neurophysiologic recording, facial response coding and video recording, as well as actigraphy monitoring, has been proven to be effective. However, they have not yet reached a mainstream level. In the future, we may see more use of this type of technology as it becomes more accessible in rehab settings.

For those with dementia or impaired cognition, there are several standardized pain assessment tools. These assessments are available online for free. These assessments are based on the behavioral pain indicators that were mentioned earlier. Some assessments combine self-reporting and observational methods.

Original Blog: https://rehabpub.com/pain-management/chronic/pain-assessment-in-clients-with-dementia/